Gastroenterology Flashcards
Liver disease and confusion
2021.2 Teaching Station
Patient with chronic liver disease presents with confusion
Teach the intern how to assess this patient:
- provide a list of differential diagnoses
- focussed history with rationale
- focussed exam with rationale
- investigations with rationale for each
Medical Expertise: Differential diagnosis and history (40%)
* Generates a relevant list of differential diagnoses after synthesising clinical information
found on initial assessment with an inherent focus on conditions requiring time critical
management
* Identifies important historical details (red flags) diagnostic of a possible important condition
Medical Expertise: Examination and investigation (40%)
* Describes expected physical signs for a diagnosis
* Creates a focused investigation plan that confirms or excludes time critical diagnoses
* Explains the reasons for selecting those tests in that investigation plan
Scholarship and Teaching (20%)
* Establishes rapport and makes learner feel safe and supported
* Demonstrates a structured approach to the topic and covers the topic in appropriate detail
* Checks understanding in learner (regularly and at conclusion) and encourages learner
participation
* Summarises the session with appropriate emphasis of key elements and suggests follow up
activities and resources
LIVER FAILURE:
- hepatic encephalopathy
- portal vein & hepatic vein thrombosis
- oesophageal varices
- hepatorenal syndrome
DIFFERENTIAL DIAGNOSES:
Hepatic encephalopathy
Decompensated liver failure
Drugs:
- medication induced delirium (opioids and sedatives)
- alcohol withdrawal
Infection: (these patients are immunecompromised)
- SBP
- pneumoniae
- UTI
- cellulitis
- meningitis/encephalitis
Metabolic causes:
- hypoglycemia (impaired gluconeogenesis)
- uremia in hepatorenal syndrome
- hyponatremia
- wernicke’s encephalopathy
Trauma:
- subdural haematoma (falls with prolonged coagulation)
Neurological:
- seizures especially SESA syndrome (subacute encephalopathy with seizures in alcoholics)
HISTORY:
Compliance with lactulose and rifaximin
Infective symptoms - fever, pain, vomiting, dysuria, cough, diarrhoea & vomiting
Alcohol use
Inciting medications - paracetamol, sedatives, opioids
Volume status - diarrhoea or vomiting, over diuresis with spironolactone
Signs of bleeding oesophageal varices - malena, coffee ground vomiting
EXAMINATION:
- jaundice, cellulitis
- signs of trauma - particularly to head
- hepatic flap
- shifting dullness with asites
- abdominal tenderness (SBP)
- chest auscultation
POCUS:
- volume status (IVC examination)
- ascites
Investigations:
- GLUCOSE**
- electrolytes (low Na+, low K+)
- Creatinine & urea (hepatorenal syndrome)
- Platelets (synthetic function)
- LFT’s (decompensation)
- Coagulation (synthetic function)
- Septic screen (WCC, CRP, Urine, CXR)
- Paracetamol level
- CT brain (subdural haematoma)
- Paracentesis to exclude SBP
- RUQ USS to exclude portal vein of hepatic vein thrombosis
Upper GI Bleeding
Oesophageal Varices
EM Cases 102 upper GI bleeding
MANAGEMENT:
Octreotide/somatostatin 50mcg IV followed by 50mcg/hr infusion for 5 days (splanchnic constrictor)
Terlipressin 1.7g IV Q4h for 5 days
Propranolol 20mg TDS
Tranexamic acid 1g IV
Prophylactic antibiotics 1g ceftriaxone daily or po norfloxacin bd has been shown to reduce early re-bleeding rate and improve survival, reduce mortality
Oral sucralfate (local anti-fibrinolytic effect)
Pantoprazole 80mg IV followed by infusion 8mg/hr
d)
Endoscopy
RSI + Intubation
Direct laryngoscopy using SALAD
(suction assisted laryngoscopy airway decontamination)
Balloon tamponade (Blakemore or Minnesota tube)
- Balloon placed in stomach
o Balloon inflated with 50ml
- CXR to confirm below diaphragm (prevent oesophageal perforation)
- fully inflate gastric balloon
- apply traction with compresses oesophageal varices
- inflate oesophageal balloon if still bleeding
- transfer to interventional radiology for TIPS
- Trans-jugular intrahepatic porto-systemic shunt (TIPS)
o stent between hepatic vein and portal vein – reduces portal pressure
o Needs to be done by interventional radiologist
o Increased risk of hepatic encephalopathy
Bowel Obstruction
2023.2 CBD Station - Abdominal pain
Medical Expertise: Investigation Interpretation (30%)
- Interpret abdominal xray
Medical Expertise: Treatment Including Resuscitation (30%)
- resuscitation
-
Prioritisation and Decision Making (40%)
Toxic megacolon in inflammatory bowel disease
Pseudomembranous colitis in C. difficile colitis
Acute colonic pseudo-obstruction (Ogilvie’s syndrome)
Mechanical bowel obstruction vs. paralytic illeus
Small bowel vs. large bowel obstruction
Complete vs. partial obstruction
Complicated vs. uncomplicated
SMALL BOWEL OBSTRUCTION
Causes:
- adhesions
- intussusception (lymphoma as lead point)
- malignancy
- incarcerated hernia
- strictures (inflammatory bowel disease)
- gallstone illeus (obstructs illeo-caecal valve +pneumobilia)
- radiation enteritis
- bezoars
- blunt abdominal trauma (duodenal haematoma)
LARGE BOWEL OBSTRUCTION:
- malignancy
- strictures
- fecal impaction
- volvulus (caecal, sigmoid)
COMPLICATIONS:
Intestinal ischemia
Perforation & peritonitis
Sepsis & multiorgan failure
Malabsorption & Dehydration
Electrolyte disturbance
ASSESSMENT:
History:
Symptoms:
- abdo pain, distension, vomiting, passing flatus, opening bowels, pr bleeding, weight loss, fevers, urine output
Risk factors:
- Previous abdominal surgeries
- Previous bowel obstructions
- Malignancy, lymphoma
- Inflammatory bowel disease
- Hernias
- Volvulus common in institutionalised elderly
- Preveious radiation therapy
Consider other differential diagnoses:
- pancreatits
- AAA
EXAMINATION:
GCS
Airway patent
Breathing spontaneously + Oxygenation
Circulation - maintaining HR & BP
Temp
BSL
Hydration - mucous membranes, skin tugor, POCUS assessment of IVC
Abdominal distension
Tenderness
Peritonism
Resonant to percussion
High pitched tinkling bowel sounds
LABORATORY:
VBG - lactate, BSL
Electrolytes -
IMAGAING:
Xrays:
Erect CXR and erect/supine AXR films (or lateral decubitus film if the patient cannot sit upright) - these have a sensitivity of 70-83% and specificity of 67-83% for small bowel obstruction.
Small bowel obstruction:
- Dilated loops of small bowel > 3 cm
- Central dilated loops
- Valvulae conniventes or plicae circulares are present
- Gas-fluid levels
Large bowel obstruction:
- Distended colon >6cm or 9cm at caecum
- contains gas and faecal matter (no fluid because water is absorbed)
- Located peripherally
- Haustral folds
Pneumoperitoneum
Pneumotosis intestinalis
Riglers sign
Lead pipe colon - chronic inflammation
Thumbprint sign - bowel wall oedema
CT abdomen:
More sensitive and specific
Can identifying transition point
Can determine the cause (hernias, adhesion, tumours, inflammation etc)
Can identify complications - necrosis, perforation
Can distinguish between true obstruction and pseudo-obstruction
MANAGEMENT:
NBM
Fluid resuscitation guided by HR, BP and POCUS assessment of IVC
IDC placed to monitor urine output aiming for 0.5ml/kg/hr
Analgesia
- Morphine 2.5-5mg IV - reassess and titrate to patient pain level
- IV paracetamol 1g
Consider NG tube for gastric decompression (vomiting or severe symptoms of gastric distension)
IV antibiotics
Surgical consultation
DEFINITIVE MANAGEMENT:
Small bowel obstruction often managed conservatively initially for 48-72hrs then surgery if no resolution. Surgery for perforation or strangulated hernia.
Gastrografin may be diagnostic and therapeutic in SBO due to adhesions
Large bowel obstruction often requires surgical management
Sigmoid volvulus –> decompression with flexible or rigid sigmoidoscopy + insertion of rectal tube
Closed loop obstruction, Caecal volvulus and bowel necrosis, perforation and peritonitis require emergency surgery
TOXIC MEGACOLON
- inflammatory bowel disease and C. diff colitis
- colon dilatation and systemic toxicity
Diagnosis:
Radiology:
- dilated colon >6cm
- multiple air fluid levels
- loss of haustral folds
PLUS at least 3 of the following:
- fever
- tachycardia
- neutrophilia
- anaemia
PLUS at least 1 of the following:
- hypotension
- dehydration
- altered mentation
- electrolyte disturbance
The main goal of treatment is to reduce the severity of colitis in order to restore normal colonic motility and decrease the likelihood of perforation.
PSEUDO-OBSTRUCTION/PARALYTIC ILLEUS/Ogilvies syndrome
- functional obstruction (uncoordinated muscle contraction)
Causes:
- post abdominal surgery
- peritonitis
- drugs (anticholinergics, opiates)
- trauma
- ischemic bowel
exacerbated by electrolyte disturbance (hypokalemia)
- disturbance of enteric nervous system or intestinal smooth muscle
MANAGEMENT:
Aim is to restore motility and prevent ischemia and perforation
Neostigmine and erythromycin.
Endoscopic Decompression in patients with Ogilvie’s syndrome
Rectal Bleeding in Jehovas Witness
2022.2 CBD station
Medical Expertise: Initial management (30%)
- Outlines an overall plan for resuscitating a patient
- Recognises and expedites any specific intervention/s essential to resuscitation
- Initiates appropriate time critical interventions
- Outlines an overall plan for ongoing treatment of a patient.
Professionalism: Informed consent (30%)
- Applies appropriate medico-legal and ethical frameworks and principles in assessment of
capacity to make decisions
- Balances respect for patient autonomy/religious beliefs with best clinical practice in patient
encounters
- Justifies setting limits in providing clinical care in challenging situations using ethical
principles.
Prioritisation and Decision Making (40%)
- Highlights high-risk features identified during initial patient assessment
- Explains the specific benefits and risks of a treatment modality
- Provides a rationale to explain and justify decisions about ongoing treatment
- Provides an appropriate list of advantages and disadvantages to explain decisions made
- Incorporates patient and family/whānau needs as part of shared decision-making.
REFUSAL OF BLOOD IN JEHOVAHS WITNESS
Respect for patient autonomy:
- every competent person has the moral right to decide what happens to their own body
- Patients have the right to freely accept or reject a physician’s recommendations.
Legal implications:
- Giving medical treatment without informed consent from the patient is illegal battery and negligence.
Has the patient been informed of benefits and risks of diagnostic and treatment recommendations, understood this information, and given consent?
Does the patient have decisional capacity?
Requires the ability to understand relevant information, to appreciate the medical situation and its possible consequences, to communicate a choice, and to engage in rational deliberation about one’s own values in relation to the physician’s recommendations about treatment options.
sick patients whose mental status may be altered by trauma, fear, pain, physiologic imbalance (eg, hypotension, fever, mental status changes), or from drugs used to treat their medical condition.
if it is unclear whether or not the patient is incapacitated, a physician may intervene in a life-threatening situation on grounds of “implied consent.”
Patients who lack decisional capacity, a surrogate decision maker is required.
Who is the appropriate surrogate decision maker?
If the patient has capacity but unwilling to cooperate with medical treatment? Identify the reasons why.
The physician is responsible for determining
- inadequate communication with the patient
- fear
- pain, or lack of trust on the part of the patient
The physician has an ethical obligation to make reasonable efforts to ensure comprehension. Explanations should be given clearly and simply; questions should be asked to assess understanding.
2019.1
Chronic abdominal pain
Multiple GP and ED visits
Normal bloods and urine
Negative STI swabs
Negative Bhcg
Normal US and CT
Surgical reviews NAD
Explain ongoing plan
discharge home, return to ED advice
Communication (50%)
- introduce self
- advise purpose of review
- acknowledge patient concerns (abdo pain with no diagnosis)
- Show empathy and acknowledge patients frustration at lack of diagnosis
- do not accuse of drug seeking or malingering
- appropriate non-verbal skills/body language
- clear explanations/avoid medical jargon
- use de-escalation techniques when required
- active listening e.g. paraphrases and clarifies what has been said by the patient
- encourage the patient to ask questions
- summarise the encounter and confirm understanding of management plan
Prioritisation and Decision Making (20%)
Health Advocacy (30%)
1)
Acknowledge that you believe the pain is real
Reassure the patient - the cause of the pain is unlikely to be serious because:
- normal bloods, urine, swabs, imaging, surgical review
ruling out serious pathology such as:
- appendicitis
- pancreatitis
- cholecystitis
- bowel obstruction
- ectopic pregnancy etc
Potential diagnoses include:
- centrally mediated abdominal pain syndrome
- gastroparesis
- function heart burn
- gastritis/PUD
- irritable bowel syndrome
- endometriosis
Will need further specialist review and investigation as outpatient
- gastroenterologist (gastroscopy or colonoscopy)
- O&G (laparoscopy, cervical smear)
2) How does the pain affect the patients day to day living?
- work/employment (sick days)
- financial pressures
- driving
- dependents to care for
- affects sleep
- relationships
-
3) Give the patient a definitive plan for dealing with the pain - ‘Multidimensional approach’
neuromodulation medication - amitrityline
psychologist referral for CBT
social worker referral
3) Set limits with explanation in response to request for narcotics
- opioids use in chronic pain can be harmful
- studies shown that only 7-10days to develop
*tolerance (need more to have same effect)
*dependence and addiction
*opioid induced hyperalgesia (increased sensitivity to pain)
*worsen symptoms (narcotic bowel)
4) Develop a negotiated plan with the patient for ongoing management (which is to discharge the patient)
Follow up with GP to review progress
- refer for specialist review
Safety net/return advice if develops concerning symptoms - fever, collapse, vomiting, inability to eat, worsening pain etc
Hernias - EM Board Bombs ep 223
Reducible vs. Incarcerated vs. strangulated
CT abdo with IV contrast to look
Discharge home advice
- abdominal binder
- avoid heavy lifting
- general surgery follow up for elective repair
How to Reduce Incarcerated Hernia
NBM in case reduction attempts are unsuccessful.
Analgesia - Morphine 5mg IV
Apply cold packs to the hernia site to reduce swelling and make reduction attempts easier.
Trendelenburg
Frog leg
Grasp and elongate the hernia neck with one hand, and with the other hand, apply firm, steady pressure to the proximal part of the hernia at the neck at the site of the fascial defect. US can aid in the identification of the fascial defect if it is not clinically obvious. Applying pressure on the most distal part of the hernia can cause bulging (or ballooning) at the hernia neck and prevent reduction.
Consult surgery if the reduction is unsuccessful after one or two attempts.
