UMEM Educational Pearls - Gastrointestional

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.

 Medical Regimen for Suspected Variceal Bleed

To review what Dr. Bond and Dr. Winters have already posted:

Three medical therapies have been shown to be effective in patients with severe upper GI bleed thought to be due to esophageal varices:

• Octreatide: 50-100 ug bolus followed by 50 ug/hour. Has been shown to lower the rebleeding rate substantially. Even if varices have not been confirmed by endoscopy, Octreatide has also been shown to be effective in ulcer bleeding as well.
• Antibiotics (3rd generation Cephalosporin): Have been to lower the rebleeding rate in variceal bleeding. 
• Intravenous Proton Pump Inhibitor: Remember that a liver patient is as likely to have a non-variceal source of bleeding (ulcer), so add a PPI drip. Raising the pH stabilizes clot. Without endoscopy, you don't know if they have an ulcer or another etiology.

Most of our gastroenterologists recommend this regimen (all three therapies)

Other things to consider:

• Platelets, FFP
• Intubate EARLY-most endoscopists will want the airway protected prior to the scope.
• Don't be too aggressive with blood replacement/IVF: The gastroenterologist don't want these patients too resuscitated with blood products. Certainly don't aim for a Hct >30.

Volvulus Quick Facts

• Volvulus causes 10-15% of large bowel obstructions and occurs most commonly in the elderly.
• The most common type of volvulus is sigmoid volvulus.
• Midgut volvulus is most common in the neonatal period.
• Cecal volvulus:
  • Occurs in all ages, but most commonly in the 25- to 35-year-old age group
  • Associated with:
    • previous abdominal surgeries
    • young, healthy marathon runners.
• Sigmoid volvulus most commonly occurs in two groups of individuals:
  • Inactive elderly persons with a history of severe chronic constipation
  • Patients with severe psychiatric or neurologic disease.

Gastrointestional Bleeding Pearls. [Quick Facts]

• Peptic ulcer disease has 2 main etiologies: 1) Helicobacter pylorus infection and 2) NSAID use. Zollinger Ellison Syndrome causes 1% of peptic ulcer disease.
• Hemorrhage is the most common complication of peptic ulcer disease, occurring in 15% of patients
• 25% of patients over the age of 60 years have an AV malformation.
• The most common cause of significant lower GI bleeding in the elderly is diverticulosis or angiodysplasia. That typically presents as painless bright red rectal bleeding.
• AV malformations are the number 2 cause of massive lower gastrointestinal hemorrhage.
• Rectal bleeding following AAA repair is from aortoenteric fistula until proven otherwise.

Medical Management of Upper GI bleeds. Peptic Ulcer Disease: Proton pump inhibitors are the main stay of therapy. Use is based on the observation that pH over 6 is required for platelet aggregation whereas pH below 5 results in clot lysis. High dose IV therapy should be reserved with those that have high risk stigmata of rebleeding as seen on endoscopy. Regular dose IV or PO omeprazole can be used in most patients. Variceal Bleeding: Consider octreatide (50 mcg bolus followed by 50 mcg/hr IV) and non-selective beta blocker therapy to reduce bleeding. Human recombinant activated factor VII has gotten a lot of press lately though it did not reduce the risk of death at either 5 or 42 days in patients with liver related GI bleeds.A Wong T. The management of upper gastrointestinal haemorrhage. [Review] [31 refs] [Journal Article. Review] Clinical Medicine. 6(5):460-4, 2006 Sep-Oct. Marti-Carvajal AJ. Salanti G. Marti-Carvajal PI. Human recombinant activated factor VII for upper gastrointestinal bleeding in patients with liver diseases. [Review] [45 refs] [Journal Article. Review] Cochrane Database of Systematic Reviews. (1):CD004887, 2007. Martins NB. Wassef W. Upper gastrointestinal bleeding. [Review] [87 refs] [Journal Article. Review] Current Opinion in Gastroenterology. 22(6):612-9, 2006 Nov.