Obviously, we've heard a lot today about a lot of different GI conditions that physicians and APPs are going to encounter. This is kind of a potpourri of different problems. And when I say GI emergencies, I'm more referring to the fact that when you get the phone call for one of these, you don't necessarily have to do anything right away, but you have to come up with a plan, you have to come up with a solution. It may not require emergent endoscopy or anything like that. But these are the phone calls that you can't put on the back burner, you've got to come up with, you see the patient and come up with a plan fairly quickly. So that's what these cases all have in common. Okay, so we'll start out with a couple of quick polling questions. The first is, which of the following should prompt immediate endoscopy for removal of a foreign body? And your choices are a smooth metallic object in the distal ilium, a sharp five centimeter long metallic object in the esophagus, a one centimeter marble in the stomach or a single magnet in the stomach. That's great. So the majority of you recognize that something like that in the esophagus warrants immediate endoscopy and we'll talk about why that's important and why the other ones don't require urgent procedure. And the next polling question, what is the initial management of patients who have a high suspicion for acute cholangitis, IV fluids and broad spectrum antibiotics, cholecystectomy, endoscopic ultrasound, or percutaneous transsympathic cholangiography? So which would be the very first thing you would do for a patient with suspected acute cholangitis? So that's the exact correct answer for somebody with suspected cholangitis. All right, so let's go on to my slides, please. So these are what I kind of lumped in with what we would all consider GI emergencies and we'll go over some of these in a little more detail than others, but they would include food bolus impaction, foreign body, GI bleeding, cholangitis, sigmoid volvulus, and colonic pseudo obstruction. And as I said, when we get a phone call or when you receive a phone call with one of these, these are the ones that you kind of have to jump to action right away to figure out how to deal with them. So this dovetails nicely with Dr. Martin's talk, but the food bolus impaction is the one that oftentimes this is an after hours presentation and this is when you get the phone call where you just kind of hang your head because you know you're going to be doing something fairly urgently. It's defined as the acute onset of dysphagia due to obstruction of the esophagus and this is usually due to a piece of meat, chicken, pork, beef. The patient is unable to swallow liquids or manage their own secretions or saliva. So as Dr. Martin indicated, this does qualify as an emergency. The telltale sign when you walk into the room is that the patient will be holding a cup or a bag and will be frequently spitting into it or even overtly drooling. And the patient, they often appear pretty darn uncomfortable while this is going on. We've just reviewed some of the risk factors for food bolus impactions. It's thought that eosinophilic esophagitis probably accounts for half of these cases. And then the others are a combination of peptic strictures, Schottky ring, mass, or occasionally achalasia. Typical endoscopic appearance, when you take a look, would be something like this. You pass the scope into the esophagus and you see oftentimes there's fluid that's pooled above this area, but then you get to the area of the food bolus and there's a piece of meat, which usually completely obstructs the lumen. So obviously the most pressing reason to remove the food bolus is because the patient would like to be able to swallow again, and they're not able to swallow anything until the food bolus has been relieved. But there are actually more significant complications that can occur if the food bolus is not managed appropriately. Perforation can occur. This tends to occur in patients that have a more prolonged obstruction, especially if there's underlying eosinophilic esophagitis. Bleeding can occur usually just due to pressure, necrosis, or irritation of the lining of the esophagus. And then depending on how the patient is with managing their secretions, there can be aspiration from fluid coming back up from the esophagus. So the management of a food bolus impaction imaging is really only necessary if you suspect that there might be a bony esophageal foreign body. So if you think perhaps the patient swallowed a piece of meat that had a bone in it, and there's some concern that maybe there's esophageal perforation, you could consider doing, for example, a CT scan. But for the most part, this food bolus impaction equals urgent endoscopy. And there's a couple of ways of relieving the food bolus impaction. Usually we start with gentle scope pressure, where you advance the scope either alongside the food bolus or gently apply pressure to the food bolus. And oftentimes, this really results in passage of the food into the stomach, and then you're kind of done with things. If that's not successful, then sometimes the food does need to be removed through the mouth. And that's usually accomplished via extraction with either a net, forceps, or a basket. You can consider intubation if there's a large amount of liquid or food in the esophagus. For example, somebody with achalasia who has a lot of food that's built up in there, sometimes we will intubate for airway protection. One of the things that the emergency doctors, emergency physician, like to do is administer glucagon. This is a very limited benefit. And given the fact that many food bolus impactions occur in the evening after dinner, by the time the patient gets to the emergency department, it's 7.30 or 8 o'clock. And if the ER physicians, again, with good intentions, are trying to relieve the food bolus by giving glucagon, oftentimes two, three hours goes by, and by the time you receive the phone call, it's 11 o'clock or it's midnight, and nobody really wants to come in and take care of the procedure at that point. So we try to encourage our ER physicians, if there's a food bolus in and it hasn't relieved itself very quickly, then call us because we'll just come in and take care of matters. You can consider dilation at the time of a food bolus impaction, although if the food bolus has been in there for a period of time, there may be irritation, ulceration of the esophagus. If there's suspected eosinophilic esophagitis, that's an appropriate time to perform a biopsy because it might negate the need for a second procedure. The next topic I'd like to go over is management of the foreign body. And this could involve just about any part of the GI tract, esophagus, stomach, small bowel, or rectum. Esophageal foreign bodies typically require urgent endoscopy. You can see a kind of an interesting photo here of a spoon. We've pulled out some rather interesting things out of people's esophagus, including pieces of bone, glass, wood, dental appliances, especially in older patients can inadvertently swallow them. Coins can get stuck in the esophagus. This requires an urgent endoscopy because there is a risk for perforation or bleeding or even fistula formation. Obviously these are not things that you just pushed out into the stomach because they need to be removed. And so we use a combination of nets, snares, forceps, whatever we need to do to get a good grip of the object and remove it. Overtube is often required. Sometimes pulling up an object through the upper esophageal sphincter can be very challenging. And of course there's the risk of dropping it into the esophagus. And with depending on what the object is, we may consider intubation for airway protection again to avoid dropping the object into the patient's trachea. Ingested foreign bodies are dealt with a little bit differently. About 80 to 90% of ingested foreign bodies will pass. So it really kind of depends on what you're dealing with. And there are a number of criteria that have been looked at to ultimately want to know what's the chance that it's going to pass through without obstructing and what's the chance that it's going to cause a perforation along the way. Obviously you can see in this case, this is a razor blade in the stomach. This is not something that you want to allow to pass through the GI tract because it's likely to perforate somewhere. But there are a couple of general rules. And so an abdominal plain fill is typically helpful for evaluation of the foreign body to see what the size of it is. And so some kind of rough criteria that we follow. If it's wider than two and a half centimeters, it's probably not going to pass the pylorus. And if it's length is greater than five centimeters, it will generally not pass the duodenal sweep. So in those cases, endoscopic or possibly surgical removal is warranted. Sharp objects should be removed. If it's a single magnet, it should be fine. It should pass on its own. But if there's more than one, the concern is that the magnets will get into different parts of the GI tract and then attract each other and basically lead to a fistula between two different parts of the intestine. So multiple magnets usually warrants removal as do batteries because of the potential for causing corrosive effects to the lining of the GI tract. Small bowel foreign bodies are a little bit more challenging because many times by the time the patient shows up, it's already reached the point where we can't get to it with an endoscope. And again, 80 to 90 percent of adjacent foreign bodies will pass. So many times these we allow to go on their own. If it's the length is greater than five centimeters and it's in the duodenal bulb, it's certainly reasonable to try to remove that with the endoscope. And then again, we use the same rules regarding sharp objects, magnets and batteries that we do for the gastric foreign bodies. Some of the more interesting cases that we get called for are patients that have foreign bodies in the rectum. And we have seen quite a few interesting things that have made their way into the rectum. If there's no evidence of perforation and you think after reviewing what the object is that you can remove it with the endoscope, it's certainly worth a try. If that's not possible, then oftentimes these patients can go to the operating room and trans anal removal can be attempted where the surgeon performs basically put in a couple anal retractors and attempts to resect that way. Occasionally, a laparotomy is necessary for depending on what the foreign body is. We had an interesting case just a couple of weeks ago. This is actually from clinical endoscopy, but a patient came in with a golf ball in the rectum. Dr. Bakari took the phone call. And you can see on the plain film that there's a clear outline of a golf ball and you can see on the CT scan that there is a golf ball within the rectum. Options here would include attempting endoscopic removal or having a surgeon take the patient to the OR for attempted trans anal removal. In the case reported in this case, you can see that they were actually able to remove it endoscopically using the panel A, that's actually a Roth med, it looks like they weren't able to quite get around it with that. But then they ended up using a basket that we actually used to remove gallstones and if you, our biggest baskets would probably fit around a golf ball and were able to to resect or remove the golf ball without the patient having to go to the OR or without having to require surgery. So the take home message with any type of a foreign body is you have to be flexible and you have to kind of think a little bit outside of the box sometimes in terms of figuring out the best way to get the foreign body out if it actually needs to be removed. I'm not going to spend really any time talking about GI bleeding because obviously we had a complete talk on that so I'll just skip ahead to the next. I think acute cholangitis is worth mentioning because this is, you know, this is again a case where when you get the phone call you need to come up with an action plan. Acute cholangitis occurs usually in the setting of either a stone, a stent, or less commonly a stricture where there's biliary stasis that leads to initially bacterial colonization and then later infection of the biliary system. These patients typically present with Charcot's triad although only 50 to 75% will have all three of those but they oftentimes have some combination of fever, jaundice, and abdominal pain. We typically will, when determining how urgent intervention is, we'll do an assessment of disease severity. We can divide these into three different categories. Severe suppurative cholangitis, these are the really sick patients. These are the ones with hypotension, altered mental status. They may be hypoxic. They may have azotemia, acute kidney injury, coagulopathy, thrombocytopenia, and these are the patients who simply can't wait. Something needs to be done promptly. Then there's moderate acute cholangitis where the patient has fever and leukocytosis or they're older, have an elevated bilirubin, have hypoalbuminemia, and then mild acute cholangitis when none of the above criteria are met. When I get a call from a referring physician or an ER doc regarding a patient like this, this is the information that I'm asking them about. I'm trying to make an assessment of just how sick the patient really is. The initial treatment, the most important thing is to initiate IV fluids and broad spectrum antibiotics. Fortunately, about 80% of patients respond to conservative management. Even if the patient is a little bit hypotensive when they come in or has a leukocytosis or fever, oftentimes when you give antibiotics and IV fluids within a short period of time, the patient looks better, they feel better, the fever has come down, and you've got a little bit of time before you need to take the next step. Definitive treatment involves decompression of the biliary system, and that is usually accomplished by ERCP with biliary sphincterotomy and stone extraction if a stone is present. Occasionally, we will also place a temporary plastic biliary stent. That is largely determined by how adequate you feel that the drainage is. If there was an obstructing stone and you do a big sphincterotomy and you get very good drainage, you can oftentimes bypass the need for a stent and avoid the patient having to come back for another procedure. This is typically accomplished within 24 to 48 hours if the patient is stable. But if you have any of those clinical signs that the patient has severe, suppurative cholangitis, this may need to be done urgently because there is mortality that can be associated with acute cholangitis if not treated appropriately. In rare cases, patients will require other routes to decompress the biliary tree, such as PTC or surgery, but those are much less commonly utilized. Sigmoid vulvus is another phone call that we will sometimes take where they're asking for kind of urgent GI intervention. This occurs when there is an air-filled loop of sigmoid colon that twists on its mesentery. And this results in luminal obstruction and with time, even vascular compromise may occur. And these patients show up with abdominal pain. Their abdomen is typically very distended. There's nausea and vomiting because of the obstruction. Oftentimes you can make a diagnosis based on a plain film. As you can see in this image here, there's a large dilated structure, which is the colon. Oftentimes it kind of points up towards the left upper quadrant, but abdominal CT is the most accurate test for making the diagnosis. So this is derived from up-to-date. It's actually a very nice kind of flow sheet for how you would manage a patient with a sigmoid vulvulus. The first question is whether or not the patient has any evidence of peritonitis. So if the patient has peritonitis on physical exam, or they've got evidence of perforation or dead bowel on imaging, there's really no role for endoscopic intervention. The patient needs to go to immediate surgery where they'll either get a subtotal colectomy or possibly a segmental colonic resection. If the patient looks stable, they don't have any peritoneal signs on exam, imaging doesn't show any evidence of perforation, it is reasonable to attempt endoscopic detortion. And basically that just involves passing a colonoscope. As you pass it through the area where the vulvulus occurs, you can actually see the scope pass into usually a dilated loop above that. That can be effective for temporizing the patient and relieving the vulvulus. Typically from that point, we do recommend that the patient have some type of an intervention to prevent it from coming back again, because these patients have long redundant sigmoid colons. And oftentimes, if you don't do something more definitive, they're going to be back with the same problem again. And the options include things like a sigmoid colectomy during that admission. And then there are some potential endoscopic therapies that may be attempted as well. Okay, and we're just kind of flying through here. This is actually the last one that I want to talk about, colonic pseudo obstruction, also known as Ogilvy syndrome. And this is another one of those phone calls that warrants kind of urgent attention. Typically the phone call is that a patient came in with some type of other medical problem like a neurologic orthopedic condition, and now has a very distended abdomen, and oftentimes has significant pain. Abdominal x-ray will show something similar to what is seen in this where there's acute colonic distension, but there's no obvious obstructing lesion. And you can see colons 8, 10, 15, 18 centimeters in diameter. And again, most of these patients have underlying comorbidities. Most of the patients are older. They've come in for some type of neurologic or orthopedic condition. Oftentimes they're associated electrolyte abnormalities, and they may be on narcotic medications or other medications that can slow down colonic motility. And the reason why this is kind of an urgent sort of management issue is because there is a risk for perforation of the colon, probably more associated with the duration, but also the size of the colon probably contributes as well. If the patient looks stable, they're not particularly tender on exam. Usually we start with conservative management where the patient has made NPO, given IV fluids. You can attempt NGD compression, although if there's not any small bowel distension that may or may not have a big effect, although it can prevent additional air from getting in from the top end. But then it's important to try to identify any precipitating factors. So oftentimes these patients are hypokalemic, so correction of potassium with potassium can be helpful. Try to avoid anything that might slow colonic motility, narcotics, calcium channel blockers, and try to increase the patient's mobility, which sometimes is not an option if they just had major hip surgery or just had some type of a neurologic issue. But we try to correct anything that's reversible. If there's no improvement, there are other options, including neostigmine, which is designed to cause a rapid evacuation of the colon or colonoscopic decompression. And either one of these is an acceptable treatment option for patients with colonic pseudo obstruction. If treatment fails or if the patient has peritoneal signs or severe pain, then these patients end up requiring surgery where either a sarcostomy or a colectomy can be performed. So just to wrap up the last talk of the day, these are some practice pearls from the GI emergency talk. GI emergencies typically warrant at least prompt diagnosis, a treatment plan, and management. Food bolus impactions pretty much equal urgent endoscopy. Management of foreign bodies really depends on the size, shape, and location, and you need to have a kind of a creative mind sometimes when dealing with these foreign bodies. Patients with acute cholangitis, most important thing is to give antibiotics and IV fluids as approximately 80% will stabilize. Sigmoid volvulus may be managed endoscopically if there's no evidence of peritonitis. And you really should reserve neostigmine and colonoscopic decompression for those cases of colonic pseudo obstruction that fail with conservative therapy.

GI emergencies

food bolus impaction

foreign body ingestion

acute cholangitis

sigmoid volvulus

colonic pseudo obstruction