Category: Gastrointestinal Emergencies
Question Of The Day #19

Which of the following is the most likely cause of the patient’s condition?
- A) Pulmonary embolism
- B) Pancreatitis
- C) Peptic ulcer disease
- D) Gastroesophageal Reflux Disorder
All patients who present to the emergency department with chest pain should be evaluated for the top life-threatening conditions causing chest pain. Some of these include myocardial infarction, pulmonary embolism, esophageal rupture, tension pneumothorax, cardiac tamponade, and aortic dissection. Many of these diagnoses can be ruled-out or deemed less likely with a detailed history, physical exam, EKG, and sometimes imaging and blood testing. This patient presents with vague, burning chest pain, nausea, and tachycardia on exam. Pulmonary embolism (Choice A) is hinted by the patient’s tachycardia, but the patient has no tachypnea or risk factors mentioned for PE. Additionally, the chest X-ray findings demonstrate an abnormality that can explain the patient’s symptoms. Pancreatitis (Choice B) and Gastroesophageal reflux disorder (Choice D) are also possible diagnoses, especially with the location and description of the patient’s pain. However, Chest X-ray imaging offers an explanation for the patient’s symptoms. The patient’s Chest X-ray demonstrates the presence of pneumoperitoneum. In the presence of NSAID use, this radiological finding raises concern over a perforated viscus from advanced peptic ulcer disease (Choice C). Peptic ulcer disease (PUD) is most commonly caused by Helicobacter pylori infection, but NSAIDs, iron supplements, alcohol, cocaine, corrosive substance ingestions, and local infections can cause PUD. PUD is a clinical diagnosis which can be confirmed visually via endoscopy. The treatment for PUD includes initiation of a proton pump inhibitor (H2-receptor blockers are 2nd line), avoiding the inciting agent, and H.pylori antibiotic regimens in confirmed H.pylori cases. The treatment for a perforated peptic ulcer with pneumoperitoneum is IV fluids, IV antibiotics, Nasogastric tube placement, and surgical consultation for repair.
Which of the following is the most likely cause of the patient’s condition?
— iem-student (@iem_student) October 30, 2020
References
- McAninch S, Smithson III CC. Gastrointestinal Emergencies. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw-Hill; Accessed August 18, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2172§ionid=165065027
- Nickson, C. (2019). Chest pain DDx. Life in the Fastlane. Accessed August 18, 2020. https://litfl.com/chest-pain-ddx/
You may want to read these
Acute Coronary Syndrome – https://iem-student.org/acute-coronary-syndome-acs/
Acute Management Of Supraventricular Tachycardias – https://iem-student.org/2020/01/10/acute-management-of-supraventricular-tachycardias/
Deadly ECG Patterns – 5 Can’t Miss ECG Findings – https://iem-student.org/2019/11/22/deadly-ecg-patterns-5-cant-miss-ecg-findings/
Cardiac Monitoring – https://iem-student.org/cardiac-monitoring/
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Question Of The Day #11

Which of the following is the most appropriate next step in management for this patient’s condition?
- A) IV antihypertensives and cardiothoracic consultation
- B) IV heparin
- C) Pericardiocentesis
- D) IV Fluids, antibiotics, and surgical consultation
IV antihypertensives and CT surgery consultation (Choice A) would be the best treatment for a patient with aortic dissection. This diagnosis is characterized by severe tearing chest pain that radiates to the back, along with hypertension. Risk factors include tobacco smoking, uncontrolled hypertension, trauma (i.e. rapid deceleration), and connective tissue diseases (i.e. Marfan syndrome). Other than chest pain with radiation to the back, this patient lacks the other risk factors for aortic dissection, making Choice A less likely. IV heparin (Choice B) would be the correct choice for the treatment of pulmonary embolism and acute coronary syndrome (i.e. NSTEMI). Both of these diagnoses are possible, but a chest CT scan with PO water-soluble contrast is not the gold standard for diagnosing PE or ACS. A CT Pulmonary angiogram is ideal for PE diagnosis, and an EKG along with troponin levels are ideal for ACS diagnosis. Pericardiocentesis (Choice C) is the treatment for cardiac tamponade. The patient’s vitals show no evidence of obstructive shock, and there is no history of penetrating chest trauma, pericardial effusion, end-stage renal disease, HIV, lupus, cancer, or other risk factors for cardiac tamponade. Choice D outlines the best course of action to take in a patient with esophageal rupture, which is the disease described in the question stem. This condition can occur spontaneously after forceful vomiting causing high pressures in the esophagus (Boerhaave syndrome). In this situation, the chest pain typically begins after the onset of vomiting. Other etiologies of esophageal rupture include deceleration injuries and penetrating trauma (i.e. gunshot wounds, iatrogenic via esophagogastroduodenoscopy (EGD)). A “Hamman’s Crunch”, subcutaneous emphysema, fever, and signs of shock can be seen on exam. Diagnosis is confirmed by an esophagram or a CT scan of the chest with water-soluble oral contrast (i.e. Gastrograffin). Esophageal rupture is a life-threatening diagnosis as esophageal contents can spill into the mediastinum, causing mediastinitis and septic shock. The treatment is typically surgical with the repair of the perforated segment and drainage of fluid collections. Correct Answer: D
❓ Which of the following is the most appropriate next step in management for this patient’s condition❓CTS: Cardiothoracic Surgery, IV: intravenous. HT: hypertensive. FL: fluids, AB: antibiotics. A detailed answer will be found in https://t.co/XvqTTNtHys on Friday 11 PM UK time.
— iem-student (@iem_student) September 4, 2020
References
Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353§ionid=219641169
Nickson, C. (2019) Oesophageal Perforation. Life in the Fast Lane. Accessed August 17, 2020. https://litfl.com/oesophageal-perforation/
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Mnemonic for Right Lower Quadrant Pain
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17 years old girl, previously known healthy, vomited blood!
17 years old girl, previously known healthy, vomited blood!
This is an extremely serious symptom. Although this patient’s vitals were totally in the normal range, actively vomiting blood should warn physicians to act immediately to protect further deterioration in the patient. This may even include early airway protection because we simply do not want them to aspirate any blood. Having a normal vitals with this picture does not mean anything, and should not create a relaxing environment in the treatment/resuscitation bay. Honestly, this patient should go directly to resuscitation bed from the triage.
Steps are straightforward. Protect the airway if necessary, start oxygen like in any other critically ill patient during/for primary evaluation(survey). Open the two large bore IV line, give fluid bolus, order type, and cross, and be ready for any deterioration in the BP and starting blood (ORh-). Obviously, even starting a transfusion earlier may be appropriate. Activating GI team for emergency endoscopy is necessary. However, some institutions may not have this luxury 24 hours. Therefore, other measures such as mechanical compressions with Sengstaken-Blakemore tube and some medications can be an only option. This patients final diagnosis was Variceal Bleeding.
To learn more about management please read two GI bleeding chapters below.
Massive Gastrointestinal Bleeding by Dan O’Brien
Gastrointestinal Bleeding by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley
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Swallowed Coin
In case you didn’t encounter a 6-year-old patient who swallowed a coin today!
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From Experts To Our Students! – GIB
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From Experts To Our Students! – Clinical Decision Tools

Clinical Decision Rules chapter written by Stacey Chamberlain from USA is just uploaded to the Website!
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How to insert NG
Nasogastric Tube Placement chapter written by Sara Nikolic and Gregor Prosen from Slovenia is just uploaded to the Website!
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RUQ pain
In case you didn’t encounter RUQ pain today!
Sonographic criteria for acute cholecystitis
the presence of gallstones,
thickened gallbladder wall,
pericholecystic fluid,
sonographic Murphy’s sign,
common duct dilatation.
How many did you see in the ultrasound image except sonographic Murphy’s sign? Feel free to give your answers to comment section at the bottom of the page.
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Selected Gastrointestinal Emergencies

Acute Appendicitis
by Ozlem Dikme Introduction About 7% of the population develops appendicitis in their lives. Males are affected 1.4 times higher than females, and teenagers more
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Acute Mesenteric Ischemia
by Rabind Antony Charles Case Presentation A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with
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Biliary Disease
by Dan O’Brien Introduction The biliary system can be defined as the organs and ducts that create, transport and store bile and eventually release it
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Massive Gastrointestinal Bleeding
by Dan O’Brien Introduction Despite advances in diagnosis prevention and treatment, nonvariceal upper gastrointestinal bleeding is still a serious problem in clinical practice. The incidence
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Perforated Viscus
by Ozlem Dikme – Turkey Case Presentation A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of worsening abdominal
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A 35-year-old female with abdominal discomfort
A New Chapter Is Just Uploaded To The Website!
A 35-year-old woman presents to the emergency department with right upper quadrant pain of two hours duration. She awoke several hours after eating a large meal. Based on increasing pain and nausea she presents for evaluation. She denies vomiting, fever or dysuria.
Her past history is notable for diet-controlled type II diabetes, dyslipidemia, and essential hypertension. Her BMI is 33. Her only medication is lisinopril 10 mg daily. She has never had surgery. Her social history is unremarkable. She neither drinks alcohol nor uses tobacco. She has begun to diet and reports recent weight loss.
Her temperature is 37ºC, blood pressure: 110 / 70 mm Hg, pulse: 90 beats per minute. Physical exam reveals an overweight female in mild distress secondary to right upper quadrant pain. She cannot find a position of comfort and describes the pain as similar to labor pains. Pertinent exam findings include: chest exam normal, cardiac exam normal, abdominal exam demonstrates normal bowel sounds and no rebound in any quadrant. She has guarding to inspiration with palpation over the gallbladder which called positive Murphy’s sign. Rectal exam normal, stool is hemoccult negative for blood.
Pertinent lab values: glucose 110 mg/dL, alkaline phosphatase 120 U/L, alanine aminotransferase (A.L.T.) 25 U/L, aspartate aminotransferase (A.S.T.) 25 U/L, gamma glutamyl transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.
The emergency physician performs a focused right upper quadrant ultrasound and finds gallstones without associated gallbladder wall thickening or pericholecystic fluid. In addition, the patient has a “sonographic Murphy sign”: there is maximal abdominal tenderness when the ultrasound probe is pressed over the visualized gallbladder.
An I.V. was established, and the patient received an isotonic fluid bolus. In addition, ketorolac 30 mg I.V. and ondansetron 4 mg I.V. were administered.
Over the course of an hour symptoms resolved. Absent evidence of gallbladder inflammation or infection, she was discharged from the emergency department and referred to a general surgeon for elective cholecystectomy. She was advised that her pain might return but if it is prolonged, is associated with fever or jaundice she is to return to the emergency department.
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