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CHAPTER 86: Gastrointestinal Procedures and Devices 551  TREATMENT Recurrence is common, particularly in the perineal region, resulting in scarring, edema, painful nodules, induration, and draining sinus tracts, all of which are difficult to treat. Small abscesses can be drained in the ED, but extensive lesions require surgical or dermatologic referral. Topical clindamycin or oral clindamycin with rifampin can be helpful. Other treatments include erythromycin, tetracycline, and doxycycline as well as retinoids, hormones, and immunosuppressive and antiinflammatory agents. Some success is seen with radiation, cryosurgery, and laser treatments. With advanced disease characterized by recurrent abscesses, multiple interconnecting fistulas, and scarring, resection of the skin and subcutaneous fat down to the fascia yields the lowest recurrence rate. RECTOVAGINAL FISTULA The lower rectum and anal canal abut the posterior wall of the vagina, so the fistula may be located anywhere along this region.  CLINICAL FEATURES The presenting complaint of patients with a rectovaginal fistula is usually flatulence and/or malodorous vaginal discharge or gross stool emanating from the vagina. They may note air or stool in the urine, or rectal urine. Table 85-5 lists various causes. A rectovaginal fistula can arise TABLE 85-5 Causes of Rectovaginal Fistulas Gynecologic or surgical trauma or foreign body Gynecologic malignancies Pelvic irradiation Leukemia Local infection Inflammatory bowel disease Congenital FIGURE 85-22. Perianal hidradenitis suppurativa in a 27-year-old man. Abscesses, draining sinuses, and scars are seen in the sacral region. [Reproduced with permission from Wolff K, Johnson RA: Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, 6th ed. McGraw-Hill, Inc., New York, 2009.] from the rectum or small or large bowel. Usually, stool is seen during the pelvic examination. CT scan or MRI confirms the diagnosis. Surgical consultation is required. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Gastrointestinal Procedures and Devices Michael D. Witting NASOGASTRIC ASPIRATION Nasogastric (NG) aspiration is used to remove liquid contents from the stomach and decompress the stomach and small bowel. The need for NG aspiration often varies with the clinical presentation ( Table 86-1). Gastric decompression is useful in small bowel obstruction, although some studies have shown that medical therapy with octreotide or somatostatin has allowed safe treatment of bowel obstruction associated with malignancy. 1,2 NG aspiration and decompression are no longer consid ered routine for the treatment of adynamic ileus. 3,4 Removal of liquid contents is useful in cases of GI bleeding, but most patients with GI bleeding can be managed without NG aspiration. In GI bleeding, a common and controversial situation for NG aspiration, aspiration of stomach contents can localize the source of bleeding, indicate the rate of bleeding, and clear the stomach for endoscopy. Patients with hematemesis virtually always have an upper GI source, and NG aspiration is helpful to assess the rate of hemorrhage rather than iden tify the source. In significant upper GI bleeding, such as suggested by refractory hemodynamic instability or large quantities of bright red bloody emesis, the rate of bleeding can determine the success of medical interventions and the need for emergent endoscopy.

lpful to assess the rate of hemorrhage rather than iden tify the source. In significant upper GI bleeding, such as suggested by refractory hemodynamic instability or large quantities of bright red bloody emesis, the rate of bleeding can determine the success of medical interventions and the need for emergent endoscopy. When the clinical picture suggests a slower rate of bleeding, such as with coffee-ground emesis or blood-streaked emesis, the need for NG aspiration is less clear because less sensitive methods of assessing the rate of hemorrhage, such as observation of spontaneous bleeding, hemodynamic assessment, and serial hematocrit measurement, are often adequate. In patients without hematemesis, NG aspiration lacks sensitivity to detect an upper GI source. 7,8 Although it has been reported that 10% of patients with hematochezia have an upper GI source, many of these are from a duodenal source and are beyond the reach of the NG tube. Most patients with melena have an upper GI source and require upper endoscopy regardless of the results of NG aspiration. In severe, ongoing rectal bleeding with hemodynamic instability, NG aspiration is relatively useful because severe upper GI bleeding is generally easier to stop than severe lower GI bleeding. The literature is riddled with case reports of bizarre mishaps result ing from the use of NG tubes, some of which are listed in Table 86-2. CHAPTER TABLE 86-1 Selection of Patients for Nasogastric Aspiration Clinical Situation Best Uses Consider Withholding GI bleeding with hematemesis Rapid bleeding (large hematemesis, refractory hemodynamic instability) Slow or mild bleeding (coffee grounds, blood-streaked emesis) GI bleeding without hematemesis Massive rectal bleeding with hemodynamic instability Clinical picture suggests lower GI source (bright red blood per rectum, age >50 y, blood urea nitrogen/creatinine <30) Small bowel dilation Small bowel obstruction Ileus Tintinalli_Sec09_p0473-0562.indd 551 8/2/19 6:51 PM

eaked emesis) GI bleeding without hematemesis Massive rectal bleeding with hemodynamic instability Clinical picture suggests lower GI source (bright red blood per rectum, age >50 y, blood urea nitrogen/creatinine <30) Small bowel dilation Small bowel obstruction Ileus Tintinalli_Sec09_p0473-0562.indd 551 8/2/19 6:51 PM 552 SECTION 9: Gastrointestinal Disorders TABLE 86-2 Complications of Placement of Nasogastric and Nasoenteric Tubes •  Epistaxis •  Intracranial  placement •  Bronchial  placement •  Pharyngeal  placement •  Esophageal  obstruction or rupture •  Bronchial  or alveolar perforation •  Pneumothorax •  Charcoal  instillation into the lungs and pleural cavity •  Gastric  or duodenal rupture •  Vocal  cord paralysis •  Pneumomediastinum •  Laryngeal  injuries •  Knotting  (preventing removal) TABLE 86-3 Equipment for Nasogastric Tube Insertion •  Absorbent  pad (blue Chux®) •  Kidney  basin •  Materials  for anesthesia and vasoconstriction •  Nebulizer  or nasal atomizer •  Local  anesthetic (4% lidocaine) •  Vasoconstrictor  (oxymetazoline, phenylephrine) •  Water-soluble  lubricant •  Cup  of water with straw •  Nasogastric  Salem sump tube—16F •  Catheter-tip  syringe •  Tubing  connected to suction device, such as wall suction TABLE 86-4 Techniques for Identifying Nasogastric and Nasointestinal Feeding Tube Placement Indicates gastric placement •  Epigastric  auscultation of air insufflated through the tube •  Aspiration  of visually recognizable GI secretions •  pH  testing of aspirates (pH <6 indicates gastric placement) Indicates tracheobronchial placement •  Coughing  or choking •  Inability  to speak •  Air  bubbles when proximal end of tube is placed in water However, the rate of adverse effects has not been systematically addressed. The main morbidity from the procedure is probably related to pain, followed by epistaxis, both of which can be minimized by good technique. The equipment required for NG tube insertion is listed in Table 86-3. The optimal positioning is with the patient seated upright with the neck slightly flexed. Topical application of anesthetic can reduce the pain of the procedure, and a vasoconstrictor can shrink the turbinates, creating a larger nasal opening, but use a vasoconstrictor with caution in hyper tensive patients. One option is to mix 4% lidocaine with oxymetazoline and instill this solution using a nasal atomizer. 10 Nebulized lidocaine also provides effective analgesia.11 Although it is tempting to use viscous lidocaine on the tip of the tube instead of premedication, this maneuver does not allow time for the lidocaine to be effective. A right-handed operator may choose the right side or the side of patient preference. Premedication with IV metoclopramide, in adults, or lingual 24% to 25% sucrose, in infants, may also decrease pain. 12-14 Also, in adults, premedication with a small dose of midazolam (2 milligrams) improves pain relief compared with topical anesthesia alone. Describing the procedure to the patient in advance and talking to the patient during the procedure will minimize anxiety. Insert the lubricated tube into the selected nostril. Direct the tube posteriorly, not superiorly, and it should naturally bend inferiorly toward the glottis. Resistance is expected at the level of the glottis. At this point, have the patient take a drink of water, and advance the tube at the time of swallowing. This step minimizes the potential for false passage at the level of the glottis. Warming the distal tip of the tube will make it more pliable and may further decrease the pain of the procedure. Once the tube is past the glottis, quickly advance the tube and aspirate stomach contents. If the patient coughs during the procedure, stop and make sure that the patient can speak clearly.

l of the glottis. Warming the distal tip of the tube will make it more pliable and may further decrease the pain of the procedure. Once the tube is past the glottis, quickly advance the tube and aspirate stomach contents. If the patient coughs during the procedure, stop and make sure that the patient can speak clearly. Failure to aspirate stomach contents should prompt visualization of the pharynx to ensure the tube is not coiled in the pos terior pharynx. If the appearance of the gastric aspirate is inconclusive, its pH can be tested, or air can be insufflated during auscultation over the stomach (Table 86-4). A chest radiograph can also be obtained to confirm tube placement. If the NG tube is to remain in place, it can be taped to the patient’s nose and connected to low-intermittent suction. Some situations make NG tube insertion more difficult, such as obstructed nares, lack of patient cooperation, or endotracheal intuba tion. In patients with obstructed nares, the orogastric route may be used, although this is often less comfortable than the NG route. In obtunded patients with a poor gag reflex, endotracheal intubation may prevent aspiration. In patients with endotracheal intubation, flexing the neck or cooling the tube in ice water to stiffen it may facilitate passage. ANOSCOPY Anoscopy can identify an anorectal cause of bleeding in patients with hematochezia. Although an uncomfortable test, it is safe if performed properly. Contraindications include suspected rectal perforation. For detailed description of technique, see Chapter 85 “ Anorectal Disorders. ” OROGASTRIC LAVAGE Orogastric lavage is used to remove pills and fragments from the stom ach. It is only appropriate for patients presenting well within 1 hour after a potentially lethal ingestion. 16 Because an NG tube is too small to retrieve pill fragments, gastric lavage for solids is done orally with a large-bore tube. Gagging and vomiting during the procedure are common, and aspiration is a significant risk, particularly when airway protection is in doubt. Many other complications are possible, including tube misplacement into the bronchi, pharyngeal injury, and viscus per foration. Endotracheal intubation before this procedure can minimize these risks when a patient is, or may become, obtunded. Equipment for the procedure includes a large-bore tube, such as the Ewald tube ® or the Tum-E-Vac® (Ethox Corp, Buffalo, NY); lubricant; suction; emesis basin; blue absorbent pad; a catheter-tip syringe; irriga tion fluid; and a bite block or oral airway to prevent patients from biting down on the tube. Patient positioning, tube advancement, and confir mation of placement are similar to NG tube insertion, but be especially sure to aim the proximal end away from others. After inserting a bite block in uncooperative patients, insert the gastric tube to the level of the glottis, and encourage the patient to swallow. Then pass the tube quickly into the stomach. Coughing or airflow from the tube raises concern for tracheal malpositioning. Have the patient vocalize to exclude tracheal placement. After suction and irrigation of gastric contents, charcoal and sorbitol can be instilled before withdrawal of the tube. ESOPHAGEAL BALLOON (SENGSTAKEN-BLAKEMORE) TAMPONADE The Sengstaken-Blakemore tube is designed to tamponade bleeding from esophageal varices ( Figure 86-1). With the increasing availability of endoscopy and success of medical therapy with octreotide, soma tostatin, and vasopressin, its use has declined. Nevertheless, it still has a role in cases in which endoscopy is unavailable or hemorrhage is refractory to endoscopic techniques. In one series, most survivors received a transjugular intrahepatic portosystemic shunt procedure, in addition Tintinalli_Sec09_p0473-0562.indd 552 8/2/19 6:51 PM

ssin, its use has declined. Nevertheless, it still has a role in cases in which endoscopy is unavailable or hemorrhage is refractory to endoscopic techniques. In one series, most survivors received a transjugular intrahepatic portosystemic shunt procedure, in addition Tintinalli_Sec09_p0473-0562.indd 552 8/2/19 6:51 PM CHAPTER 86: Gastrointestinal Procedures and Devices 553 to balloon tamponade. 17 It is only useful in patients with esophageal varices that are known or suspected from the clinical picture, such as in patients with severe hematemesis and signs of cirrhosis. The procedure frequently provokes emesis, and aspiration can be minimized by endo tracheal intubation. Other risks include gastric or esophageal rupture. Insert the tube orally after the same procedure described in the sec tion “Orogastric Lavage. ” After confirming tube placement as described earlier, expand the distal balloon with water or normal saline and apply gentle traction to the tube. Because varices are often at the gastroesophageal junction, this often stops the bleeding. If not, expand the proximal balloon. To maintain traction, tape the proximal end of the tube to the face guard of a baseball catcher’s mask or lacrosse helmet that has been already placed onto the patient. The patient will not be able to swallow secretions with this in place, so proximal suction, whether from a proximal port in the device or an NG tube inserted proximally, will further minimize the risk of aspiration. Once the tube is in place, maintain traction to the minimum amount necessary to stop the bleeding to minimize the risk of tissue ischemia. Maintain balloon tamponade until more definitive measures can be taken. ABDOMINAL PARACENTESIS In paracentesis, ascitic fluid is removed for diagnostic or therapeutic purposes. Patients with ascites and abdominal pain or other GI symp toms may have peritonitis, requiring diagnostic paracentesis. This may be true even if the abdominal pain is mild and unaccompanied by signs of systemic infection. 18 Patients with respiratory compromise or severe pain due to tense ascites require therapeutic paracentesis, in which a large quantity of fluid, often greater than 5 L, is removed. Large-volume paracentesis, in which greater than 5 L is removed, is time-consuming and associated with complications such as hyponatremia, renal impair ment, and encephalopathy. Many of these patients require other treatment, including albumin infusion. 19,20 Therefore, it is generally best reserved for the admitting team or ED observation unit, except in rare cases in which pain or respiratory compromise cannot be controlled in the ED with medications or supplemental oxygen. Other risks of paracentesis in general, whether diagnostic or therapeutic, include bowel perforation, ascitic fluid leak, hemorrhage, and introduction of infection. Equipment for diagnostic paracentesis (See Video: Abdominal Paracentesis) includes sterile drapes (both fenestrated and nonfenestrated), sterilizing solution (povidone-iodine or chlorhexidine), gauze, assorted syringes (3, 10, or 30 mL), a small-bore (27-gauge or smaller) needle, three medium-bore (21-gauge) needles, local anesthetic (lidocaine), and containers for cell count and culture for the laboratory. If paracentesis is also to be therapeutic, a three-way stopcock, sterile tubing, and a source of suction—either vacuum bottles or a setup for wall suction—are nec essary, and a large-bore needle or plastic catheter (18- or 16-gauge) will speed the procedure. Ultrasonography can confirm ascites and identify a target fluid collection to minimize the potential for bowel perforation (Figure 86-2). US guidance can also assist the operator in avoiding subcutaneous vessels dilated by portal hypertension, and it decreases the risk of bleeding.

r 16-gauge) will speed the procedure. Ultrasonography can confirm ascites and identify a target fluid collection to minimize the potential for bowel perforation (Figure 86-2). US guidance can also assist the operator in avoiding subcutaneous vessels dilated by portal hypertension, and it decreases the risk of bleeding. If the patient has severe coagulopathy (INR >2.5) or thrombocyto penia (platelets <50,000/μL), consider correcting deficiencies before paracentesis. 22,23 Place the patient in a comfortable supine position, and cleanse and sterilely prepare the site of expected needle insertion. The left lower quadrant is generally a good area because this minimizes the potential for liver injury, but the right lower quadrant may also be used if the left lower quadrant has distorted anatomy, such as with prior scarring or ostomy surgery (Figure 86-3). Anesthetize the skin over the target area by raising a wheal, and then switch to a larger-bore needle to infiltrate to the level of the peritoneum. A Z-track technique, in which traction on the skin is used to create a displaced track to the peritoneum, Esophageal balloon inflation Gastric aspiration Gastric balloon inflation Esophageal balloon Gastric balloon FIGURE 86-1. A. Sengstaken-Blakemore tube. B. Insertion of Sengstaken-Blakemore tube. FIGURE 86-2. US view of a desirable puncture site for paracentesis ( arrow). Tintinalli_Sec09_p0473-0562.indd 553 8/2/19 6:51 PM

phageal balloon inflation Gastric aspiration Gastric balloon inflation Esophageal balloon Gastric balloon FIGURE 86-1. A. Sengstaken-Blakemore tube. B. Insertion of Sengstaken-Blakemore tube. FIGURE 86-2. US view of a desirable puncture site for paracentesis ( arrow). Tintinalli_Sec09_p0473-0562.indd 553 8/2/19 6:51 PM 554 SECTION 9: Gastrointestinal Disorders can minimize the potential for infection and persistent leakage. 20 At a depth expected to be near the peritoneum, apply suction to the syringe and infiltrate lidocaine while advancing until peritoneal fluid is aspi rated. Once the fluid is aspirated, change the syringe with the needle still in place, and then aspirate at least 50 mL of fluid into the fresh syringe for laboratory analysis. In therapeutic paracentesis, attach tubing to the needle, catheter, or stopcock, and connect to suction. Even if the goal is diagnosis, removal of 1 to 2 L is unlikely to cause complications and may provide significant symptomatic relief. Then withdraw the needle or catheter and cover the insertion site with a dressing. A purse-string suture can be placed to minimize leakage. Recheck the patient in 30 minutes to identify persistent leakage or an increase in symptoms to suggest a complication. Patients with largevolume paracentesis should be monitored for hypotension for several hours after the procedure. Cover the puncture site with a dry dressing for 48 hours. TRANSABDOMINAL FEEDING TUBES Although the techniques for the initial placement of transabdominal feeding tubes (gastrostomy [G-tube], jejunostomy [J-tube], and gastrojejunostomy) are beyond the scope of emergency physicians, complications related to these tubes need to be recognized (Table 86-5). These tubes can be placed by a surgeon using open technique, by a gastroenterologist using endoscopic technique (percutaneous endoscopic gastrostomy), or by a radiologist with percutaneous techniques. The radiographic tech nique has been associated with fewer complications than has open or endoscopically assisted placement. Frequent minor complications are associated with the use of these tubes, including purulent drainage and leakage around the stomal site, clogging, dislodgement, diarrhea, and vomiting. Drainage from the stomal site is a common finding and represents a foreign-body reaction due to the catheter. As long as there is no evidence of cellulitis or necrotizing fasciitis, local skin care will usually clear up the problem. Local bleeding from granuloma formation may be treated with silver nitrate. Leakage of gastric contents is a common problem. Gastric contents may leak due to excessive pressure between bolsters, which can limit blood flow ( Figure 86-4). 25 Leak can also result from excessive tube mobility, either in-and-out (from excessive distance between bolsters) or side-to-side. Tube malposition can also cause leakage. Management strategies include gently withdrawing the tube and adjusting the outer bolster, tube replacement, or removing the tube for 24 to 48 hours to allow healing (if tract is mature). 25 CT or plain radiographs, after injection of gastrograffin through the tube, can be used to assess placement of the original or replaced tube. Consider surgical consultation for assis tance with bolster adjustment or tube replacement (if tract maturity is uncertain). FIGURE 86-3. Sites for needle introduction in the left or right lower quadrant (x) for abdominal paracentesis. TABLE 86-5 Complications Seen With Transabdominal Feeding Tubes Complication Initial Considerations Leakage from stoma Check outer bolster position, consider tube malposition. Tube occlusion Attempt irrigation; most often, just replace. Dislodged tubes Gently replace; confirm placement with x-rays. Pneumothorax High index of suspicion; consider needle aspiration.

inal Feeding Tubes Complication Initial Considerations Leakage from stoma Check outer bolster position, consider tube malposition. Tube occlusion Attempt irrigation; most often, just replace. Dislodged tubes Gently replace; confirm placement with x-rays. Pneumothorax High index of suspicion; consider needle aspiration. Bacteremia Consider as potential source in septic patient. Bleeding from tract If recently inserted, consider local injection, consult. Bleeding from granuloma buildup Local therapy with silver nitrate. Infection of surrounding skin Consultation, pull tube, IV antibiotics. Necrotizing fasciitis Consider MRI to help confirm; surgical debridement. Peritonitis Determine if fistula exists; consultation, IV antibiotics. Pulmonary aspiration of feedings Reduce flow rate, half-strength feeds, consider J-tube. Vomiting or diarrhea Reduce flow rate, half-strength feeds, stop feeds. Gastroesophageal reflux Reduce flow rate, half-strength feeds, consider J-tube. Intestinal obstruction Step feedings, NPO, admit, and observe. Gastric outlet obstruction Reposition tube. Gastric volvulus Surgical consult. Gastric perforation Surgical consult. Esophageal perforation Surgical consult. Colonic perforation Surgical consult. Colocutaneous fistula Surgical consult. Electrolyte abnormalities Change feedings or increase free water. GI bleeding Endoscopy and therapy directed at cause. Bolster buried in abdominal wall Surgical consult. Abbreviations: J-tube = jejunostomy tube; NPO = nothing by mouth. G-tube BolsterStomach FIGURE 86-4. Percutaneous endoscopic gastrostomy tube (G-tube) with a mushroom bolster in place. Tintinalli_Sec09_p0473-0562.indd 554 8/2/19 6:51 PM