080. Esophageal Emergencies, Gastroesophageal Reflux Disease, and Swallowed Foreign Bodies

Peptic Ulcer Disease and Gastritis

H2 blockers: histamine receptor. 1-3 hr peak. Tolerance develops – will have to increase the dose.

PPIs: inhibit H/K ATPase, work with acidic environment. No tolerance – thats why drips work.

UGI

PUD 50% of causes, varices in 10%. Tx for improving clot stability. Increased acid, less likely to form clot.

PPI vs H2 – meta-analysis 11 studies – end point persistent / recurrent bleeding. 6.7% in PPI vs 13.4% in H2. No difference in mortality. No difference in need for surgery. No comment of method of delivery.

Conclusion: PPI superior for H2 blocker.

H2 vs placebo in meta-analysis in 30 trials. 1 out of 5 and 1 and 4 placebo, no change in mortality, no difference of significance, no need in UGI.

PPI: Cochrane of 24 trials: sign reduction rate of re-bleeding, surgery, no difference in mortality.

PPI > H2 blocker for PUD.

Oral PPI for PUD bleeding. IV vs PO, 80mg q12 vs 80mg bolus with 8mg/hr IV dosing x 3d. No difference in rate of re-bleeding. Only 25 pts.

Larger study 112 pts. Prilosec 40mg q12 x 3. No diff rebreeding, transfusion, transfusion, mortality. Patients had low-risk stigmata on EGD. No active bleeding, clot was not adherent to ulcer. Unable to get in the ED.

We want to prevent the re-bleeding by increasing the gastric pH.

GERD

Ranitidine (zantac) 30d $4, Lansoprazole 30d $20, omeprazole (prilosec) 30d $21, pantoprazole (protonix) 30d $162, esomeprazole (nexium) 30d $173, aciphex >$200

Lansoprazole vs Ranitidine: GERD tx. 901 pts confirmed GERD. either dose of prevacid significantly reduced symptoms compared to ranitidine. Called pts back weeks later and showed better improvement.

Omeprazole vs ranitidine. 138 vs 130 pts. Called back. Omeprazole decreased symptoms. PPI spent less in medical expenses – actually SAVED money.

PPI intermittently? 14 trials. effective for mild sx and non erosive GERD, ineffective for erosive GERD.

PPI may take 5 days for acid suppression. PPI not as effective given WITH H2 blocker (will raise pH and make PPI less effective – consider taking H2blocker during the day and PPI at night). No evidence that any specific PPI is superior. Patient response varies between PPIs. Consider prevacid or prilosec though be careful for higher price.

No evidence that a Rx PPI is necessary.

PUD

PPI healed fast than H2 blocker. Newest PPs healed faster than omeprazole, though not significant (a couple days).

Resources

eMed Home – Jack Perkins – Are PPIs better than H2 blockers Video – 26min

Esophagus Foreign Body
Flat on AP view, on its side on lateral view. Typical board question.
Most are witnessed. Few are symptomatic. May have chest pain or dysphagia.
Lodge in areas of psychologic narrowing: Cricopharyngeal muscle (C6 – MCC Peds), aortic arch, or LES (T10 – MCC Adults). Coins most common.
Fishbone ingestions – some fishbones can be seen on X-ray, though poor utility/accuracy of neck X-rays. – Cochrane Review – both sens/spec terrible.
If FB goes into stomach, 90% will pass. Serial X-rays outpatient.
Button battery: double ring density difference. Lithium batteries are the worse. Emergent Event and needs emergent treatment. Can perforate within 2 hours. Need to get out quickly.
Glucagon: moderate success (doses of 0.25mg IV). Try with gas forming water agents with glucagon. Given antiemetic as well. Feel like its worth trying. There is a foley catheter technique, though be careful with aspiration with possible airway disaster.
Intestinal Foreign Body
Intervention only: sharp, long (>6cm) diameter > 2cm, multiple magnets in the esophagus or stomach, patient showing signs of compromise.
Sharp object in the abdomen – if asymptomatic (no abdomen pain, n/v), need serial exams and admission. Likely will need CT scan as well. Surgery consult. No good literature on enemas.
Rectal Foreign Body
Male and mostly 40-50s. Enemas and catheters to aid in removal still controversial. Avoid retrieval of sharp objects unless prepared to deal. Do X-ray first.
If delivered, don’t assume it did no damage. Observaton and scope post extraction. NEED TO OBSERVE.
Relaxation / sedation is the key. Valsalva or suprapubic push and two intrarectal fingers to pass sacral prominence.
Foley trick to reduct suction with gentle traction. Time and gentle traction are key.
Stuart Swadron – most successful: sedation and small hands. Foley and other catheters don’t work. Recommend procedural sedation – proposal / versed.
Other Foreign Bodies 
If FB very superficial impaided, you can just cut the skin and repair the laceration rather than worrying about splinters when passing it through.
Fishhooks – get a quick X-ray. If deep/eye/more serious, consult. Techniques – string yank – just pull it out – yank once. Usually with superficial.
Advance and cut: Cut at end and push through. The better solution. Give tetanus. Irrigation is key as well.
PPI vs H2 blocker

Ranitidine (zantac) 30d $4, Lansoprazole 30d $20, omeprazole (prilosec) 30d $21, pantoprazole (protonix) 30d $162, esomeprazole (nexium) 30d $173, aciphex >$200

Lansoprazole vs Ranitidine: GERD tx. 901 pts confirmed GERD. either dose of prevacid significantly reduced symptoms compared to ranitidine. Called pts back weeks later and showed better improvement.

Omeprazole vs ranitidine. 138 vs 130 pts. Called back. Omeprazole decreased symptoms. PPI spent less in medical expenses – actually SAVED money.

PPI intermittently? 14 trials. effective for mild sx and non erosive GERD, ineffective for erosive GERD.

PPI may take 5 days for acid suppression. PPI not as effective given WITH H2 blocker (will raise pH and make PPI less effective – consider taking H2blocker during the day and PPI at night). No evidence that any specific PPI is superior. Patient response varies between PPIs. Consider prevacid or prilosec though be careful for higher price.

No evidence that a Rx PPI is necessary.

References/Resources

eMed Home – Jack Perkins – Are PPIs better than H2 blockers Video – 26min

USC Grand Rounds – ENT Foreign Bodies – Kwon, Oct 3, 2013

080. Esophageal Emergencies, Gastroesophageal Reflux Disease, and Swallowed Foreign Bodies

076. Disorders Presenting Primarily with Diarrhea

Clostridium Difficile

General

Discovered in 1978. Incidence increased by antibiotic use, increased colonization in hospitals, and use of PPIs. Some new risk factors include IBD, immunosuppression, pregnancy.

Two guidelines: American College of Gastroenteriology 2013 guidelines and the European Society of Clinical Microbiology and Infectious Disease 2014 guidelines.

Mild disease (per ACG): diarrhea as only symptom.

Moderate disease (per ACG): diarrhea + additional symptoms

Severe disease (per ACG): serum albumin < 3 g/dl + abdominal tenderness or WBC > 15000. Also includes one of the following: ICU admission, hypotension, temp > 38.5, ileum or abdominal dissension, AMS, WBC > 35000 or < 2000, lactate > 2.2, end-organ damage.

ESCMID does either severe or non-severe. Severe characteristics: fever, rigors, hemodynamic instability, ileus or peritonitis, mixture of blood with Cdiff, WBC > 15000, marked left shift, rise in serum creatinine > 50%, lactate > 5, reduced albumin < 30g/L

Diagnostic Testing

NAAT for Cdiff toxin such as PCR as superior to toxins A+B EIA testing. Repeat testing should be discouraged.

Mild-to-Moderate / Nonsevere Management

Treat if high suspicion even without testing back. Any inciting antibiotic should be discontinued.

Treat with metronidazole 500mg orally TID x 10 days. If allergic or pregnant, use standard dosing vancomycin 125mg orally QID.

Also consider Fidaxomicin 200mg orally daily for 10 days (newer – only recommended by ESCMID and expensive).

Use of antiperstaltic agents to control diarrhea should be avoided as they may precipitate complicated disease.

If unable to do oral, IV metronidazole 500mg TID x 10 days.

Severe / Complicated Management

Vancomycin 125mg QID x 10 days. Supportive care. Oral and enteral feeding to be continued unless ileum/distention. CT recommended for complicated CDI.

Vancomycin oral + IV metro is treatment of choice for severe/complicated with no significant abdominal distention. Vancomycin oral + rectally (500mg in volume of 500mL QID + IV metro for complicated CDI with ileum or toxic colon and/or significant abdominal distention.

Surgical consult when complicated with hypotension, signs of sepsis or organ dysfunction, WBC > 50000, lactate > 5, or failure to improve after 5 days.

ESCMID recommends Fidaxomicin 200mg orally BID x 10 days as well. Can also increase vancomycin dose to 500mg QID x 10 days.

Use of oral metro in severe CDI is discouraged. Vancomycin does not work IV; need to either do orally through PO or NG or rectal enema.

Recurrent Management

First recurrence can be treated with the same regiment. Second recurrence should be treated with pulsed vancomycin regiment.

Limited evidence for probiotics to decrease recurrence. Rate of recurrence is 10-20% within 8 weeks. Rate of second recurrence is 50%.

Did not mention fecal microbial transplant wherein fecal flora from healthy donor are transferred to the colon of patient with CDI and has been show to have very high cure rate (90%).

Other Recommendations

Anyone admitted with IBD should be tested.

Anyone pregnant with diarrhea should be tested.

Two probiotics help decrease risk of antibiotic-associated diarrhea (Lactobacillus rhamnosus GG an Saccharomyces boulardii), though have not shown to help with Cdiff.

Highest risk antibiotics: Clindamycin, cephalosporins, fluoroquinolones.

Alcohol-based hand hygiene does not reduce the amount of spores. Hand washing with soap/water recommended.

References

EMPractice Guidelines Update: Current Guidelines for Diagnosis, Treatment, and Prevention of Cdiff Infection

Inflammatory Bowel Disease

Ulcerative Colitis

– 25% just rectal, 10% can have pancolitis; continuous, mucosa only

 Crohn’s Disease

– Transmural, can be throughout the entire GI tract, ‘skip’ lesions. Can have stricturing/penetrating/fistulas.

Flare Up

Common findings: both usually have bloody stools

 Symptoms: diarrhea/constipation, rectal bleeding, tenesmus, abdominal pain/fever, fatigue, weight loss

 Causes? Smoking/stress/NSAIDs. abx, foods, non-compliance

Tests: 

UC: Check ESR and CRP – can follow progression of course. ESR > 30 usually moderate/fulminant state.

 CBC – check for anemia. ESR/CRP. Newer testing: Fecal calprotectin.

Check stool cultures; check C. Diff enzyme immunoassay or PCR – 50% likely reoccurrence

 If you look sick or ‘something is different’, likely need to do further imaging.

Consider abd X-rays for SBO or toxic megacolon. Barium enema can show thumb printing, though do not use it. Can worsen toxic megacolon or perforation.

Next step is CT.

Management

Diarrhea: avoid antidiarrheal agents, avoid anticholingerics – can precipitate toxic megacolon.

Rule out infection: stool cultures, sense 50-90%, consider giving 3-4 other sample containers to increase the sensitivity. CDiff PCR – sometimes 2 hour turn around.

 Aminosalicylates (5-ASA), oral 4-6g, NNT=6 for UC, NNT=11 for Crohns.

Abx: Only for Crohns, no real good data for UC. Good for septic complications, increased risk for CDiff SE. Usually Cipro/Flagyl.

Probiotics: some effect in UC, not as promising in Crohns. No real great benefit.

Steroids: hold off if possible. IV – hydrocortisone 100mg q8hr, Oral prednisone 10-40mg/d; NNT=3-5. Try to start as low as possible.

Other Drugs: Thiopurine (6-MP, AZA), Anti-TNF alpha antibodies, Methotrexate

Complications

Strictures, fistula, perforation, toxic megacolon,

Extraintestinal manifestations: arthritis, optho, derm, urinary, apthous ulcers

Surgery?

Obstruction, abscess, megacolon. 74% CD, 25% UC, colectomy is curative, complications with pouchitis.

Pregnancy?

Steroids and 5-ASA are safe. Women – no change in fertility

 Pediatrics?

Crohns > UC. Similar tx as adults.

 References

My IBD Flared Up – Steve Tantama, MD – AAEM 19th Scientific Assembly – 30min video

076. Disorders Presenting Primarily with Diarrhea