UMEM Educational Pearls - Gastrointestional

This study, done out of Australia, examined the association between abdominal pain and severity of liver injury in patients presenting after acute acetaminophen overdose. 

539 cases were identified where N-acetylcysteine was administered to patients with acetaminophen overdose. The investigators explored parameters including presence of abdominal pain, time post-ingestion, and peak ALT. 

Patients less than 8 hours post overdose WITH abdominal pain were as likely to develop hepatotoxicity as those presenting WITHOUT abdominal pain. (OR=1.18 [0.07 to 19.4])

Patients presenting 8 or more hours post overdose WITH abdominal pain were as likely to develop hepatotoxicity as those WITHOUT abdominal pain (OR=1.28 [0.39 to 4.21])

Don't let lack of pain fool you! Just as we all learned in medical school - let your history be your guide!

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I don't know about you, but I'm always eager to hear new and alternative methods of pain control…

This study examined the effectiveness of transcutaneous electrical nerve stilumlation (TENS) in patients with abdominal pain. Patients were randomized to TENS or sham applied to the abdomen. The primary outcome of interest was change in pain score 30 min after the intervention, and secondary outcome was percentage of patients requiring rescue analgesia. Pain scores were measured on a verbal numeric score scale with a range from 0 to 10, with any adult patients with a minimum score of 5 being eligible. 

The mean reductions in pain scores after the intervention were also similar in patients treated with TENS and sham TENS (1.9 vs. 1.7 respectively, p = 0.81). THe use of rescue analgesia was 49% in patients treated with TENS and 51% in those who received sham TENS (p=0.66). No adverse events were noted. 

The authors did note that there is a challenge in blinding due to toeh absence of electrical stimulation in the sham group; nonetheless, TENS was not found to be more effective than sham.  It also did not reduce the need to rescue analgesia.

Guess I'll keep looking…

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By now, most of us are aware that there's evidence supporting the use of an antibiotics-only approach for acute uncomplicated appendicitis. One of the major trials evaluating this is the Appendicitis Acuta II Trial. Our paper today continued longitudinal follow up of the original cohort enrolled in this study.

Patients were randomized to receive either oral antibiotic monotherapy (moxifloxacin 400 mg/d x 7 days) or IV and oral antibiotics (IV ertapenem 1 g/d x 2 days plus oral levofloxacin 500 mg/d + metronidazole500 mg q8h x 5 d). 

Primary endpoint: resolution of acute appendicitis and hospital discharge without surgery and no reoccurence at time of follow up (3 years later).

There were 582 patients in the three year follow up cohort; Success was 63.4% (1-sided 95% CI, 58.8% to ?) in the oral antibiotics only group and 65.2% in the IV + oral antibiotics(1-sided 95% CI, 60.5% to ?). The difference in success rate was -1.8% (1-sided 95% CI, ?8.3 percentage points to ?; P?=?.14 for noninferiority).

No significant difference in secondary endpoints, including treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave. 

In this secondary analysis of the three year cohort from the APPAC II trial, there was a slightly higher appendectomy rate in patients who received oral antibiotic therapy; noninferiority of this regimen (as composed to combined) could not be demonstrated.

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Oftentimes, CT imaging is used in diagnosis of emergent abdominal pathology. However, there may be instances where there is hesitancy to use IV contrast, whether due to patient factors or extrinsic factors (remember the contrast shortage during covid?) 

This study examines the diagnostic accuracy of dry CT. 3 quaternary centers with residency training programs participated, and contrasted images underwent further processing to remove any IV or oral contrast. Both residents and faculty reviewed the images, and findings were compared to both the initial read by radiologist as well as independent reads by a panel of experts. They looked for both primary findings (those that explained the abdominal pain) as well as actionable secondary findings (ie incidental findings requiring additional imaging or further management).

When compared to contasted imaging, the accuracy of dry CT was 70% (faculty, 68% to 74%; residents, 69% to 70%). Faculty had higher accuracy than residents for primary diagnoses but lower accuracy for actionable secondary diagnoses. 

Thus when considering the necessity of contrast, please consider the potential for missed diagnosis.

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How many times have you discharged a patient with a clinical impression of “abdominal pain” with no clear explanation or diagnosis? 

How many of these times do you direct them to follow up with gastroenterology? And more importantly, how often do they actually do so?

This study discussed a multi-disciplinary approach to ensuring adequate follow up for patients, utilizing an EMR based transition of care (TOC) program. The study stratified patients into 2 groups, pre and post TOC program implementation, to assess rates of appointment scheduling and attendance, as well as rates of return to ED within 30 days. Patients were further stratified based on their Distressed Communities Index (DCI) score (a composite of 7 different socioeconomic metrics) into 5 tiers: Distressed Communities, At Risk Communities, Mid-Tier Communities, Comfortable Communities, and Prosperous Communities. Prior to the implementation of the TOC program, the onus was on the patient to schedule their appointment. The TOC program consisted of an order placed in EMR, which triggered review of the patient's chart by the gastroenterology attending or NP. This individual would then message the information to the appropriate GI subspecialty clinic, along with a time frame in which the patient should be seen. The clinic would then check the patient's insurance reach out to the patient directly to schedule the appointment.

While there was no signifcant difference in 30-day readmission between the pre and post TOC program patients, the post-implementation group was found to both schedule appointments (50% vs 27% p-value <0.01) AND show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. Additionally, post-TOC patients in the At-Risk and Distressed DCI groups were 22x more likely to follow up than the same groups in the pre-TOC group (OR 22.18, 95% CI 4.23–116.32).

Though the study had promising results, it did admittedly have some limitations, namely the size of the at-risk and distressed groups.  Another consideration, though not mentioned in the paper, is that access to a working phone is necessary to the success of this program. Nevertheless, the idea of a TOC program is worth consideration as a means to ensure that patients are not lost to follow up and potentially reduce the risk of adverse events.

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This retrospective cohort study examined patients over a one year period to evaluate factors associated with unfavorable outcomes in acute abdominal pain. 

Unfavorable outcomes were defined as any of the following: 1) shock requiring an invasive procedure such as central line insertion or mechanical ventilation 2) emergency surgery 3) post-operative complications OR 4) in-hospital cardiac arrest

951 patients were included in the study. 

Physical exam and laboratory signs associated with the above unfavorable outcomes included:

-diastolic BP < 80 mmHG

-RR ? 24/min

-RLQ tenderness

-abd distension

-hypoactive bowel sounds

-presence of specific abdominal signs (ie Murphy's sign, psoas sign, etc).

-leukocytosis

-ANC >75%

Further, ED Length of Stay of > 4 hours was also associated with unfavorable outcomes.

Food for thought when considering serial abdominal exams when diagnosis is unclear…

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Think before placing a nasogastric tube!

Multiple articles which discussed complications of NGT placement were included in this integrative review, with the majority (n=67) publishing results in English. The authors categorized adverse events into two broad categories:

1) Mechanical adverse events - including respiratory, esophageal, and pharyngeal complications, obstructed tube, intestinal and intracranial (!) perforation, and tube withdrawal 

-The largest cohort (n=44) was respiratory, with displacement or placement of tube to the respiratory tract

2) Others - pressure injury and misconnection

-One study showed pressure related injury in 25%, and 5 articles discussed complications of misconnection (including extravasation of gastric fluids and inadvertent connection to central venous catheters)

16 of the 69 studies reported death as a consequence of improper placement. 

One big takeaway: there is no universally accepted standard for verificaiton of tube placement. Xray is considered to be *most* accurate. Tubes should also be checked periodically and depth should be marked. Evidence-based guidelines need to be developed to improve patient safety, outcomes, and quality of care.

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Diverticular disease is a common condition, with 60% of individuals over age 80 and 30% of those over age 45 (!) having diverticula. Recent estimates show that 10-25% of this subset with suffer at least one episode of acute diverticulitis in their lifetime. Fortunately, the majority of these cases are uncomplicated. This study provides evidence that outpatient treatment of acute diverticulitis is reasonable. 

Study Design:

The DINAMO study was a multicenter randomized open-label non-inferiority trial evaluating the utility of antitbiotics in uncomplicated diverticulitis. The study included adult patients with uncomplicated diverticulitis without significant comorbities. The diagnosis was based on modified Neff classification with patients with a mNeff of 0 being included. Eligible patients were randomized to one of two treatment groups:

1) 600 mg ibuprofen q 8 h alternating with 1000 mg of acetaminophen q 8 h x7 d (Exerimental arm) OR

2) 875/125 mg amoxicillin/clavulanate q 8 h x 7 d in addition to the above (Control arm)

Outcomes of interest and Results: 

Any patients who returned to the hospital underwent repeat CT. Primary of outcome of interest was admission to the hospital on revisit, with secondary outcomes being revisit itself, follow up, pain control, and recovery

There was no statistically significant difference in any of these (for numbers, please refer to article 1 linked below); further, no patients required emergency surgery. 

Implications:

There is a low likelihood ot treatment failure when antibiotics are avoided in acute uncomplicated diverticulitis. This study finds this treatment regimen ot be noninferior to antibiotic treatment in terms of hospital admission, revisit rates, and recovery.  Consider this treatment regimen in eligible patients. 

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This Scandinavian study from the Lancet says yes. They randomized 1800 patients over age 18 to appendectomy either within 8 hours or 24 hours and found no difference in perforation rate or other complications. 

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In recent years, there has been an uptick in non-operative management of acute appendicitis. This study examins outcomes in older patients (>65 years old).

The study authors evaluated retrospective data and included 474845 patients in the US with acute uncomplicated appendicitis betwen 10/2021 and 04/2022. All participants survived at least 24 hours postoperatively and none carried a diagnosis of inflammatory bowel disease; there were 43,846 patients treated nonoperatively and 430,999 who underwent appendectomy. The primary outcome was incidence of post-treatment complications, with secondary outcomes of mortality, length of stay, and inpatient costs. 

In patients 65+, there was a 3.72% decrease in risk of complications, 1.82% increase in mortality, and increased LOS and costs. 

Ultimately, operative management of acute appendicits was associated with reduced mortality, length of stay, and costs across all adult patients. While nonoperative management remains an option in the treatment of acute appendicits, surgical management continues to be the accepted standard. 

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POCUS can be used to screen for appendicitis.

A recent study showed a sensitivity of 66.7% (CI 95% 47.1–82.7), and a specificity of 96.8% (CI 95% 83.3–99.9) during pregnancy, with the highest sensitivity in the first trimester. 

2 methods to locate the appendix are:

1) have your patient point to the area where it hurts the most

2) perform a lawnmower technique over the right lower quadrant looking for the right psoas mucle and the iliac vessels. The appendix will usually be near these structures. 

Sometimes it is easiest to use your curvilinear probe to identify an area of inflammation and then change to the linear probe for better visualization. 

On ultrasound, appendicitis is defined as a non-compressible blind pouch with an outer diameter greater than 6 mm. On short axis the inflammed appendix will look like a target sign:

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Bottom Line: With the increasing acceptance and legalization of marijuana and its derivatives, emergency departments have seen an increase in patients with cannabis hyperemesis syndrome (CHS). In this patient population, when other pathologies have been excluded, consider droperidol (0.625 mg – 2.5 mg) or haloperidol (0.05 mg/kg or 0.1 mg/kg) for management of symptoms.

Two separate articles were reviewed for this pearl. One is a systematic review of existing literature, and the other is a randomized controlled trial.

The systematic review examined 17 existing studies, including case reports, RCTs, retrospective studies, and other systematic reviews. This included adults aged 18-85 who were using recreational or medicinal cannabinoids. There was a consensus that cessation of cannabinoid use is the best way to alleviate symptoms of CHS. Other options discussed include: 

1. Hot water hydrotherapy (ie hot baths or showers), which redirects blood flow to the skin and activates a vanilloid receptor which releases substance P, a neuropeptide associated with inflammation and pain. While this provides temporary relief of symptoms, the receptor can become unresponsive with chronic THC exposure. Only qualitative evidence was available for this therapy.
2. Topical capsaicin cream, which is theorized to have a similar mechanism as hot water hydrotherapy. 0.025-0.1% creams were discussed, with studies agreeing on shorter length of stay and improvement in nausea and vomiting; however all studies used small cohorts (of 4 or less).
3. Droperidol is a short-acting dopamine antagonist. In a systematic review, use of 0.625-2.5 mg of IV droperidol was the only treatment showed a statistically significant difference in visual analog scale when compared to placebo. Use of droperidol also results in shorter length of stay and decreased need for other anti-emetics.
4. Benzodiazepines have limited evidence, but one case study of four patients showed 2 doses of 0.5 mg clonazepam lead to rapid relief of symptoms and discharge within 24 hours.
5. Haloperidol is another dopamine antagonist with good eppicacy in cessation of nausea vomiting. Various studies have been performed, with most being case studies, with varying doses recommended. One study was a randomized controlled trial, more on this below.
6. Propranolol was discussed in a single case study, with two doses 1 mg IV given one hour apart leading to complete resolution of symptoms. This was the only such case study in the body of literature.
7. Aprepitant is a neurokinin1 receptor agonist and acts similar to capsaicin with regards to substance P. A case report discussed a patient that was refractory to all other treatments; however, a dose was not described.

As mentioned above, the HaVOC study examined various doses of haloperidol versus odansetron. This randomized controlled trial was triple blinded and had three groups: haloperidol 0.05 mg/kg or 0.1 mg/kg or odansetron 8 mg IV. The outcome of interest was reduction in abdominal pain and nausea at two hours after treatment. Either dose of haloperidol was found to be superior to odansetron, with improvements in pain and nausea (54% versus 29%; 95% CI -16% to 59%), and less use of rescue antiemetics (31% versus 59%, with 95% CI -61% to 13%). Haloperidol also resulted in shorter ED length of stay (3.1 h vs 5.6 h, 95% CI 0.1-5.0 h, p=0.03). However, 2 patients in the high dose haloperidol group had dystonic reactions precipitating return visits. The study does not specifically discuss differences in outcomes between the high and lower dose haloperidol groups.

Neither paper discussed the best alternatives when QTc prolongation is of concern. Clinicians should use their best judgment and the available information when deciding on a treatment option.

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Bottom Line:

1. The most often cited meta-analysis regarding route of PPI use in bleeding peptic ulcer disease evaluates rebleeding AFTER endoscopic treatment and only ulcers with high-risk features.  There is no good data on optimal pre-endoscopy dosing.
2. These studies appear to show non-inferiority of intermittent dosing with a trend towards superiority when compared with continuous dosing.
3. The proper dosing, frequency, and route of intermittent PPI use is widely variable without good data on an optimal regimen.
4. ED decision of intermittent vs continuous PPI should consider other patient factors including severity of illness, compatibility of IV lines (pantoprazole is often incompatible), and patient disposition.

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Infectious Diarrhea:

Have your wondered what you should do with patients that you suspect have infectious diarrhea. Well the IDSA has updated their 2001 guidelines for the management of infectious diarrhea. The TAKE HOME Points are:

• Most patients with diarrhea do not need to be tested for an infectious cause. Stop ordering those cultures.
• Testing IS recommended in the folllowing populations:
  • Patients younger than 5 years
  • Elderly
  • Patients that are immunocompromised
  • Patients with bloody diarrhea
  • Patients with severe abdominal pain or tenderness, or have signs of sepsis.
  • Testing may be considered for C. difficile in people >2 years of age who have a history of diarrhea following antimicrobial use and in people with healthcare-associated diarrhea
• Some additional recommendations that are noteworthy:
  • Fecal leukocyte examination and stool lactoferrin detection should NOT be used to establish the cause of acute infectious diarrhea
  • A peripheral white blood cell count and differential and serologic assays should NOT be performed to establish an etiology of diarrhea
  • Reduced osmolarity oral rehydration solution (ORS) is recommended as the first-line therapy of mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause

You can find all the recommendations at https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America

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Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements. 

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Diverticular Bleeding

• Diverticular bleeding is the  most common source of lower GI bleeds and accounts for 17 to 40 percent of cases
• The most common presentation (80%) is massive painless rectal bleeding. 
• Patients may have some cramping prior to a bloody bowel movement but otherwise will typically have no abdominal pain.
• The majority of the cases will resolve spontaneously, but those requiring more than 4 units of Packed Red Blood Cells should be considered for an angiogram or  surgery.
• Angiography can be used to localize the site of bleeding and embolize the bleeding source. 
• If embolization fails the patient may require a partial colectomy to treat the bleeding source.

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Complications of Liver Biopsy

Some considerations for the patient who presents with pain after a liver biopsy:

• Hemothorax
• Pneumothorax
• Biopsy of other organ
• Hemorrhage (subcapsular hematoma, intraperitoneal bleeding, hemobilia)
• AV Fistula

Consider getting a chest xray and a RUQ ultrasound to evaluate for these complications if they show up in the ED. CT scanning might also be required.

Also consider getting Interventional Radiology  involved early in cases of bleeding as this is often the preferred treatment for biopsy site bleeding. In addition, a surgical consult is wise

in case the patient requires operative intervention. 

I am sure everybody has received a patient from a nursing home that had a malfunctioning PEG tube.  Now if they would only crush the tablets before putting them down the tube, or better yet use liquid medications our life would be easier.

But what do you do if it is Friday and the GI lab is not open to Monday.  The answer is that you can remove the PEG and replace it with another PEG tube or even a foley catheter will do for the weekend.  The original PEG tube has a semi-rigid plastic ring (as shown in photo) and does not have a balloon that can be default.  You can pull these out by placing counter traction on the abdominal wall and pulling with steady firm pressure.  This may take a little more force than you are initially comfortable with.

Please see the attached photo of a PEG tube, and remember the other option is to admit these patients for IV fluids until the GI lab opens.

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Biliary Colic and Narcotics:

It is common to give patients with biliary colic narcotics inorder to relieve their pain.  It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi.  It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.

So this weeks pearls are:

1. Morphine and diluadid can be used to relieve the pain associated with biliary colic.
2. However, narcotics should be avoided at least 4 hours prior to a HIDA scan as it can affect the length of the exam and the sensitivity of it.  A HIDA scan can take up to four hours to perform, however, morphine is typically given during the test as it can shorten the exam time to 1.5 hours by increasing filling of the gallbladder through the cystic duct. 

Some simple facts about Pancreatitis:

1. Causes (First two are the most common in the United States)
   1. Gallstones
   2. Alcohol
   3. Hyperlipidemia
   4. Medications [azathioprine, corticosteroids, sulfonamides, thiazides, furosemides, NSAIDs, mercaptopurine, methyldopa, and tetracyclines]
   5. Peptic Ulcer Disease
   6. Scorpion and Snake Bites
   7. Trauma
   8. Infections [ ascaris, mumps, coxsackie virus, cytomegalovirus, Epstein Barr Virus, mycoplasma]
2. Chronic Pancreatitis may not be associated with an elevation of lipase or amylase.
3. Lipase is more specific for pancreatitis
4. Amylase can be elevated in:
   1. pancreatitits
   2. salivary gland injury/disease
   3. ruptured ectopic pregnancy
   4. ovarian cysts
   5. salpingitis
   6. inflammation of the bowel [appendicitis, obstruction]
   7. end stage renal and liver disease [due to decreased clearance]
5. Treatment:  mild cases can be discharged home with clear liquid diet and pain medications, more severe cases needed to be admitted for IV fluids and pain control.  Maintain NPO status.
6. Complications:
   1. Pseudocyst
   2. Phlegmon
   3. Necrosis of the pancreas
   4. Hemorrhage
   5. Intestional obstruction
   6. fistula formation.