Today we’re going to talk about Level 1 gastroenterology content.
Let’s just review. Remember, with Level 1 content we need to recognize what’s most likely going on and go get help. What would make it most likely? There are signs or symptoms and there are risk factors. If it’s most likely a red light or Level 1 disorder, we get help.
Now, today we’re going to talk about gastroenterology. That includes caustic ingestion, intussusception, ischemic bowel, large-bowel obstruction to include a toxic megacolon, esophageal varices and that includes Mallory-Weiss tear, pyloric stenosis, hepatitis, anal abscess/fistula, celiac disease, cholangitis, cirrhosis and colon cancer.
Looking at these globally, as someone who’s worked emergency medicine, you know Mallory-Weiss isn’t that big of a deal or at times neither is an anal abscess. I’m not sure why the NCCPA is saying, “Hey, go run and get help on these right away.” But that’s irrelevant. It’s what’s going to be on our boards and what they’re disclosing. This is what we have to study.
Ingestion of Caustic Substance
Caustic ingestion means someone swallowed or intentionally drank or, I guess, from an abuse case, was made to drink some kind of cleaner like a drain cleaner. They would have burns in their upper airway but it would typically be caustic ingestion. You should be able to see lesions in the mouth and they will look quite sick because it will burn a hole in their esophagus. They’ll have kind of like a Boerhaave Syndrome, where they have hydrochloric acid flowing into the mediastinal space and they’ll look incredibly sick. Someone who ingested something that’s caustic that may burn their esophagus, is something we need to get help for.
This typically occurs in kids, and it happens because of their mesenteric lymphadenopathy, which is just swollen lymph nodes in the belly – it’s not anything bad. An infection in the lymph nodes made them a little bit swollen. Their bowel then telescopes. These are kids that are going to have what’s described as colicky-like pain, which means they have really, really, really bad pain. The kids lift their knees up to try to decrease the pressure and then the pain completely goes away. What happens is, as the bowel telescopes, the bowel becomes ischemic and they have agonizing pain. It’s kind of like intermittent ischemic bowel in a child. This is where they classically describe current jelly stool and that’s blood and mucus mixed together. If you have a kid that has intermittent belly pain where it’s really, really, really, really bad and then nothing. Really, really, really bad, then nothing, we have to think intussusception. We go get help.
Ischemic Bowel Disease
This comes in two forms: acute versus chronic. Any time you do not get blood flow to an area of your body that’s supposed to get blood flow, the pain is agonizing. Same thing with ischemic bowel. They’re going to have agonizing pain. It could be either acute or it could be chronic.
Acute classically is from atrial fibrillation, where the heart flicks off a clot because of the irregular heart rate and the irregular beating. The patient gets in an embolic phenomenon, where they have agonizing pain but it would have come on very acute. Embolic phenomena are acute in onset. If they ask this in a question, they’re going to talk about the irregular heart rate. That would be one of the risks.
If it’s a chronic mesenteric ischemia, this is someone who has phantom belly pain. You can’t figure it out. Normally they’re older, normally they have some kind of vascular disease. Classically, it’s a smoker, diabetes, where 20, 30 minutes after they eat they get such agonizing belly pain that they stop eating. It’s almost like they get an ice cream headache but in their bowel. They’ll have very significant weight loss because the pain is so bad they just don’t eat.
Those are going to be the presentations of ischemic bowel. They will have no rebound, guarding or rigidity because it is a pain out of proportion to exam. Every time I’ve seen them clinically, I thought they were malingering because they’re writhing so much in pain but they have a really soft exam.
Large Bowel Obstruction and Toxic Megacolon
There are large bowel obstruction or toxic mega colon. They’ll have no bowel sounds whatsoever. They’ll have distended belly. You should do a rectal exam to see if they have an obstruction because normally it’s an obstruction in the sigmoid, but they’ll have a distended belly, no vomiting. If you put down an NG tube, it does not make their belly go down. It doesn’t take this distension down.
Large bowel obstructions at the ileocecal valve, if that stays closed, are a closed loop. Their bowel fecal material dumps into the sterile peritoneum and they’re very sick. If that ileocecal valve pops open, the patient will vomit and the vomit will smell like feces. If someone vomits and it smells like feces, that’s a large bowel obstruction and we go get help. If you put an NG tube in somebody and it doesn’t depress their stomach, if it doesn’t take the pressure down, you have to think, it’s not small bowel, it’s got to be large bowel and that ileocecal valve is closed. You need to get a supervising doc or a surgeon involved right away.
Esophageal Varices and Mallory-Weiss Tear
Both of these are upper GI bleeds. Esophageal varices is classically linked to someone with portal hypertension. That’s almost always from cirrhosis due to alcoholism or hepatitis. These are people that are vomiting. Be very careful about ever dropping an NG tube down someone with esophageal varices because it could hit that blood vessel and make them bleed out. If you’ve never seen someone die of an upper GI bleed, it’s painful and hard.
Beware of something, guys. I think this is very important. The most sensitive test for an upper GI bleed is where you put an NG tube in somebody and you evacuate the stomach and you get coffee ground emesis out. That’s great but you’re not done. There are a lot of PAs who think once you drop an NG tube and you get coffee ground emesis out, you’re done. You are not done. What you do then is you detach the NG tube from the suction catheter then flush it with 100 ccs of saline and then suck the saline back out a minute later. If you get saline out, that implies that the bleeding has stopped. They had some bleeding but now it’s stopped. You put them on a proton pump inhibitor and everything’s great.
If you get pink Kool-Aid out, pink lemonade, something that looks like there’s a faint amount of blood, they’re actively bleeding and that’s concerning. We call that technique gastric lavage. Gastric lavage is the most sensitive way to detect an upper GI bleed. Those are typically from peptic ulcer disease, from H pylori or NSAIDs.
Pyloric stenosis is classically in a five-week-old child that’s just vomiting. They can’t keep anything down. You can’t send them home because they’re going to look really sick. If you have a five-year-old that’s rebound vomiting, immediately projectile vomiting, we get help.
Acute and Chronic Hepatitis
A patient comes in, it could be that they’re jaundice, could be right upper quadrant pain. The big thing is that you check liver functions and there are transaminases. Their AST and ALT are jacked up really high. When you we have some with elevated ASTs and ALTs, you go get help.
Now, when it’s a red light or Level 1 disorder, we don’t even have to know how to interpret those tests. If you have someone with right upper quadrant pain that is yellow, get a consultation. Who will we be concerned with? It could be a viral hepatitis or an alcohol hepatitis. Who’s at risk for viral hepatitis? Risky lifestyle behaviors such as homosexuality or I.V. drug use will increase an individual’s risk.
This kind of speaks for itself. If you have someone with a big anal abscess you should get help. The track mark needs to be managed appropriately. If you have someone with an anal abscess or fistula, we get colorectal involved.
Cholangitis is where Reynolds’ pentad comes in. Now, Reynolds’ pentad is right upper quadrant pain, fever and jaundice and that’s really what we look for. If you have someone who’s just yellow and they have no pain at all you need to image them because we’re thinking cancer. If they have jaundice and fever and pain, that’s when we think cholangitis.
Biliary colic is right upper quadrant pain. Normally it’s a female, 40 years old. If that 40-year-old female now has fever and jaundice at the same time with that right upper quadrant pain, that’s ascending cholangitis. We get help.
There will be right upper quadrant pain and at times jaundice as well. The risk factors would be hepatitis, typically due to drug use, or alcoholism.
This is someone who might have presented with diarrhea and/or constipation. You do a rectal exam and they have OB positive stool. We have to get a consultation on that. They need a colonoscopy for biopsy.
These are people that just don’t absorb things while they have all sorts of GI symptoms. It’s a tricky diagnosis and it goes very deep, meaning that it causes all sorts of different problems within the body. This is someone who has really difficult bowel patterns: diarrhea, constipation, malabsorption of some nutrients. Anybody who you are concerned about malabsorption-like syndrome, you should think celiac disease and talk to your doc about possibly running some diagnostic tests and/or biopsy.
Folks, my hope is that this red light content is getting you thinking about the things you only need to know preliminary information about. You need to know if, hidden in the question, they have these key features and it makes it most likely that you should get to get your doc. I cannot fathom a test where a number of answers aren’t going to be get immediate supervising physician consultation because that’s what we do anyways clinically. That’s really how they’re going to have to structure the questions.
Good luck in preparing for your boards.