1 British Thoracic Society guidelines available at (cid:27)www.brit-thoracic.org.uk/guideli nes-and-quality- standards/bronchiectasis-guideline/ _OHFP.indb 285 _OHFP.indb 285 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank Chapter 9 Gastroenterology 287 Abdominal pain emergency 288 Abdominal pain 289 GI bleeding emergency 298 Acute upper GI bl eeds 299 Acute lower GI bleeds 301 Nausea and vomiting 304 Diarrhea 306 Constipation 310 Li ver failure emergency 312 Liver failure 313 Jaundice 318 _OHFP.indb 287 _OHFP.indb 287 30/05/2014 16:18 30/05/2014 16:18 288 CHAPTER 9 Gastroenterology Abdominal pain 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 3Call for senior help early if patient deteriorating. \200 15l/min O2 if SOB or sats <94% \200 Monitor BP, pulse oximeter, defi brillator \200\231s ECG leads if unwell \200 Obt ain a full set of observations, are they haemodynamically stable? \200 Take brief history if possible/check notes/ask ward staff \200 Examine patient: condensed RS, CVS, abdo, wound exam \200 Consider serious causes (see box) and treat if present \200 Initiate fu rther treatment, see b p289 \200 Venous access, take bloods: FBC, U+E, LFT, amylase, CRP, clotting, X-match 4 units, bld cultures Give IV \202 uids if hypovolaemic or shocked (b p476) \200 Analgesia as appropriate \200 Arterial blood gas, but don \200\231t leave the patient alone \200 Erect CXR (porta ble if unwell) and consider plain AXR \200 ECG \200 Urine dipstick and B-hCG (all pre-m enopausal women), catheter \200 Keep patient NBM if likely to need theater \200 Call for senior help \200 Reassess, starting with A, B, C \200 Life-threatening causes and emergencies Perforation \200 Bowel infarction/ischaemia \200 Bowel obstruction \200 Acute pancrea titis \200 Acute cholangitis \200 Appendicitis Leaking abdominal aortic aneurysm (AAA) \200 Strangulated hernia \200 Testicular or ova rian torsion \200 Ruptured ectopic pregnancy \200 Referred pain (MI, aortic dissection) OHFP.indb 288 OHFP.indb 288 30/05/2014 16:18 30/05/2014 16:18 289 ABDOMINAL PAIN Abdominal pain Worrying features sudden onset, iHR, dBP, dGCS, massive distension, peritonism, expansile m ass, persistent vomiting, haematemesis, massive PR bleeding; if life-threatening, see b p28 8. Think about pain by anatomical structure, see Fig. 9.1; common gas- troenteritis, peptic ul cer, gastro-oesophageal refl ux disease (GORD), constipation, infl ammatory bowel disease ( IBD), irritable bowel syndrome (IBS), diverticular disease, adhesions, mesenteric adenitis, renal colic, UTI/ pyelonephritis, urinary retention, biliary colic/sepsis, pancreatitis, b leeding AAA, incarcerated hernia, ischaemic bowel; obs/gynae ectopic preg- nancy, ovarian c yst, ovarian torsion, PID, endometriosis, labor; other trauma, MI, pneumonia, sickle-cell c rises, DKA, psoas abscess, porphyria. See Table 9.1. Ask about nature of pain (constant, colicky, changes with eating/ vomiting/bowels), duratio n, onset, frequency, severity, radiation to the back, dysphagia, dyspepsia, abdominal swell ing, nausea and vomiting, stool color, change in bowel habit, urinary symptoms, weight loss , breathlessness, rashes, lumps, chest pain, recent surgery, last period; PMH DM, IBD, IHD, jaundice, gallstones, pancreatitis, previous abdo surgery; DH NSAIDs; SH alcohol. Obs temp, HR, BP, RR, sats, fi nger-prick glucose, urine output. Look for jaundice, sweating, pallor, pulse volume, clubbing, leuconychia (white nails), lym phadenopathy (Virchow \200\231s node), abdominal scars, dis- tension, ascites, visible peri stalsis, tenderness, peritonitis (tenderness with guarding, rebound or rigidity), loin tend erness, hepatomegaly, sple- nomegaly, masses (?expansile/pulsatile), check hernial orifi ce s, examine external genitalia (4: testicular vs. epididymal tenderness), femoral pulses, bo wel sounds, lung air entry; PR perianal skin tags, fi ssures, warts; tender- ness, masses, prostate hypertrophy, stool, check glove for blood, mucus, melaena and stool color. Investi gations urine dipstick, B-hCG in all pre-menopausal women of reproductive age, MSU; blds FB C, U+E, LFT, amylase, Ca2+, glucose, 9cardiac markers, venous lactate, clotting, bld cultur es if pyrexial; ABG if unwell; ECG to exclude MI; erect CXR to exclude perforation; plain A XR to exclude bowel obstruction or KUB for renal colic; USS espe- cially if hepatobiliary c ause suspected; CT abdo discuss with senior. Treatment Give all patients O2, analgesia antiemetics; insert a urinary catheter if unwel l. Keep NBM until urgent surgery is ruled out. \200 Shocked IV fl uids 3urgent senior rev iew \200 Peritonitic with IV fl uids, IV antibiotics 3urgent senior review \200 >50yr i n severe pain ?AAA, IV fl uids 3urgent senior review \200 Abdo pain and vomiting consider obstruction, IV fl uids, NG tube, AXR (b p588) 3urgent senior review GI bleed resuscitate with IV fl uids (b p298) 3urgent senior review. _OHFP.indb 289 _OHFP.indb 289 30/05/2014 16:18 30/05/2014 16:18 290 CHAPTER 9 Gastroenterology Table 9.1 Common causes of abdominal pain History Examination Peritonitis, 9 bowel sounds Distension, tenderness, tinkling bowel sounds Shock , generalized tenderness Investigations 3Perforation Rapid onset, severe abdominal pain Gas under diaphragm, acidotic Dilated loops of bowel on AXR Bowel obstruction Pain, distension, nausea, vomiting, constipation iWCC, ilactate/ acidotic, AF or previous MI on ECG iWCC, iCRP Bowel ischaemia/ infarction Sudden onset, severe pain, previous arterial disease, AF Appendicitis RIF pain (initially periumbilical), anorexia, nausea, vomiting Slight temp, RIF tenderness, peritonitic Strangulated hernia Sudden onset pain, Tender hernial mass Epigastric tenderness Needs urgent surgery Consider need for OGD previous hernia Dyspepsia, heartburn, anorexia, NSAIDs GORD/peptic ulcer itemp, epigastric tenderness, no peritonitis Tender mass peritonitis iWCC, iCRP Gastroenteritis Rapid onset, vomiting, diarrhea iWCC, iCRP, iplts, oedematous bowel on AXR, lesions on colonoscopy iWCC, iCRP, diverticulae on colonoscopy iiiamylase, iWCC, iCRP, iglucose, dCa2+ Infl ammatory bowel disease Weight loss, mouth ulcers, PR blood mucus, diarrhea Diverticular disease Pain, diarrhea, Tenderness, peritonitis constipation, PR bleeding Constant epigastric pain radiating to back, vomiting, anorexia, i alcohol or gallstones Abdominal and back pain, collapse, prev heart disease/iBP, age >50yr, 4 3Acute pancreatitis Shock, epigastric tenderness, dbowel sounds 3Abdominal aortic aneurysm (AAA) Expansile mass, unwell, often dBP, dleg pulses Urgent USS (bedside if possible); immediate surgery if leaking Renal colic Sudden severe colicky fl ank pain, radiates to groin, nausea/ vomiting Constant or colicky RUQ pain, gallstone Sweating, restless, loin tenderness 60% of stones visible on KUB; >99% on non- contrast CT Deranged LFTs; dilated CBD on USS B- hCG +ve, lesions seen on USS Hepatobiliary disease Obs/gynae disease Lower abdo pain, PV RUQ tenderness, jaundice Lower abdo tenderness, PV exam abnormal Tender testicle, swell ing bleeding, irregular/ absent periods Sudden onset severe unilateral groin pain 3Testicular torsion Urgent surgery OHFP.indb 290 OHFP.indb 290 30/05/2014 16:18 30/05/2014 16:18 291 ABDOMINAL PAIN Esophagus, stomach, duodenum, heart Stomach, spleen, left lung Liver, gallbladder, duodenum, right lung Abdominal aorta, small bowel, appendix Meckel \200\231s diverticulum Right kidney, colon, ureter, musculoskeletal Left kidney, colon, ureter, musculoskeletal Caecum, appendix, right ovary and right fallopian tube, right testicle, ureter Sigmoid colon, left ovary and left fallopian tube, left testicle, ureter Bladder, uterus, rectum, colon Fig. 9.1 Abdominal organs and pain, by region. Causes of abdominal pain in this section and elsewhere Bowel b p293 Appendicitis b p293 Adhesions/ischaemia b p295 Dyspepsia/peptic ulcers b p294 Diverticular disease b p292 b p307 Hernias Gastroenteritis Infl ammatory bowel disease b p3 09 Irritable bowel syndrome b p308 b p291 Obstruction b p292 Perforation Hepatopancreatobiliary Biliary colic/cholecystitis b p295 Hepatitis Pancreatitis (acute/chr onic) b p296 b p315 Genitourinary Ectopic pregnancy Ovarian cyst Testicular torsion b p498 Endometriosis b p500 b p500 Pelvic infl ammatory disease b p500 b p463 Other Abdominal aortic aneurysm b p474 Renal colic b p296 3Perforation (OHCM9 b p608) Causes peptic ulcer, appendicitis, diverticulitis, infl ammator y bowel disease, bowel obstruction, GI cancer, gallbladder. Symptoms acute abdominal pain w orse on coughing or moving; PMH peptic ulcer, cancer, IBD; DH NSAIDs; SH alcohol. Signs iHR , dBP, iRR, peritonism (abdo tenderness, guarding, rebound, rigidity), reduced or absent bowel sounds. Investigations blds iWCC, dHb, iamylase, ilactate; CXR erect fi lm shows air under the diaphragm, obstruction on AXR; ABG acidosis. Management seek senior review; res uscitate with IV fl uids, 15l/min O2, good IV access (large \2272), analgesia (eg morphine 5 \200\22310mg IV with cyclizine 50mg/8h IV), NBM and urgent X-match 4 units: IV antibioti cs (eg co-amox- iclav 1.2g/8h IV) insert NG tube and urinary catheter, consider emergency C T once stable, prepare for emergency laparotomy (b p112). _OHFP.indb 291 _OHFP.indb 291 30/05/2014 16:18 30/05/2014 16:18 292 CHAPTER 9 Gastroenterology Bowel obstruction (OHCM9 b p612) ) ( p Causes of intestinal obstruction Outside the bowel Within the bowel wall Tumors, IBD, diverticular disease, infarction, Adhesions, hernias, masses, volvulus congenital atresia, Hirschsprung \200\231s disease Impacted feces, FB, intussusception, str ictures, polyps, gallstones Post-op, electrolyte imbalance, uraemia, DM, anticholinergic dr ugs Inside the bowel lumen Paralytic ileus (pseudo-obstruction) Symptoms vomiting (may be faeculant), colicky abdo pain, pain may improve with vomiting, co nstipation (9absolute \200\223 no fl atus or stool), bloating, anorexia, recent surgery. S igns iHR dBP, iRR, distended abdomen, absent or tinkling bowel sounds, peritonitis, scars from previous surgery, hernias. Investigations blds mild iWCC and iamylase acidosis; AXR look for dilated bowel (?small or large) or volvulus (b p588); erect CXR ?free air. Manage ment may need fl uid resuscitation and analgesia, treat according to the type and location of the obstruction: \200 Strangulated constant severe pain in an ill patient with periton itis (acute abdomen); can be small or large bowel. This will require urgent surgery especially i f caused by a hernia Small bowel early vomiting with late constipation, usually caused by hernias, adhesions or Crohn \200\231s. Treat conservatively with NBM, an NG tube and IV fl uids (b p380) \200\223 often referred to as drip and suck \200\223 until the obstruction resolves; surgery if patient deteriorates. K+ is often lost into the bowel and needs to be replaced in fl uids (eg 20mmol/l) \200 Large bowel early absolute constipation with late vomiting, usually caused by tumors, diverticulitis, volvulus (sigmoid or caecal) or feces. IV fl uids, NBM and refer to a senior surgeon. Urgent surgery may be required if the caecum is >10cm across on AXR otherwise a CT, colonoscopy or water-soluble contrast enema may be requested to investigate the cause. Surgery is usually required except for: \200 sigmoid volvulus \200\223 sigmoidoscopy and fl atus tube insertion \200 fecal obstruction \200 \223 laxative enemas (b p205) \200 colonic stenting \200\223 may be off ered for tumor p alliation \200 Paralytic ileus loss of bowel motility can mimic the signs and symptoms of a mechanical blockage. It is a response of the bowel to infl ammation locally ( eg surgery) or adjacently (eg pancreatitis). The main distinguishing feature is the relativ e lack of abdo pain, although the pathology responsible for the ileus may cause abdo pain i tself. USS abdo, contrast enema or CT may be required to exclude mechanical obstruction. Tr eat conservatively with NBM, NG tube, IV fl uids (b p380) until the underlying pathology im proves. Check and correct electrolyte abnormalities, including K+ and Mg2+ both of which ma y need to be replaced. Complications strangulation, bowel infarction, bowel perforation, dK+, hypovolaemia. OHFP.indb 292 OHFP.indb 292 30/05/2014 16:18 30/05/2014 16:18 293 ABDOMINAL PAIN Adhesions Causes previous surgery, abdominal sepsis, IBD, cancer, endometriosis. Symptoms a nd signs chronic intermittent abdominal pain and tenderness, may develop bowel obstruction (distension, vomiting, constipation). Management analgesia and stool softeners; may need op erative division of adhesions, but this may lead to new adhesions forming. Bowel ischaemia/ infarction (OHCM9 b p622) Symptoms unwell, sudden onset severe constant abdominal pain, PR blood; PMH AF, MI, polycythaemia. Signs iHR (?irregular), dBP, iRR, itemp, cold extremiti es, generalized tenderness but few specifi c signs. Investigations blds iWCC, iamylase, met abolic/lactic acidosis; sigmoidoscopy biopsy may show pale, ulcerated mucosa. Management NBM, resuscitate with IV fl uids; analgesia, IV ABx (eg co-amoxiclav 1.2g/8h IV), consider anticoagulation with IV heparin (b p406), surgical resection is often necessary. Very poor prognosis \200\223 clarify premorbid state and consider ICU care as appropriate. Appendici tis (OHCM9 b p610) A common diagnostic challenge1 \200\223 complications can be severe if left untreated, but 15 \200\22340% of appendicectomy specimens are normal. Can occur in any age group; classical cases are easy enough to spot, variable anatomy and extremes of age c an make presentation atypical. Diff erential UTI, diverticulitis, gastroenteritis, mesenter ic adenitis, perforated ulcer, IBD, diverticulitis; gynae ectopic pregnancy, ovarian torsio n, ruptured ovarian cyst, salpingitis. Symptoms central, abdominal colicky pain worsening o ver 1 \200\2232d then developing into constant RIF pain (sensitivity and specifi city of 78 0%2), worse on moving, anorexia, nausea, vomiting, may have constipation, diarrhea, dysuria , oliguria (all non-specifi c and common). Signs itemp, iHR, dBP, RIF tenderness guard ing/rebound/rigidity, RIF pain on palpating LIF (Rovsing \200\231s sign), PR tender on righ t (there is no evidence that this has diagnostic utility in adults, but failure to perform PR still considered negligent). Investigations iWCC, neutrophilia>75%, iCRP (a useful triad with nega- tive predictive value >97% in adults, but beware children and elderly); bld cul tures (if pyrexial), G+S; US and contrast-enhanced CT reduce laparotomy rates, but this mus t be balanced against risks of radiation exposure and local resources. Management surgery \200\223 NBM, IV fl uids, analgesia, IV ABx (eg co-amoxiclav 1.2g/8h IV). Laparascopic appr oaches reduce scarring, post-operative pain, recovery time and incidence of wound infection s, but require more opera- tive time and higher skill levels than open appendicectomy. If p eritonitic send for immediate surgery, otherwise reassess regularly whilst awaiting surgery . If diagnostic uncertainty a short period of safe observation imaging can be informativ e. 1 And hence an all too common source of tension between ED staff and junior surgical doctor s try to avoid becoming part of this seemingly perpetual clich when your turn comes. 2 See Yeh, B. Ann Emerg Med 2008 52:301, for an excellent review of the clinical utility of signs and symptoms in adult appendicitis; available free at: (cid:27)www.annemergmed.com/article/ S0196-0644(07)01732-5/fulltext _OHFP.indb 293 _OHFP.indb 293 30/05/2014 16:18 30/05/2014 16:18 294 CHAPTER 9 Gastroenterology Dyspepsia1 (OHCM9 b p242) Any persistent symptom referable to the upper GI tract. This will include patients with peptic ulcer disease, gastro-oesophageal refl ux disease, oesophagit is, and rare upper GI malignancies, as well as those without signifi cant endoscopic change s. Aim to identify those at risk of signifi cant pathology, and control symptoms in those w ithout. Symptoms burning retrosternal or epigastric pain, worse on bending and lying, water brash (excess saliva), acid refl ux, nausea, vomiting, nocturnal cough, symptoms improved b y antacids; symptom patterns are poorly predictive of endoscopic fi ndings. Signs epigastri c tenderness (no peritonitis), rarely epigastric mass. Common risk factors smoking, alcohol , obesity, pregnancy, hiatus hernia, medications (bisphosphonates, calcium antagonists, nit rates, corticosteroids, NSAIDs). Investigations urgent endoscopy if \200\230red fl ag \200 \231 symptoms (chronic GI bleeding/ iron defi ciency anemia, unintentional weight loss, pro gressive dysphagia, persistent vomiting, epigastric mass) or \211 55yr and persistent/unex plained dyspepsia. Else test and treat for H. pylori (see box). Some reserve testing for th ose who fail empirical treatment with 1mth full dose PPI. Consider low- dose maintenance or as-required PPI for those who respond. If symptoms persist, consider endoscopy or 24h ambu latory pH monitoring. Management lifestyle advice weight loss, smoking cessation, alcohol r educ- tion, avoid foods/drugs which exacerbate symptoms, especially NSAIDs. \200 GORD ant acids (b p184) PRN if mild; full dose PPI for 1 \200\2232mth, then low dose or PRN PPI; H2 receptor blockers (eg ranitidine) less eff ective than PPI, bu t individual patients may respond better; surgical fundoplication (rarely) if severe Oesophagitis as for GORD; frequency of surveillance if Barrett \200\231s esophagus detected requires specialist guidance Peptic ulcer 1 \200\2232mth full dose PPI. 95% of duodenal and 80% of gastric ulcers are re lated to H. pylori, therefore ensure eradication (see box). Gastric ulcers are also associa ted with malignancy, therefore repeat endoscopy at 6wk to confi rm healing. If symptom recu rrence, retest, since eradication may require diff erent or prolonged antibiotics, and re-i nfection can occur Gastric/oesophageal malignancy urgent multidisciplinary team referral for surgery/palliation. H. pylori infection and eradication \200 13C-urea breath testing reliably detects infecti on or confi rms eradication and is widely used in secondary care; fecal antigen tests are u sed in primary care CLO tests require a biopsy taken at OGD and rely upon pH indicator changes A \200\230wash-out \200\231 period of 2wk off PPI is needed for these tests; serological tests are less reliable, but can be used in a patient on a PPI Treatment is with triple therapy for 1wk, eg lansoprazole 30mg/12h PO, amoxicillin 1g/12h PO, clarithromycin 500mg/12h PO BNF 1.3 Regimens containing metronidazole may increase resistance and may be better reserved for 2nd-line therapy 2wk courses increase eradication rates by 10%, but are not cost-eff ective. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG17 OHFP.indb 294 OHFP.indb 294 30/05/2014 16:18 30/05/2014 16:18 295 ABDOMINAL PAIN Diverticular disease (OHCM9 b p630) Diverticulosis = diverticulae (out pouchings) in the la rge bowel. Diverticulitis = infl ammation of diverticulae; acutely symptomatic. Symptoms ab dominal pain/cramps (usually left sided, improves with bowel opening), irregular bowel habi t, fl atus, bloating, PR bleeding. Signs itemp, iHR, dBP, LIF tenderness, peritonitis, distension. Investigations blds iWCC, iCRP; CT/colonoscopy for indirect/direct visualizatio n. Management diverticulosis high-fi bre diet, antispasmodics (eg mebeverine), laxatives (e g senna, b p205); diverticulitis NBM, analgesia, fl uids and ABx (eg co-amoxiclav 1.2g/8h I V). Complications obstruction, perforation, abscess, adhesions, strictures, fi stula, PR bl eeding (usually painless). Renal colic (OHCM9 b p640) Always consider other causes of abdom inal pain, including AAA, especially if no previous renal stone disease. Symptoms acute ons et severe unilateral colicky pain radiating from loin to groin, nausea and vomiting, sweati ng, haematuria, dysuria, strangury (fre- quent, painful passage of small volumes of urine w ith sensation of incomplete emptying); iliac fossa or suprapubic pain suggests another path ology. Signs iHR, sweating, patient restless and in severe pain, usually no tender- ness on palpation unless superimposed infection. Investigations urine Hb on dipstick (790% cases), nitrates suggest UTI, B-hCG if 5; blds FBC, U+E, Ca2+, urate; KUB detects 60% stones, CT > 99%. Management analgesia (NSAID fi rst, then opioids), if <5mm should pass spontaneously. If evidence of infection give IV ABx (check local policy). If evidence of infection or hydr onephrosis refer urgently to urologist for nephrostomy or stent. Complications pyelonephrit is, renal dysfunction. Biliary colic Contraction of the gallbladder or cystic duct around gallstones. Symptoms rec urrent colicky or constant RUQ/epigastric pain (especially on eating fatty foods), nausea, vomiting, bloating. Signs RUQ tenderness, non-peritonitic, not jaundiced. Results blds norm al; USS gallstones. Management analgesia, dietary advice and elective cholecystectomy. Comp lications passage of stone into common bile duct may cause choles- tatic jaundice, cholangi tis or acute pancreatitis. Acute cholecystitis Gallbladder infl ammation eg s to cystic duct occlusion by gallstone. S ymptoms continuous RUQ/epigastric pain, unwell, vomiting. Signs itemp, RUQ tenderness and p eritonitis, Murphy \200\231s sign (pain and cessation of deep inspiration during palpation in RUQ, not present on LUQ). Results blds iWCC, iCRP; USS gallstones and thickened gallblad der. Management NBM, analgesia, ABx (eg co-amoxiclav 1.2g/8h IV); consider urgent cholecyst ectomy vs. interval procedure. ERCP if distal CBD stone. _OHFP.indb 295 _OHFP.indb 295 30/05/2014 16:18 30/05/2014 16:18 296 CHAPTER 9 Gastroenterology 3Acute pancreatitis1 (OHCM9 b p638) Varies from a mild self-limiting illness to severe and life-threatening. Causes \200\230I GET SMASHED \200\231: idiopathic, gallstones (50%), eth anol (25%), trauma, steroids, mumps, autoimmune, scorpion bites (rare),2 hyperlipi- daemia, hypercalcaemia, hypothermia, ERCP, drugs (eg thiazide diuretics). Symptoms constant severe epigastric pain radiating to the back, improved with sitting forward, nausea, vomiting, an orexia. Signs iHR, dBP, itemp, cold extremities, epigastric tenderness with peritonitis, abdominal distension, dbowel sounds, mild jaundice, Cullen \200\231s (bruised umbilicus) or Gray \200\223Turner \200\231s (bruised fl anks) sign. Results blds dHb, iWCC, iiilipase (o r amylase),3 iglucose, dCa2+, deranged clotting ( DIC), LFT; USS ?gallstones; CT if diagno sis in doubt. Management IV fl uid resuscitation, O2, analgesia, urinary catheter, NBM, NG tube. If severe (Table 9.2) involve ICU and plan ERCP if gallstone etiology. Monitor fl uid balance, obs, glucose. Daily U+E, FBC, CRP; prophylactic LMWH (b p406). Complications DIC, renal failure, respiratory failure, hemorrhage, throm- bosis, sepsis (infected necrosis), pseudocysts, abscess, chronic pancreatitis. Table 9.2 Modi \201 ed Glasgow score for predicting acute pancreatitis severity In 1974 Ranson developed a scoring system, validated for use in alcohol-induced acute pancr eatitis; this remains widely used. The modi \201 ed Ranson criteria (1979) have been valid ated for gallstone related disease. In 1984, Blamey et al.4 at the Royal Infi rmary in Glas gow modifi ed 8 of the 11 Ranson criteria and validated these for prognostic use in both al cohol and gallstone induced acute pancreatitis. Variable Criteria Age PaO2 WCC Ca2+ (uncorr.) Glucose ALT LDH Urea Albumin >55yr <8.0kPa >15 x 109/l <2mmol/l >10mmol/l >100u/l >600u/l >16mmol/l <32g/l Score 1 point for each parameter present on admission or within the \201 rst 48h. A score of \211 3 predicts an episode of severe pancreatitis and should prompt ICU/HDU referral. 4 Original article available free at www.ncbi.nlm.nih.gov/pmc/articles/PMC1420197 Chronic pancreatitis (OHCM9 b p280) Causes usually alcohol, but can be due to gallstones (w hich may also cause recurrent pancreatitis), familial, cystic fi brosis, hyperparathyroidis m, iCa2+. Symptoms general malaise, anorexia, weight loss, recurrent epigastric pain radiat ing to back, steatorrhoea, bloating, DM. Signs cachexia, epigastric tenderness. Investigati ons blds glucose (?DM, b p328); stool delastase; USS ( endo- scopic), CT. Management analg esia, advise to stop drinking alcohol; diet refer to dieti- cian: low fat, high calorie, hi gh protein with fat-soluble vitamin supplements; pancreatic enzymes eg Creon before eatin g; surgery coeliac-plexus block, stenting of the pancreatic duct, pancreatectomy. 1 British Gastroenterology Society guidelines available at (cid:27)gut.bmj.com/content/54/suppl_3/ii i1.full 2 Case series available free at (cid:27)www.ncbi.nlm.nih.gov/pmc/articles/PMC170054 7 3 Lipase slightly more specifi c. Overall trend in relation to pain is more important tha n absolute values. OHFP.indb 296 OHFP.indb 296 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 298 CHAPTER 9 Gastroenterology GI bleeding emergency Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEAM Airway Breathing Circulation 3Call for senior help early if patient deteriorating. \200 Lay the patient on their side if vomiting \200 15l/min O2 if SOB or sats <94% \200 Monitor pulse oximeter, BP, defi b rillator \200\231s ECG leads if unwell \200 Obtain a full set of observations including t emp \200 Two good (large) sites of venous access, take bloods: \200 FBC, U+E, LFT, clot ting, urgent 4 unit X-match 0.9% saline 1l IV \200 Take brief history if possible/check notes/ask ward staff \200 E xamine patient: condensed CVS, RS and abdo exam \200 Correct clotting abnormalities if pr esent (b p404) \200 Arterial blood gas, but don \200\231t leave the patient alone \200 Initiate further treatment, see following sections \200 Consider serious causes (see box) and treat if present \200 Seniors may consider giving terlipressin 2mg IV over 5min if g astro- oesophageal varices suspected (b p300) If bleeding is severe and the patient haemodynamically unstable: \200 Call for senior hel p \200 Give O \200\223ve blood, request X-matched units \200 Contact the on-call endosc opist and alert surgeons \200 Reassess, starting with A, B, C \200 Life-threatening causes Peptic ulcer \200 Vascular malformations Gastro-oesophageal varices \200 Upper GI malignancy OHFP.indb 298 OHFP.indb 298 30/05/2014 16:18 30/05/2014 16:18 299 ACUTE UPPER GI BLEEDS Acute upper GI bleeds 1 (OHAM3 b p224) Worrying features dGCS, iHR, dBP, postural BP drop, durine output, frank haematemesis, fran k PR blood, chest pain, coagulopathy, liver disease. Think about common peptic ulcer (NSAIDs, H. pylori), Mallory \200\223 Weiss tear, gastro-oe sophageal varices, oesophagitis, swallowed blood (eg epistaxis); other oesophageal or gastr ic cancer, vascular malforma- tions, underlying coagulopathy (Table 9.4). Ask about color, quantity, mixed in or throughout vomit, frequency, onset, stool color and consistency (thos e on iron may have black stool but it should not be tarry), chest pain, abdominal pain, dys phagia, dizziness, fainting, sweating, SOB, weight loss; PMH coagulopathy, liver problems ( ?varices), peptic ulcers; DH NSAIDs, anticoagulants, steroids; SH alcohol. Obs Pay special attention for iHR, dBP; check postural BP, GCS. Look for continued bleeding, color of vomit , cold extremities, sweating, pulse volume, bruises, other bleeding (nose, mouth), abdomina l tender- ness9peritonitis, masses, signs of chronic liver disease (b p313); PR fresh blood /melaena. Investigations blds FBC, U+E, LFT, clotting, G+S or 2-4 unit X-match; low platele ts may indicate hypersplenism (?s to portal hypertension/chronic liver disease); iiurea (ou t of proportion to icreatinine); check for coagu- lopathy; ECG ?ischaemia; OGD allows diagn osis and defi nitive treatment only after adequate resuscitation; timing guided by clinical assessment of severity: Risk scoring can be useful in this regard (Table 9.3), but does no t replace clinical judgment. Discuss all potential major bleeds with seniors and an endosco pist at an early stage. Table 9.3 Rockall risk scoring system for GI bleeds Clinical information allows initial risk stratifi cation, to which endoscopic fi ndings (in italics) are added for complete assessment. \211 2 = low risk Feature 0 1 2 3 Age Shock: systolic BP and HR Comorbidity <60yr >100mmHg <100/min Nil major 60 \200\22379yr \211 80yr <100mmHg >100/min Heart failure, IHD All other Renal/liver failure Upper GI malignancy Recent Metastatic disease Mallory \200\223 Weiss/none Nil recent Diagnosis Bleeding on OGD The Rockall score was developed to predict risk of death or rebleeding based upon the compl ete score calculated after endoscopy (eg will occur in 11% of those with Rockall=3). 3Suspi cion of rebleeding requires urgent discussion with the endoscopist and surgeon on call in terventional radiology. As an alternative, the Blatchford score was developed to predict th ose not requiring intervention based upon admission parameters, marginally outperforming th e Rockall score in this regard. It is somewhat more complex and less widely used (online ca lculators available eg (cid:27)www.mdcalc.com). NICE has managed to end up recommending the use of both scores. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG141 _OHFP.indb 299 _OHFP.indb 299 30/05/2014 16:18 30/05/2014 16:18 300 CHAPTER 9 Gastroenterology Table 9.4 Common causes of upper GI bleeding History Epigastric/chest pain, heartburn, melaena, previous ulcers, NSAIDs, alcohol Heartbu rn, NSAIDs, alcohol, hiatus hernia Frank haematemesis previous liver disease, alcohol Force ful vomiting precedes bloodstaining Examination Epigastric tenderness, may be peritonitic if perforated Epigastric tenderness E pigastric tenderness, signs of chronic liver disease Epigastric tenderness Investigation Ulcer on OGD, CLO test may be +ve Peptic ulcers Oesophagitis/ gastritis Gastro- oesophageal varices Mallory \200\223 Weiss tear Infl ammation/ erosions on OGD iPT, deranged LFT, varices on OGD Tear seen on OGD if not resolving Management NBM until OGD, O2, two large-bore cannulae. IV fl uids blood,1 regular obs (H R, BP, postural BP, urine output); consider cath- eterisation, CVC line and HDU/ICU: \200 Blood transfusion is often vital and lifesaving. However, over-transfusion is also associa ted with increased mortality and rebleeding.1 Assess each patient carefully and discuss tra nsfusion targets with a senior 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