Constantinos A Parisinos


Initial Assessment

Initial Investigations

ent ABG: Important to assess patient acid–base status. Look out for evidence of a metabolic acidosis. A lactate of>2.5 suggests significant tissue hypoperfusion

ent CXR: To rule out possible aspiration. Ensure you look under the diaphragm for free air, a radiological sign of perforation

ent AXR: Urgent investigation to rule out the presence of toxic megacolon, which is a surgical emergency. Consider a need for daily AXR especially if there are signs of colonic distension and/or there is significant deterioration in clinical condition/blood parameters

ent ECG: Diarrhoea and vomiting may lead to dangerous electrolyte imbalances, which may in turn predispose the individual to potentially fatal arrhythmias

ent Bloods: Full blood count, clotting, urea and electrolytes, liver function tests, serum albumin, glucose, CRP, ESR, blood cultures, group and save. Look for evidence of infection, assess renal function and possible electrolyte abnormalities. Ensure blood cultures are taken. Group and save is vital as the patient may require early surgical intervention. Daily bloods are required in severe ulcerative colitis

ent Stool samples: Stool culture and C. difficile assay on at least three stool samples to detect 90% of cases. Cytomegalovirus (CMV) should be considered in severe or refractory colitis. Results should not delay the administration of corticosteroid treatment

ent Flexible sigmoidoscopy: Flexible sigmoidoscopy and biopsy should be requested and available within 72 hours (ideally 24 hours) and a histological diagnosis within 5 days to confirm diagnosis and exclude CMV

ent Urine dipstick: To look for possible evidence of a UTI (with abdominal pain), and for evidence of bleeding elsewhere (in urine)

‘Blood tests: Hb 110 g/L, WCC 14×109/L, CRP 120 mg/L, normal clotting, glucose, liver and renal function. ABG: PaO214 kPa, PaCO23.2 kPa, HCO319 mmol/L, lactate 2.7 mmol/L, pH 7.3 (metabolic acidosis, with partial respiratory compensation). AXR: distal faecal loading, featureless descending colon consistent with colitis, no evidence of toxic megacolon. Urine dip: positive for ketones (+).’

Definitive Management

ent IV corticosteroids: Either hydrocortisone 100 mg four times a day or methylprednisolone 60 mg/day. IV corticosteroids are generally given for up to 5 days. Consider giving a proton pump inhibitor for gastric protection.

ent IV antibiotics: Only if infection is considered, or immediately prior to surgery

ent Subcutaneous LMWH: To reduce the risk of thromboembolism

ent Bone protection: Current guidelines recommend the use of calcium and vitamin D (e.g Adcal D3 1 tablet BD or Calcichew D3 Forte 1 tablet BD) during chronic corticosteroid use

ent Stool chart: To record number and character of bowel movements, including the presence or absence of blood and liquid versus solid stool

ent Toxic megacolon: If there is evidence of toxic megacolon (diameter>5.5 cm, or caecum>9 cm), organize an urgent surgical review

ent Surgical input: A stool frequency of>8/day or CRP>45 mg/L at 3 days appears to predict the need for surgery in 85% of cases. Surgical review and input from specialist colorectal nurse or stoma therapist is appropriate at this stage

ent Early specialist input: Patients admitted with known or suspected IBD should be discussed with (and normally transferred to the care of) a consultant gastroenterologist or colorectal surgeon within 24 hours of admission. Joint surgical and medical management is appropriate.

ent Disease modifying agents: Consider use of disease modifying agents such as infliximab or cyclosporin in severe cases that fail to respond to treatment with systemic corticosteroids

Station 4.2: Spontaneous bacterial peritonitis

You are the junior doctor covering the medical assessment unit. You are called to see a 72-year-old gentleman (Andrew Reddy 12/08/42) with known alcoholic liver cirrhosis, who presents with mild abdominal pain and confusion. You recognize him immediately as you also work on the gastroenterology ward, where this patient attends every few weeks for therapeutic paracentesis.

A diagnostic paracentesis should be performed in all cirrhotic patients with ascites, in those who have signs and symptoms of peritoneal infection, including the development of encephalopathy, renal impairment, or peripheral leucocytosis without a precipitating factor. image

Initial assessment

Initial Investigations

ent Bloods: Full blood count, U&Es, liver function tests, clotting screen, C-reactive protein, lactate. Patients with alcoholic liver disease are almost invariably thrombocytopaenic, ensure, however, that the platelet count is stable and at least in double figures. Haemogloblin may be low due to anaemia of chronic disease. Liver failure and renal failure are both associated with a low sodium

ent ABG: Allows assessment of the patient’s metabolic state as well as ventilation/oxygenation. May find a metabolic acidosis secondary to sepsis

ent CXR: Look for evidence of a lower respiratory tract infection precipitating the patient’s decompensated liver disease. Evidence of an aspiration pneumonia secondary to encephalopathy may also exist. Look for air under the diaphragm, as ‘secondary peritonitis’ may be due to perforated bowel

ent ECG: Look for evidence of myocardial ischaemia or arrhythmias from electrolyte imbalances, or an acute bleed

ent Urine dipstick and culture: As part of septic screen

ent Diagnostic paracentesis: Mandatory in all patients with cirrhosis requiring hospital admission, as part of a general septic screen. It should further be performed in all cirrhotic patients with ascites who have signs and symptoms of peritoneal infection, including the development of encephalopathy, renal impairment, or peripheral leucocytosis without a precipitating factor. Ascitic fluid should be inoculated into blood culture bottles at the bedside. If the neutrophil count is>250 cells/mm3, then treat as spontaneous bacterial peritonitis (SBP)

‘Hb 104 g/L, WCC 16×109/L, platelets 95×109/L, bilirubin 60 µmol/L, ALT 140 IU/L, ALP 180 IU/L, Na 128 mmol/L, K 3.6 mmol/L, urea 6.4 mmol/L, creatinine 90 µmol/L, CRP 170 mg/L, lactate 2.7 mmol/L. Normal clotting. Blood gas shows a metabolic acidosis, with a pH 7.3, a bicarbonate of 19 mmol/L, and PaCO2of 5 kPa. You are bleeped from the microbiology lab with the ascitic fluid results: neutrophil count>250 cells/mm3, RCC>20 cells/mm3.’

Nov 18, 2017 | Posted by in PHARMACY | Comments Off on Gastroenterology
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