Gastrointestinal EMERGENCIES

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Gastrointestinal (GI) emergencies can crop up at any time — during a routine endoscopy, or as an admission via the emergency room. Experts agree — several situations constitute an emergency that requires immediate endoscopy. And some patient populations may need special considerations.

“The usual run-of-the-mill is esophageal bleeding or colonic bleeding,” says Kathy Greene, MSN, administrative nurse manager at Montefiore Medical Center in Bronx, N.Y. “Those are the two most common reasons for an emergency. The most unusual is when people get objects stuck in unusual places, like Coke bottles in the rectum.”

Endoscopy nurses will be expected to assemble all the items a physician might request during a procedure. “If it’s a bleeder, [you may need] the injector or the cautery or any medications they might use, such as injecting epinephrine if the patient has variceal bleeding. If it’s one of these ‘unusual’ episodes, we have different types of material to place over the scope, an overtube; so when pulling objects from the esophagus, you don’t tear the esophagus as they’re coming out,” she adds.

“The other emergency we get sometimes is for endoscopic retrograde cholangiopancreatographies(ERCPs),” she says. “When they have a stone in the duct, their labs go out of whack. So they usually try to do that emergently so the labs can come down to normal.”

“In pediatric gastroenterology, there are two situations requiring emergency endoscopy and one requiring urgent endoscopy: gastrointestinal bleeding, foreign bodies and caustic ingestion, respectively,” says Anthony M. Loizides, MD, assistant professor of pediatrics at the Albert Einstein College of Medicine and an attending physician in the division of pediatric gastroenterology and nutrition at the Children’s Hospital at Montefiore. “In terms of GI bleeding requiring emergent endoscopy, the most common emergency that we see in pediatric practice is usually upper GI bleeding presenting as coffee ground emesis or frank hematemesis, usually due to gastritis, esophagitis, helicobacter pylori infection or even peptic ulcer disease. What would make it an emergency is if the child is clinically unstable.”

Loizides recommends asking for a complete blood count (CBC), a type and cross, aminotransferases, albumin and a prothrombin time (PT) at the very least, and then performing an nasogastriclavage to ensure that blood is truly coming from the proximal to the ligament of Trewitz in the GI tract. Rarer causes of bleeding are varices, due to ongoing cirrhosis.

“Stranger still are vascular anomalies,” he says. “I had a child during my fellowship who had Blue Rubber Bleb Nevus syndrome. It is a rare syndrome composed of venous malformations. They are irregular blue or black macules or papules that look basically like blueberries on the skin, usually on the feet, and one can have similar lesions in the GI tract causing bleeding. In general, if one sees vascular anomalies on the skin, one gets concerned about vascular anomalies in the intestines causing bleeding. You may try to use cautery or even argon plasma coagulation to destroy them. But most of the time they do have involvement of the small intestine, so you would do a procedure in conjunction with a surgeon, in needing to resect sections. But that’s usually only kids who have extensive GI bleeding. Blue Rubber Bleb Nevus syndrome usually does not cause bleeding that requires emergent endoscopy, however.”

Other causes of bleeding include gastrointestinal duplications and Crohn’s disease. “But Crohn’s usually doesn’t present with extensive upper GI bleeding that requires an emergent endoscopy. Rarer is the Dieulafoy’s lesion, which is an artery right under the mucosa. The mucosa has eroded due to gastritis, and the artery ruptures,” he says.

A Mallory-Weiss tear may also be a cause of bleeding, or coagulopathy, such as in an infant who does not have sufficient vitamin K. A true emergency, however, is a spurting vessel. “There aren’t that many lower GI bleed emergencies unless the bleeding is extensive enough to cause instability, so a change in blood pressure is ominous in children. But the person who is tachycardic or dehydrated needs fluid or blood to keep their vital signs stable,” Loizides explains. “It really depends on the history and physical exam, and of course you want to know if it’s blood itself, because there are things that cause fictitious GI bleeding.”

Some infants may vomit blood that is actually maternal blood. Other children may appear to be vomiting blood from their gastrointestinal tract, but actually have a non-gastrointestinal source. For example, there was one child with aortopulmonary collaterals from prior cardiac surgery for his congenital heart disease that had excessive blood vessels to hypertrophy of blood vessels in his lungs. He was actually coughing up blood but appeared to be vomiting it. "The blood was coming out his g-tube, and appeared to be from his GI tract, but the source was pulmonary, not gastrointestinal," says Loizides. “Common things like JELL-O® or strawberries could cause what looks like blood. It’s the same thing for lower GI bleeds. If someone’s taking ampicillin, it can look like blood, or if they’re eating beets, or if it’s a young woman and she’s menstruating, that could be a confused lower GI bleed.”

Lower GI bleeding does not often constitute an emergency; it can be due to polyps, Crohn’s disease or ulcerative colitis.

Caustic ingestion may constitute an emergency as well; however this is less common, partially because there are not as many extremely basic substances available now, such as lye, which causes extensive necrosis in the esophagus and esophageal perforation. “Some kids required a colonic interposition, taking a piece of colon to function as an esophagus,” Loizides adds. “Caustic ingestions are less frequent, but they should be treated with care. The first thing is to find out what the child ingested and how long ago, and if they’re symptomatic. If they’re drooling, or have a hoarse voice, are unable to swallow, unable to tolerate fluids, then that’s cause for immediate endoscopy. There’s some controversy; some people say to do an endoscopy within the first 12 to 24 hours to take a look at the mucosa. You may start steroids to decrease inflammation, and antibiotics to prevent infection, or you may just watch and wait and give fluids by mouth. If kids aren’t symptomatic but there’s a history of caustic ingestion and it’s a substance known to have some basic substance in it but it’s not as bad as lye, most people at this point would still do an esophagogastroduodenoscopy (EGD) within 12 to 24 hours, earlier if there’s some drooling. One paper based it on symptoms; if they had drooling and vomiting, or drooling and stridor, that was predictive of more extensive damage to the esophagus.”

It is possible that doing a scope on these patients could cause more damage, which is one reason for the “watchful waiting” recommendation. “There’s no definite therapy; data on steroids is contradictory,” Loizides observes.

Substances that can cause problems include sodium hydroxide, as well as calcium or lithium hydroxide. One child, Loizides recalls, ingested hair relaxer. “It comes in an attractive cup; it is white and looks like icing. If the hair relaxer is taken out of the cup it’s sold in and is placed in a bowl or drinking cup, the child would not know the difference,” he relates. Other items include liquid hardeners, paint removers, and anything lyebased, such as dishwasher drying booster or industrial-strength detergent.

Foreign bodies are the remaining category of potential emergencies; the most commonly ingested are coins. “The rule of thumb is that quarters in less than two years of age usually don’t pass the pyloris. But in an older child, say five years of age, a coin will probably pass, and we can wait six to eight weeks before you go in and retrieve it endoscopically, unless of course they’re symptomatic. Greater than 2 cm in width and greater than 5 cm in length is not going to pass. Other things that are worrisome are nails larger than 1.5 cm.

“If you think they ingested something you can’t see, we recommend a radiologic study with contrast,” says Loizides. Other common things are food and meat impaction associated with strictures or inflammations, usually in the kids who had eosinophilic esophagitis. At that point, you could try to take the steak apart, but it’s hard, and some people give a little glucagon to relax the lower esophageal sphincter and push it through and then sometimes it will pass by itself. If they’re greater than 12 to 24 hours in the esophagus, one worries about perforation. Button batteries are another big thing; the high pH can cause quite a bit of damage, more so in the esophagus than in the stomach. If it’s in the esophagus, it should probably come out as soon as possible, and you shouldn’t try to induce vomiting because it could lead to aspiration and impaction in the respiratory tree,” he adds. “With symptoms like coughing, gagging, nausea, vomiting, chest and abdominal pain, you should take the battery out as soon as possible.

“A girl was admitted to our service after ingesting a toothbrush. She had chewed off the end of the brush so the bristle part was no longer there. She said she was distracted by the TV and swallowed the toothbrush. However, there is literature on toothbrush ingestions, and most of these are young women between the ages of 16 and 32, and they do it intentionally, because they have a history of bulimia and/or anorexia. The thought is they’re trying to make themselves vomit, but somehow gag and the toothbrush gets ingested.”

One patient vomiting blood had a hepatoblastoma that was resected; she also had radiation therapy. She kept coughing up fecal material; she then had respiratory distress that required her to be intubated, and each time she was bagged, medical staff noticed that her stomach distended. An X-ray revealed that her colon was filled with air, and she had a bronchocolonic fistula. It was resected, she developed cirrhosis from her original disease, then started vomiting blood. “We saw her again, did the endoscopy in the OR, the surgeons who had done the surgery came in, and she ended up having just an ulcer,” Loizides relates.

“If I look at adult endoscopy, I come up with one definitive true emergency, and that would be a patient with ascending cholangitis from an impacted gallstone,” says Brian Edelstein, MD, a pediatric gastroenterologist at Sinai Health System in Chicago. “The data clearly shows lives are saved by performing urgent ERCP and common bile duct drainage.”

“The literature suggests if someone has an active ulcer bleed, heater probe coagulation of selected ulcers plus epi decreases: (1)length of stay, (2)decreases units of blood transfused (3)decreases urgent surgeries and (4) shows a trend toward improving survival. There are no data on that in children, but if somebody was throwing up red blood, and they didn’t have a nosebleed, that would get me out of bed and to an urgent endoscopy,” he adds. “There are weird congenital conditions that can be definitively treated endoscopically — one is an antral web. It’s not an emergency, but it’s a pure indication for urgent endoscopy. There are also duodenal webs.

“Diagnostically, if someone has ingested an alkali and has a severe burn of the esophagus, it’s recommended they have endoscopy to assess the degree of the burn; that’s a bit of an emergency also, because if they drink something like Drano, and there’s a third- or fourth-degree burn, we know that the esophagus will stricture down quite a bit when it heals. We can put an NG tube in and keep the esophagus open so it heals around the NG tube.

“For rectal bleeding, it can be useful to determine whether somebody has colitis, vs. intussusception vs. a Meckel’s diverticulum bleed. If you have a child with rectal bleeding, eighteen months of age, who’s crying a lot, and we haven’t gotten any stool out, we do a quick flex sig to see if there’s colitis. If there is, then we know it’s not those two other relative diagnostic emergencies. We can also find if there is red blood in the colon, and then analyze that to see if it has fresh red blood cells, which would be more of a Meckel’s diverticulum; intussusception would be more senescent, with injured blood cells.”

Endoscopic medications do not differ greatly for children compared to adults, Edelstein says. “I tend to use Versed and Demerol. Demerol’s not so popular these days, but I still think it’s better than any of the other narcotics, and I deal with the nausea afterwards by giving Zofran. The longer they sleep after endoscopy, the less vomiting, I’ve noticed, so sometimes I’ll give a little extra Versed at the end so that they tend not to wake up and vomit. I just find Demerol more reliable as far as getting to a certain dose and it usually works, as opposed to fentanyl.”

Asked about general anesthesia, Edelstein answers that he rarely goes that far — only for ERCP does he regularly put children under. He sees no reason why an adult gastroenterologist should fear becoming a pediatric gastroenterologist, either; “They’re better endoscopists in general than we are by their sheer numbers, and I think they should feel comfortable having to deal with being forced into a corner. It’s like Churchill said: ‘There’s nothing to fear but fear itself.’ Adult gastroenterologists don’t have to temper the decision to use endoscopy; however, if they stick to the ones where there’s a clear-cut indication, they should not be afraid to do it if they feel they’ve thought it out, and they think they can clearly help somebody get to point of diagnosis sooner.”

He also recalls a patient with congenital Blue Rubber Bleb Syndrome. “There are these hundreds of venous malformations raised up like mulberries, so we’ve done combined endoscopic procedures where we’ve tried to band ligate them or burn them. Eventually, the frequency of blood transfusions can be decreased or even stopped.”

“I once had a patient who was a seamstress; she was hemming pants and accidentally swallowed a pin,” says Ann Showan, MD, director of strategic clinical affairs at Somnia, Inc., a board-certified anesthesiologist and professor of anesthesiology at the University of Pennsylvania Medical School.

“We knew it was an emergency, but we were all trying to remain as calm as possible because we didn’t want her to get into any unusual positions that would poke the pin from the esophagus into an organ.”

Emergency situations from foreign bodies, impactions or bleeding are a concern not just because of their emergent state but also because a “normal” upper endoscopy is done with the patient in a controlled setting, not having had anything to eat or drink from midnight the night before, so the stomach is empty. “Therefore, when the endoscope is introduced, usually under sedation, in the normal routine situation, there’s no food to slide back up the scope. With a moderate amount of sedation, the endoscope is tolerated nicely, and the patient doesn’t have too much of a gag reflex, because the sedation suppresses that,” Showan says.

“But in the emergency situations, one has to worry that any food or blood or foreign body could slide back up the esophagus alongside the scope, and then be accidentally introduced or breathed into the airway,” continues Showan. “The No. 1 concern after trying to figure out how to get a diagnosis has to be how we protect the airway.”

Securing the airway is paramount in many cases, Showan says. “If the situation is viewed as moderately complicated, if a patient is a candidate for a scope by a skilled endoscopist with a tiny bit of amnestic medication, such as Versed, the patient retains the cough reflex. Some people would probably be comfortable with a limited endoscopy under very light sedation, and no obtunding of the reflexes, so the patient would still retain the ability to cough anything out of the airway.”

In emergencies, in order to achieve a clear look at the esophagus and stomach, it is necessary to protect the airway first. “That means that general anesthesia has to be induced so the patient can tolerate the placement of an endotracheal tube. The patient would be intubated in many cases first, because it’s too dangerous in general to anticipate doing a lot of work in the esophagus, with the patient coughing. The unsafe tendency would be to sedate the patient more, but the cough reflex goes away, and then it would be very hazardous to proceed with a full stomach,” she explains.

“Anesthesia by propofol is commonly used for sedation in the GI suite, and it can also be used in larger amounts to initiate general anesthesia,” she says. “That’s one of the concerns many people in anesthesia have, because propofol can go on so easily to general anesthesia. The sedating practitioner has to be very careful. It’s short-acting; we’re talking minutes after a bolus. It’s an ideal situation for an emergency, because a patient can receive an intravenous bolus, be totally under general anesthesia for the placement of an endotracheal tube, and then can be maintained on the general anesthesia-type infusion while the endoscopy goes forward.”

In order to place an endotracheal tube when the patient has a full stomach, several maneuvers are required, as well as a second pair of hands for the anesthesia provider, Showan says. “A nurse might be called upon to assist with cricoid pressure, so that the back wall of [the cricoid ring] presses on the esophagus and prevents the passive regurgitation of food or blood while the patient’s being intubated.

“Once the tube has been placed, the cuff that seals off the trachea is inflated, and the nurse will be asked to hold her fingers on the cricoid ring until breath sounds on bilateral lungs are verified.” Showan adds.

“The most critical thing about the endoscopy is the start of it, just getting the breathing tube in, or even the step before that, to recognize that a full stomach endoscopy is quite different from a patient who has been fasting.

“The second most serious time is the extubation, because if there is residual blood, even though suction catheters have been used, one can never be sure the stomach is completely empty,” Showan adds. The awakening of the patient has to be done very carefully, and the breathing tube should not be removed until the patient has his or her airway reflexes returned. The endonurse would be asked to stand by the patient with emergence, because the breathing tube causes quite a bit of coughing, and the patient could even vomit more as he awakens.”

“With regard to pediatric patients, propofol changes the airway dimensions of children a lot quicker; with adults, we seem to be able to titrate sedation a little easier, so in a pediatric patient I think it would be rare for people to say, ‘Let’s give a small amount of sedation and have a quick look around.’ Propofol can go from what looks like a mild sedative to causing laryngospasm in children. Because it has such an unpredictable effect on pediatrics, it’s really not recommended right now for pediatric sedation, and when propofol is used with children, it should be used knowing that general anesthesia is very likely to happen. If emergency procedures are going to be done, I think it would be really very poor judgment to proceed without first securing the airway and intubating the child.”

Showan has seen a great many airway emergencies, and has had to intubate patients who received sedation and then had too much soft tissue airway obstruction when the scope was removed. “Perhaps there was a little edema, and extra secretions stimulated by the scope, so even in a routine case, the patient’s airway has to be very carefully observed afterwards,” she comments. “I’ve had a couple of cases where I’ve had to either manage the patient’s airway with positive pressure and an oral airway, or even intubate the patient until the they were more fully awake. I would caution people that for every upper endoscopy, airway equipment should be readily available. I’ve had a couple of asthma attacks precipitated because of upper endoscopy, because just tickling the back of the pharynx can stimulate an asthma attack. So what looks like a routine endoscopy sometimes turns out to be quite hairy.”

Although the patients might not have had anything to eat or drink, they still produce gastric acid. During an upper endoscopy, one of Showan’s patients complained that her eye was stinging. They theorize that the patient had some regurgitation onto the pillow when her head was turned, and gastric acid slid up along her face. “In this case, the patient probably had some irritation of her eye, a little chemical conjunctivitis from the acid. That changed my practice; it wasn’t a catastrophe, but it’s nice to be able to fine-tune your practice, because all those little things can make life miserable for a day or two. You want to appeal to the best possible practices,” Showan concludes.

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