GI emergencies

Hitting the high points,

by Meredith Greer
GI bleed
The basics
2 large bore IVs
 20G – 60 cc/min (1L in 16 mins)
 18G – 100cc/min
 16G – 180cc/min
 14G – 240cc/min (1L in 4 mins = 4U blood?)
 Cordis – 126cc/min (333 w/ pressure bag)
 Central line – 52cc/min for brown port, 26 lousy
cc/min for blue and white
 Moral of the story?
 LEARN HOW TO PLACE EJs!!!
The basics
 Fluidresuscitation
 pRBCs resuscitation
 Correction of bleeding/coags
 IV PPI BID
 Octreotide gtt (if varices, or suspect)
 Abx + Alb if liver patient
 GI consult STAT
 ?When to involve IR
 ?When to involve surgery
Do NOT
 Over-resuscitate a variceal bleeder
 You will increase splanchnic pressures, and can
worsen the bleed
Do NOT
 Underestimate the crump potential of a variceal
bleeder
 Once they’ve bled once, 75% chance of rebleed
during that hospital stay
 Better to overcall (over admit/over monitor) rather
than wait until they open up
Upper GI bleed
Esophageal Gastric Duodenal Misc.
Varices PUD PUD Iatrogenic
Mallory-Weiss Varices Cancer Coagulopathy
Tear
Cancer Gastritis AV fistula Ischemia
Esophagitis Cancer Angiodysplasi
a
Dieulafoy’s Hemobilia
lesion
So you’re going to call GI…
 Agree w/ above (endoscopy)
 Your main role is resuscitation and to keep them
stable enough to scope
 Do what we discussed above, and for varices,
think of the following…
 Fix the other stuff!
 Cardio
Levophed! Levophed!
Agents that have more B2 agonist
activity, such as dopamine, should be
avoided because they can cause
splanchnic vasodilation.
 Infectious
Ceftriaxone! Ceftriaxone!
The presence of infection is associated
with rebleeding owing to the
induction of hyperdynamic
circulation and increased portal
pressure.
 Hematologic
FFP! FFP! Cryo >100.
Kcentra if on Warfarin too.
Platelets >50.
 Neurologic
Lactulose! Lactulose!
HD/CRRT if needed (uremia).
Protect the airway and tube if
you have to.
Stuff to know to ask for?
 TIPS  Blakemore
 Transjugular  Essentially a large tube
intrahepatic that helps you
portosystemic shunt? tamponade the
 Indications? stomach and
 Contraindications? esophagus to stop the
bleeding
 DO NOT DO THIS
YOURSELF!!!
Lower GI bleed
Small intestine Large intestine Rectum Misc.

Angiodysplasia Diverticulosis Hemorrhiods Iatrogenic

Cancer Angiodysplasia Fissures Coagulopathy
Ischemia Cancer Cancer
Trauma IBD Ulceration
Aortoenteric fistula Trauma Varices
Meckel’s diverticulum Ischemia Trauma
Radiation
enteritis
Infection
Aortoenteric
fistula
Again, you’re calling GI…
 Agree w/ above (colonoscopy)
 Your main role is resuscitation and to keep them
stable enough to scope
 Do what we discussed above, and for negative
colonoscopy, think of the following…
How/when to call IR…
Angiography

 Requires active bleeding occurring when the test is

performed
 The rate of bleeding must be brisk 0.5-1 ml/min
 In the case of upper GI bleeding, angiography may
demonstrate a bleeding site in 75% of patients
 In the lower GI bleed the diagnostic yield decreases to
about 60%
How/when to call IR…
Tagged red blood cell scan

 Offers the abilty to detect rates of less than 0.5 ml/min

 48-hour stability of the tagged red blood cells allows
repeated nuclear imaging to 2 days following administration
of the radionuclide in the setting of intermittent bleeding
 A positive study only localizes the bleeding only to an area
of the abdomen and cannot define the mucosal location of
the bleeding site precisely
How/when to call surgery?
 Recurrent diverticular bleed, esp in people requiring
anticoagulation
 Massive ongoing bleeding with high transfusion
requirements (>6 units of packed RBCs in a 24-hour
period)
 Think…is this actually ischemic bowel?
Acute Liver Failure
It is scary
The basics
 STAT PAN labs, q6h
 Utox, tylenol, salicylates, alcohols
 “ALF” panel – viral, autoimmune
 Medication review
 ONLY TIME TO USE AMMONIA PLEASE
 CT head to eval for cerebral edema
 May need mannitol or HTS
 Call GI immediately for tx evaluation
Anticipate
 Intubation for airway protection
 AVOID SEDATION w/ BENZOS PLEASE
 Early dialysis
 D10 drip (no coding from hypoglycemia)
 Rapid decompensation
 Brain herniation
 Need for transfer if tx is on the table
Acute on Chronic Liver Failure
It is less scary, and more common
The basics
 What’s the cirrhosis from? (top 3 causes)
 What’s their MELD/Na? (what goes into it)
 What are their complications? (5 major)
 Why did they decompensate? (causes)
 Are they a tx candidate?
Anticipate
 SBP
 GIB
 Very bad hepatic encephalopathy
 Intubate for airway protection, avoid BZs
 High output state, low BPs, wide PP
 ?Portopulmonary HTN
 ?Hepatopulmonary syndrome
 Family meeting (know your percentages)
Perf’d bowel
Not our territory, but we’re happy to help
The basics
 Physical exam
 Tense gut
 No bowel sounds
 Severe pain (may be tubed/AMS)
 NGT output
 Lactate out of proportion
 History of hernia, abd surg, or cancer
 Acute decompensation
Anticipate
 Severe acidemia  respiratory failure
 Severe shock refractory to medication
 Needs tons of fluids (losing all in gut)
 Needs OR NOW!!!

NOW!!!!!
The end…
May expand more on liver failure next week 