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    Gi Emergency

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    girishkiran23

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    Gi Emergency

    Uploaded by

    girishkiran23
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    7 views29 pages

    Gi Emergency

    Uploaded by

    girishkiran23

    Copyright:

    © All Rights Reserved
    Download as KEY, PDF, TXT or read online from Scribd
    Download as key, pdf, or txt
    of 29

    GI EMERGENCY

    Common GI
    EMERGENCIES

    UGI BLEED
    HEPATIC ENCEPHALOPATHY
    LIVER FAILURE
    DILI
    UGI BLEED

    BLEEDING FROM ANYWHERE BETWEEN ORAL CAVITY TO DUODENUM


    Manifesting as:

    Hematemesis
    Malena
    Hematochezia
    1. PUD
    2. Esophageal or Gastric varix
    3. Portal hypertension related lesion
    4. Esophagitis
    5. Angiectasia
    6. Mallory Weiss tear
    7. Dieulafoy lesion
    8. Neoplasm
    Management of UGI BLEED

    RESUSCITAION:
    2 large bore canuula(14 or 16G)
    Infuse normal saline to keep HR<100 and SBP>100
    Target to keep Hb>7, Plt>50,000, PT<15. In CAD target Hb is 9

    ET Intubation:
    Ongoing bleed
    Altered sensorium
    Respiratory insufficiency
    Initial medical management

    PPI: 80mg stat followed by 8mg per hour infusion


    VASOPRESSORS: Octreotide or terlipressin
    Antibiotics in cirrhotic UGI Bleed
    IV Metoclopramide 30 t0 90 min before UGI endoscopy
    Saline lavage with orogastric tube help to evacuate blood clots

    Timing of Endoscopy:
    Hemodynamicalyy stable patient: with in 24 hours
    Unstable but resuscitable: with in 12 hours in ICU
    Unstable: with in 6 hours in OT
    Esophageal Varices
    Treatment of PUD:
    1a, 2a, 2b: inj Epinephrine with hemoclip
    1b and 2c inj Epinephrine is sufficient.
    3 no endoscopic therapy required

    Treatment of Esophageal Varices:


    Endoscopic band ligation
    Hepatic Encephalopathy
    Classification of HE

    TIME COURSE:
    Episodic
    Recurrent
    Persistent

    SPONTANEOUS OR PRECIPITATED

    TYPES OF HE:
    A: ALF
    B: Portosystemic bypass
    C: Cirrhosis or portal hypertension
    Precipitating factors of HE

    Infection
    GI Bleed
    Constipation
    Electrolyte abnormalities
    Dehydration - diuretics
    Excessive dietary protein
    Hypoglycemia
    Anemia etc
    Treatment of HE

    Treatment of precipitating factors


    Lactulose
    Enema
    Rifaximin
    Acarbose
    Probiotics
    Zinc
    Others: sodium benzoate, LOLA
    Acute Liver Failure

    Acute severe deterioration of liver function

    Jaundice: 3mg/dl

    Coagulopathy Altered sensorium


    Mortality: 40-90% if untreated
    3 phases of acute liver failure:
    Prodromal phase
    Icteric phase
    Hepatic encephalopathy

    Duration: 3 months, from onset of symptoms to hepatic encephalopathy.


    Classification based on the duration:
    From the onset of jaundice to HE interval
    Hyperacute: <7 days
    Acute: 1 week to 1 month
    Subacute: 1 - 6 months
    Chronic Liver disease: >6 months
    Causes of ALF
    Complications of ALF

    Neurological: Encephalopathy, intracranial hypertension and cerebral edema, brain herniation


    and death
    Hemodynamic changes and circulatory failure
    Infections
    Acute kidney injury: pre renal issues due to GI bleed, dehydration, direct injury due to bile
    salts causing AKI, sepsis
    Hematologic abnormalities: both bleeding and hypercoagulable state
    Management of ALF
    ICP MONITRING:
    Patients with hyperacute and acute presentation with ammonia level : 150-200
    Renal impairment
    Vasopressor support
    Sensorium not improving on mannitol, hypertonic saline, or after hyperventilation or
    hypothermia.
    Methods to modulate central blood flow:
    Elevate head of bed by 20-30 degrees
    Correct volume overload
    Maintain MAP 50-60 mmhg
    Hyperventilation to keep PaCO2 low
    Correct factors that increase ICP:
    Minimize head turning
    Treat agitation by paralyzing with intubation and sedation
    Treat hypotension
    Monitor seizures
    Correct hypoxemia
    Direct measures:
    Correct hypo osmolarity
    Mannitol (0.5-1g/kg bw) iv bolus
    Induce hypernatremia: Na: 150-155
    Liver Transplantation
    Antidotes

    Paracetamol: NAC
    HBV: Tenofovir
    Amanita: Silymarinb/penicillin
    Herpes Simplex: Acyclovir
    Lassafever, Yellow fever: Ribavarin
    Autoimmune hepatitis: steroids
    Wilsons: high dose peniccin or doxyxline
    Leptospirosis: penicillin or doxycycline
    Other Treatment: fluid and electrolyte, acid base disturbances and Nutrition
    Acetaminophen/Paracetamol toxicity treatment

    MCC of drug induced ALF in west


    Its an intrinsic hepatotoxin
    <4g /day: safe, upto 2g per day in CLD
    presents with hyperacute LF with high cerebral edema, high coagulopathy
    Features of injury starts from day 3, >AST/ALT while Bilurubin lebel are lower
    Centrilobular (zone 3) necrosis
    AKI seen in 70% cases, direct tubulotoxic
    15g: hepatotoxicity
    >20g: consistent with ALF
    Liver Transplantation

    Not all patients require liver


    Contraindications are:
    Prolonged raised ICP >40mmhg
    MODS with sepsis
    Malignancy
    Strict indications are needed:
    30% operative moratlity
    Require lifelong immunosuppressants
    Source of liver is scarce
    Indications and contraindications of liver transplantation
    Hepatic/primary ALF
    Drug related
    Acute viral hepatitis
    Budd-Chiari syndrome
    Autoimmune
    Pregnancy related
    Extrahepatic/secondary
    Hypoxic hepatitis-aka ischemic
    Lymphoma
    Infections- malaria
    Infiltrative diseases etc
    Criteria for Liver Transplantation

    Kings college
    Clichy criteria
    APACHE Score
    Liver Biopsy
    Serum lactate
    DILI

    Toxins can be:


    Industrial toxins
    Pharmacological agents
    Complimentary and alternative medicines
    Hepatic injury can be:
    Direct injury
    Immune response to the agent
    DILI can be suspected when:
    ALT >5xULN without symptoms
    ALT >3xULN with symptoms or TB> 2xULN
    ALP >2xULN
    Pattern of liver injury
    R Ratio: ALT/ ULN of ALT/ ALP/ ULN of ALP
    Hepatocellular: >5
    Cholestatic: </=2
    Mixed: 2-5
    Mechanisms of Liver Injury
    Alterations in Hepatic morphology produced by some commonly used drugs
    Cholestasis: rifampicin, nitrofurantoin, carbamazepine, TCAs, clopidogrel, nefidipine,
    lisinopril
    Fatty liver: amiodarone, valoproate
    Hepatitis: halothane, isoniazid, flucanazole, phenytoin, indomethacin, chlorthiazide,
    methyldopa
    MeIxed: amoxicillin-clavulunate, cotrimaxazole, clindamycin, azathiprine
    Toxic (Necrosis): paracetamol, carbon tetrachloride, yellow phosphorus, amanita phalloides
    Granulomas: quinidine, sulfonamides, carbamazepine, allopurinol
    Vascular injury: oxaliplatin, melphalan

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