A 50-year-old man with a history of hypertension, active smoking, and a laparoscopic Roux-en-Y gastric bypass 5 years prior presents to the emergency department with 4 weeks of upper abdominal pain that acutely worsened on the morning of presentation. He:
His abdomen is diffusely tender and he is guarding. He has:
Blood cultures are sent and broad-spectrum antibiotics administered. A CT scan shows a moderate amount of free fluid in the upper abdomen.
What is the BEST definitive management of this patient?
Correct Answer: D
The patient in this scenario has a perforated marginal ulcer. A marginal ulcer is a known complication of Roux-en-Y gastric bypass surgery at the anastomosis between the gastric pouch and the jejunum. An ulcer is usually formed on the jejunal side, and the greatest risk factor for marginal ulcer formation is smoking. As with all patients who present with intestinal perforation, a perforated marginal ulcer must be recognized promptly. As in this situation, patients with intestinal perforation may not present with the classic finding of “free air” on CT scan or abdominal Xray. Instead, they may have free fluid or fat stranding. In patients who present with peritonitis and manifest the hemodynamic effects of sepsis, even with more subtle CT findings, clinical suspicion for perforation must be high and these patients should be taken to the operating room urgently.
In this case, the patient has peritonitis and is septic, and solely admission to the ICU with serial examinations and antibiotics is not appropriate in the absence of operative intervention. Although nasogastric tube placement is reasonable, this is not sufficient to treat the underlying problem of a perforation. Endoscopy is appropriate for outpatient evaluation of a suspected marginal ulcer in a patient with occult anemia or pain, but it is not indicated in the setting of perforation. Finally, while the patient is tachycardic, she has no melena or hematochezia to suggest that she is bleeding. Although marginal ulcers can present with bleeding, particularly in patients on anticoagulation, those patients generally do not also present with peritonitis. Because this patient is not bleeding, a consult to interventional radiology for angioembolization would not be helpful.
A 66-year-old man presents to the emergency department with melanotic stools, dizziness, and hypotension. He is admitted to the ICU, his hemoglobin and blood pressure normalize after three units of packed red blood cells, and his melena slows down. Upper GI endoscopy and colonoscopy are performed, which do not show any source of bleeding. Shortly thereafter he develops more melena and a drop in hemoglobin. A repeat endoscopy, tagged RBC study, and CT angiogram all fail to identify a bleeding source, but hemoglobin again normalizes with two more units of packed red blood cells. The following day he again develops hematochezia, with a worsening transfusion requirement and associated hypotension.
Which of the following is the next best step to managing this bleeding?
Correct Answer: C
The general approach to GI bleeding should start with the ABCs, including confirming that the patient has large bore IV access and is in the appropriate clinical setting for close hemodynamic monitoring. Evaluation should begin with upper GI endoscopy and colonoscopy. When these tests are negative, it is possible that :
If bleeding persists a repeat endoscopy can be considered to catch an intermittent source of bleeding that may have been missed. If these are unrevealing, other diagnostic tests can be considered. GI bleeding is often intermittent, and in many cases does require multiple tests to identify and treat the site of bleeding.
The patient in this scenario has an intermittent, brisk bleed resulting in hemodynamic instability requiring continued transfusion. At this point, continued transfusion and just observing the patient is not appropriate given that the bleeding is ongoing, brisk, and now resulting in hemodynamic instability. A tagged RBC study can assist in locating slow, occult bleeds, but will only grossly localize bleeding when more brisk and will not allow intervention. It is generally not useful in hemodynamically unstable patients. Once blood pools in the small bowel, the study carries a false positive rate at downstream locations. In the patient above with a brisk bleed, a repeat tagged RBC study would be unlikely to yield new, helpful information. VCE has the potential to identify a bleeding source in the small bowel, but has many limitations. There is no way to mark the site of bleeding, the information is reviewed retrospectively, and in many cases the intestinal mucosa cannot be completely visualized. Other techniques available at some centers to evaluate the small bowel include push endoscopy, in which a pediatric endoscope is used to examine 50 to 70 cm past the ligament of treitz, or single or double balloon endoscopy that allows an endoscope to be advanced deep into the small bowel. Surgically, there is very limited ability to localize GI bleeding intraoperatively. Occasionally, intraoperative enteroscopy can also be used to look intraluminally at the small bowel but is difficult to perform and invasive. Surgery should very rarely be performed on patients with GI bleeding that is unlocalized preoperatively, as the capacity to identify the site of bleeding intraoperatively is very limited.
An angiogram has both diagnostic and therapeutic potential. A standard angiogram will demonstrate active extravasation if bleeding is greater than a rate of 0.5 mL/min. Most hemodynamically unstable patients are bleeding at this rate or higher. An angiogram can also be done in a “provocative” fashion with anticoagulants, vasodilators, and antifibrinolytics to encourage bleeding and assist with identifying the site. This does come with the risk of exacerbating hemorrhage, and a surgery team is available to assist in the event of uncontrolled hemorrhage. If the site of bleeding is identified at a focal area, embolization of the area of active extravasation can be performed. For this patient who is hemodynamically unstable and has already undergone multiple other diagnostic procedures, an angiogram gives the best chance of identifying and treating the bleeding source.
A 75-year-old woman presents to the emergency department with perforated diverticulitis and undergoes emergent surgery in which there is diffused fecal contamination. She is admitted to the ICU postoperatively, where she remains on broad-spectrum antibiotics and is hemodynamically stable. She is started on clear liquids on postoperative day 2. On postoperative day 4 her abdomen is distended, and she is vomiting and has no ostomy output. An abdominal X-ray shows diffusely dilated loops of small bowel.
What is the best next step in management of this patient?
Correct Answer: A
This patient has a postoperative ileus. Following any operation, there is a risk of postoperative ileus, and diffuse contamination is another risk factor. Additionally, opiates administered postoperatively may contribute to ileus. An ileus usually presents a few days after the operation with increased abdominal distention, nausea, and vomiting, along with minimal to no bowel function. The management of an ileus involves placement of a nasogastric tube for decompression, initiating intravenous fluids for resuscitation, minimizing narcotics, and electrolyte monitoring and repletion as needed. Often these will resolve on their own in several days, but if not resolving, particularly in the setting of a rising WBC or fevers, it may also be important to look for an underlying cause, such as abscess. At this point, there is no need for urgent reexploration. Enemas, while effective in the management of constipation, are not effective in helping resolve an ileus, as the issue is primarily one of reduced small bowel motility. Promotility agents are not effective in the management of ileus, and any delay in placement of a nasogastric tube (ie with attempted management solely with antiemetics) not only fails to resolve the ileus but may increase the risk of aspiration if the patient continues to vomit. Also, endoscopy is not necessary for diagnosis or treatment of ileus.
A 34-year-old man with a history of Crohn disease presents with foul-smelling drainage from his abdominal wall. He has experienced malaise and poor oral intake over the preceding 3 weeks and had been having worsening abdominal pain for 5 days. In the last 3 days, he noticed swelling of his abdominal wall superior to his umbilicus, in an area that began to drain foul-smelling, greenish drainage. The area has become erythematous and very tender. The drainage has increased in volume over the past 24 hours to the point that it saturates his clothes, and he has started to develop fevers, chills, and dark urine. On arrival he has the following vitals:
A CT scan shows oral contrast extravasation from the small bowel that exits at the site of drainage, but no drainable fluid collection in the abdominal wall.
Which is the most appropriate management at this time?
Correct Answer: B
This patient presents with a new enterocutaneous fistula (ECF). Patients with inflammatory bowel disease (IBD) are particularly prone to ECF formation. These often present following a prior operation but can also appear spontaneously, particularly in patients with IBD. When patients first present with an ECF, they are often volume depleted with electrolyte disarray from intestinal losses and can have sepsis. This requires broadspectrum antibiotics and drainage of any associated intra-abdominal abscesses if present. Depending on how proximal the fistula is, nutritional losses can be considerable. Patients should be started on TPN until the anatomy of the fistula is defined and output can be controlled. The anatomy can usually be defined with a CT scan with enteral and IV contrast, which has the added benefit of defining any undrained intraabdominal fluid collections. If the anatomy is unclear, a fistulagram can be performed, in which water soluble contrast is injected into the fistula’s external opening to identify the location of the fistula and any communication with any additional fistulas or abscess pockets. Wound care and control of the fistula effluent to minimize skin breakdown and manage output can be complex and may require the assistance of an enterostomal therapy or wound nurse.
In addition to identifying the location of the fistula, the cause and any factors that would inhibit closure should be identified. In this case, underlying IBD is the cause, and in these patients, medical treatment of the underlying Crohn disease should be optimized. Factors that can impair fistula closure include the presence of a foreign body (eg mesh used in herniorrhaphy), prior radiation exposure, undrained or untreated intraabdominal infection, malignancy as the cause of the fistula, distal intestinal obstruction, or immunosuppression. Whenever possible these perpetuating factors should be minimized or eradicated. When underlying factors cannot be addressed (for example prior radiation exposure), their recognition can at least allow accurate prognostication about the chances of spontaneous fistula closure and the need for surgery.
In any patient population—with or without IBD—principles of managing a new ECF include sepsis control, nutritional support, fluid and electrolyte repletion, and defining the anatomy and cause of the fistula. It is not recommended to take the patient to the OR urgently. The majority of ECFs will heal on their own, and if needed, surgery should be performed in a delayed manner when the patient has been well resuscitated, nutritional status is optimized, and intra-abdominal inflammation has subsided somewhat, often many months after the initial presentation. In this case incision and drainage is not needed as there is no drainable fluid collection in the abdominal wall on CT scan, but it is important to perform imaging with CT to evaluate undrained intra-abdominal or abdominal wall collections. Percutaneous jejunostomy tube would not be appropriate before fully defining the anatomy of the fistula. In this case, neither upper GI endoscopy nor colonoscopy would be beneficial, as we suspect this fistula to be located in the small bowel and there are more effective methods of localization that better depict the small bowel.
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