Case 10 - Diverticulitis Flashcards
Learning differential diagnosis and treating acute conditions
For each NEWS2 score, give the response?
For each NEWS2 score gicve the frequency of monitoring and detailed clinical response
What is a Diverticulum and where does it normally occur?
A disease where a small pocket or pouches protrudes from the digestive tract.
It normally affects the colon (LEFT side); feaces become stornger. It can occur any where. it happens when the inner layer of digestive tract pushes through weak spots in outer layer
What is diverticulosis and who can get it.
Diverticuli without any symptoms and inflammation; 3 out 4 people with diverticuli do not get symptoms. Hence diverticuli is found incidentally during a colonoscopy or flewxible sigmoidoscopy when looking for a polyps.
What other imaging tests can be used to look for a diverticuli
- Barium Xrays
- CT
*
Sometimes diverticuli presents with symptoms, what are they and what should you do?
Symptoms are:
- fever
- severe abdominal pain (normally lower left)
- bloating
- abdominal cramps
- constipation.
What is Diverticular Disease? Give relevant features
Diverticuli but it presents with intermittent lower abdominal pain and bloating (without inflammation and infection).
the pain is normnally in left lower abdomen and the pain/bloating can be relieved wioth passing stools.
Some people develop diarrhoea /constipation and some people pass mucus in the stool.
what other disease is Diverticular disease similar to and how can you differentiate them?
IBS- but it affects younger people unlike diverticuli disease.
However if the symptoms occur in older people, early bowel cancer needs to be excluded.
What is diverticulitis ? Give symptoms
When diverticuli becomes inflamed and infected. Feaces are trapped in diverticulum and gut bacteria multiply.
It has same symptoms of diverticular disease but has nausea and vomiting also
An infected diverticuli can become serious and cause complications. what are they?
- Obstruction of the colon
- Abscess forming inthe abdomen
- fistula to other organs like the bladder
- Hole in bowel wall that can lead to perotinitis
what are the treatment options for diverticulosis
high fibre (soluble) diet. need to get between 18g-30g of fibre each day.
There are other treatments that prevent it to escalate to diverticular idsease or diverticulitis. which ARE:
- STOP smoking
- exercise
- lose weight
what are the treatment options for divertiuclar disease
- Diverticulosis diet
- lots of fluids -avoid fizzy drinks
- paracetamol - ease pain. DO NOT USE NSAIDS or opiods
- antispasmodics such as mebevrine.
What is the approach to all critically ill pts?
- Use the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach to assess and treat the patient.
- Do a complete initial assessment and re-assess regularly.
- Treat life-threatening problems before moving to the next part of assessment.
- Assess the effects of treatment, remembering it can take a few minutes for treatments to work
- Recognise when you will need extra help. Call for appropriate help early.
- Use all members of the team. This enables interventions (e.g. assessment, attaching monitors, intravenous access), to be undertaken simultaneously.
- Communicate effectively - use the Situation, Background, Assessment, Recommendation (SBAR) or Reason, Story, Vital signs, Plan (RSVP) approach.
Airway.
What are the potential problems of the airway
- Decreased GCS (GCS ≤8 usually requires intubation)
- Excessive secretions
- Foreign body
- Airway swelling / inflammation
- Trauma
AIRWAY.
How do you assess this?
- There may be paradoxical chest and abdominal movements
- There may be use of accessory muscles - In partial obstruction there may be noisy breathing (snoring, stridor, wheeze) with diminished air entry
- In total obstruction there will be no breath sounds at the nose or mouth
- Central cyanosis is a late sign
AIRWAY
What actions can you take if the somehow the airway is compromised?
- Airway opening manoeuvres - head tilt and chin lift, or jaw thrust
- Suction to remove debris (don’t ever use your fingers!).
- Simple airway adjuncts – nasopharyngeal airway, oropharyngeal airway (aka Guedel)
- Supraglottic airway (eg iGel)
- Advanced airway interventions – intubation, emergency surgical airway
- Then give oxygen at high concentration
Breathing.
What are the potential problems affecting breathing?
- Reduced GCS
- Acute severe asthma or COPD
- Pneumonia or lung infection
- Pulmonary oedema
- Pneumothorax or tension pneumothorax
- Pulmonary embolism
- Haemothorax (blood in the pleural cavity, often secondary to trauma)
- Respiratory depression (e.g. secondary to drug toxicity)
Breathing
What assessments can you make to check breathing function?
- Obtain oxygen saturations (pulse oximeter) and count RR
- Are they able to talk in sentences? Words? Not at all?
- Look for use of respiratory muscles, central cyanosis, sweating
- Look / feel for symmetry of chest movement and for chest deformity
- Feel for the trachea – deviation to one side may indicate a tension pneumothorax or large effusion on the contralateral side, or collapse on the ipsilateral side
- Percuss the chest - hyper-resonance may suggest a pneumothorax; dullness usually indicates consolidation or pleural fluid
- Listen to the chest – for air entry and any added sounds (crackles, wheeze, stridor). Absent or reduced sounds suggest a pneumothorax or pleural fluid or lung consolidation caused by complete obstruction to that region.
- Look at the calves for any signs of DVT (which might indicate possibility of PE)
Breathing
What actions can you do to intervene with any immediatye life threatening breathing problems
Specific treatment will depend on cause (for example adrenaline in anaphylaxis, chest drainage in pneumothorax, Naloxone in opioid overdose, bronchodilators in airway disease)
- An arterial blood gas analysis is likely to be useful
- Sit the patient up if possible and they’re short of breath
- All critically ill patients should be given oxygen. For most patients, the oxygen saturation target should be >94%*
- If the patient’s rate or depth of breathing is insufficient or absent, use bag-mask or pocket mask ventilation to improve oxygenation and ventilation, whilst calling immediately for expert help
- If breathing doesn’t improve, non-invasive ventilation or intubation and ventilation may be required.
Circulation
What are the potential problems?
Hypovolaemia (bleeding, burns, diarrhoea / vomiting, dehydration)
- Pump failure
- Cardiogenic eg heart failure, myocardial infarction, arrhythmia
- Non-cardiogenic eg cardiac tamponade, tension pneumothorax, PE -
Vasodilation (sepsis, anaphylaxis)
Circulation.
What assessments can you make to check the circulations
- look at colour of hand
- assess libm temperature
- CRT
- HR
- ECG- 3 LEAD OR 12 lead
- Look at neck for JVP- high shows fluid poverload/ heart failure
- check all pulses- bounding pulses shows sepsis. low shows Cardiac failure
- Ausculate the heart for mumurs
- BP- remember it is not always low even if there’s pathology
Circulation
What actions can you take to improve circulation
Insert one or more large intravenous cannulae
- Take blood from the cannula for routine haematological, biochemical, coagulation and microbiological investigations, and cross-matching. A lactate level can give an indication as to tissue perfusion.
- If the BP is low, give a fluid challenge – this may be 250ml up to 1000ml of Crystalloid fluid, depending on the patient and the situation (use less if the patient is elderly or known to have heart failure). Monitor the heart rate and BP in response to the fluid
- If the patient is bleeding, replace blood with blood (rather than Crystalloid).
- If BP does not improve despite IV fluid resuscitation, the patient may benefit from specific drug infusions on intensive care to improve the function of their heart or to stimulate vasoconstriction
Disabilty.
What does it look for and what are the problems with it.
Looks at levels of consciousness and neurological fucntioning
Problems
- Profound hypoxia or hypercapnoea
- Drugs: sedatives, opioids, toxins, poisons
- Cerebral hypoperfusion (eg from profound hypotension)
- Raised intracranial pressure
- CVA
- Metabolic dysfunction eg hypoglycaemia
Disabilty
What assessments can you make?
Think ABC-DEFG – Don’t Ever Forget Glucose! Check the BM
- Take the temperature
- Assess the neurological status
- Rapid assessment - ACVPU (Alert – confused – respond to voice – respond to pain – unresponsive)
- Formal assessment - GCS
- Check the pupils for size, equality and reactivity to light
- Assess for pain
- Check the drug chart for possible culprits / reversible causes of depressed consciousness
Disabilty
What actions can you take to help with this?
- Provide oral or parenteral glucose if needed (follow local protocols)
- Provide analgesia for pain
- Specific action for specific problems eg treat seizures, treat opioid toxicity with Naloxone, seek specialist input if raised intracranial pressure
Explain what you must do for assessing EXPOSURE
Examine head to toe, front and back. Look for bleeding, swellings, rashes, sores, wounds, catheters etc
- Perform a focused exam of any relevant systems eg the abdomen
- Take a full clinical history from the patient, any relatives or friends, and other staff.
- Review the patient’s notes and charts
- Review the results of laboratory or radiological investigations.
What were the likely causes of confusion for Bill after observation?
- Infection
- Gastro-intestinal
- Toxins
Where is homelessness a problem?
- a lot in London: homelessness is acceptable as the price for profitable housing
- and in big cities
- less in rural areas as people are chased out
- concentrations in areas where councils are forgiving
- europe wide: also refugees, in UK more english people
- UK has highest homelessness and most expensive
- authorities in finland are pretty nice
What is the Glasgow Coma Scale?
- A brain injury severity scale that assesses depth and duration of impaired consciousness and coma.
- Eye response
- Motor response
- Verbal Response
How is altered mental state described?
- level of consciousness (attentiveness)
- cognition (mental processes or thoughts)
A patient may have disorders of one or both
What is used to determine the cause of confusion?
Symptoms sieve
• Primary Neurological
• Infection
• Cardiorespiratory
• Gastro-intestinal
• Metabolic/Endocrine
• Toxins
• Psychiatric
bill’s confusion could be due to all of these
What is the progression of sepsis?
What are the key responses to sepsis?
give 3, take 3
- Give O2 to keep sats above 94%
- Take blood cultures
- Give IV antibiotics
- Give a fluid challenge
- Measure lactate
- Measure urine output
Why are key tests ordered?
- Lactate - hypoperfusion/organ failure/sepsis
- Creatinine/Urea - kidney
- GGT - liver function test
- WBC/Neutrophils/CRP - inflammation, infection, SIRS
- Toxicology - drugs, suicide attempt (antidepressants, paracetamol)
What can cause pain in the left iliac fossa?
- descending colon
- sigmoid colon (do CT abdo and plevis)
- referred pain from left adrenals
- if female always do a pregnancy test
What are different types of homelessness?
• homelessness on the streets
> increases by 15% in 1 year
- in tents or carparks
- many people on the edge of homelessness
- people in hostels
- people in rentevers
only see the tip iceberg
What is the mortality rate associated with homelessness?
- average age of death of 47
- many health problems
> eg. drug users
> anxiety (just as big as unemployment)
> depression
> skin
> breathing
What can be done to help homelessness?
- requisition empty warehouses, and but in beds
- provide emergency housing
- change rent regulations
- reducing amount of landlord evicting people
- better quality of housing
What medical provisions are needed to help homelessness?
- practice exclusively for the homeless
- aware of more complicated range of issues
- identifying that underlying problem is insecurity of housing
- reducing the stigma around homelessness
what high fibre foods should you eat and how
Don’t increase dramatically. ease into it or you might get some wind/bloating.
Effects of hgih fibere diets could take between days or 4 weeks to be seen
Don’t take insoluble fibre in wheatbran or nuts (get symptoms of wind/bloasting)
hIgh fibre Food are:
- Whole grains, fruit and vegetables.
- Wholemeal or wholewheat bread and flour (for baking).
- Wholegrain breakfast cereals such as All-Bran®, Weetabix®, muesli, etc.
- Brown rice and wholewheat pasta.
- Wheat bran.
- Beans, pulses and legumes.
what are sourcesa of soluble and insolube fibre
Dietary sources of soluble fibre include oats, ispaghula (psyllium), nuts, flax seeds, lentils, beans, fruit and vegetables. A fibre supplement called ispaghula powder is also available from pharmacies and health food shops.
Insoluble fibre is chiefly found in corn (maize) bran, wheat bran, nuts and some fruit and vegetables.
Diverticular disease can lead to bleeding? how do you deal with this
Use CT to see cause of bleeding and stop it.
Sometimes it stops on it’s own (75%)
Give blood to prevent hypovolaemia
Blood is normally painless and abrupt.] and leaves from anus .
