PPIs reduce rebleeding, need for surgery and mortality, but only when given after endoscopy to high-risk patients (bolus then 72h infusion) \200 Mallory \200\223Weiss tears (OHAM3 b p234) occur after repeated forceful vomiting, often after alcohol excess. Bright red blood appears as streaks or mixed with vomit. Bleeding often resolves spontaneously Clotting abnormalities (b p404) consider: platelet transfusion if active bleeding and plts <50x109/l; FFP if PT/APTT >1.5 x control; Prothrombin complex conc entrate if on warfarin \200 H. pylori (b p294) test and eradicate if positive. 3Gastro-oe sophageal varices (OHAM3 bp232) Symptoms of chronic liver failure (b p313); known liver dis ease, excess alcohol; varices are asymptomatic until they bleed. Signs of chronic liver fai lure (b p313). Investigations varices seen on OGD. Acute bleed resuscitate according to b p 298 then: \200 Terlipressin 2mg/over 5min IV if not already given \200 Antibiotics cirr hotic patients have dimmune function; spontaneous bacterial infections are associated with imortality (eg Tazocin 4.5g/8h IV) OGD (urgent) for banding (oesophageal) or sclerotherapy (gastric) \200 Bleeding still unc ontrolled consider a Sengstaken \200\223Blakemore tube and transjugular intrahepatic portosystemic shunting (TIPS) Once bleeding controlled Terlipressin 1 \200\2232mg/6h over 5min IV, for up to 5d; treat ca use of liver failure; drisk of recurrent bleeding by dportal pressure (by TIPS or propranol ol 40 80mg/12h PO) or further banding. (by TIPS or propranolol 40 \200\22380mg/12h PO) or f urther banding. What about other drugs? Once haemostasis is achieved, continuation of aspirin where previously indi- cated (under P PI cover) is associated with reduced mortality (albeit at a higher risk of rebleeding).2 NS AIDs should be stopped and alternative analgesics pre- scribed. Data for other antiplatelet drugs and anticoagulants are more complex and each case will need careful discussion betwe en the relevant specialists. 2 Sung J.J.Y. et al. Ann Intern Med. 2010 152:1 (subscription required \200\223 check ATHENS). 1 Villanueva C. et al. NEJM 2013 368:11 free at (cid:27)www.nejm.org/doi/full/10.1056/NEJMo a1211801 OHFP.indb 300 OHFP.indb 300 30/05/2014 16:18 30/05/2014 16:18 301 ACUTE LOWER GI BLEEDS Acute lower GI bleeds Worrying features continuous bright-red PR bleeding, iHR, dBP, postur al drop, dizziness, dGCS, abdominal pain, weight loss, vomiting. Think about common polyps, diverticular disease, angiodysplasia, hemorrhoids, IBD, colon ca ncer, upper GI bleed (b p299); other aorto- enteric fi stulae, ischaemic colitis, radiation proctitis, Meckel \200\231s diverticulum. Ask about onset, quantity, color (red, black, clots), type of blood (fresh, mixed with stoo l, streaks on toilet paper), abdominal pain, vom- iting (color), pain on opening bowels, st raining, change in bowel habit, anorexia, weight loss, dizziness, SOB; PMH previous bleedin g, divertic- ular disease, IBD, peptic ulcer, liver disease, AAA; DH NSAIDs, antico- agulan ts, steroids, iron; FH IBD, bowel cancer; SH alcohol. Obs HR, BP, postural BP, GCS, RR, sats. Look for pale and cold extremities, sweating, pulse volume, bruises, other sources of bleed ing (nose, mouth), abdominal tenderness 9peritonism, masses, signs of chronic liver disease (b p313); PR blood, melaena, palpable mass, hemorrhoids. See Table 9.5. Investigations blds FBC, clotting, U+E, LFT, G+S or X-match 2 units; ABG only if unwell; OG D to exclude upper GI bleed, urgent if shocked; ECG if age >50yr; sigmoidoscopy/colonoscopy for investi- gation, biopsy and treatment; may require mesenteric angiography or capsule e nteroscopy if bleeding source cannot be identifi ed. Management lower GI bleeding is traditionally managed by sur- geons whilst upper GI bleedin g is usually a medical condition. Although 85% lower GI bleeds will settle with conservati ve management, always beware the brisk upper GI bleed presenting as PR bleeding. \200 Dia gnosis it is rarely possible to tell the cause of signifi cant lower GI bleeds from history and examination alone, investigations are essential \200 Fresh blood on toilet paper or streaking stool only and patient well: Treat as hemorrhoids/anal fi ssure, but arrange foll ow-up fl exible sigmoidoscopy to rule out bowel cancer Mild bleeding (no evidence of shock) should usually settle with conservative management. Consider early discharge and follow-up \200 Moderate bleeding (p ostural drop, iHR) secure IV access and fl uid resuscitate blood until haemodynamically stable, catheterise, hourly fl uid balance, senior review, may need urgent OGD if possibili ty of upper GI source 3Severe bleeding (fresh bleeding/clots, dBP) resuscitate according to b p298, transfuse, ca ll senior, on-call endoscopist and surgical registrar. 15% of patients with acute, severe PR bleeding will have an upper GI bleeding source identifi ed on OGD. For the remainder, op tions include colonoscopic haemostasis, radiological embolisation, or surgical resection. _OHFP.indb 301 _OHFP.indb 301 30/05/2014 16:18 30/05/2014 16:18 302 CHAPTER 9 Gastroenterology Table 9.5 Common causes of lower GI bleeding History Examination Investigation dHb, iurea, lesion on OGD Upper GI bleed Haematemesis, fresh PR bleeding, clots or melaena, epigastric pain Change in bowel habit, w eight loss, abdominal pain Abdominal pain, diarrhea, weight loss, mouth ulcers Liver disease, epigastric tenderness, PR blood or melaena PR blood or melaena, mucus, palpa ble mass itemp, abdo tender peritonitic, PR blood, mucus, melaena Tenderness, peritonis m, PR blood, mucus Shock, generalized tenderness PR blood or melaena dHb dMCV, lesion on sigmoidoscopy or colonoscopy dHb, iWCC, iCRP, lesions on sigmoidoscopy or colonoscopy dHb, diverticulae on colonoscopy GI cancer or polyps Infl ammatory bowel disease Diverticular disease Abdominal pain, fever, change in bowel habit Abdo pain, previous arterial disease Recurrent fresh PR blood, old age, previous pelvic radiotherapy iWCC, acidotic, AF or previous MI on ECG dHb, lesions on colonoscopy, consider argon plas ma coagulation Lesions seen on proctoscopy Bowel ischaemia Angiodysplasia or radiation proctitis Hemorrhoids Painless, fresh red Often not palpable on PR, perianal tags, may have rectal prolapse Posterior/anterior PR tea r, perianal tags, tenderness blood on toilet paper, perianal itch, constipation Pain on defecating, fresh blood on toile t paper, constipation Anal fi ssure Proctoscopy to visualize lesions Chronic gastrointestinal blood loss Causes oesophagitis, gastric erosions, gastritis, pepti c ulcer, gastric/bowel cancer, polyps, IBD, angiodysplasia, GI lymphoma. Symptoms anorexia, weight loss, tired, change in bowel habit, melaena, vague intermittent a bdo pain. Signs pale/anemic, cachexic, mild abdo tenderness; PR blood, mass. Investigations stool fecal occult blood (FOB), ova, cysts and parasites; blds FBC (dHb, dMC V1), iron, ferritin, B12, folate, U+E, LFT; OGD colonos- copy; may need a video capsule e ndoscopy or small bowel CT/MRI if small bowel disease suspected. Treatment investigate and treat the cause, treat anemia with ferrous sulfate 200mg/8h PO, c onsider admission for transfusion if Hb <80g/L or if symptomatic with anemia. 1 Those with a simultanous iron defi ciency and B12 and/or folate defi cieny may have a nor mal or raised MCV; in this instance, signifi cant variation in red cell size will be refl ected in an increased red cell distribution width (RDW). OHFP.indb 302 OHFP.indb 302 30/05/2014 16:18 30/05/2014 16:18 303 ACUTE LOWER GI BLEEDS Colorectal polyps (OHCM9 b p618) A common fi nding at colonoscopy; their importance lies in the premalignant potential of adenomatous polyps. Causes vast majority sporadic; rare fami lial syndromes. Symptoms often none; intermittent abdo pain, altered bowel habit, blood or melaena in stool, tenesmus, weight loss. Signs PR palpable mass if very distal, blood, mucu s. Investigations dHb, lesion on colonoscopy. Treatment polypectomy (send for histology), m ultiple polyps may need colonic resection or regular colonoscopy follow-up.1 Hemorrhoids (O HCM9 b p634) Dilated and displaced perianal vascular tissue (anal cushions). Symptoms recur rent fresh red blood on toilet paper or streaking stools pain or pruritus ani (anal itch) , constipation. Risk factors constipation with straining, multiple vaginal deliveries. Sign s not palpable unless prolapsed; PR blood, otherwise normal. Investigations proctoscopy to visualize hemorrhoids, sigmoidoscopy to identify other pathology (eg malignancy). Treatment high-fi bre diet, topical Anusol , injection of sclerosants, band ligation, coagulation, cryotherapy, may need haemorrhoidectomy. Strangulated hemorrhoids painful, tender mass, una ble to sit down, treat with ice packs, stool softeners, regular analgesia and bed rest. Onc e stable, inject piles and consider elective haemorrhoidectomy. Anal \201 ssure (OHCM9 b p632) Symptoms new onset extreme pain fresh red blood on opening bowels, history of consti pation and straining (beware Crohn \200\231s and cancer). Signs anal tear visible posterior ly on the anal margin (10% anterior), perianal ulcers, fi stulae; PR may be impossible due to pain. Investigations sigmoidoscopy if suspicious of pathology once pain controlled. Trea tment conservative high-fi bre diet; 5% lidocaine ointment, 0.2 \200\2230.3% GTN ointment, botox injection all marginally better than placebo;2 internal sphincterotomy cure rate 95%. Angiodysplasia (OHCM9 b p630) Submucosal arteriovenous malformation, often ascending colon . Symptoms elderly, recurrent blood in the stool, abdo pain is rare. Signs may be normal, p allor; PR blood or melaena. Investigations fecal occult blood, colonoscopy, mesenteric angi ography. Treatment angiographic embolisation if active bleeding; argon plasma coagu- lation (endoscopic); rarely resection; treat anemia, eg ferrous sulfate. Causes of rectal bleeding covered elsewhere Infl ammatory bowel disease b p309 Upper GI bleed Bowel ischaemia b p299 b p293 Diverticular disease b p295 Infective diarrhea b p307 1 The British Society of Gastroenterology guidelines for colonoscopic follow-up are at (cid :27)www. bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/ccs_10.pdf 2 For a useful meta -analysis, see (cid:27)http://summaries.cochrane.org/CD003431 _OHFP.indb 303 _OHFP.indb 303 30/05/2014 16:18 30/05/2014 16:18 304 CHAPTER 9 Gastroenterology Nausea and vomitingg Worrying features iHR, i/dBP, dGCS, severe pain (head, chest, abdomen) , head injury, constipation, blood/coff ee grounds, purpuric rash. Think about life-threatening raised intracranial pressure (ICP), men- ingitis, MI, bowel ob struction, acute abdomen, DKA; common post-op, pain, drug induced (opioids), gastroenteriti s, other infection, alcohol; other gastroparesis, paralytic ileus, pregnancy, electrolyte i mbalance (Ca2+, Na+), migraine, labyrinthitis, M ni re \200\231s, chemotherapy, Addison \200\231s, eating disorder (Table 9.6). Ask about frequency, timing, relation to food or me dications, color, blood, coff ee grounds, melaena, dizziness, diarrhea, constipation, fl at us, pain, headaches, head trauma, visual problems, pregnancy; PMH previous surgery, migrain es, DM; DH opioids, chemotherapy, digoxin; SH alcohol. Obs temp, fl uid balance, HR, BP, bl ood glucose, GCS, stool chart. Look for and assess volume status (b p380), SOB, distended/ tender/peritonitic abdomen, tinkling bowel sounds, hernias, surgical scars, mouth ulcers, n eck stiff ness, rash, photophobia, papilloedema. Investigations vomiting without the worryi ng features usually does not require urgent investigation. If recurrent, check U+E for dehy dra- tion or electrolyte imbalance and AXR if bowel obstruction suspected. Otherwise invest igate according to related symptoms. Consider: blds FBC, U+E, LFT, glucose, amylase, Ca2+, Mg2+; CXR aspiration; ABG if acutely unwell; CT brain if head trauma (b p438); gastric empt ying studies if suspect gastroparesis. Treatment Investigate and treat underlying disease; vomiting is distressing \200\223 so see b p185 for pharmacology and selection of appropria te antiemetics. Table 9.6 Common causes of nausea and vomiting History Examination Investigations iWCC/N \230/CRP, abnormal CT brain or CSF results Raised ICP/ meningitis Headache, blurred vision, dizzy, feels ill, drowsy Febrile, stiff neck, photophobia, rash, low GCS Bowel obstruction or ileus Colicky pain, absolute constipation, brown vomit Distended tender abdomen, tinkling bowel sounds Distended bowel loops on AXR, (b p588) Pneumoperitoneum on CXR dHb, iurea Acute abdomen Severe abdo pain Tender, rigid, guarding, rebound Upper GI bleed Blood/coff ee-ground vomit Tender abdomen, PR melaena iWBC, iL \230 or N \230, positive stool culture Gastro- enteritis Diarrhea, feels better after vomiting Febrile, epigastric tenderness, not peritonitic Labyrinthitis Dizziness predominant, tinnitus Unable to stand Acute investigations normal (b p363) Acute investigations normal B-hCG+ TFTs often i, iurea if dehydrated Migraine Visual aura, headache Photophobia, visual fi eld defects 5 usually between 7 \200\22312/40 Hyperemesis gravidarum Normal; palpable uterus Drug induced Many medications can induce vomiting, particularly opioids, chemotherapy and digoxin toxicity OHFP.indb 304 OHFP.indb 304 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 306 CHAPTER 9 Gastroenterology Diarrhea Worrying features iHR, dBP, low urine output, PR blood, weight loss, abdo pain. Think about acute gastroenteritis, antibiotics, laxatives, drugs, pseu- domembranous coliti s (see b p308), overfl ow diarrhea (2 to constipa- tion), post-chemotherapy, bowel ischae mia; chronic IBD, IBS, colorectal cancer, diverticular disease, alcoholism, malabsorption d isorders (eg coeliac, chronic pancreatitis), thyrotoxicosis, bowel resection, parasitic/fun gal infec- tions, autonomic neuropathy, carcinoid, Addison \200\231s disease (Table 9.7). Traveler \200\231s diarrhea E. coli, Salmonella, Shigella, Campylobacter spp., giardiasis, amoebic dysentery, cholera, tropical sprue. Ask about normal bowel habit and frequency, onset/frequency of diarrhea, recent constipatio n, stool character (fl oating, greasy, bloody, mucus), color, abdominal pain, pain relief o n opening bowels, nausea, vomiting, fl atus, fl uid intake, weight loss, mouth ulcers; PMH colorectal cancer, IBD, diverticular disease, IBS, surgery; DH recent ABx, immuno- suppress ion; SH travel abroad, other household members aff ected/sick contacts, occupation (food, h ealthcare), alcohol. Medications causing diarrhea: antibiotics, laxatives, colchicine, digoxin, iron, NSAIDs, ra nitidine, thiazide diuretics, propranolol, PPIs. Obs temp, HR, BP, postural BP, RR, sats, fl uid balance, stool chart. Look for volume statu s (b p380), cachexia, mouth ulcers, clubbing, jaundice, rashes, pale conjunctiva, thyroid m ass, abdomen tenderness peritonitis, masses, distension, surgical scars; PR pain, masses, stool color, consistency; may reveal a rectum loaded with feces suggesting overfl ow diarr hea, particularly in the elderly, immobile patient with poor diet and recent constipation \200\223 treat as constipation (b p310). Investigations stool M,C+S x3, C. diffi cile toxin , ova, cysts and parasites; blds FBC, U+E, glucose, LFT, Ca2+, TFT, CRP, B12, folate, iron studies, anti tissue transglutaminase (TTG) antibodies, bld cultures; AXR obstruction, muco sal oedema, fecal impaction; sigmoidoscopy if not improving (or within 24h if known IBD/lik ely fl are); colonoscopy if cancer suspected. General management of diarrhea \200 Conservative increase fl uid intake, review drugs (co nsider alternatives without GI side eff ects); start stool chart \200\223 this will often be kept more accurately on a busy ward if you educate patients to complete it themselves Infective isolation and barrier nurse if infective source thought possible, ABx if systemically unwell Medical anti-motility agents should be avoided in infective diarrhea, IBD or pseudomembranous colitis. OHFP.indb 306 OHFP.indb 306 30/05/2014 16:18 30/05/2014 16:18 307 diarrhea Table 9.7 Common causes of diarrhea History Examination itemp, sweating, abdo tenderness Investigation iWCC, iCRP, +ve microbiology on stool sample iWCC, iCRP; mucosal oedema or me gacolon on AXR; lesions seen on sigmoidoscopy Diagnosis of exclusion; normal investigations dHb, dalbumin, dCa2+ anti-TTG or endomysial antibodies dHb, dMCV, lesion on colonoscopy Gastroenteritis Sudden onset, 9vomiting, abdominal cramps Crampy abdo pain, weight loss, blood in stool, mouth ulcers Abdo tenderness, peritonitis, PR blood/mucus, eye/skin/joint manifestations Abdo tenderne ss, non-peritonitic Infl ammatory bowel disease Irritable bowel syndrome Bloating, abdominal cramps, relieved by defecation Weight loss, pale greasy stools, tired, anemia Pale, abdo tender - ness, oedema, bloating, PR pale stool Malabsorption disorders PR blood or melaena, mucus/ palpable mass LIF tenderness, 9peritonitis Bowel cancer Abdo pain, weight loss, fresh blood or melaena LIF pain, PR bleeding iWCC, iCRP, diverticulae on colonoscopy iWCC, iCRP, C. diff . toxin +ve; AXR may show toxic dilatation AXR may show fecal loading Diverticular disease itemp, abdo tenderness, PR green, foul smelling, blood Abdo distension and tenderness, PR palpable stool Pseudo- membranous colitis Recent antibiotics (days/weeks), crampy abdo pain, green watery stool Constipation, poor mo bility, abdominal pain Overfl ow diarrhea Infective gastroenteritis (OHCM9 b p390) Diarrhea, accompanied by nausea, vomiting abdomi nal pain; in most cases due to viruses (including norovirus) but other infectious agents im portant. Symptoms rapid onset, recent vomiting and/or diarrhea, patient may implicate a cer tain food, feels unwell, crampy abdominal pain, fl u-like symptoms, pyrexia; other members of household/contacts aff ected. Appearance of stool blood 2 colonic ulceration (typical for Campylobacter or Shigella spp.); watery \200\230rice \200\231 stool suggests cholera. Signs itemp, iHR, dehydrated, fl ushing, sweating, abdominal tender- ness, general malaise; PR tender, peri-anal erythema. Investigations stool culture result may take \211 48h; C. diff . toxin assays and norovirus PCR where clinical suspicion; blds iWCC, iCRP, iurea; if prolonged, consider sigmoidoscopy and discuss with microbiology. Treatment Admit if clinica l concern or not meeting fl uid needs orally; isolation/barrier nursing with rigorous hand- washing by nurses, doctors and visitors; push oral fl uids oral rehydration solutions, an tiemetics (b p185); IV fl uids if not tolerating oral fl uids. Surprisingly few indications for antibiotics, even after identifi cation of a causative bacterium \200\223 always disc uss with microbiology. Some causes are notifi able (b p487). _OHFP.indb 307 _OHFP.indb 307 30/05/2014 16:18 30/05/2014 16:18 308 CHAPTER 9 Gastroenterology Pseudomembranous colitis Overgrowth of Clostridium diffi cile, often following antibiotic u se. Diffi cult to treat, with a high mortality in vulnerable groups, always remember this c ondition when tempted to start antibiotics on scanty evidence. Symptoms usually 3 \200\2239 d after antibiotic therapy (can be 24h \200\2236wk), rapid onset of high-quantity green, fo ul-smelling stool, crampy abdo pain. Investigations blds iiWCC, dK+; stool C. diffi cile to xin, M,C+S. Treatment stop unnecessary antibiotics; isolate and barrier nurse, rehydrate wi th PO/IV fl uids and correct electrolyte abnormalities, metronidazole 400mg/8h PO and/or va ncomycin 125mg/6h PO (oral route targets GI tract). Can use IV metronidazole and PR vancomy cin as per ID advice. Complications toxic megacolon, perforation, high risk of spread to ot her patients via hands of healthcare workers; spores not killed by alcohol gels. Irritable bowel syndrome \200\223 IBS1 (OHCM9 b p276) Consider in those with >6mth abdo pain, bloati ng or altered bowel habit. Diagnostic criteria central/lower abdo pain or discomfort, this is relieved by defecation or associated with altered bowel frequency/stool form, and is acc ompanied by at least 2 of: bloating, passage of mucus, altered stool passage (eg straining, urgency), symptoms worse on/after eating. Red \202 ags that should prompt urgent conside ration of other diagnoses include unintentional weight loss, rectal bleeding, age >60, fami ly history of bowel or ovarian cancer. Signs often normal or generalized abdo tenderness; e xclude a pelvic mass. Investigations If fi ts diagnostic criteria and no red fl ags, exclud e other pathology by checking for normal FBC, ESR, CRP, anti-endomysial anti- bodies; furth er tests only if suspicion this is not IBS (eg TFT, sigmoidoscopy, colonoscopy, OGD, parasi tes). CA125 if 5 with persistent bloating/pain. Treatment2 reassure and explain; basic life style, exercise and dietary advice including attention to regular meals and non-caff einate d drinks, with limited intake of foods high in insoluble fi bre (eg bran); consider dietici an referral; mebeverine 135mg/8h PO, loperamide or Fybogel according to symptoms, amitrip tyline 10mg OD or SSRIs (2nd line) can have visceral analgesic eff ect. Malabsorption disor ders (OHCM9 b p280) Impaired absorption of nutrients owing to a wide range of GI pathology. Causes coeliac disease, chronic pancreatitis, tropical sprue, cystic fi brosis, small bowe l/gastric resection, bacterial overgrowth, IBD. Symptoms diarrhea steatorrhoea, weight los s, tiredness, SOB, dizziness, bruising, swelling, vomiting, gluten intolerance, abdo pain. Signs cachexia, pale, dehydrated, mouth ulcers, sore tongue, abdo ten- derness, oedema, bru ises. Investigations blds dHb, dMCV, dCa2+, dalbumin, diron, dfolate, iPT; +ve anti-endomys ial antibodies sensitive for coeliac disease but duodenal biopsy gold standard; stool elast ase for assessment of pancreatic function; hydrogen breath test for small bowel bacterial o vergrowth. Treatment refer to dietician and gastroenterologist, may need nutrient 9 pancrea tic supplements, gluten-free diet (coeliac). 1 See (cid:27)www.romecriteria.org for diagnos tic resources 2 (cid:27)NICE guidelines available at (cid:27)guidance.nice.org.uk/CG61 OHFP.indb 308 OHFP.indb 308 30/05/2014 16:18 30/05/2014 16:18 309 diarrhea In \202 ammatory bowel disease \200\223 IBD1 Ulcerative colitis (OHCM9 b p272), Crohn \200\231s disease (OHCM9 b p274). Symptoms recurrent diarrhea blood mucus associated wi th abdo pain, malaise, tiredness, anorexia and weight loss. Signs itemp, iHR dBP, pale, a bdo pain peritonism, palpable abdo mass, abdo swelling (toxic megacolon), malnourished; f i stulae fi ssures in Crohn \200\231s ) (Table 9.8). ( Extra-intestinal signs mouth ulcers*, erythema nodosum*, pyoderma gangrenosum*, conjunctivi tis*, episcleritis*, iritis*, acute arthropathy*, clubbing, sacroiliitis, ankylosing spondy litis, fatty liver, primary scle- rosing cholangitis, cholangiocarcinoma. *related to disea se activity Investigations blds iWCC, iCRP, dalbumin (as a marker of infl ammation, not nutrition), dK+ (diarrhoeal losses), dCa2+, diron, dfolate, dB12 (terminal ileal disease), bld cultures; s tool cultures vital in ruling out infective causes of exacerbation including C. diffi cile; AXR mucosal oedema, toxic megacolon >6cm, fecal residue suggests uninvolved mucosa; sigmoi doscopy colon- oscopy shows characteristic appearances/ulceration and allows biopsy; CT if concern of abscess and if surgery being considered. Complications toxic megacolon, bowel obstruction, perforation, malab- sorption, fi stulae, fi ssures, strictures, malignancy. Table 9.8 Diff erentiating between ulcerative colitis and Crohn \200\231s Feature Symptoms Ulcerative colitis (UC) Diarrhea and PR blood/mucus prominent Crohn \200\231s Diarrhea, abdo pain and weight loss prominent Anywhere along GI tract, most commonly terminal ileum Infl amed, thickened mucosa, skip lesions Infl ammation extends be yond the submucosa, granulomas present GI involvement Colon only, extending proximally from rectum to variable extent Sigmoidoscopy Infl amed mucosa, continuous lesions Mucosal and submucosal infl ammation, crypt abscesses, reduced goblet cells Histology Treatment depends upon disease severity. Rehydrate and correct elec- trolyte imbalances; av oid antimotility/antispasmodic agents. Systemically well patients with mild-moderate diseas e (<6 stools/day) should start oral 9rectal steroids (eg prednisolone 30 \200\22340mg/day P O). In UC oral9rectal mesalazine (eg Pentasa 1g/12h PO) should be added. More severe dise ase requires IV steroids (eg hydrocortisone 100mg/6h IV), as well as antibiotics until infe ctious causes ruled out (eg co-amoxiclav 1.2g/8h IV). Monitor the patient closely (daily ab do exam, bloods AXR) and involve surgeons early. Elemental diet, immunosuppressive drugs (eg azathio- prine) and biological agents (eg infl iximab) may also be used. Surgery is ind icated as an emergency procedure in cases of perforation or massive hemorrhage. Urgent surg ery is performed in UC for toxic megacolon or failure to respond to maximal medical therapy after 5 \200\2237d; delaying beyond this risks poor operative results. Surgery in Crohn \200\231s is never curative and associated with high recurrence and complication rates, but is indicated for obstruction, abscesses, and fi stulae. 1 See (cid:27)www.ecco-ibd.eu for a range of European guidelines. _OHFP.indb 309 _OHFP.indb 309 30/05/2014 16:18 30/05/2014 16:18 310 CHAPTER 9 Gastroenterology Constipation Worrying features abdominal pain, distension, nausea/vomiting, iHR, dBP, absent/tinkling bo wel sounds, weight loss, PR bleeding. Think about serious bowel obstruction, bowel/ovarian cancer; common medications, poor diet, paralytic ileus, dehydration, functional dis- orders; other anal fi ssure/stricture, pelvi c mass, spinal injury, hypothyroid (Table 9.9). Ask about abdo pain, nausea, vomiting, date bowels last opened, normal bowel habit and freq uency, stool consistency and color, blood in stools, pain on opening bowels, straining, blo ating, fl atus, fl uid intake, weight loss, tenesmus, recent surgery; 5: periods, discharge ; PMH IBD, diverticulosis, hernias, previous surgery, colon cancer, hypothyroidism; DH (see box) SH mobility, diet. Medications causing constipation: opioids, iron supplements, non- magnesium antacids, calci um-channel blockers, psychotropic drugs, anticholinergics, chronic laxative use (may lead t o the development of a dilated atonic colon). Obs temp, HR, BP, fl uid balance. Look for volume status (b p380), tenderness peritonism , distension, masses, absent/tinkling bowel sounds, hernias, scars; PR anal fi ssures, rect al masses, fecal impaction, melaena/blood. Investigations blds FBC, U+E, TFT, Ca2+; AXR to exclude obstruc- tion sigmoidoscopy biopsy if sub-acute onset; colonoscopy if cancer susp ected. General management of constipation \200 Conservative increase fl uid intake, high-fi bre diet, review drugs: consider alternatives without GI side eff ects; start stool chart \200 \223 this will often be kept more accurately if you educate patients to complete it themsel ves Medical see b p205 for detailed laxative prescribing information; mild symptoms respond to senna or lactulose; more severe symptoms may require sodium docusa te or Movicol ; glycerol suppositories will soften impacted stool, whilst phosphate enemas or Picolax bowel prep should be reserved for when other measures fail Surgical disimpaction scooping hard feces from the rectum is a seriously unpleasant point o f last resort for everyone concerned. OHFP.indb 310 OHFP.indb 310 30/05/2014 16:18 30/05/2014 16:18 311 CONSTIPATION Table 9.9 Common causes of constipation History Pain, distension, nausea, vomiting, constipation Absence of fl atus, recent operati on Abdo pain, weight loss, fresh blood or melaena Fresh red blood on toilet paper, pain A norexia (eg post- op), low-fi bre diet See \200\230Medications causing constipation \200 \231 box Examination Distension, tenderness, absent/ tinkling bowel sounds Distended abdomen, absent bowel sounds PR blood or melaena, mucus/palpable mass Investigation Dilated loops of bowel on AXR Bowel obstruction Distended bowel loops on AXR, dK+ dHb, lesion on sigmoidoscopy/ colonoscopy Proctoscopy or sigmoidoscopy dHb, dMCV, dCa2+ Paralytic ileus Bowel cancer Perianal tags, may have a tear or tenderness Cachexia Ano-rectal pathology Poor diet Drugs Poor diet A surprising number of in-patients fail to achieve adequate nutrition, with major impacts on wound healing, recovery, and physical condition. Try to recognize this and invo lve dieticians where appropriate, whilst avoiding prolonged NBM periods where possible. Mar kers for nutritional adequacy are problematic, but end of the bed assessment is useful. Whe re consti- pation is a feature, encourage to aim for regular high-fi bre meals, with good f l uid intake and regular physical activity. Hints and tips \200 Prescribe prophylactic laxatives for patients at risk of developing constipation (eg when prescribing opioids, post-op) Exclude obstruction before prescribing a laxative \200 Lactulose is poorly tolerated by m any patients and is associated with abdominal pain and bloating Reassess regularly for resolution of constipation \200\223 do not put off doing a rectal examination Consider malignancy in all patients >40yr presenting with altered bowel habit. Causes of constipation covered elsewhere Anal fi ssures/hemorrhoids b p303 Infl ammatory bowel disease b p309 b p308 Irritable bowel syndrome Bowel obstruction b p292 b p303 Polyps _OHFP.indb 311 _OHFP.indb 311 30/05/2014 16:18 30/05/2014 16:18 312 CHAPTER 9 Gastroenterology Liver failure emergency Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM Airway Breathing Circulation If no palpable pulse \200\223 CALL ARREST TEAM Disability If GCS \211 8 \200\223 CALL anesthetist Altered mental state or coagulopathy in the presence of jaundice. 3Call for senior help ear ly if patient deteriorating. Airway \200 Look inside the mouth, wide-bore suction if secr etions present \200 Jaw thrust/head tilt/chin lift; oro/nasopharyngeal airway if tolerate d. Breathing \200 15l/min O2 if SOB or sats <94% \200 Monitor O2 sats and RR. Circulati on \200 Venous access, take bloods: FBC, U+E, LFT, PT/APTT, CRP, glucose, amylase, Ca2+, Mg2+, 3 \200\223, bld cultures, paracetamol levels, viral serology PO4 Start IV \202 uids 1l of 5% glucose over 4 \200\2236h \200 Monitor HR, ECG, BP. Disabil ity \200 Check blood glucose treat if <3.5mmol/l (b p322) \200 Check GCS, pupil refl ex es, limb tone, plantar responses. Exposure \200 Check temp \200 Ask ward staff for a br ief history or check notes: previous liver disease, likely causes Examine patient brief RS, CVS, abdo and neuro exam: signs of chronic liver disease ECG, ABG and urgent portable CXR \200 Stabilize and treat, see b p313 \200 Call for sen ior help and arrange transfer to HDU/ICU \200 Reassess, starting with A, B, C \200 Causes of liver failure Acute liver failure Paracetamol overdose, drugs, toxins, viral hepatitis, autoimmune hepatitis, ischaemic hepatitis (heart failure and shock), Budd \200\223Chiari Al cohol excess, malignancy, GI bleeds, metabolic disturbances, sedatives, portal vein thrombo sis, acute illness, surgery, infection (eg spontaneous bacterial peritonitis) Decompensated chronic liver disease OHFP.indb 312 OHFP.indb 312 30/05/2014 16:18 30/05/2014 16:18 313 LIVER FAILURE Liver failure Worrying features Ascites, hepatic fl ap, altered mental state and jaundice are cardinal fe atures of decompensation in liver disease; also beware active bleeding, renal failure, iHR, dBP. Think about emergencies acute liver failure, decompensated chronic liver disease, hepatic e ncephalopathy; acute liver failure paracetamol overdose (b p495), viral hepatitis (A, B, C, E, CMV, EMV), pregnancy, medications (see below), toxins (eg poisonous mushrooms), vascula r (eg Budd \200\223Chiari), sepsis, Weil \200\231s disease, abscess; chronic liver failure alcohol, medications (see below), idiopathic, autoimmune, hepatitis (B D, C), malignancy, Wilson \200\231s disease, haemochromatosis, A1-antitrypsin defi ciency. Drug-induced hepatotoxicity1 may result in response to a large number of drugs, ranging fro m mild elevations in LFTs to fulminant hepatic failure. Paracetamol, NSAIDs, ACE inhibitors , erythromycin, fl uconazole and statins commonly cause hepatocellular injury (ALT >2x uppe r limit normal with normal/minimally iALP). Chlorpromazine, oestrogens, ciprofl oxacin, iso niazid, phenytoin, erythromycin and co-amoxiclav can all cause cholestasis (iALP, with or w ithout associ- ated hepatocellular damage). Always ask about recreational drugs (eg cocaine , mushrooms) and over the counter or herbal medications. 1 Useful review article available free at (cid:27)www.ncbi.nlm.nih.gov/pmc/articles/PMC2773872 Ask about tiredness, jaundice (+onset), abdo pain, drowsiness con- fusion, bruising, ble eding (skin, nose, bowel, urine), distension, ankle swelling, vomiting, rashes, recent infe ctions (sore throat), weight loss, hair loss, darkening skin; PMH previous jaundice, gallst ones, blood transfusions; DH see box above; FH liver disease, recent jaundice; SH alcohol, IVDU, tattoos, piercings, foreign travel, sexual activity. Obs temp, HR, BP, RR, O2 sats, G CS, blood glucose, urine output. Look for volume status b p380; acute liver failure drowsin ess, confusion, slurred speech, jaundice, fl apping tremor (asterixis), poor co-ordination, bruising, foetor hepaticus (sweet, fecal smelling breath), abdominal tenderness, hepatomeg aly, ascites; chronic liver disease cachexia, palmar erythema, clubbing, xanthelasma, spide r naevi, caput medusa, gynaecomastia, muscle wasting, splenomegaly, genital atrophy, track marks (IVDU), pneumonia/chronic lung disease, darkened skin. Investigations These are aimed at establishing the extent and possible cause of liver damage, and fi nding a possible cau se of any decompensa- tion, especially intercurrent infection urine MSU; blds FBC, clotting , iron, ferritin, U+E, LFT, hepatitis serology (A, B+C), EBV and CMV serology, caeruloplasm in (if <50yr), autoimmune screen (antimitochondrial, antinu- clear and anti-smooth muscle a ntibodies, b p593), bld cultures; urgent USS abdo looking for parenchymal mass(es), dilated ducts or portal vein thrombosis; urgent ascitic tap (b p550) and white cell count to check for spontaneous bacterial peritonitis (b p316). _OHFP.indb 313 _OHFP.indb 313 30/05/2014 16:18 30/05/2014 16:18 314 CHAPTER 9 Gastroenterology 3Acute liver failure (OHAM3 b p268) Acute encephalopathy, coagulopathy and jaundice without previous cirrhosis (Table 9.10). Table 9.10 Types of acute liver failure Liver failure <7d of disease onset Liver failure 1 \200\2234wk of disease onset Liver failu re 4 \200\22312wk of disease onset Liver failure 12 \200\22326wk of disease onset Late-onse t hepatic failure Hyperacute fulminant hepatic failure Acute fulminant hepatic failure Subacute fulminant hep atic failure Symptoms bruising/bleeding, drowsy confusion, abdo pain. Signs drowsiness, confusion, slurred speech, jaundice, fl apping tremor (asterixis), poor c o-ordination, bruising, hepatomegaly, ascites. Investigations initiate liver screen as deta iled (b p313) blds iPT/APTT, iiALT, iALP, ibilirubin, iammonia, iWCC, dglucose, dMg2+, dPO4 3 \200\223; ABG respiratory alkalosis, metabolic acidosis (poor prognosis); USS masses, ec hogenicity, portal vein fl ow. Treatment discuss with a senior early, often needs ICU/HDU with inva- sive monitoring, and may need transfer to a specialist liver center, where may be considered for transplantation . Monitor blood glucose every 2h; insert a catheter and monitor fl uid balance. \200 iPT give one-off dose of vitamin K 10mg IV: always discuss with a senior; PT prolongation is used to monitor disease progress; FFP may be indicated if the patient is bleeding or needs an invasive proc edure Stop aspirin, NSAIDs and hepatotoxic drugs (b p313); check all drugs in BNF Antibiotic prophylaxis in all patients (eg cefotaxime) antifungals \200 Daily bloods ( FBC, U+E, LFT, PT1) \200 Lactulose 10 \200\22320ml/8h PO in all patients (helps remove am monia) \200 Close monitoring of cardiovascular status and blood glucose; if need IV fl uids, avoid Na+ if chronic liver disease/ascites. Complications renal failure (hepatorenal syndrome), respiratory failure (ARDS), cerebral oe dema, bleeding, sepsis, dglucose, iNa+, dK+. Vascular liver disease Diagnosed by Doppler USS; these diseases can cause hepatic jaundice or acute liver failure, often treated by anticoagulation or endovascular methods. \200 Bu dd \200\223Chiari hepatic vein obstruction \200 Portal vein obstruction (pain and derange d LFTs; jaundice only if other causes of liver disease coexist) Liver ischaemia due to hypotension and/or hepatic artery stenosis. Typically causes massive ALT rise. 1 Strictly, the INR is specifi c for warfarin therapy; the pattern abnormal clotting in liv er disease is diff erent and more reliably reported as PT and APTT prolongation. OHFP.indb 314 OHFP.indb 314 30/05/2014 16:18 30/05/2014 16:18 315 LIVER FAILURE Glandular fever (infectious mononucleosis, Epstein \200\223Barr virus, EBV) Symptoms usuall y young (10 \200\22330yr), sore throat >1wk, fever, lethargy, malaise, rash, lumps in the n eck, anorexia. Signs red tonsils white exudate, tender lymphadenopathy, splenomegaly, ras h (especially with amoxicillin/ampicillin), palatal petechiae, jaundice. Investigations bld s ilymphocytes (atypical on fi lm), iALT, +ve Monospot/Paul Bunnell, +ve IgM for EBV. Manag ement rest, rehydration, analgesia, gargle with warm saline/ aspirin, avoid amoxicillin/amp icillin, avoid alcohol, consider short course of oral steroids if very severe (eg hepatic e ncephalopathy). Complications hepatitis, liver failure, thrombocytopenia, splenic rupture, haemolysis, encephalitis. Acute viral hepatitis (OHCM9 b p406) Causes hepatitis A,B,C and E , cytomegalovirus (CMV) and EBV. Symptoms jaundice, rash, diarrhea, abdo pain, fl u-like sy mptoms (eg fever, malaise, anorexia, fatigue, nausea, vomiting, arthralgia, sore throat). S igns may have no signs, itemp, urticarial rash, jaundice, hepatomegaly, splenomegaly, lymph adenopathy. Investigations blds iWCC, ibilirubin, iALT iPT, +ve hepatitis serology (Table 9.11). Management avoid alcohol, supportive treatment, monitor for progression to acute li ver failure (b p314) which may need interferon-A. Complications natural history varies wide ly depending upon virus and host; risks include acute liver failure or chronic disease. Chr onic viral hepatitis (OHCM9 b p406) Hepatitis >6mth, caused by hepatitis B ( D) and C. Sym ptoms and signs usually asymptomatic, signs of chronic liver disease. Investigations blds d eranged LFT iPT; abnormal viral serology (Table 9.11); USS liver may be suggestive of cir rhosis. Treatment avoid alcohol, consider referral to a hepatologist for specifi c antivira l treatment (eg interferon-A or ribavirin).1 Complications cirrhosis (20%), hepatocellular carcinoma (esp HBV). Table 9.11 Serology in hepatitis B