EM Boards Survival Guide: Gastrointestinal 1

Author: Alex Koyfman, MD (@EMHighAK) // Edited by: Brit Long, MD (@long_brit)

emDocs will be providing you with regular tips and must-know items for EM boards and inservice. Each post will feature several key takeaways on a specific organ system.

Boards Must-Knows:

1) Anal fissure: Most common cause of painful lower GI bleeding. Posterior midline location is most common, otherwise consider pathologic condition.

2) Aortoenteric fistula: Recent AAA surgery + GI bleed. Duodenum most common location. Trx: Resuscitate, consult vascular surgery.

3) Caustic ingestion: Alkali (hydroxide; liquefaction necrosis) worse than acidic (coagulation necrosis). Upper endoscopy within 12-24 hours. Delayed complication: strictures. Don’t neutralize!

4) Cholangitis: Know Charcot’s triad and Reynold’s pentad, although clinically not as useful. Abx + GI (ERCP) + Gen Surg.

5) Crohn’s vs Ulcerative Colitis: Know anatomy affected in each. Know common complications and extraintestinal manifestations. Toxic megacolon and malignancy more common in UC.

6) Diverticulosis: Most common cause of painless/severe lower GI bleed in adults. Diverticulitis: infection; ciprofloxacin/metronidazole.

7) Esophageal foreign body: Pediatric patient (location at C4, cricopharyngeus muscle); adult (T10/11, lower esophageal sphincter). Coin in frontal plane on x-ray: esophageal. Button battery: esophagus (immediate removal); stomach (outpatient f/u); >5cm x 2cm or sharp (immediate removal). Food impaction: adult; meat; distal esophagus.

8) Esophageal perforation: Most common cause is iatrogenic (upper endoscopy). Know classic XR findings. Management: Resuscitation, Antibiotics, Thoracic Surgery.

9) Peptic Ulcer Disease: Most common cause of upper GI bleeding. H. pylori and NSAIDs. Know H. pylori treatment. Know perforation X-ray.

10) Hemorrhoids: Internal vs external. Most common presentation: bleeding (bright red blood per rectum). Thrombosed external: elliptical excision and drainage. Internal at risk for incarceration/strangulation.

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