1. Gemma WALTERS 5th year medical student
GI EMERGENCIES
Gemma WALTERS
5th year medical student

2. Objectives Common GI emergencies Cases Management
Paediatric GI emergencies
QUIZ

3. Case 1 Mrs Smith, 48 year old lady PC: Abdo pain S: Epigastric
O: Started 2/7 ago, progressively worse
C: Dull ache at first, now more sharp
R: ‘All over’ abdo
A: Vomited x 2, feels nauseous
T: Not related to time/food etc
E: Worse on movement, at first was relieved a little by co-codamol but not now
S: 9/10

4. Case 1 continued.. O/E: Obese patient, uncomfortable
NOB 4/7, unsure if passing flatus.
Last bowel motion fairly hard/difficult to pass but normal for her.
Has felt generally unwell 4-5/7, anorexia, no fever/rigors
PU’ing as normal. ROS: Unremarkable
PMH: Obesity (BMI 40), Gallstones (open cholecystectomy 2 years ago), hysterectomy 10 years ago, haemorrhoids, constipation.
Meds: Laxatives Nil. NKDA
O/E: Obese patient, uncomfortable
Distended abdomen, generalised tenderness. Tinkling bowel sounds.
DRE – Empty rectum.
What would you expect to find on exam/what are you looking for?

5. Investigations Bloods: FBC, U&E, CRP, clotting, ?G&S/crossmatch BM
AXR and erect CXR – why?
USS (?masses)
Bloods – normal
BM – 10
CXR – nil acute

6. Management Plan? A to E Assessment IV access NBM IVF
+/- NG tube (if vomiting)
Broad spectrum Abx
Call surgeons - theatre
What else do you need to know before prescribing fluids?? Heart failure/fluid overloaded

8. Small Bowel Obstruction Large Bowel Obstruction Causes Adhesions
Hernias
Inflammatory swelling (IBD)
Malignancy
Faeces
Diverticular masses
Volvulus
Ileus and pseudo-obstruction (no cause found, elderly pt)?
Radiological findings:
Dilatation of SB >3cm = abnormal
Central
'valvulae conniventes'
Dilatation of the caecum >9cm is abnormal
Dilatation of any other part of the colon >6cm is abnormal
In the distribution of LB
Haustra
What’s lleus?

9. Case 2 Mr Daniels, 67 year old gentleman PC: ‘Vomiting blood’ HPC:
2 x episode of vomiting ‘bright red’ blood
Mixed in with vomit
Denies abdo pain
BO – yesterday, no blood/melaena
PU’ing as normal
Feels well in self

10. Case 2 continued.. PMH: Pancreatitis, HTN, OA Meds: Amlodipine. NKDA
SH: Alcohol approx. 30 units/week. Non-smoker. No recreational drugs
O/E:
A: Patent
B: RR 20, equal expansion/air entry, lungs clear
C: HR 101 regular, BP 100/65, CRT <2, feels cold
D: Pupils equal and reactive, BM 5
E: Temp 37.0

11. Differentials Oesophageal varices Peptic ulceration Mallory-Weiss tear
Oesophagitis
Gastric Ca
Coagulation disorder / anticoagulation medication

12. G.I Bleed - Management Plan
Regardless of cause…
Investigations: Bloods – FBC, U&E, clotting, LFTs, crossmatch. ABG – (if low sats). Endoscopy (?urgent)
Management:
A to E
Oxygen
IV access - Crossmatch
Monitor urine output
Fluids – what fluid??
If anticoagulated consider reversing
Senior help
ABG – acidotic? Hypoxic?
Fluid – colloid or o neg blood

13. Rockall Score Points 1 2 3 Age <60 60-79 >80 Shock HR <1001 2 3
Age
<60
60-79
>80
Shock
HR <100
SBP >100
HR >100
SBP <100
PMH
HF, IHD, any major comorbidity
Renal failure
Liver failure
Malignancy
Age 67 = 1
Shock HR >100 = 1
Total = 2
Any patient scoring more than 0 = high risk

14. VITAMIN K ( )
PHYTOMENADIONE
See BNF:

15. Varices
= dilated veins (varices) at the junction between the portal and systemic venous systems.
Usually distal oesophagus and/or the proximal stomach but isolated varices may be found in the distal stomach, large and small intestine.
Associated with CLD. Severity is related to portal HTN.
Management:
- A to E (as above)
- Terlipressin
- Check INR, give Vit K if required
- Prophylactic antibiotics (e.g.ciprofloxacin)
- Senior help
- Urgent endoscopy (variceal band ligation, balloon tamponade if uncontrolled)
Mortality rate 30-50%
What is terlipressin? Synthetic vasopressin, vasoconstriction = reduced blood flow to portal system
Venous collaterals that have enlarged to compensate
Prophylaxis: B Blockers (propranolol, reduces CO therefore reducing pressure on portal system), repeat banding, transjugular intrahepatic portosystemic shunting TIPSS
Can present with haematemesis or melaena

16. Case 3 18 month old boy No temperature
PC: Persistent crying, ‘think he’s in pain’
HPC:
Nappies wet as usual
Since this morning has been crying on and off
Some loose stools this AM
Lasts for about minutes then seems to settle, then starts again
PMH: Reflux
Not usual for him, normally happy settled baby
Meds: Nil. NKDA
Not taking fluid/food offered
SH: Mum, Dad, baby at home. Non-smoking household.
Was fine yesterday, no one else at home is ill
Vomited x 1

17. Case 3 continued What else do you ask in a paediatric hx?
Pregnancy – normal. NVD
Meeting developmental milestones
Up to date with vaccinations
O/E: Crying, distressed baby
Drawing up legs
Abdo slightly distended
Observations in normal range

18. Management ?Intussusception,
= One segment of the bowel (intussusceptum) invaginates into another (intussuscipiens) just distal to it, leading to obstruction. The bowel may simply 'telescope' on itself (non-pathological lead point), or some pathology may be the focus of the invagination (pathological lead point).
Key words: Colicky, drawing up legs, ‘redcurrent’ stools, sausage shaped mass RUQ, 6-12 months.
Ix: Abdominal X-ray - may show dilated gas-filled proximal bowel, paucity of gas distally, multiple fluid levels (but may be normal in the early stages).
Ultrasound - may show doughnut or target sign, pseudokidney/sandwich appearance
Bowel enema - barium has been gold standard (crescent sign, filling defect) but air and water- soluble double-contrast now available; each has pros and cons - the choice is left to the individual radiologist.
Meckel's diverticulum, CF, inflamed appendix

19. Management continued…
Resuscitation - 'drip and suck' - nasogastric tube and IV fluids.
Radiological:
Reduction (three tries for three minutes each).
Air enema <120 mm Hg of pressure or barium enema[4].
The choice of enema is usually left to the radiologist (many now favour air enema)[7, 9].
Laparotomy (reduction/resection) - indications:
Peritonitis.
Perforation.
Prolonged history (>24 hours).
High likelihood of pathological lead point.
Failed enema.

20. Spot diagnosis
Sigmoid volvulus. ‘coffee bean sign’. What is it? Difference between sigmoid and caecal? What hx will the pt give?

21. Spot diagnosis 2
Diaphragmatic hernia. What would the history be? Respiratory distress. ET intubation, ventilation, NGT, surgery

22. MCQ 1
A 3 week old baby presents with forceful vomiting after feeds, however his mother reports that he still seems hungry afterwards. O/E there is an olive sized abdominal mass.
Which electrolyte disturbance is most likely?
A) Hyperchloremic, hypokalemic metablic alkalosis
B) Hypochloremic, hypokalemic metabolic alkalosis
C) Hypochloremic, hyperkalemic metabolic alkalosis
D) Hypochloremic, hypokalemic metabolic acidosis
Key words: Projectile, still hungry after feeds, poor weight gain, ‘olive’ mass on palpation +/- visible peristalsis at start of feed (test feed), young (<12 weeks old), 1st degree relative FH, first born male.
Immediate management = correct fluid/electrolye imbalance
Definitive Management = surgery (pyloromyotomy)
Investigation = USS
Answer = B This prolonged vomiting causes progressive loss of fluids rich in hydrochloric acid, which causes the kidneys to retain hydrogen ions in favor of potassium.
The dehydration may result in hypernatremia or hyponatremia

23. MCQ 2
A 17 year old female presents to the AED with a 1/7 hx of severe abdominal pain, which is poorly localised. She has vomited once. O/E she is tachycardic and most tender in the RLQ.
What is the most important investigation?
- Ultrasound abdo/pelvis
- Plain AXR
- Urine beta-hCG
- Blood cultures

24. MCQ 3
A 77 year old man with a hx of gout, HTN, IHD and T2DM presents with sudden onset, severe abdo pain. O/E = tender, rigid abdo with guarding. Slightly tachycardic. Looks pale but otherwise obs are within normal range.
What is the most appropriate investigation?
- AXR
- Erect chest xray
- Abdo USS
- FBC
Gastric = worse after eating. Duodenal = worse at night/fasted state

25. Exam tips If in doubt - A to E Assessment
Keywords and phrases – e.g. ‘redcurrent jelly stools’, ‘tinkling bowel sounds’, ‘coffee ground vomit’, any mention of alcohol/LF.
Abdo pain:
Central epigastric pain that then goes to RIF, N&V, low grade fever, young-ish pt = appendicitis
Young woman – think ectopic, always do pregnancy test.
Abdo pain, young person, thirsty, SOB – DKA.
Difference between definitive management and initial – e.g. if bleeding and question says immediate/first – think resus.
Gold standard investigations – NICE guidelines.

26. References / recommended reading
Patient.uk
Oxford handbooks
Get Ahead
Pass Medicine