GI Bleeding
Hx:
Upper GIB
hematemesis (bright red or coffee grounds), melena or hematochezia (BRBPR).
Etiology:
peptic and esophageal ulcers (drugs/infectious/ Z-E/GERD), portal HTN, vascular
lesions, trauma, tumors.
Lower GIB
presents with hematochezia or melena.
Etiology: diverticulosis,
vascular lesions, infection, ischemia, IBD, radiation, tumors.
Dx: if active
bleed (1cc/min) tagged RBC scan in nuclear medicine may be useful – if positive
halsted surgery for GI resection vs CVDL for embolization
Rx: two 16-18
gauge peripheral IVs, NG lavage until clear, T&S (ABO Rh), NPO, q6h Hcts,
IVF correct coagulopathies (FFP, plts),
IV Protonix 8mg/hr, GI consult for endoscopy, Halsted surgery consult for
potential resection.
Etiology:
infection (HAV, HBV, HCV, CMV, HSV, toxoplasmosis, VZV), metabolic
(hemochromatosis, Wilson’s disease), cholestasis (choledokolithiasis, etc.),
immune (autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing
cholangitis), alcoholic hepatitis (AST:ALT > 2:1), non-alcoholic
steatohepatitis, medications (acetaminophen), toxins (carbon tetrachloride, Amanita phalloides), vascular (shock
liver, Budd-Chiari, veno-occlusive disease – as in chemotherapy/BMT), Reyes
syndrome, and malignancy.
Dx: serum
volatiles, ammonia, acetaminophen level, PT, PTT, direct bilirubin, viral
serologies for hepatitities, CMV, HSV, EBV & monospot, VZV, ferritin &
iron studies (usually elevated in acute hepatitis), ceruloplasmin, ANA,
anti-smooth muscle / anti-mitochondrial, anti-LKM (liver/kidney
microsomal). If negative obtain
hemochromatosis gene mutation (C282Y, H63D) (path 3 form code 8872), 24 hr
urine copper, CEA, AFP, ophthalmology consult to assess for Kayser-Fleischer
rings, liver biopsy.
Rx: lactulose
for encephalopathy.
Alcoholic
hepatitis: Maddrey discriminant factor [4.6 x (PT – control PT) + total
bilirubin (mg/dL)] if > 32 risk of death is high (>50%) treat with
steroids & pentoxifylline 400mg po tid x 4wks.
Liver Transplant
MELD Score
(Model for End-Stage Liver Disease): (United Network for Organ Sharing version)
http://www.mayoclinic.org/gi-rst/mayomodel6.html
Predicts 1 yr survival with liver failure &
survival post-transplant. [Hepatology (2001) 33: 464-70]
Liver transplant w/u:
NH4, HBsAg, HbcAg, HCV, HCV-pcr, CMV IgG, EBV, serology, HSV serology, VZV IgG,
RPR, HIV, ABO typing, CEA, AFP, PSA (if male), 3-D CT of liver, PFTs
(flow-volume & DLCO), CXR, dobutamine stress echo + cardiology consult (if
> 45y/o or has DM), vaccinate: HBV, HAV, pneumovax.
Acute Pancreatitis
Etiology: alcohol or gallstones (account for 60-75% of
cases), idiopathic, hypertriglyceridemia, post-ERCP, hypercalcemia, drugs
(including ddI, pentamidine, Lasix, 5-ASA, azathioprine, sulfonamides),
infections (CMV, VZV, HSV, Hepatitis B, Mycoplasma, Legionella, Toxoplasma),
abdominal trauma, pancreas divisum, pregnancy.
Hx: Acute onset of abd pain, upper abdomen/epigastric
with radiation to the back (sometimes, relief with bending forward),
nausea/vomiting, abdominal distention.
Look for Grey-Turner’s & Cullen’s signs.
Ranson’s
criteria (predictors of bad outcome): On admission: age > 55yrs, WBC >16K, Glucose >
200, LDH > 350, AST > 250. During
initial 48hrs: >10% decrease in Hct,
> 5mg/dl (1.8mmol/liter), Ca < 8, PaO2 < 60, base deficit >
4mmol/liter, fluid sequestration > 6 liters
Dx: Amylase, lipase. Consider lipid panel and infectious work-up can be ordered. CRP as possible predictor of severity and
outcome of acute pancreatitis. Abdominal CT with contrast (r/o abscess,
pseudocyst, necrosis), AXR (r/o perforation, obstruction), RUQ U/S, especially
for first-time pancreatitis
Rx:
NPO, IVF, pain control (may require PCA).
NGT indicated for patients with severe ileus or vomiting. Patients with gallstones may benefit from
ERCP or surgical cholecystectomy. Abx
indicated for evidence of pancreatic necrosis/sepsis (meropenem).
Defn: ascitic
infection without evidence of surgically treatable source.
Ascites plus one or more of the following: Temp>
100 F, abdominal pain, delta MS, ascitic PMNs > 250/mm3
Dx:
Paracentesis -- Give 10g albumin per liter of ascitic fluid
removed before or during procedure. Send fluid for CBC/diff, albumin (send
blood CMP at same time), protein (ascitic fluid total protein—AFTP), culture
(use blood culture aerobic and anaerobic bottles for greater yield, changing
skin needles before inoculating culture bottles), glucose, LDH, Gram stain,
cytology.
SAAG (serum albumin – ascitic albumin) > 1.1
(portal-HTN related)
< 1.1
(non-portal HTN related).
CHF (cardiac ascites): SAAG > 1.1, AFTP >
2.5 g/dL
SBP: SAAG < 1.1, AFTP < 2.5 g/dL
Rx: Rule-out
secondary (surgically treatable) causes (eg, ruptured viscus, abscess, etc):
Abdominal CT w/ IV and PO contrast, high LDH, polymicrobial infection, ascitic
protein > 1g/dL, glucose < 50 g/dL suggest secondary peritonitisàsurgical
consult STAT! 2) Gentle diuresis w/ po
spironolactone/lasix (see above) to concentrate peritoneal fluid proteins and
increase opsonization. 3) Cefotaxime 2 g q8hrs x 5-10 days (add metronidazole
if evidence of secondary SBP) 4) Albumin IV 1.5 g/kg at diagnosis, followed by
1g/kg at day 3.
5) Prophylaxis in pts w/ ascitic fluid protein <
1g/dL, variceal hemorrhage, or prior episodes of SBP—Norfloxacin 400 mg po qd
while in hospital. Bactrim DS 1 qd on
discharge home.
[Aliment Pharmacol Ther 2001; 15: 1851-1859.]
Cirrhosis
Ascites: (caused by portal hypertenson > 12 mmHg)
Rx:
Bedrest; Na restriction to 2g/d; fluid restriction (if hyponatremic); avoid
NSAIDs; gentle diuresis w/ spironolactone 100 mg po qd and Lasix 40 mg po qd
(avoid hypokalemia by keeping this ratio constant—increase to a maximum of spironolactone 400 and Lasix 160 po qd.
Restrict fluid loss to maximum of 500-800 mls/day to avoid intravascular
depletion and azotemia—fluid movement out of peritoneal cavity restricted by
capillaries to ~500 mls/day); paracentesis if new-onset ascites, symptomatic
(tense abdomen, respiratory compromise, hypotensive) s/sx of SBP present, or if
ascites is diuretic resistant (after titrating up spironolactone/lasix doses).