GI Cocktails: Cases to Remember

Zachary Hartsell, PA-C, DHAWake Forest Baptist Medical Center

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• At the conclusion of this session, the participant will be able to:

– Distinguish between upper and lower GI bleeds based on clinical

presentation

– Develop a cost-effective, evidence-based approach to evaluation of

elevated LFTs

– Identify indications for surgical intervention in hospital patients

diagnosed with small bowel obstruction

– Differentiate between uncomplicated and complicated diverticulitis

and discuss how this differentiation affects management

Objectives

Mr. Roberts

2

ABG

• 42 yo male, with past medical history of HTN and

osteoporosis presents to ER with one week of

black stools and lightheadedness who passed out

in the shower while getting ready for work.

• Brought in by wife.

• Hit his head but he is awake and talking.

• Reported heartburn at night which he was taking

OTC Pepcid.

• Current medications include HCTZ and Naproxen.

• Non smoker, denies alcohol or drug use.

Mr. Roberts

3

ABG

• Vitals: HR: 101, RR: 12, BP: 90/60, Temp: 38.9 C

O2 sat: 95% on RA

• Has a small scalp laceration on back of head

• Conjunctival pallor

• Heart and lungs: CTA

• Abd: Epigastric tenderness to

palpation. No rebound.

No hepatomegaly.

• Rectal exam: good sphincter tone,

no masses, hemoccult positive.

Mr. Roberts

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CXR: Normal cardiac silhouette.

No lung space pathology

identified. No free air.

A. Place 2 large bore IV

B. Call GI

C. Repeat CBC

D. Emergent CT scan of the Abdomen and Pelvis

What is the most appropriate next step?

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• Upper- proximal to the ligament of Treitz

– Esophageal

– Small Intestine

• 5-10%

• Lower- distal to

the ligament of Treitz

– Large Intestine

• Obscure

– Source of bleeding

cannot be identified

GI Bleeding

Jmarchn.2019

• Variceal bleeding most common

– Liver patients

• Esophageal ulcers

GI Bleed: Esophageal

• Distal to ampulla of Vater, proximal to ileocecal

valve

• Overt

– Melena or hematochezia

– Small bowel source

• Occult

– Iron deficiency anemia

– +/- guaiac positive stool

– Small bowel source

GI Bleeding: Small Bowel

GI Bleeding: Small Bowel

Under 40 Over 40

IBD Meckel’s

diverticulum Polyposis

syndromes

Dieulafoy’slesions

Malignancy

Angioectasia Anti-inflammatory

induced

• Comorbidities

– Bleeding diathesis

– Diabetes (increase risk of peptic ulcer bleeding )

– Liver disease

• Prior procedures

• Medications

– NSAIDS

• Family history

– Polyposis syndrome

• Alcohol use

GI Bleeding: History

Peng et al 2013

• Vital signs

– Orthostatic

• Dermatologic

– Mucous membranes

• Stigmata of liver disease

GI Bleeding: Physical Exam

• Labs

• Radiology

– Tagged RBC Scan

– IR

• Endoscopy

GI Bleeding: Evaluation

• General considerations

– 2 large bore IV

– ICU vs Floor

• Medications

– H2 Blockers vs PPI

– Octreotide

– Others

• Role of antibiotics in variceal bleeding

GI Bleed: Management

• Mrs. Daniels is a 42 year old female with a history

of alcohol abuse who presents to the ER with

jaundice for the past two weeks.

• She also has mild RUQ pain. She denies fevers,

chills, or N/V or diarrhea.

• The patient has not drank alcohol in approximately

2 weeks because she has been feeling so poorly.

Mrs. Daniels

• On physical examination:

BP 98/50, HR 120, RR 18, O2 97% RA

– General → WDWN. Appears older than her stated age. NAD but only

awakens to verbal stimuli briefly and is unable to engage in a

conversation. Smells of alcohol.

– HEENT → Non-icteric sclera. PERRLA.

– Heart → Tachycardic without MRG.

– Lungs → CTA B/L.

– Abdomen → +BS. Soft. ND. NT.

– Extremities → Peripheral pulses 2+ B/L. No edema B/L.

– Neurologic → Opens eye to verbal stimuli. Does not consistently

follow commands. Moves all four extremities. No tremor or asterixis

Mrs. Daniels

• Wide range of definitions

– Asymptomatic ↑ LFT’s → fulminant failure

• Typically present in 40-50’s

• Heavy drinkers, long-standing drinkers

– 6+ drinks/day for approximately 20 years

• Mortality variable depending on severity

– Up to 35%

• 20% proceed to ESLD even if they stop drinking

Alcoholic hepatitis

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• Model for End-stage Liver Disease (MELD)

– Validated to predict 90-day mortality for patients with

alcoholic hepatitis

• Maddrey’s discriminant function (MDF)

• Glasgow alcoholic hepatitis score

• ABIC score

Classification Systems

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• Anorexia

– Enough to even stop drinking

• Fever

• Jaundice

Alcoholic hepatitis

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• Hepatomegaly

‒ +/- tenderness to

palpation

‒ Bruit over liver

• Ascites

• Encephalopathic

Signs and symptoms

13.9 133 101 18.0

15.2 41.7 130 3.9 28 1.0

Mrs. Daniels

19

Magnesium 1.9 Total bilirubin 7.2

Calcium 9.1 Albumin 2.0

AST 251 Total protein 6.9

ALT 120 INR 1.80

Alk phos 115 MCV 105

BAL 0 UA (-)

98

• Moderately ↑ LFTs

– AST>ALT

– ↑ total bilirubin

• ↑INR

– Mean INR 2.1

• ↓ Albumin and pre-albumin

– Liver function or nutritional status?

• Leukocytosis

– ↑↑ acute phase reactants

Laboratory Findings in Alcoholic Hepatitis

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• ALT:

• AST:

• Alkaline phosphatase: Zinc metalloproteinase

• Bilirubin: Breakdown of RBCs

– Unconjugated (Indirect): Predominant

– Conjugated (Direct)

• Albumin: Plasma protein synthesized by liver

Hepatic Panel

Aminotransferases

• AST and/or ALT

– Borderline: <2x ULN

– Mild: 2-5x ULN

– Moderate: 5-15x ULN

– Severe: >15x ULN

– Massive: >10,000 IU/l

• Fulminant hepatic failure / Acute liver failure

– Rapid development acute liver injury with severe

impairment of synthetic function (prolonged PT) and

hepatic encephalopathy

Degree of AST/ALT Elevation

• R ratio:

(ALT value/ALT ULN)

(Alkaline Phosphatase value/Alkaline Phosphatase ULN)

• Interpretation:

– >5 hepatocellular

– <2 cholestatic injury

– 2-5 mixed

Patterns of Elevation

• Albumin

– Reduction generally indicates decline in function > 3wks *

• Prothrombin time

– More sensitive

– Changes may be seen within 24 hours

– COAGULATION CASCADE!

• Extrinsic pathway

Markers of Liver Function

• “Normal” range of ALT/AST varies widely

–Defining normal population for reference range

• Account for comorbidities

–Guides clinical decision making

–Normal values ≠ absence of liver disease

–Morbidity and mortality risk

Standardization of Normal Ranges

• Acetaminophen level

• Hepatitis panel

– Hepatitis A IgM

– Hepatitis B surface antigen

– Hepatitis B core IgM

– Hepatitis C virus (HCV) antibodies & RNA

• US liver

• Liver biopsy is rarely needed in alcoholic hepatitis

but the gold standard in severely elevated LFT

without obvious etiology

Evaluation: Beyond the Basics

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• Viral hepatitis

• Non-alcoholic fatty liver disease (NAFLD)

• Alcoholic liver disease

• Autoimmune

• Metabolic/Genetic disorders

• Drug/Supplement

Differential Diagnosis of Elevated LFTs

• Supportive

– Alcohol Cessation

• COMPLETE ABSTINENCE

– Fluid support

– Nutritional support

– Correct coagulopathy?

– Treat encephalopathy

• Prednisolone vs. Pentoxifylline

– Mixed studies

– Optimal treatment depends on comorbid conditions

– MDF score ≥32

Treatment

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Ms. Williams

29

ABG

• 38 yo female, with no past medical history who

presents to ER with 3 days of abdominal pain,

nausea and vomiting.

• History of C- section

• Denies taking any current medications

• Non smoker, denies alcohol or drug use.

Ms. Williams

30

ABG

• Vitals: HR: 101, RR: 12, BP: 1030/60, Temp: 37.2

C, O2 sat: 95% on RA

• Abd: Scar across lower pelvis. Distended. General

tenderness to palpation. Tympanic to percussion.

Scattered high pitch bowel sounds. No rebound.

No hepatomegaly.

Ms. Williams

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• Etiologies

– Adhesions

• 60-70%

• History

– Abdominal pain

– Distention

– Vomiting

– Obstipation

– Previous surgery

• Physical

Small Bowel Obstruction

• Diagnostics

– Labs

• CBC

• BMP

• Lactate

– Image

• Supine and erect AXR

• Abdominal US

• Abdominal CT

• Abdominal MRI

Small Bowel Obstruction

• Classification

– Adhesional

– Non-adhesional

– Early

– Late

– Partial

– Complete

– Low-grade

– High-grade

Small Bowel Obstruction

• Nonsurgical management

– Shorter LOS

– Higher recurrence

– Shorter time to readmission

– Controlled symptoms

– Partial obstruction

– No e/o peritonitis, strangulation, bowel ischemia

– Recurrent episodes, multiple prior laparotomies

– NG tube

– IVF

– Monitoring of clinical status

Small Bowel Obstruction

• Surgical intervention

– Delay may lead to increased morbidity and mortality

– Repeated laparotomy and adhesiolysis may worsen adhesion formation and

severity

– Laparoscopy?

– Lack of resolution with conservative management

• NG tube output >500mL on hospital day 3

– Peritonitis

– E/O bowel ischemia on CT

– Strangulation of bowel

– Complete

– Surgery within prior 6 weeks

Small Bowel Obstruction

Colonel Wilkens

37

ABG

• 93 yo male World War 2 Veteran with past medical

history of TIA, HTN, Osteoporosis, who presents

to the ER for evaluation of abdominal pain,

diarrhea and low grade fever for 10 days.

• Primary care physician saw him three days ago

and diagnosed him with diverticulitis and started

him on Cipro but symptoms continued to worsen

over the last 24 hours.

Colonel Wilkens

38

ABG

• Vitals: HR: 90, RR: 12, BP: 103/60, Temp: 39.1 C,

O2 sat: 95% on RA

• Abd: Non distended. General tenderness to

palpation with increased tenderness in left lower

quadrant. No rebound. No hepatomegaly.

Colonel Wilkens

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• Increasing prevalence of diverticulosis in US

– Increases with age

– 20% develop diverticulitis

• 300,000 hospitalizations per year

– 1.5 million inpatient days

• 1.5 million oupatient visits per year

Diverticular Disease

• History and Physical

– LLQ discomfort/tenderness

– +/- peritoneal findings, fever

• CBC

– Leukocytosis?

• UA

– Exclude UTI, kidney stones

• Abdominal radiographs*

– Exclude obstruction

Diverticulitis

• CT abdomen/pelvis

– Most appropriate initial imaging if suspected diverticulitis

– Diverticulosis with

• Colon wall thickening

• Fat stranding

• Phlegmon

• Extraluminal gas *

• Abscess

• Stricture

• Fistula

– Eval for alternative dx

Diverticulitis

Severity on CT correlates with:- Risk of failure of nonoperative mgmt- Long-term complications

• Uncomplicated

• Complicated

– Perforation

– Abscess

– Fistula

– Stricture

Diverticulitis

• Treatment

– Non-operative

• Oral or IV antibiotics: Gram negatives and anaerobes

• Diet modifications

• Outpatient

– Stable patients, uncomplicated disease

– Able to tolerate oral antibiotics

• Inpatient

– Complicated disease

– Unable to tolerate oral medications/hydration

– Comorbidities *

– Lack of adequate home support

Diverticulitis

• Pathophysiology

– Microperforation and bacterial infection

VS

– Primary inflammatory process

• AVOD study: 623 inpatients with uncomplicated, left-sided

diverticulitis

– IV fluids

– IV fluids + antibiotics

» Did not prevent complications

» Did not accelerate recovery

» Did not prevent recurrences

Diverticulitis

• Treatment

– Operative

• Image-guided percutaneous drainage

– Large diverticular abscess (>4cm)

– Accessible

– Poor response to medical therapy

• Urgent sigmoid colectomy

– Diffuse peritonitis

– Failed nonoperative mgmt

Diverticulitis

• Follow up

– Flex sigmoidoscopy or Colonoscopy

• First episode

• No recent endoscopic evaluation of colon

– Flexible Elective colectomy

• Not to be recommended for prevention of recurrence

• Not dependent on number of recurrences

• Not dependent on age

• Immunocompromised

• Mesocolic abscess ≥ 5cm or pelvic abscess

• Stricture or fistula

Diverticulitis

• Prevention of recurrence

– Supplemental fiber

– Rifaximin

– Antispasmodics

– Mesalamine

– Probiotics

* Evidence?

Diverticulitis

• Full history and physical should not be limited in

lieu of diagnostic testing

• Identifying abnormal liver studies as either liver

injury or decreased function will guide further

work-up

• Trend in diverticulitis management favors

conservative management

Lessons for Practice