Good afternoon everyone. So we're right after lunch. We're getting started with questions on GI, liver, minus the alcohol as you said. So we're gonna get started. 82 year old woman was admitted to the hospital six days ago with acute limb ischemia. She underwent thromboembolectomy of the right common femoral artery and has been anticoagulated since then. She's now in the ICU with atrial fibrillation and rapid ventricular response. Yesterday she began to have increasing right lower quadrant abdominal pain. She has not had a bowel movement since the previous morning, has voluntary guarding and rebound in the right lower quadrant and marked abdominal distension. Her WBC count is 27,000. Lactate is 5. CT scan is shown below and what is the most appropriate next step? So I'll take it to the next slide and then bring it back. So that's a CAT scan. Obviously see a lot of air, air fluid levels and a little bit of air where we don't want it. So I'll bring it back. Our options are next step would be total parenteral nutrition, nothing by mouth, surgical consultation for intestinal resection, improvement of cardiac output with inotropes, administration of IV metronidazole and oral vancomycin or administration of methyl naltrexone. The majority of people have the right answer. It is surgical consultation. So this patient is at high risk for embolic disease with the atrial fibrillation. Physical exam and lab findings were both suggestive of bowel ischemia. CT scan does demonstrate pneumatosis of the right colon. Surgical consultation in this situation should not be delayed. Improving cardiac output will help patients who have poor perfusion due to shock but haven't really gotten to a stage where intestine is dead. Close observation again is warranted in those situations where we don't have a complete bowel ischemia. There's no history suggestive of C. diff at this point in this patient and a bowel regimen along with methyl naltrexone would be appropriate only for opioid-induced constipation. I think this is an important point. When you look at this bowel wall, you see how thin that is? That is very typical for acute arterial mesenteric ischemia. They look like they are collapsed. They have no blood flow. It is very different than the mesenteric venous thrombosis patient where their walls are really thick. This provides you a very good clue as to what kind of ischemic process there is. More important than that, this is not just pneumatosis. It's non-dependent pneumatosis. It is on the dependent side of the bowel. So gas should go up. If the gas is in a spot where it should not be based on gravity, that is another important clinical sign that that truly is ischemic bowel. And it has, in this space, you can see some fluid between the bowel loops. Lactate, pneumatosis, non-dependent, thin wall, fluid. That's an ischemic bowel. Just to add on to that, a lot of times you would see something similar in patients with dialysis, end-stage renal disease patients coming right after dialysis. They show up in ICU, hypotensive, some abdominal pain, but a lot of their labs are stable and you send them down for acute CAT scan. They come back with signs of pneumatosis. That is a patient where you do not want to go down the route of acute surgical intervention. You can call surgery for consultation, but those are the patients that have gotten to a volume deficit side. You give them volume, they recover fairly well, keeping in mind that those patients are not in a shock with lactic acidosis and all those things. Okay. Second question. Okay. Second question. 54-year-old patient with a history of alcohol dependence and IV drug abuse is admitted with jaundice and a three-day history of fever. He has a temperature of 101.6, pulse rate of 105, and blood pressure of 130 over 85. Exam reveals tenderness in the right upper quadrant and enlarged liver, ascites, and optentation. Results of liver tests are as follows, AST-130, ALT-70, bilirubin of 28, INR of 1.9, abdominal ultrasound with Doppler study shows ascites and hepatomegaly, but blood flow in the major hepatic veins and IVC is normal. Which of the following is the most likely diagnosis? Non-alcoholic steatohepatitis, acute hepatitis B infection, acute hepatic failure with acetaminophen overdose, or acute alcoholic hepatitis alone. Okay, so the correct answer, majority of people have the correct answer. The pattern of AST to ALT ratio of greater than one argues against the non-alcoholic steatohepatitis and acute hepatitis B. That is more consistent with acute alcoholic hepatitis. The pattern and the degree of elevation is not consistent with Tylenol overdose. There's very few conditions where AST is higher than ALT. Most of the other primary liver-related problems will always have ALT higher than AST, except alcohol. And the demographic clinical presentation and the normal blood flow rules out Bacheri syndrome. Great. 23-year-old woman presents after a motor vehicle crash. She's a restrained driver. GCS is a little low, airway is okay. You can see that she's quite tachycardic and hypotensive. Unremarkable chest X-ray. Pelvis has minor superior and inferior pubic rami fractures. On the left, her FAST is positive, revealing free intraabdominal fluid. In the right upper quadrant and the pelvis, what is the most appropriate next step? CT scan, angioembolization of the pelvis, exploratory laparotomy, diagnostic peritoneal lavage, or orotracheal intubation. It's fluctuating. But exploratory laparotomy is the right answer. Let's talk about why the other things are not right and why this one is the most correct. When you look at someone who's hypotensive, tachycardic, and has free fluid, FAST will tell you there's fluid or not fluid. It doesn't tell you what kind of fluid it happens to be. And so the confounding diagnoses, I have chronic kidney disease, I have a disorder of lymphatic flow, it will all put fluid in your pelvis. But most of that is fairly dependent fluid. This is right upper quadrant and pelvic fluid in a hypotensive patient, so the assumption must be that that person has blood in their belly. And therefore, some things become less safe, sending them to CAT scan, for instance. They're now removed from the ED, you don't have all of your pieces of equipment, and that does absolutely nothing to control bleeding. And that is your imperative is to arrest hemorrhage. Angioembolization of the pelvis, that may be a really good choice, and it may be part of your algorithm, but not for this kind of a minor pelvic fracture. Superior and inferior pubic rami, we generally tend to go, that's tiny, have some pain medication. That's not unstable. Major pelvic disruptions, you might angioembolize that patient, but not with FAST like this and not with hypotension. You might do pre-peritoneal packing in that space, peeling the peritoneum back and putting laparotomy pads that are rolled up between the peritoneum and the anterior ring of the pelvis. Diagnostic peritoneal lavage, who's done one besides the surgeons? Anyone? What did you do it for? Because it was 15 years ago. Okay, that's exactly right. We don't do this anymore, except in places where we don't have an ultrasound, because it's been largely supplanted by an ultrasound. You might do a diagnostic peritoneal aspiration to determine is this blood or is it not blood, but that's still pretty uncommon. This person I wouldn't bother with. They simply need to go to the OR, and I would not, not one bit, put in an oral endotracheal tube and deliver positive pressure ventilation until I was ready to open that patient's abdomen, because all of that increase in pressure will decrease venous return. And then you'll be in the elevator getting to the OR, and you will have a dead patient on your hand. So let's stick with operating. Lots of references. Some of these are old, like from 1995 when we started doing FAST as a routine thing to something more recent. Okay, we have more opportunities for you. 49-year-old man, eight hours acute onset, severe epigastric pain. He smokes cigarettes, does amphetamines, some heroin, some cocaine. It's like one from column A and one from column B. I always go with the Phoenix Nest. It's always better. Vital signs are a little hypertensive, heart rate's a little bit on the high side, not febrile, breathing quickly. On exam he is guarding an abdominal rebound tenderness. White count is elevated. The other labs are okay. I'll show you a CAT scan in a moment. He gets a liter of crystalloid and gets started on broad-spectrum antibiotics. What should we do next? Operate, CT with arterial phase contrast, upper endoscopy, or non-invasive ventilation. Here is his CAT scan. There are some notable findings on the CAT scan, like that. Time to vote. Yes, this person has free air. They need an operation. Arterial phase contrast, let's go back to the CAT scan. Not a thin wall. Arterial mesenteric ischemia would have a thin wall, even for your stomach. This is not a thin wall, so you don't need the arterial phase. Upper endoscopy, I don't know any of the gastroenterologists that would be happy to drive a scope with gas through someone's upper GI tract when there is pneumoperitoneum. Non-invasive ventilation, if you think there is possibly an upper perforation, is also contraindicated. I know it's easy. I'm a surgeon. I like to operate. A chance to cut is a chance to cure. The questions are not all aligned on that way, but mostly. This is you. So, we have a 66-year-old patient that was admitted to the intensive care unit for evaluation of hematochesia. During the preceding 12 hours, he's had three large-volume liquid maroon stools, denies symptoms of peptic ulcer disease, aspirin or NSAID use, ethanol use, or antecedent vomiting, including hematomasis. He lacks a prior history of diverticular disease. Blood pressure is 105 over 60 and a heart rate of 130 beats per minute, so hypotensive tachycardic gastric lavage and aspiration yield clear fluid. He has a loud systolic murmur best heard in the aortic area. He has hyperactive bowel sounds and a diffusely tender abdomen without peritoneal signs. Coagulation studies are within normal limits. The tagged RBC scan is shown right here. Not most of us don't really read these scans, we only read the reports, but the scan is pretty self-explanatory. So, which of the following diagnostic and therapeutic steps is the most appropriate? Options being obtain an angiogram, ensure adequate volume resuscitation with crystalloids and blood products as indicated, along with continued vigilant observation, begin a systemic infusion of vasopressin at 0.3 units per hour, or perform an upper GI endoscopy. So here the answer essentially is obtain an angiogram. The rationale for this is on the CAT scan we do see an active, on the tagged RBC scan we see an active bleed, and an active bleed needs to be controlled with some form of an intervention. Until an active bleed has been identified, continuing with fluid resuscitation is the right approach, but once you have identified that, then the goal should be to try to approach it with a more definitive intervention. Providing systemic vasopressin would not be of much benefit. This is a lower GI bleed, so vasopressin wouldn't really provide much benefit. Angiodysplasias of the large bowel is often a difficult diagnosis to establish, and recurrent lower GI bleed without a clearly identified source is common. This person is in the right age group and has a cardiac murmur consistent with aortic stenosis, which has been associated with sacral angiodysplasias or AV malformations. So that is most likely the etiology for bleed. Can I argue with you? Sure. How many people get a tagged red blood cell scan? Who gets a CTA? Yeah. So I think that if you don't have access to a CTA, a tagged cell scan is fine. But if you do, most people now get a CTA. We may have done a small study about that. And therefore, our radiologists won't even look at the patient without a CTA. So that they define that there's enough bleeding and exactly where it is, and then they have a road map, if you will, as opposed to the tagged red blood cell scan. So some places, they just can't get a good CTA. Tagged cell scan is great. I think the most common thing now is CTA as an initial evaluation. Was that your question? You're still in therapy, but if you're going to send a patient to get an angiogram, then not necessarily. So the problem is the way this is written, right? So it's written diagnostic and therapeutic. Yeah. So that you can't get both of those from the resuscitation. Practically speaking, you're right. I'm going to resuscitate the patient while I'm calling for a CTA. Yes. So one of the things I think, so first of all, the answer is angiogram, CT angiogram versus IR angiogram. I think that's up for the grabs. A lot of times when we get these patients that have had these tagged RBC scans, those are the patients that are getting upgraded from the floor that were on stepped-on ICU overnight, got a tagged RBC scan because GI was not too excited about going in with a colonoscopy without having something preemptively done. And then we see that, yes. I think our interventional radiologists, the CT is right next to them. So their answer always is have them pit stop at the CTA, and then they can directly come from CTA to the IR suite just so they know exactly how to intervene. Or if they want to blindly go and do embolization, they know exactly which area to blindly angioembolize. In terms of what you said, I think one of the things, and this is predominantly geared towards boards, I took my critical care boards last year in the spring, and I can tell you at least three of the four options they give you, that is something that all of us have a default of doing all three of those together. And the vigilant observation part is the predominant reason why this is not the answer. So last question for this Q&A session. A 38-year-old woman is admitted to the intensive care unit for management and evaluation of the massive lower GI bleed after developing orthostatic changes and a hemoglobin of 6.1. Patient had otherwise been in good health. Her chief concern is painless bright red blood per rectum. She states that her last menstrual period was three weeks ago and urine pregnancy test was negative. She denies any blood in her bowel movements or a recent change in the bowel habits, but she states she has occasionally had painful hemorrhoids. Patient is on no medications at present. Evaluation at an outlying hospital prior to transfer included a flex sig to 35 centimeters, and there was significant blood reported. Patient is currently receiving two units of packed RBCs. The most appropriate next step in her diagnostic evaluation includes which of the following? A mesenteric angiogram, tagged RBC scan, an endoscopic examination, or a colonoscopy. So the correct answer here is, surprisingly, an anoscopic exam. And the reason for that is, yes, I think the last time I did that in an ICU was never. So what I can tell you in this situation is this is essentially when your gastroenterologist is there to do a full colonoscopy. And when they're prepping, that is when they realize, during their initial assessment, that this is a hemorrhoidal bleed. And that is how it should be approached. There are several occasions when this has been identified through the initial colonoscopic evaluation when the gastroenterologist was going in, unless it is an external hemorrhoid, which are generally not that painful. So this is where we are. The answer here is an anoscopic examination based on the way a patient's history is described of painful hemorrhoids and also a bleeding, bright red blood per rectum, which is not associated with stool. Because if this was a colon-based bleeding, you would notice some stool mixed with blood. Yes. Yes, so a severe bleeding that happens through hemorrhoids can actually do retrograde. And then to answer your question, yes, they should have seen, but that doesn't rule it out. It's very interesting. If you watch people do their flexible sigmoidoscopy, there is about this much of the scopes that goes in before they look at anything. And they will miss low-lying hemorrhoids, and you won't miss that with uranoscopy examination. So it depends how it's done. You don't miss that with rigid sigmoidoscopy, but that is much less commonly done in the acute setting. So I don't like this question, I'll tell you that. I don't like the blood at 35. But there's absolutely internal hemorrhoids that get missed that have blood that ascends. So you will see this. I mean, our gastroenterologists have seen this, we're in the room most of the time because you're actively doing conscious sedation for these patients. And I can say at least two or three times a year, we identify hemorrhoidal bleed as presenting as massive GI bleed. Yeah, especially in those that have any degree of portal hypertension or cirrhosis, they get all kinds of interesting venous bleeds. So it seems like it should be a different answer, but it's actually endoscopic evaluation. I think that is the end for, or do we have another one? I don't think so. Practically, who would do an endoscopic evaluation? What service does it? I mean, surgery, GI? Yes. Okay. Yes, surgery does it, GI does it. Quite often, GI says to me, you're in the ICU, will you do this? It's fine. And then I say to my fellow, hey, when's the last time you did an endoscopic evaluation? He goes, yeah, it's been years. Today's the day. Hardest thing is finding the endoscope. We have it stored in the nurse practitioner's office. Moving on to a different question. 52-year-old, upper abdominal pain, nausea, and vomiting. Regular alcohol and tobacco use, they seem to go together with the consumption of the bar pie. Afebrile, tachycardic, a little hypotensive, breathing quickly. Sat is a little bit low on room air. White count's high, BUN is okay. Kratonin is elevated, sort of out of proportion to the BUN. Amylase is 400, lipase is 1,200. Admitted to your ICU with a diagnosis of pancreatitis and acute kidney injury. Which of the following is the next most appropriate step in management? Contrast enhanced pancreatic protocol CT scan? Placement of a PICC line for TPN? Fluid resuscitation guided by POCUS and lactate? Initiation of broad spectrum empiric antibiotics? Or nephrology consultation for potential dialysis? Let's see what you come up with. You seem to have all the questions that have controversy. I like it. So let's see. Everyone wants to do fluid resuscitation. I couldn't get anyone to bite on the CAT scan. So you don't need that CAT scan initially. As long as you have things that diagnose pancreatitis, you have a good history, you have an exam that matches, and you have laboratory abnormalities. So you don't need that. You also don't need to feed them with TPN. You can feed them orally. Empiric broad spectrum antibiotics do one thing. Well, maybe two. One is it gets your pharmacist to yell at you. And two is it creates multidrug-resistant organisms, but does not change the instance of any kind of infection. And while the nephrologist is happy to send their fellow, they're not dialyzing this patient with a simple isolated elevated creatinine. Okay. This has been multiply studied and recently as well.

gastrointestinal conditions

liver conditions

surgical consultation

acute alcoholic hepatitis

GI perforation

lower GI bleed management