Master the board step 3

Gastroenterology
Treatment
Antibiotics are the mainstay of treatment for diverticulitis. Combine agents
against gram-negative bacilli, such as a quinolone or cephalosporin, with an
agent against anaerobes, such as metronidazole. Ciprofloxacin and metronidazole
are a standard combination.
LLQ Pain + Tenderness
+ Fever + Leukocytosis =
Diverticulitis
Gastrointestinal (GI) Bleeding
GI bleeding presents in various ways:
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Red blood: Usually indicates lower GI bleeding. In about 10 percent of
cases, extremely brisk/rapid or high-volume upper GI bleeding leads to red
blood from the rectum.
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Black stool: Indicates upper GI bleeding, which is usually defined as that
occurring proximal to the ligament of Treitz (demarcation between the
duodenum and the jejunum). Black stool usually results from at least 100
mL of blood loss.
··
Heme-positive brown stool: This can occur from as little as 5–10 mL of
blood loss.
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Coffee ground emesis: Needs very little gastric, esophageal, or duodenal
blood loss—as little a 5–10 mL.
A 74-year-old man with a history of aortic stenosis comes to the emergency
department having had 5 red/black bowel movements over the last day. His pulse
is 112, blood pressure 96/64. What is the next best step in management?
a. Colonoscopy
b. Consult gastroenterology
c. CBC
d. Bolus of normal saline
e. Transfer to the intensive care unit
Answer: D. The most urgent step in severe gastrointestinal (GI) bleeding is fluid resuscitation.
When the systolic blood pressure is low or the pulse high, there has been at
least a 30 percent volume loss. Step 3 does not allow you to order specific doses; hence,
all you can order is a “bolus.” It is fortunate that you do not have to spend a lot of time
calculating or memorizing specific doses of fluids or specific medications. Although
endoscopy, such as colonoscopy, is important, it is not as important as fluid resuscitation.
The most important thing to do in acute GI bleeding is to determine if there
is hemodynamic instability. Orthostatic hypotension means a drop in blood
pressure or rise in pulse when going from a lying to a standing or seated position.
Orthostasis is defined as a drop in systolic pressure of > 20 mm Hg or a
rise in pulse of > 10 beats per minute.
Orthostasis presents with
one of the following:
• Systolic blood pressure
< 100
• Heart rate > 100
Either of these implies more
than 30% volume loss.
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