Upper GI Bleeds

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75% of all gastrointestinal bleeds are classified as upper GI bleeds. An upper GI bleed is defined as a bleeding taking place proximal to the ligament of Treitz, a suspensory ligament where the fourth portion of the duodenum transitions to the jejunum.

Etiology

·      Above the GE junction

o   Epistaxis

o   Esophageal varices (10~30%)

o   Esophagitis

o   Esophageal cancer

o   Mallory-Weiss tear (10%)

·      Stomach

o   Gastric ulcer (20%)

o   Gastritis (20%)

o   Gastric cancer

o   Gastric antral vascular ectasia (rare condition where small blood vessels are dilated around the antrum of the stomach—resulting in “watermelon stomach”; associated with cirrhosis, chronic kidney failure, and collagen vascular disease.)

o   Dieulafoy’s lesion (very rare where a large, tortuous arteriole in the submucosa of the stomach erodes and bleeds)

·      Duodenum

o   Ulcer in bulb (25%)

o   Aortoenteric fistula: rare and lethal; usually only if previous aortic graft has been done

·      Coagulopathy (drugs, renal disease, liver disease)

·      Vascular malformation

Clinical features includes patient noticing blood is coming out his/her GIT. This can be in a variety of forms. In order of decreasing severity of the bleed: hematochezia (blood—usually fresh—passed through anus, can be along with or mixed in stools), hematemesis (vomiting up blood—usually fresh), coffee ground emesis (vomiting old blood), melena (old blood passed through anus), and occult blood in stool.

ALWAYS ask about NSAID, aspirin, or anticoagulant drug use!

Initial management

1.     Resuscitate patient with 2 large bore IVs, IV fluids, monitor vital signs

2.     Send blood for CBC, cross and type, platelets, prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, BUN, creatinine, and liver function tests.

3.     Keep the patient fasting

4.     NGT can be considered to determine upper vs. lower GIT bleeding

5.     Endoscopy is done to establish bleeding site and treat lesion

·      For bleeding peptic ulcers, the most commonly used method of controlling bleeding is injection of epinephrine around bleeding point and thermal hemostasis via bipolar electrocoagulation or heater probe. Less often thermal hemostasis may be used alone. Injection alone is not recommended

·      Endoclips

·      Hemospray—mineral blend powder specifically used for endoscopic hemostasis. It absorbs water to form a cohesive and adhesive mechanic barrier around the bleeding site.

6.     Administer PPI (IV) to decrease the risk of rebleeding if endoscopic predictors of rebleeding are seen

·      PPI is given to stable the clot, not to accelerate ulcer healing

·      If given before endoscopy, it decreases need for endoscopic therapeutic intervention

7.     For variceal bleeds, administer octreotide 50 micrograms loading dose followed by constant infusion of 50 micrograms/hour

8.     Consider IV erythromycin or metoclopramide to accelerate gastric emptying prior to gastroscopy to remove clots from stomach.

Review—PT vs. PTT

Both PT and PTT are tests done to assess whether the patient has a coagulation problem. PTT stands for partial thromboplastin time (sometimes also called activated partial thromboplastin time APTT) and measures the function of the intrinsic coagulation pathway; PT stands for prothrombin time and measures the function of the extrinsic coagulation pathway. The way to remember the difference is this: the 2 T are no longer together à they are “exes” à PT measures extrinsic pathway. Why are they not together anymore? Because one of them got the “7 year itch” à PT/extrinsic pathways deals with factor VII while PTT deals with all other factors.

Prognosis

·      80% stop spontaneously

·      Peptic ulcer rebleeding occurs in 25% of patients. If there is no rebleeding, mortality is low 2%; however, it rises to 10% if rebleeding occurs.

·      Endoscopic predictors of rebleeding includes: spurt or ooze, visible vessel, or fibrin clot

·      H2-antagonists have little impact on rebleeding rates and need for surgery

·      Esophageal varices have a high rebleeding rate (55%) and mortality (29%)

·      Patients can be sent home if:

o   They are clinically stable

o   Bleeding was minor

o   No comorbidities

o   Endoscopy shows clean ulcer with no predictors of rebleeding

Inflammatory Bowel Disease Part 2

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This week we continue to explore inflammatory bowel disease:

Ulcerative colitis is defined as an inflammatory disease affecting colonic mucosa anywhere from the rectum (ALWAYS involved) to the cecum, causing anything from proctitis (rectum-only) to pancolitis (entire colon); inflammation limited to rectum or left colon is more common than pancolitis. On colonoscopy, the inflammation seen is diffuse, continuous, and confined to the mucosa. The incidence of ulcerative colitis is 2~10/100,000 and prevalence is 35~100/100,000. This makes it more common than Crohn’s disease. Two-thirds of patients have disease onset by age 30, with a second peak after age 50; like Crohn’s disease, the distribution is equal between male and female patients. There is a small hereditary contribution—15% of cases have 1^st degree relative with disease. Risk is LESS in smokers.

The hallmark clinical feature of ulcerative colitis is rectal bleeding. Diarrhea can also be present, as well as abdominal cramps/pain (especially with defecation), tenesmus, urgency, and incontinence; systemic symptoms include fever, anorexia, weight loss, and fatigue. The severity of the colonic inflammation correlates with the symptoms (e.g. stool volume, amount of blood in stool). Patients with ulcerative colitis present with characteristic exacerbations and remissions; 5% of cases are fulminant.

Although there is no single confirmatory test, sigmoidoscopy with mucosal biopsy is often sufficient for diagnosis, but a colonoscopy would be helpful in determining the extent of disease (but contraindicated in severe exacerbation). CT colonography (formerly barium enema) can be done if colonoscopy not possible. Stool culture and microscopy and C. Difficile toxin assay should be done to exclude infectious causes.

The mainstay of treatment is 5-ASA derivatives (suppository and enema form in acute treatment; oral form can be used in maintaining remission) and corticosteroids (IV for acute disease; suppositories/enemas/topical applications can be used for disease distal to splenic flexure) for mild to moderate disease; the use of 5-ASA medications such as sulfasalazine or mesalamine may decrease rate of colorectal cancer. Immunosuppressants (e.g. 6-MP) and biologics (e.g. infliximab) are used in hospitalized patients with severe ulcerative colitis; biologics can also be used for outpatients with moderate to severe disease, particularly those that are steroid-unresponsive or steroid-dependent. Azathioprine can also be used in those who are steroid-dependent, but they are most commonly used to maintain remission while corticosteroids are being withdrawn; when given together with biologics, azathioprine increases the efficacy of biologics and decreases the likelihood of tolerance to biologics (around 10% chance/year). Diet change is of little value in decreasing inflammation but may alleviate symptoms. Anti-diarrheal medications are generally not used in ulcerative colitis. When all else fails, colectomy is a curative option; bowel continuity can be restored with ileal pouch-anal anastomosis (IPAA). Other indications of colectomy include toxic megacolon, uncontrollable bleeding, pre-cancerous changes detected by endoscopy/colonoscopy/biopsy, overt malignancy, or inability to taper corticosteroids.

Complications of ulcerative colitis are similar to that of Crohn’s disease, except that there are more liver problems involved in ulcerative colitis (especially primary sclerosing cholangitis in men). There is a greater risk of colorectal cancer in ulcerative colitis; the risk increases with duration and extent of disease and also increases with active mucosal inflammation and development of sclerosing cholangitis. Thusly, regular colonoscopy and biopsy in pancolitis of ≥ 8 years is indicated. Toxic megacolon (traverse colon diameter > 6cm on abdominal x-ray) with immediate danger of perforation is also a major complication! This is lethal and requires immediate treatment using steroids +/- surgery.

A comprehensive list of complications of ulcerative colitis is as follows:

Urinary calculi

Liver problems

Cholelithiasis

Epithelial problems

Retardation of growth/sexual maturation

Arthralgia

Thrombophlebitis

Iatrogenic complications

Vitamin deficiencies

Eye problems

Colorectal cancer

Obstruction

Leakage (perforation)

Iron deficiency

Toxic megacolon

Inanition (wasting)

Strictures

In patients with only proctitis, the disease usually runs a benign course. However, most patients present in chronic relapse pattern. More colonic involvement in the first year of onset correlates with increased severity of attacks and increased colectomy rate. Post colectomy most patients can have normal life expectancy.

The biggest difference between Crohn’s disease and ulcerative colitis is that Crohn’s disease can affect any part of the GIT where as ulcerative colitis is limited to the large intestines.

And as promised... the bonus chart of extra-intestinal manifestations of IBD!

Review of Gastroenterology part 1 - Anatomy of GIT

Finally we move on from Emergency Medicine to General Medicine, and what better way to start than a revision! In today's episode (part 1 of 2), we review the anatomy of the whole gastrointestinal tract; and if you tune in to our podcast episode, Dr. Oli leaves us with some mysteries questions--which will be answered in part 2 of the review!

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Consent (as applicable in Canada)

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Medico-legal issues are such “downers” to talk about, but in this day and age it really needs to be discussed because we all want outcomes that are safe and fair for all parties involved. Since I’m hoping to practice medicine in a different country than the one I was trained in, it’s especially important for me to learn about the laws and regulations in Canada.

According the Canadian Medical Protective Association (CMPA) three criteria required for informed consent:

1.     Patient must have the mental capacity to understand the nature and possible consequences of the procedure/treatment.

2.     The patient must be fully informed about the procedure/treatment.

a.     The physician should disclose the diagnosis.

b.     The physician should disclose the nature of the proposed investigation/treatment.

c.      The physician should disclose the expected consequences for forgoing the proposed investigation/treatment.

d.     The physician should disclose reasonable alternatives to the proposed investigation/treatment.

e.     The physician should disclose any material risks of the proposed investigation/treatment and answer questions posed by the patient.

                                               i.     Not every possible complication needs to be conveyed to the patient.

                                              ii.     Complications that occur frequently should be disclosed.

                                            iii.     Complications, however rare, with significant consequences for the patient (e.g. death, paralysis) need to be disclosed.

                                            iv.     Risks that a reasonable person in the patient’s position would consider significant should also be disclosed.

3.     The consent must be given voluntarily

The consent form itself does not equal real consent. The explanation given by the physician and the dialogue between physician and patient about the proposed procedure/treatment is the all-important element of the consent process (no explanatory pamphlet/video can replace this, but if supplementary material was provided it should also be documented). A signed form will be of relatively little value later if the patient can convince a court that the explanations were inadequate or absent. A summary of the consent discussion entered into the medical record at the time is the best defense against an allegation of lack of informed consent; the documentation of the consent discussion need not be lengthy or detailed. The physician can delegate the responsibility of obtaining consent to a colleague, medical trainee, or nurse who has the knowledge and experience to provide information tailored to the requirements of the patient and circumstances.

In witnessing a signature, the witness simply confirms the identity of the patient who signed the document and that the person’s mental state at the time appeared to allow for an understanding of what was signed. The witness has no obligation to provide pre-treatment explanations and is in no way attesting to the adequacy of the explanations given by the physician.

If a surgeon at a teaching hospital delegates certain surgical procedures to his/her trainees, he should disclose to patients the involvement of trainees in these procedures.

Battery in the medico-legal context is when a physician carries out an investigation/treatment in the absence of valid consent or when treatment went beyond or deviated significantly from that for which consent was given. Assault and battery may also apply when consent was obtained by way of serious misrepresentation.

In the emergency department, however, consent is not needed when a patient is at imminent risk of serious injury AND obtaining consent is either not possible or would increase risk to the patient. This rule assumes that most people would want to be saved in an emergency. However, a capable and informed patient can refuse treatment or part of treatment (even if it is life-saving); and emergency treatment CANNOT be initiated if a competent patient has previously refused the same or similar treatment (for same problem) and there’s no evidence to suggest he has changed his mind or an advanced directive (such as DNR) is available. Refusal of help in a suicide situation still warrants treatment. When in doubt, initiate treatment; it can be withdrawn at a later time.

Children presenting to the ER are treated in the same way: treat immediately if the patient is at imminent risk. The patient does NOT have to reach age of majority to give a valid informed consent. However, if the patient in question is obviously not capable to make a decision (like a baby or toddler), parents/guardians have the right to make treatment decisions; if they refuse treatment that is life-saving or will potentially alter the child’s quality of life, Children’s Aid Society (CAS—there is one in every hospital) must be contacted, in which case the consent of CAS is needed to treat.

Common issues needing consent include HIV testing and administration of blood products. Jehovah’s Witnesses are the most common group who will have issues with latter; they may refuse all blood products (even autologous), in which case treatment needs to provide the highest possible quality of care with out the use of blood products (e.g. crystalloids for volume expansion like hydroxyethyl starch). They will generally sign hospital forms releasing medical staff from liability.

An extension of informed consent is the topic of informed discharge. During informed consent, patients are informed of what can potentially go wrong; during informed discharge, patients are informed of the symptoms and signs that would indicate something wrong may be happening. They should also be given a sense of urgency of the response required and where best to seek medical attention. The information should be tailored to each patient and clinical situation.

In the emergency room setting, for many patients there are diagnostic uncertainty on an initial/subsequent visits. These patients should be made aware of this uncertainty—what is known and what is unknown—so that any continuation, escalation, or change in symptoms may prompt reevaluation. Just like informed consent, a discussion between physician and patient is warranted; any detailed explanatory pamphlet or video would not suffice. Documentation of the advice provided on discharge should be documented in the medical records.