Acute gastroenterology Flashcards
in which 3 clinical situations can acute diarrhoea constitute an emergency?
acute watery diarrhoea, usually infectious
diarrhoea with blood
toxic dilatation- occurs in severe UC or colonic Crohn’s, infectious colitis, acute distal obstruction e.g. carcinoma or volvulus, and acute pseudo-obstruction- Ogilvie’s syndrome.
what does pt resuscitation in acute diarrhoea involve?
oral rehydration therapy
blood tests in acute diarrhoea?
FBC- ?raised Hb with dehydration, raised pack cell volume, lowered Hb with inflammation-raised WCC, ESR and platelets, and CRP.
Us and Es- raised blood urea
low Mg2+ and K+
reduced venous HCO3-, decreased arterial blood pH, raised lactate and base defecit on ABG if acidosis
eosinophilia with helminthic infections
causes of acute upper GI bleeding?
peptic ulcer mallory-weiss tear gastroduodenal erosions oesophagitis oesophageal varices malignancy vascular malformations causes of swallowed blood e.g. epistaxis, hamoptysis, facial trauma
signs and symptoms of acute upper GI bleed?
haematemesi melaena dizziness syncope abdo pain dysphagia postural hypotension hypotension tachycardia cold and clammy extremities reduced JVP, urine ouput telangiectasia or purpura jaundice- if alongside biliary colic and melaena then suggests haemobilia
signs of CLD e.g. clubbing, palmar erythema, duputren’s, spider naevi, dilated abdo veins, gynaecomastia in males, test atrophy
note prev GI problems, alcohol and drug use
how is pt assessed for shock in acute upper GI bleed?
cool and clammy extremities CRT more than 2s tachycardia-pulse more than 100bpm JVP less than 1cm H20 systolic BP less than 100mmHh postural hypotension-postural drop more than 20mmHg on standing urine ouput less than 30ml/h
how is pt managed in acute upper GI bleed if not shocked?
insert 2 big cannulae-start slow IVI 0.9% sodium chloride
check blds, monitor vital signs and urine ouput
aim to keep Hb more than 8g/dL
immediate management of shocked pt in acute upper GI bleed?
protect airway, keep NBM
insert 2 large-bore cannulae-14-16G
draw blds FBC, UandE, LFT, glucose, clotting screen
X match 6 units
give high flow O2
rapid IV crystalloid infusion up to 1L
if remains shocked, give blood- O Rh-ve if X match not done
otherwise, slow saline infusion to keep lines open
transfuse as dictated
correct clotting abnormalities- Vit K, FFP, platelet concentrate
set up CVP line to guide fluid replacement, aim for more than 5cm H20
catheterise and monitor urine output, aim for more than 30ml/hr
monitor vital signs every 15 mins until stable, then hrly
notify surgeons of all severe bleeds
urgent endoscopy for diagnosis and possible bleeding control
acute drug therapy in acute upper GI bleed?
if major ulcer bleeding and had successful endoscopic therapy, give omeprazole 80mg stat IV over 5min then 8mg/hr for 72hr
specific management of upper GI variceal bleeding?
resuscitate,
then urgent endoscopy for banding/sclerotherapy
give terlipressin 2mg SC qds
may pass a Sengstaken-Blakemore tube
start tment to avoid hepatic encephalopathy
omeprazole 40mg PO may help prevent stress ulceration
when is endoscopy performed in acute upper GI bleed?
within 4hr if variceal bleeding suspected
within 12-24hr if pt shocked O/A or signif comorbidity
define acute liver failure (ALF)/fulminant hepatic failure
potentially reversible condition, consequence of severe liver injury, with onset of encephalopathy within 8 wk of appearance of 1st symptoms (usually jaundice) and in absence of pre-existing liver disease, although may occur in those with previous liver damage e.g. in Budd-Chiari or Wilson’s disease.
how is ALF recognised?
liver synthetic dysfunction- prolonged INR with or without low albumin, in pt with severe liver injury- usually signif raised ALT, but with no evidence of previous liver disease or cirrhosis.
immediate actions in suspected ALF?
obtain specialist hepatology/gastroenterology opinion as soon as possible
if unavailable, discuss with liver transplant registrar
ideal management is to transfer to liver transplant unit prior to onset of encephalopathy or meeting Kings criteria.
what are the Kings criteria?
criteria which determine which patients will benefit from a liver transplant in ALF.
