Group Teaching - Disorders of the Upper GI Tract

Question 1

Case 1

Mr Zoot, a 45-year-old carpenter, has been experiencing intermittent epigastric pain over the last year. He states that “My stomach is always worse when I’m hung over or when I’ve smoked too much”. Over the last week the pain has increased in intensity requiring him to double the dose of the Ibuprofen that he normally takes for the pain. Earlier in the day the pain suddenly became worse affecting the whole of his abdomen and he started vomiting. On clinical examination he looks unwell, is sweating, and his abdomen is rigid with four quadrant tenderness. He’s pyrexial (Temp 379), tachycardic (pulse 110 bpm), and hypotensive (BP 100/60). Urgent bloods reveal Hb 15.1, WCC 16.4, CRP 180 and an amylase of 105.

You immediately start to resuscitate him with IV fluids. What are the first investigations you’d perform in order to establish a diagnosis?

Answer 1

CXR & AXR

Question 2

Case 1

Mr Zoot, a 45-year-old carpenter, has been experiencing intermittent epigastric pain over the last year. He states that “My stomach is always worse when I’m hung over or when I’ve smoked too much”. Over the last week the pain has increased in intensity requiring him to double the dose of the Ibuprofen that he normally takes for the pain. Earlier in the day the pain suddenly became worse affecting the whole of his abdomen and he started vomiting. On clinical examination he looks unwell, is sweating, and his abdomen is rigid with four quadrant tenderness. He’s pyrexial (Temp 379), tachycardic (pulse 110 bpm), and hypotensive (BP 100/60). Urgent bloods reveal Hb 15.1, WCC 16.4, CRP 180 and an amylase of 105.

Images 1 & 2 (see below) were obtained from the investigations you requested. What radiological signs do they show and what is the most likely diagnosis?

Answer 2

Unclear image: Possible perforated small intestine with intestinal contents in the abdominal area (Perforated viscus)

Question 3

Case 1

Mr Zoot, a 45-year-old carpenter, has been experiencing intermittent epigastric pain over the last year. He states that “My stomach is always worse when I’m hung over or when I’ve smoked too much”. Over the last week the pain has increased in intensity requiring him to double the dose of the Ibuprofen that he normally takes for the pain. Earlier in the day the pain suddenly became worse affecting the whole of his abdomen and he started vomiting. On clinical examination he looks unwell, is sweating, and his abdomen is rigid with four quadrant tenderness. He’s pyrexial (Temp 379), tachycardic (pulse 110 bpm), and hypotensive (BP 100/60). Urgent bloods reveal Hb 15.1, WCC 16.4, CRP 180 and an amylase of 105.

Images 1 & 2 (see below) were obtained from the investigations you requested.

What is the most likely perforated organ?

Answer 3

Duodenum

Rigler’s sign: Free intraperitoneal air & Free subdiaphragmatic air

Question 4

Case 1

Mr Zoot, a 45-year-old carpenter, has been experiencing intermittent epigastric pain over the last year. He states that “My stomach is always worse when I’m hung over or when I’ve smoked too much”. Over the last week the pain has increased in intensity requiring him to double the dose of the Ibuprofen that he normally takes for the pain. Earlier in the day the pain suddenly became worse affecting the whole of his abdomen and he started vomiting. On clinical examination he looks unwell, is sweating, and his abdomen is rigid with four quadrant tenderness. He’s pyrexial (Temp 379), tachycardic (pulse 110 bpm), and hypotensive (BP 100/60). Urgent bloods reveal Hb 15.1, WCC 16.4, CRP 180 and an amylase of 105.

How would you manage this patient?

Answer 4

• Pre-operative:
  
  • Nasogastric tube (NGT)
  • Nil by mout (NBM)
  • IV fluids resucitation
  • ABx
• Operative:
  
  • Identification of aetiology of peritonitis
  • Eradication of the peritoneal source of contamination
  • Peritoneal lavage and drainage

Question 5

Case 1

Mr Zoot, a 45-year-old carpenter, has been experiencing intermittent epigastric pain over the last year. He states that “My stomach is always worse when I’m hung over or when I’ve smoked too much”. Over the last week the pain has increased in intensity requiring him to double the dose of the Ibuprofen that he normally takes for the pain. Earlier in the day the pain suddenly became worse affecting the whole of his abdomen and he started vomiting. On clinical examination he looks unwell, is sweating, and his abdomen is rigid with four quadrant tenderness. He’s pyrexial (Temp 379), tachycardic (pulse 110 bpm), and hypotensive (BP 100/60). Urgent bloods reveal Hb 15.1, WCC 16.4, CRP 180 and an amylase of 105.

He remains stable with normal observations for first 48 hrs following his laparoscopic omental patch. On the 3rd post-operative day, however, he complains of shortness of breath (SOB), his O2 saturations (sats) drop from 99% to 87% on 2L nasal specs, he’s pyrexial (Temp 385), tachycardic (pulse 100 bpm). Clinical examination reveals bibasal crepitations on auscultation Rt > Lt. What changes does the subsequent CXR show below (Image 3), what is the most likely diagnosis, and how would you treat it?

Answer 5

Diagnosis: Pneumonia
Management: IV Abx

Question 6

Case 2

Miss Floyd, a previously fit and well 45-year-old, has presented to A & E with a 2-day history of severe, constant upper abdominal pain associated with vomiting. She has experienced similar but self-limiting upper abdominal pain intermittently for 1yr, especially after eating Mars bars. On clinical examination she has tenderness and guarding in her epigastrium, is pyrexial (Temp 378), tachycardic (pulse 100 bpm), and normotensive (BP 110/65). Urgent bloods reveal: Hb 14, WCC 20 (neutrophilia), bilirubin 35, Alk phos 366, CRP 150 and amylase 2150.

What is the most likely diagnosis, how would you manage this pathology?

Answer 6

Diagnosis: Acute Pancreatitis
Management:
* Fluid resuscitation (IV fluids, urinary catheter, strict fluid balance monitoring)
* Analgesia
* Pancreatic rest (+/- nutritional support if prolonged recovery [NJ feeding or PN])
* Determining underlying cause

Modified Glasgow criteria (alternative is Ranson’s criteria):
P – PO2 < 8KPa
A – age > 55yrs
N – WCC > 15
C – calcium < 2mmol/L
R – renal: urea > 16mmol/L
E – enzymes: AST > 200iu/L, LDH > 600iu/L
A – Albumin < 32g/L
S – sugar > 10mmol/L

Score of 3 or > within 48hrs of onset - suggests severe pancreatitis

CRP is an independent predictor of severity
>200 suggests severe pancreatitis

Question 7

Case 2

Miss Floyd, a previously fit and well 45-year-old, has presented to A & E with a 2-day history of severe, constant upper abdominal pain associated with vomiting. She has experienced similar but self-limiting upper abdominal pain intermittently for 1yr, especially after eating Mars bars. On clinical examination she has tenderness and guarding in her epigastrium, is pyrexial (Temp 378), tachycardic (pulse 100 bpm), and normotensive (BP 110/65). Urgent bloods reveal: Hb 14, WCC 20 (neutrophilia), bilirubin 35, Alk phos 366, CRP 150 and amylase 2150.

Once she is resuscitated what would be your first investigation?

Answer 7

USS abdomen

Question 8

Case 2

Miss Floyd, a previously fit and well 45-year-old, has presented to A & E with a 2-day history of severe, constant upper abdominal pain associated with vomiting. She has experienced similar but self-limiting upper abdominal pain intermittently for 1yr, especially after eating Mars bars. On clinical examination she has tenderness and guarding in her epigastrium, is pyrexial (Temp 378), tachycardic (pulse 100 bpm), and normotensive (BP 110/65). Urgent bloods reveal: Hb 14, WCC 20 (neutrophilia), bilirubin 35, Alk phos 366, CRP 150 and amylase 2150.

An USS of her abdomen subsequently confirms that she has gallstones. Although she remains clinically well overall, on day 5 of her admission her LFTs remain deranged/abnormal. What would be your next investigation?

Answer 8

MRCP

Question 9

Case 2

Miss Floyd, a previously fit and well 45-year-old, has presented to A & E with a 2-day history of severe, constant upper abdominal pain associated with vomiting. She has experienced similar but self-limiting upper abdominal pain intermittently for 1yr, especially after eating Mars bars. On clinical examination she has tenderness and guarding in her epigastrium, is pyrexial (Temp 378), tachycardic (pulse 100 bpm), and normotensive (BP 110/65). Urgent bloods reveal: Hb 14, WCC 20 (neutrophilia), bilirubin 35, Alk phos 366, CRP 150 and amylase 2150.

Her MRCP is shown below (Image 1). What abnormality does this show? What would be your next step in her management?

Answer 9

• Blockage in common bile duct
• Management:
  
  • Remove stones / blockade with ERCP
  • Avoid fatty food, drink lots of water, potentially remove gallbladder if it reoccurs