Gastrointestinal

Rapid Review

• Background
  • Use of anoscope to visually inspect the anus, anal canal, and internal sphincter, primarily for the purpose of identifying rectal bleeding. 
• Indications
  • Evaluation of anorectal symptoms (bleeding, pain, discharge, protrusions, foreign bodies)
• Contraindications
  • Imperforate anus, active bleeding. Relative contraindications included severe anal pain or recent surgery.
• Complications:
  • Perineal skin/mucosa injury, infection, shearing of hemorrhoidal tissue.

Pearls

• Insertion of the anoscope can be made easier by asking the patient to bear down or perform a valsalva maneuver during insertion. 
• Topical 2% lidocaine jelly can be applied to the anal canal 10-15 minutes prior to insertion to reduce pain/discomfort. 

Deep Dive

• How To Do Anoscopy (Merck Manual)

Rapid Review

• Background
  • Placement over an orogastric tube with balloon tamponade capabilities designed for the management of esophageal or gastric bleeding. Specifically devices include the sengstaken-blakemore tube, minnesota tube, and linton-nachlas tube
• Indications
  • Unstable patient with massive upper GI bleed
• Contraindications
  • Recent esophageal or gastric surgery
• Complications
  • Esophageal rupture, mucosal ulceration, aspiration

Pearls

• Ideally, the patient should be sedated and intubated prior to performing this procedure due to the pain and difficulty 
• A manometer should be used to measure endotracheal cuff pressures to decrease the risk of perforation. If you do not have a standadr manometer, you can instead use a sphygmanometer (detached from standard BP cuff)

Deep Dive

• Balloon Tamponade of Massive GI Bleeding (First 10 EM)

Rapid Review

• Background
  • Involves passage of foley catheter into the esophagus behind the foreign body, inflating the balloon, and carefulling retrieving the object. Often used to retrieve coins
• Indications
  • Smooth, radiopaque foreign bodies lodged in the upper/middle esophagus
  • Must be recently ingested (< 48 hours). For button batteries, must be within 2 hours.
• Contraindications
  • Sharp foreign bodies, button battery > 2 hours, multiple objects, total esophageal obstruction. 
• Complications
  • Laryngospasm, aspiration, epistaxis

Pearls

• Filling the foley catheter with barium ahead of time can help identify the location of the catheter on X-ray if needed.
• A reasonable alternative to a foley catheter would be a magnet attached Levine catheter, which has the added benefit of being able to reach deeper in the esophagus and even into the stomach or duodenum

Deep Dive

• Foreign Body Removal in Children Using Foley Catheter or Magnet Tube from Gastrointestinal Tract (PubMed)

Rapid Review

• Background
  • Gastrointestinal decontamination technique involving sequential administration and aspiration of fluid via an orogastric tube. Utilized for the purposes of emptying the stomach of toxic substances.
• Indications
  • Life-threatening poisoning or unconscious presentation following suspected toxic ingestion
  • Most likely to be successful if performed within the first hour
• Contraindications
  • Corrosive or hydrocarbon ingestion.
  • Do not perform if poisoning is non-lethal or if highly effective antidote (ex. NAC) is available.
• Complications
  • Incomplete decontamination, aspiration of gastric contents, esophageal rupture, profound bradycardia

Pearls

• This technique is rarely used due to a lack of proven efficacy and the risk of complications. However, it may play a role in life-threatening ingestions that occur within 1 hour. 
• If toxic injection was from a suspected beta blocker or calcium channel blocker, gastric lavage may significantly worsen bradycardia. These patients should be pretreated with atropine. 

Deep Dive

• Gastric Lavage (LITFL)

Rapid Review

• Background
  • Replacement of gastrostomy tube (G-tube) for purposes of continued nutrition/medication for patients. Should be treated as a medical emergency, as tube tracts can close narrow or close within hours of tube removal. 
• Indications
  • G-tubes with established tracts. If G-tube has be recently been established (within last 3 weeks), attempts to replace may cause separation of the stomach from the abdominal wall.
• Contraindications
  • Newly established G-tubes (within 3 weeks). Must consult the physician who placed it.
  • Any evidence of infection (erythema, warmth, exudate)
• Complications
  • Misplacement of G-tube into peritoneal cavity (may be lethal), placement too far into the proximal duodenum, infection

Pearls

• If the stoma from the G-tube site has already started to close, you can try inserting a smaller sized tube to salvage the site.
• Abdominal X-ray should be used after reinsertion to ensure the G-tube was not inadvertently placed into the abdominal cavity.

Deep Dive

• Troubleshooting G-tubes & J-tubes: Common Scenarios/Tips & Tricks (emDocs)

Rapid Review

• Background
  • Placement of a tube via the nasogastric route to provide access to the stomach for therapeutic or diagnostic purposes. 
• Indications
  • Gastric decompression, administration of medication, administration of radiographic contrast, bowel irrigation
• Contraindications
  • Recent nasal surgery, severe facial trauma
• Complications
  • Pulmonary placement, epistaxis, gagging/vomiting

Pearls

• Allowing the patient to take a sips water during insertion can substantially improve your chances of success and improve patient comfort.
• Nasogastric tubes can be very painful for the patient. Consider anesthetizing the nares and oropharynx first with lidocaine jelly or nebulized lidocaine.

Deep Dive

• Nasogastric Tube Placement (Internationl Emergency Medicine Education Project)

Rapid Review

• Background
  • Insertion of a needle/catheter into the peritoneal cavity to drain ascitic fluid for diagnostic or therapeutic purposes.
• Indications
  • Acute onset of ascites, suspected bacterial peritonitis
• Contraindications
  • Acute abdomen requiring surgery, severe thrombocytopenia, active bleeding
• Complications
  • Hemorrhage, bladder/bowel perforation, vessel laceration, infection, ascites fluid leak

Pearls

• Ultrasound should always be used when available to avoid injury to the bowels
• Do not remove greater than 5L of fluid without prophylactic albumin, as this may cause circulatory dysfunction.

Deep Dive

• Pocket Full of Sunshine: Paracentesis in the ED (emDocs)

Rapid Review

• Background
  • Process of removing rectal foreign bodies. Common objects include bottles, vibrators, vegetables, fruit, or balls. May also be caused by drug packing/stuffing
• Indications
  • Bedside removal indicated if object is less than 10 cm proximal to anal verge or palpable on digital rectal exam
• Contraindications
  • Perforation, peritonitis
• Complications
  • Local tissue trauma, tearing of rectal mucosa

Pearls

• For analesia, consider performin a perianal block prior to removal.
• Objects that are longer than 10 cm, located in the sigmoid, or have been retained for more than 2 days, are unlikely to be successfully removed in the emergency department.

Deep Dive

• Rectal Foreign Bodies: Not always a Simple ED Diagnosis (emDocs)

Rapid Review

• Background
  • Administration of a osmotically balanced polyethylene glycol electrolyte solution to induce liquid stool and prevent absorption of ingested matter
• Indications
  • “LIMPS” (lithium, iron, metals, packers/stuffers, sustained release drugs)
  • Mainstay treatment for drug packers who are asymptomatic
• Contraindications
  • Bowel obstruction, intractable vomiting, compromised airway, hemodynamic instability
  • Signs of leakage from drug packets (ex. Tachycardia, hypertension, respiratory depression, hyperthermia)
• Complications
  • Injuries from nasogastric tube insertion, hypersensitivity reactions, nausea/vomiting

Pearls

• Whole bowel irrigation is not routinely recommended for GI decontamination according to the AACT and EAPCCT. However, it may be useful if the ingested material is not well adsorbed by activated charcoal (lithium, iron, metals, etc.)
• Polyethylene glycol (PEG) use during whole bowel irrigationsignificantly reduces the the binding capacity of activated charcoal.

Deep Dive

• ToxCard: GI Decon (emDocs)