Transcript PowerPoint Presentation - Geelong

About Dr Chris Hair
Gastroenterology and Endoscopy
Colonoscopy, Crohns disease, ulcerative colitis, coeliac disease and IBS
Clinical Teaching
-Clinical senior lecturer Deakin University
-Director of National training in capsule endoscopy (small intestine)
-Co-director of gastroenterology training in Suva, Fiji
-International Trainer, Solomon Islands, Fiji
-Founding member, Australia and New Zealand Gastroenterology International
Training Association (ANZGITA)
-Member of World gastroenterology Organisation (WGO) training committee
www.drchrishair.com www.anzgita.org
The yellow man in pain
Dr Chris Hair
Gastroenterologist
Epworth Private Hospital, Geelong
Case Presentation
65 yo man presents to Belmont GP
37.5 C
Crampy Epigastric pain overnight
P 110 regular
Shivers and shakes
BP110/80
Single vomit
RUQ palpation, seems very tender
PHx
Stable angina,
Mild COPD
A few stubbies per night
Metoprolol, perindopril, aspirin
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presentation
No stigmata of chronic liver disease
Whilst examining him he offers:
- no alcohol use
-
No recent travel or unwell contacts
-
No recent antibiotic use or new
medications
-
No injecting drug use
-
No family history of liver problems
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Review the stigmata of chronic liver
disease
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Painful Jaundice
What are the clinical and examination features
that help us to define the urgency and severity
comorbidity
Pain severity
Older Age
Fever
Hemodynamic
stability
Onset acute
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DDx
• Gallstones
• Cholangitis
• Cholecystitis
• Acute Hepatitis
(mild)
• Hepatic abscess
• Gallstones
• Cholangitis
• Cholecystitis
• Abscess
Acute
Painful
The medical emergency cases are acute
cholecystitis, ascending cholangitis, and liver
abscess – prompt referral and
managment
Unstable
Fever
• Viral hepatitis, typhoid
• Cholangitis, Cholecystitis
• Abscess
• Rarer; alcoholic
hepatitis, drug reaction
(hepatitis), portal
pyemia
patient
• Severe Infections
• Acute cholecystitis
and ascending
cholangitis
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Clinical Clues in the clinic
Cholangitis
Cholecystitis
Viral
hepatitis
Alcoholic
hepatitis
Liver abscess
pain
yes, colic
yes, colic to
constant
rarely
Yes, mild
constant
ache
Yes,
signficant
fever
Yes, spiking
Yes
Prior to
jaundice
onset
Mild low
grade
Yes, spiking
rigors
Generally
Yes
No
no
yes
peritonism
No
Yes
No
no
sometimes
Jaundice
Yes, mild
initially
Occasionally
Yes
Yes
Mild
Unstable
Potentially
Potentially
No
No
potentially
onset
Acute
Acute
Subacute
Subacute
acute
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Dx: Ascending cholangitis – the not quite
peritonitic abdomen…
Acute cholangitis is a bacterial infection superimposed on an obstruction of the
biliary tree most commonly from a gallstone, but it may be associated with
neoplasm or stricture.
The most common organisms isolated in bile:
Escherichia coli (27%),
Klebsiella species (16%),
Enterococcus species (15%),
Streptococcus species (8%),
Enterobacter species (7%), and Pseudomonas aeruginosa (7%).
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Ascending cholangitis
Symptoms include the following:
Charcot triad: right upper quadrant (RUQ) pain, fever, and jaundice (15-20% )
Fever is present in approximately 90% of cases.
Jaundice is thought to occur in 60% of patients.
Most patients complain of RUQ pain; however, some patients (ie, elderly
persons) are too ill to localize the source of infection.
Consider cholangitis in any patient who appears septic, especially in patients
who are elderly, jaundiced, or who have abdominal pain.
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Ascending cholangitis
Prognosis
The prognosis depends on several factors, including the following :
- Early recognition and treatment of cholangitis
- Response to therapy
- Underlying medical conditions of the patient
Mortality rate ranges from 5-10%, with a higher mortality rate in patients who
require emergency decompression or surgery.
The following patient characteristics are associated with higher morbidity and
mortality rates:
Hypotension , renal failure, abscess, cirrhosis, older age and multiple
comorbidity, fail to respond early to antibiotics
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Pre hospital management
Mild cholangitis may present with abdominal pain, jaundice, and fever.
When transporting these patients to the hospital, place the patient on a monitor
and insert an intravenous (IV) line (can rapidly deteriorate)
In unstable patients with cholangitis, prehospital care should include the
following:
- Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure
measurements, blood glucose measurement)
- Stabilization (eg, oxygen, placement of large-bore IV, administration of IV fluids
to unstable patients)
- Rapid transport
- Empirical antibiotics (?after blood culture) (Amp/Gent/Metronidazole)
(timentin)
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TAKE HOME MESSAGE; painful jaundice
Pain severity
Fever
comorbidity
Older Age
Onset acute
Hemodynamic
The medical
emergency
cases
are
acute
stability
cholecystitis, ascending cholangitis, and liver
abscess – prompt referral and managment
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The Pale Woman
Dr Chris Hair, Gastroenterologist
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Presentation
A elderly woman presents tired and pale
Fatigue, lethargy 2 months
Sleeping a lot more 1 month
Off food last few days, had occasional dark
stool
PHx:
CAD and stents, AF
Mild CVA and DM
Ticagrelor, warfarin, metformin, lipitor
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Which dark colour stool has you
worried?
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Investigating pallor
Afebrile, BP 130/90, P 80 reg, good JVP,
lungs clear, abdomen soft n/t
Sent for investigations:
Hb 99, urea 12.9, Creatinine 98, INR 1.2
Blood film: microcytic anaemia:
ddx IDA,
Thalassemia,
acquired microcytosis (anaemia
chronic disease)
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Interpreting iron studies
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Medical Care
Starts with the investigation of the cause of IDA
Commence oral iron supplementation immediately
Referral to specialist with expertise in upper and lower endoscopy +/- capsule
endoscopy
refer all male patients and post-menopausal woman
refer pre-menopausal with severe iron deficiency anaemia
consider early referral of pre-menopausal woman with recurrent
anaemia or failure to respond to oral iron
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How to manage IDA
Crohns, UC, coeliac (early)
Iron polymaltose 1% allergic reactions, cheap, slow infusion
Iron carboxymaltose 0.5% allergic reactions, more expensive, IV push
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Returns for review to clinic
Collapses in the waiting room toilet and calls for help,
P 120, BP 60/40
Transferred to clinic treatment room
Large coffee ground vomit and then large malena
What Management?
A: call ambulance
B: insert cannula if avail, apply oxygen, and ECG monitoring (if avail)
C: Fluid support (eg 1L IV saline stat)
D: administer maxalon 10 mg IV
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Who to call
All cases of suspected or confirmed acute
UGIB (hematemesis or malena) to an
emergency dept after initial management
Patients with ‘subacute’ presentation who
are not unstable can be discussed with
specialist and baseline investigations sent
Patients with chronic UGIB symptoms can
be investigated and managed as
outpatients unless there is severe anaemia
present.
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