* 3/4 GI bleeds are from the upper GI tract, which is from tip of nose to the ligament of Treitz. The other 1/4 are usually from the colon with very few before the ileocecal valve. For those that bleed from the colon, typically bleed from hemorrhoids, polyp, cancer, angiodysplasia, or diverticulosis; these usually affect the older patient. So if patient is 25yo and has GI bleeding, very likely to be upper GI tract. Older patient could be from anywhere. If patient is vomiting blood, it is from the upper GI tract. Management is endoscopy.
* 33yo man vomits a large amount of bright red blood. Answer for next step is upper GI endoscopy. Management when the bleeder is found could be photocoagulation with the endoscope.
* 33yo man has had three large bowel movements recently that he describes as made up entirely of dark red blood. He is diaphoretic, pale, BP 90/70, pulse rate of 110. Answer for next step of management is place a nasogastric tube and aspirate. This would confirm upper GI bleed and then we can do the endoscopy. As a note, blood is a GI irritant so the transit may be quick and thus not have full digestion, leading to blood per rectum and not necessarily melena. * 65yo man has had three large bowel movements recently that he describes as made up entirely of dark red blood. He is diaphoretic, pale, BP 90/70, pulse 110. NG tube returns clear green fluid without blood. If the fluid were white, this excludes up to the pylorus. Here it is green (bile) so we exclude up through the duodenum. Assumption is fluid replacement to correct hemodynamics. Answer for management would not involve a colonoscopy, as the bleeding in this case is going right into the instrument. Answer for next step is anoscopy, as diagnosing hemorrhoids via angiography would not be a good idea. If bleeding is at a large rate, 2cc/min or more, an emergency arteriogram may be used. 2cc/min is 120cc/hour so a unit of blood every 4 hours would be a sign of bleeding at a fast rate. If the patient is bleeding less than 0.5cc/min, 16hours for a unit of blood, an arteriogram would not be useful. Answer here would be colonoscopy once bleeding stops. If we’re in between though, from 0.5cc/hour to 2cc/hour, there is some
controversy involving the radioactive tagging of red blood cells. Nuclear medicine can then give an approximate idea of where the bleeding is occurring and some physicians do this before an arteriogram.
* 72yo man had three large bowel movements that he describes as made up entirely of dark red blood, the last one was two days ago. He is pale with normal vital signs. NG tube returns clear green fluid without blood. So, this patient is not actively bleeding and the NG tube isn’t too useful because it was two days ago. Answer for
management is endoscopy of both ends of the GI tract, with upper GI (3/4 of bleeds) and lower GI (1/4 of bleeds). * 7yo boy passes a large bloody bowel movement. Answer is Meckel diverticulum. Answer for diagnosis is radioactively labeled Technetium-99m exam, to recognize gastric mucosa.
* 41yo man has been in the ICU for two weeks being treated for idiopathic hemorrhagic pancreatitis. He has had several percutaneous drainage procedures for pancreatic abscess, chest tubes for pleural effusions, and
bronchoscopies for atelectasis. He has been in and out of septic shock and respiratory failure several times. He recently vomited bright red blood and as you enter the room he vomits what looks like a pint of blood. Answer is stress ulcers, multiple shallow furiously bleeding ulcers. This is the reason all ICU patients are always on H2 blockers, antacids, and/or PPIs like pantoprazole (Protonix) to keep pH above 4. Answer for diagnosis is endoscopy. Answer for treatment is angiogram with selective catheterization and embolization, typically the left gastric artery. --- General Surgery: Abdominal Pain (Acute Abdomen)
* Three causes are perforation (sudden onset with constant severe generalized pain), obstruction (sudden onset with localized colicky pain), and inflammatory (gradual onset with localized constant pain, fever, and leukocytosis). * 59yo man arrives at the ED at 2am accompanied by his wife who is wearing curlers in her hair and a robe over her nightgown. He has abdominal pain that began suddenly an hour ago, is now generalized, constant, and severe. He lies motionless on the stretches, is diaphoretic, and has shallow rapid breathing. His abdomen is rigid, is tender to palpation, and has guarding and rebound in all quadrants. Answer is perforation, causing peritonitis. Most likely duodenal ulcer. Answer for management is exploratory laparotomy, we don’t know the cause but we’re very close to finding out (as close as the thickness of the abdominal wall). Answer first though is a CXR, ECG, plain abdominal x-rays, and amylase/lipase for diagnosis.
* 62yo man with cirrhosis of the liver and ascites has generalized abdominal pain starting 12 hours ago. He has moderate tenderness over the abdomen with some guarding and rebound. He has mild fever and leukocytosis. Answer is primary/spontaneous bacterial peritonitis (SBP). Answer for diagnosis is get ascites and grow cultures expecting to get a single bacteria (versus multiple with a perforation). Answer for treatment is antibiotics. * 43yo man develops excruciating abdominal pain at 8:18pm. When seen in the ED soon after, he has a rigid abdomen, lies motionless on the table, has no bowel sounds, and is in great pain described as constant. X-ray shows free air under the diaphragm. Answer is perforation of the GI tract. Answer for management is emergency
exploratory laparotomy.
* 44yo alcoholic man presents with severe epigastric pain that began shortly after a bout of heavy alcohol intake. It reached maximum intensity over two hours. The pain is constant, radiates to back, is accompanied with nausea, retching, and vomiting. He had an episode two years ago. Answer is acute pancreatitis. Answer for next step is order serum amylase or lipase (if soon after problem) or urinary amylase/lipase if three days later.
* 43yo obese mother of six children has severe right upper quadrant abdominal pain that began six hours ago. The pain was colicky, radiated to the right shoulder and back, accompanied by nausea/vomiting, pain has been constant for past two hours, has RUQ tenderness/guarding, temp is 101F, WBC is 16000, episodes in past brought about after eating fatty foods. Answer is acute cholecystitis. Answer for next step of management is sonogram (ultrasound). * 52yo man has right flank colicky pain of sudden onset that radiates to the inner thigh and scrotum. Microscopic hematuria is found. Answer is acute nephrolithiasis, stone in ureter. Answer for next step is intravenous pyelogram (IVP), sonogram, or CT scan.
* 59yo woman has a history of three prior episodes of LLQ abdominal pain for which she was hospitalized and received antibiotics. She has discomfort starting 12 hours ago, now constant LLQ pain, tenderness, vaguely palpable mass, fever, leukocytosis. Answer for management is CT scan, which could show the likely diverticulitis or unlikely things like twisted tubo-ovarian cyst.
* 82yo man develops severe abdominal distension, nausea, vomiting, and colicky abdominal pain. He has not passed any gas or stool for the past 12 hours, has a typanitic abdomen with hyperactive tinkling bowel sounds, x-ray shows distended loops of bowel, and very large gas shadow in RUQ tapering to LLQ with the shape of a parrot’s beak. Two conditions to think of are mesenteric ischemia and sigmoid volvulus. Answer here is sigmoid volvulus, as seen by the “beaking” on the x-ray at the location of the twist. Answer for diagnosis is protosigmoidoscopic exam, as we can untwist the bowel on the way in and then leave a rectal tube/stent to prevent recurrence.
* 79yo man with atrial fibrillation develops an acute abdomen and comes to the ED two days later. He has a silent abdomen with diffuse tenderness and mild rebound, there is a trace of blood on rectal exam, he has acidosis and looks quite sick. X-ray shows distended small bowel and distended colon up to the transverse colon. Two conditions to think of are mesenteric ischemia and sigmoid volvulus with elderly patient. Answer here is mesenteric ischemia from the atrial appendage in a patient with atrial fibrillation or mural thrombi from patient who had a recent MI. Up to transverse colon is territory of the SMA and acidosis due to dead bowel. Answer for diagnosis is exploratory laparotomy. Answer for management is resection of ischemic segment. Vascular surgery can possibly do an arteriogram with clot removal if the pain started immediately prior to being seen.
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