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馬偕紀念醫院 健檢中心主治醫師 胃腸內科兼任主治醫師 楊安民

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Presentation on theme: "馬偕紀念醫院 健檢中心主治醫師 胃腸內科兼任主治醫師 楊安民"— Presentation transcript:

1 馬偕紀念醫院 健檢中心主治醫師 胃腸內科兼任主治醫師 楊安民
病房常見之消化系 問題與處理 馬偕紀念醫院 健檢中心主治醫師 胃腸內科兼任主治醫師 楊安民

2 GI bleeding Never forget the general principle of internal medicine.
Airway, Breathing, Circulation Stabilize vital sign and aggressive resuscitation. Well explanation to the family. Acquire thorough history and past medical history. Differential diagnosis of GI bleeding UGI & LGI Make the diagnosis by yourself! Arrange adequate diagnostic procedure. Emperical treatment

3 一旦懷疑,利用vital sign評估出血量最重耍 (occult bleeding or overt bleeding)
消化道出血的間接症狀: dizziness , fainting, tachycardia, cold sweating, shock, abdominal fullness, poor appetite, cons. change 一旦懷疑,利用vital sign評估出血量最重耍 (occult bleeding or overt bleeding) Orthostatic hemodynamic change – 10 to 20% blood loss Drop in systolic pressure > 10 mmHg, raise in pulse rate >15/min Supine hypotension – greater than 20% blood loss 定位 UGI or LGI 同時評估 medical treatment or surgical treatment GI bleeding vs Non-GI bleeding: 吐血 vs. 咳血 vs. internal bleeding

4 Study in GI bleeding Digital exam for collect stool
NG aspiration for DDx UGI and LGI PES: Panendoscopy or EGD( esophago-gastro-duodenoscopy): should be perform early in the clinical course after vital sign stable or management. Colonoscopy/ rigid sigmoidscopy RBC scan: only in Taipei MMH: >0.1cc/min or 6 cc/hour Angiography: >0.5cc/min or 30 cc/hour Enteroscopy or capsule endoscopy Surgery

5 Why the GI bleeding patient need NPO
Not every GI bleeding patient should NPO Prepare for emergency study or management Avoid aspiration

6 GI bleeding 處理原則 Again and again : Check vital sign
Evaluate NPO or not If NPO, IVF supply Arrange laboratory study CBC, PT, PTT, Blood group and cross match, liver and renal function. Blood product : Whole blood vs. pack RBC, FFP vs. FP, 代用血漿(ex.6HES) Medication How to arrange the study: NG irrigation, Blood sampling, PES, Angiography, Colonofiberscope, RBC scan

7 Vital sign for GI bleeding
Orthostatic hypotension: drop SBP over 10 mmHg, rise in pulse rate over 15 beat/min: blood loose 10-20% Supine hypotension: more than 20% Shock index: SBP/HR<1 which hint blood loose over 25% If the patient got Inderal using, the tachycardia may be disappear ( pacemaker also cover the risk sign)

8 IVF supply in GI bleeding
Large-bore IV line ( gauge catheter) is better than central line. Isotonic solution (NS), LR can be initiated plus plasma expander ( ex 5% hetastarch or 6 HES) The IVF amount is dependent on: hemodynamic condition, other CV/renal condition, age The IVF content is dependent on: underline disease ( DM, LC, Uremia, CHF…) Some drug add in the IVF( KCL, HRI, st-B..) or the IVF is for therapy (PPI or H2RA for PUD; pitression/glypression, sandostadin in EV/GV)

9 Blood product using in UGI bleeding
When transfusion is indicated: bleeding is massive, ongoing, or severe enough that colloid infusion alone is not adequate for tissue oxygenation. ( keep Ht over 25-30%) The unit is different in Taiwan( 1 unit is about 250cc but not 500cc) Whole blood is better than pack RBC if the patient got no risk for fluid overload ( ex. CHF, uremia..) Keep platelet over 50000, and correct the PT with vit K, PTT with FFP(also for massive transfusion) Add Bena/Decadron in allergy patient and Lasix avoid fluid overload, Sincal after massive transfusion


11 UGI bleeding Differential diagnosis of Variceal and Non-variceal bleeding History of liver cirrhosis with/without variceal bleeding Massive hematemesis Signs of liver cirrhosis – Spider nevi, Gynecomastia, Splenomegaly, Ascites, Jaundice Lab data suggest liver cirrhosis – Hypoalbuminemia, PT prolonged, Mild impaired liver function (GOT>GPT) with hyperbilirubinemia, History of alcohol abuse.

12 Treatment of variceal bleeding
The most important of all: STABILIZED THE VITAL SIGN. WELL EXPLAIN TO THE FAMILY – on critical, 1/3 mortality in each episode. Pharmacological treatment: Glypressin (Terlipressin) : 1 amp iv stat and q6h. Sandostadin: 2 amp iv drip stat and 12 amp in 500 c.c. D5W run 24 hours Pitressin: 20 amp in 480 c.c. D5W or NS (conc. 0.8IU/ml), run 12 cc/hr to 54 cc/hr (0.2IU/min to 0.9IU/min), side-effect: chest pain, peripheral cyanosis– combine nitrate--- Seldom used in recently years

13 Treatment of variceal bleeding
Endoscopic treatment – highly operator dependent, high failure rate in acute bleeding, once the procedure succeeded, the outcome is good. Esophageal varices: band ligation Gastric varices: Scleosing therapy SB tube – trachea intubation first, the effect is not good.

14 TIPS -- transjugular intrahepatic portosystemic shunt
Operation : Shunt surgery Precipitating factors of variceal bleeding --- treat the precipitating factor SBP Sepsis Impending hepatic failure







21 Peptic ulcer disease Etiology of peptic ulcer disease
Mucosal defensive factor Mucosal barrier to ion diffusion Two component mucous barrier Bicarbonate, Phospholipids Local mucosal blood flow Prostaglandins, EGF Intrinsic mechanism that inhibit gastric secretion.

22 Peptic ulcer disease Etiology of peptic ulcer disease
Aggressive factors Gastric acid and pepsin NSAIDs H. Pylori Free radical

23 Typical symptoms of PUD
上腹疼痛: 燒灼感, 悶痛, 脹痛 慢性: 患者常會斷斷續續痛好幾年 節律性: 每天固定時間疼痛, 通常空腹時痛 週期性: 每年固定一個時期發作

24 Diagnosis of PUD Esophagogastroduodenalscopy (EGD)
Gastric ulcer and duodenal ulcer Description of PUD in EGD Stage : A1, A2, H1, H2, Scar Size : the risk of recurrent bleeding increased if greater than 2 cm Location : antrum, body, fundus, anterior wall, posterior wall, great curvature side, lesser curvatyre side SRH (Stigmata of recent hemorrhage) Gastritis and Erosion.




28 Risky sign in the PES description of UGI bleeding
Varix: RCS ( red color sign) which hint bleeding: red-whale marking, cherry-red spot, active bleeding; Cb>Cw,F3>2>1 Ulcer: A1-2(active), H1-2(healing) and S1-2(scaring); active bleeding vs SRH (stigmata of recent bleeding) Bleeding with unknown cause

29 Medication/Management in UGI bleeding: PUD
PPI ( losec/nexium, takepron, pariet,) : losec 1Amp + NS cc drip over 10 min st and q12h; the 1# qd H2RA (zantac , tazac, famox): Zantac 3 Amp + 500cc IVF run 20cc/hr ; then 1# bid Sukit/gelfos 1pk q1h x4-6 times Sucrate gel 1Pk bid or ulsanic 1# qid (avoid using with antiacid, H2RA or PPI) Therapeutic endoscopy with bosmin injection, heat probe, hemoclip, laser.. Sometimes, surgical intervention still indicated


31 Medication/Management in UGI bleeding: Surgical intervention in PUD or other Dx
Hypovolemic shock can not control by medical treatment Massive transfusion over 4-6U/8U(2000cc) in 24 hours or over 10U( cc) overall Recurrent or intractable bleeding after non-surgical treatment Risk factor for OP: over 60y/o, transfusion over 5 unit, shock, hematemesis with hypotension, coagulopathy, large ulcer over 2 cm, emergency Op, co morbid illness, rebleeding within 72 hours

32 處理較特殊之處 一般內科病患需在最短時間內判斷病況是否危急(critical);但面對腸胃科病患時,必須同時找出有緊急手術適應症的患者
判斷是否有緊急檢查的適應症 某些特殊的狀況(ex. Severe pancreatitis, hepatic failure, hypovolemic shock..)處置必須移入ICU處理( ex. SB tube, plasmaphrosis) 檢查前的預備工作 Call GI CR for emergent endoscopy! 各護理站皆有on call CR 的電話, 若找不到CR, 直接找VS, 切勿猶豫

33 Low GI bleeding Hemorrhoid, anal fistula, angiodysplasia, radiation proctitis/colitis, aortoenteric fistula, tumor Urgent colonoscopy : difficult due to poor preparation Consult Proctologist for the surgical intervention Fortunately, most common LGI bleeding may stopped spontaneously.



36 Ileus Very dangerous diagnosis when new patient arrive with this diagnosis Paralytic vs Mechanical NPO in most cases IVF supply Overlapping with acute abdomen Series F/U the same kind x ray film





41 Nausea and vomiting(1) Bowel obstruction or pregnancy must exclude first. Besides, extra-abdominal problem ( IICP, metabolic problem..)also need exclude. The vomitus also help for identified the obstruction level by color NG decompression amount is another key for evaluate the degree for obstruction

42 Nausea and vomiting (2) Novamin( proclorperazine): ADR- drowsiness, acute dystonic reaction, EPS, postural hypotension.. Dopamine antagonist - primperan (metoclopramide- EPS is notorious ADR) and motilium (domperidone). Cisparide is not approve in FDA now Ondansteron (zofran) and Granisetron ( kytril) are 5HT3 (serotonin) receptor inhibitor for C/T

43 Diarrhea(1) The definition of diarrhea include the BM increase over 3 times per day and the amount increase Acute diarrhea vs chronic diarrhea : 2 week NPO is the first step in DDx the secretary and osmotic diarrhea (but IVF supply also indicated after NPO especially in DM patient) Stool study : stool OB, pus cell and culture when infectious diarrhea is suspected esp. in bacterial infection). PMC need special agar for culture. Ameba and parasite ova in chronic diarrhea also need considered.

44 Diarrhea (2) Drug may be the most common cause of diarrhea in hospital( senokot, MgO, antacids, digitalis, quinidine, colchicine, antibiotic..) PMC( pseudomembranous colitis)must be carefully monitor when antibiotic using Parasite still need consider esp. in MMH Taitung branch. Most AGE is caused by virus and self-limiting. Diarrhea in cancer patients post radiotherapy is dangerous.

45 Diarrhea (3) Review the drug sheet
Evaluate the risky sign: BM over 6 times, bloody stool or tenesmus, fever, severe abd pain, dehydration Hydration by enteral feeding if possible Symptomatic treatment with : Kaopetin cc/ Tannalbin for loose stool, Anti-muscarinics ( buscopan-scopolamine, trancolon-mepenzolate, bentyl-dicyclomine, esperan-oxapium), Smooth muscle relaxant ( Spasmonal-alverine, Cospanon-Flopropione, Duspatalin-Mebeverine) Imodium 2# st Codeine and Morphine Antibiotic in Infectious diarrhea after stool culture and study: FQ and sulfa drug

46 PMC or AAC Pseudomenbranous colitis or antibiotic-associated colitis
C. difficle is not the only cause Cleocin is most notorious drug. PCN and Cepha got most patient! Dx: scope , toxin, culture( in anaerobic condition) Tx: stop antibiotic, symptomatic control, oral antibiotic ( metronidazole, vancomycine), IV antibiotic may be the last choice. Inferon Berna enema…

47 Constipation(1) Medication also the main cause of constipation ( Calcium channel blocker, opiates, anticholinergic, iron, barium sulfate) Besides, old age and several disease (DM, hypothyroidism, scleroderma, myotonic dystrophy..) patient also got constipation tendency Intestinal obstruction must exclude first

48 Constipation (2) Fiber supplementation: Konsyl or Normacol
Emollient laxative: Mineral oil Stimulant cathartics: Castor oil, Anthraquinones ( senokot 1-2# qhs), Bisacodyl ( dulcolax 1-2# qhs or supp) Osmotic cathartic: Mg citrate, lactulose.. Fleet enema

49 TPN Indication: 不能吃,不想吃,吃不下 Time: not over 7 days NPO
How to order: gradually increase the dose and concentration How to calculate the water amount How to calculate the calori demand How to calculate the protein demand How to calculate the fat supply How to supply the trace element, Vit…

50 TPN(2) Complication of TPN Mechanical problem: caused by CVP insertion
Chemical problem: BS, electrolyte balance.. Infection problem Other problem: GB stasis and stone, LFT impairment, drug interaction

51 Complication of hepatic insufficiency
Fulminant hepatic failure Hepatic encephalopathy Hepato-pulmonary syndrome Hepato-renal syndrome Portal hypertension Ascites SBP Coagulopathy

52 Hepatic failure How to identified the hepatic failure?
PT is more important than AST/ALT Bilirubin also very important parameter Hypoglycemia and hypocholesterol also risky sign Cons. Level must evaluate carefully and closely The NH3 level is not parallel to cons. Level Very high mortality if no chance for liver transplant The Child-Turcott-Pugh score ( A: , A: slightly, Bil: 2-3, Encephalopathy 1-2, PT 4-6) – A: 5,6 ; B: 7-9 ; C: 10-15

53 Hepatic encephalopaghy ( HE)
Correct the precipitating factor: azotemia, tranquilizer, opioid, sedative-hyponotic, GI bleeding, hypokalemia, alkalosis, constipation, infection, diarrhea, porto-systemic shunt Medication : lactulose po and enema; Neomycine po and enema, Metronidazole po, BCAA chain supply (aminopoly-H) The possibility of intra-cranial lesion must exclude ( ex. ICH, SDH, brain tumor)

54 Hepato-pulmonary sndrome
Intra-pulmonary shunt increase Hypoxia Prove by angiography or contrast heart echo.

55 Hepato-renal syndrome
Similar to pre-renal azotemia Difficult in DDx Check Urine Na Also caused by peripherial arteriol dilatation Acute vs. Chronic The kidney is normal !!

56 Portal HTN PE: caput medusa, hemorrhoid…
Normal portal presssure: 7 mmHg ( about 10 cm H2O) Portal HTN: over 10 mmHg ( got S/S if over mmHg) EV or GV bleeding (dependent on which collateral circulation)

57 Ascites and SBP Aldactone is the first choice for diuretic in LC related ascites Any LC patient with fever, abdominal pain need screen the SBP Neutrophile over 250/ul E coli, KP and Strep pneumoniae Empiric antibiotic: 3rd cephalosporine or 1st + aminoglycoside ( risk for renal toxicity) Norfloxcin 400 mg qd can reduce the recurrence for SBP

58 Coagulopathy PT prolong Thrombocytopenia
PTT prolong if the condition worsen or complication

59 Pancreatitis Lab data can not complete exclude or include all cases
CT is most sensitive diagnosis tool in severe pancreatitis Hydration is the key point for treatment Biliary pancreatitis is more common in Taiwan and female patient. Alc related pancreatitis is most common cause in USA and increase in Taiwan Hypertriglycemia vs. DM vs. pancreatitis

60 Pancreatitis (2) Biliary pancreatitis need drainage ASAP
Ranson criteria and APACHE II: if Ranson over 3 point or APACHE over 5, the patient got severe pancreatitis Identified the severe vs mild pancreatitis: clinical course (CV, chest, GI, nephro complication), scoring system, CT staging

61 Ranson criteria On admission: Alcoholic (Non-alcoholic)
WBC: >16000 (18000) Blood sugar: >200 (220) LDH: >350 (400) AST: >250 (440) Age: >55 (70) During the first 48 hours of admission Fall in hematocrit: >10% (10%) Serum calcium: <8 mg/dl (8 mg/dl) Base deficit: >4 mEq/L (5 mEg/L) Increase in BUN: >5 mg/dl (2 mg/dl) Fluid sequestration: >6L (6L) Arterial PO2: <60 mmHg (60 mmHg)

62 Pancreatitis (3) Nature course: Acute renal failure and M. acidosis
Lung complication (ARDS..) Ileus and GI bleeding 2nd infection of necrotic tissue (2week) Pseudocyst (6weeek)

63 Acute cholangitis vs cholecystitis
Comparison of the triade: RUQ pain+ fever+ leucocytosis RUQ pain + fever+ jaundice (Charcot triade) +shock+ cons change (Raynold pentade)

64 Thank You for Your Attention!

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