GI chest 2025

  • GI bleed

  • classically, ligament of Treitz is used to differentiate between upper and lower GI bleed

  • positive bloody aspirate can help decrease suspicion for lower GI bleed

  • non bloody aspirate is not necessarily a rule out. Duodenal ulcers may not reflux blood into stomach

  • if unstable: transfuse

  • if stable use goal of 7, except for CAD patients (MINT study)

Risk

  • AIM65 good for mortality prediction

UGIB

  • 10-15% patients, lesion not found
  • omeprazole vs placebo. IV PPI very important
  • neutral gastric pH is critical for stability of clot formation
  • intermittent PPI preferred over ggt
  • erythromycin 30-90 min before procedure. Does not improve other outcomes
  • octreotide: decrease gastric acid secretion and blood flow. Really only if EGD not available
  • this is for non variceal bleeding
  • very early not necessarily better than 24 hours
  • unstable patients may benefit from very early intervention. However, first step is always stabilize and resus
  • if patient decompensating, scoping is next
  • this is for stable patients
  • this is for non variceal bleeding

  • adherent clot: 25-30% chance of rebleed
  • visible vessel: 50% rebleed risk
  • active bleed: 90% chance rebleed. Keep in ICU and monitor for extra day
  • new powder, sprayed on surface of bleed
  • 2nd endoscopy if rebleed
  • PPI better than placebo and H2 in preventing clinically important bleeding (hemodynamic instability, EGD intervention needed)

Variceal bleeding

  • don’t over transfuse
  • people with continued bleeding are found to have higher pressure gradient, which can be from over transfusion
  • vasopressin is helpful but at the dose required can cause systemic vasoconstriction and other side effects
  • continue to use after hemostasis
  • variceal bleed, very early EGD
  • banding is superior
  • patient needs to be intubated
  • Minnesota tube has esophageal port could be better for proximal suctioning
  • salvage therapy
  • great for very high pressure (> 20 mmHg)
  • TIPS increases flow to right heart and can worsen other hemodynamics (TIPS can cause portopulmonary hypertension)

LGIB

  • first step is rule out UGIB

C Diff

  • must have diarrhea
  • must have clinical suspicion
  • screening + confirm test
  • toxin B produces symptoms
  • megacolon

  • fulminant
    • increase vanc dosing
    • consider adding rectal vanc if ileus
    • IV flagyl
    • do not give fidaxomicin
    • get EGS on board for potential surgery

Pancreatitis

  • amylase with short half life, stick around for 2-3 days. Lipase can stick around up to 2 weeks
  • amylase: not elevated in 20% of cases. People with alcoholic pancreatitis might not have elevated amylase (just not able to make any) and also in 50% of hyper triglyceride pancreatitis (triglycerides interferes with amylase assay)
  • moderately severe: peripancreatic fluid, necrosis, pseudocysts
  • 20cc/kg bolus + 3cc/kg/hr vs 10cc/kg bolus + 1.5 cc/kg/hr
  • tube does not need to be post pyloric
  • TG with lactic acidosis, hypocalcemia: consider plasmapheresis
    • treat with insulin gtt until TG < 500