Gastroenterology: top tips for on calls

Gastroenterology: top tips for on calls

Dr Laura Hopkins BM BSc MRCP

Gastroenterology SpR

Clinical teaching fellow

West Middlesex University Hospital

Discuss clinical scenarios within gastroenterology that you will be exposed to in FY1 doctor

acute presentations

procedures

Identify potential challenges in the clinical scenarios and formulate plans on how to manage them

Learning objectives

27 year old male

Know IBD (UC)

Current Rx: Asacol 2.4g OD

Presents with: bowels opening 8/day with blood, abdominal discomfort

Observations: BP 120/65, HR 102, Temp 36.7, sats 98%, RR 18

On examination: tender in LIF, no guarding, soft abdo

Clinical scenario 1

Question 1:

What next investigation would help assess the severity of this patients presentation?

a) Abdominal XR

b) Stool culture

c) CXR

d) Haemoglobin

e) Flexible sigmoidoscopy

Investigations

Mild Moderate Severe

Bloody stools/day <4 4 more if ≥6 AND 1 of

Pulse <90 ≤ 90 bpm > 90 bpm

temperature < 37.5 ≤ 37.8 > 37.8

Hb > 11.5 ≥10.5 g/dl < 10.5 g/dl

ESR/CRP ESR <20 ≤ 30 > 30

Truelove and Witt

ADMISSION

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 29399

Question 2: Which of the following meets the criteria for a diagnosis of toxic megacolon?

a) Transverse colon dilated to 6 cm

b) Small bowel dilated to 2.5 cm

c) Severe abdominal pain with guarding

d) Caecum dilated to 7 cm

e) Absence of bowel sounds

Abdominal XR

Question 3:

What treatment below should NOT be given to this patient?

a) Phosphate enema prior to flexible sigmoidoscopy

b) Prophylactic LMWH

c) IV hydrocortisone

d) IV fluids

e) Ensure (nutritional drinks)

Management

IV steroids (hydrocortisone 100mg QDS) Stool cultures X 3 (c.diff and bacterial)

VTE prophylaxis IV fluids +/- KCl

Unprepared flexible sigmoidoscopy + biopsy (CMV)

Ensure gastro team are aware of patient

Severe colitis: IP management

57 year old female

Known Alcoholic liver disease

Current Rx: spironolactone 100 mg OD, thiamine, vit B co-strong, omeprazole 40 mg

Presents with: jaundice, swollen abdomen

Observations: BP 100/50, HR 95, Temp 36.2, sats 95% OA, RR 20

Examination: yellow sclera, distended abdomen with shifting dullness, palmer erytherma, spider naevi

Clinical scenario 2

Question 4:

Which of the following information is needed to calculate the Child-Pugh score?

a) Presence of varices on OGD

b) UEs

c) Albumin

d) Cause of liver disease

e) ALT

Decompensated liver disease

Used to assess the severity of liver disease

Includes grade A-C (C=most severe)

C = only 45% chance of survival at one year

To calculate need: Alb/INR/bili

Ascites

Encephalopathy grade

Child-Pugh score

Infection

Chest/urine

SBP

GI bleed

Decompensated liver disease Jaundice, ascites, encephalopathy

Why have they decompensated?

Bloods Urine dipstick/culture Blood cultures Ascitic tap

Bloods: Hb, Plts, INR Reverse coagulopathy (vit K) PR examination Postural BPs Hx of Varices?

Question 5:

Which of the following confirms a diagnosis of spontaneous bacterial peritonitis?

a) Abdominal tenderness

b) PMN count > 250 cells/mm2

c) Positive ascitic culture

d) Lymphocytes > 300 cells/mm2

e) Serum ascites-albumin gradient (SAAG) > 11g/dl


Question 6: When performing an ascitic tap it is important to send the ascitic fluid for the following (can select multiple options and please rank in order of importance): a) WCC and gram stain b) Protein c) Ascitic culture d) Cytology e) CRP f) Amylase


Electrolyte/metabolic abnormality

Hepatocellular carcinoma

Alcohol consumption


UEs (Na/K) Bone profile BM

AFP Abdominal US

Signs of withdrawal (6-48hrs) Recent consumption

Detox regime Chlordiazepoxide (CIWA) PRN/regular

Nutrition Ensures/NG feeding

Pabrinex (48 hours) (I+II pairs TDS)

Bowels Lactulose (aim for bowels opening 2-3/day)

Review nephrotoxics (spironolactone)

Other management

80 year old male

Presents with black stool for 24 hours, dizzyness

PMHx: AF, IHD, Diabetes, HTN, high cholesterol, Right THR, OA

Medications: warfarin, ramipril, amlodipine, bisoprolol, simvastatin, novomix 30 BD, PRN paracetamol

Observations: BP 82/60, HR 120, Temp 36, RR 28, sats 95%OA

Examination: pale, mild epigastric tenderness, meleana on PR

Clinical scenario 3

Question 7:

What is the next most important step in his management?

a) OGD

b) Giving vitamin k

c) Speaking to haematology

d) Organising a blood transfusion

e) Abdominal XR

Clinical scenario 3

Bloods:

FBC (Hb 7.5, plts 122)

UEs (urea 15, creat 80)

INR (6.2)

Resuscitation (stage 3 shock: 1.5L)

Fluids

blood

Upper GI bleed

Question 8:

What is the best antidote we can give to reverse the effects warfarin when someone is actively bleeding?

a) Vitamin K

b) FFP

c) Stop warfarin

d) Unit of RBC

e) Prothrombin complex concentrate (PCC)

Upper GI bleed

Bloods:

FBC (Hb 7.5, plts 122)

UEs (urea 15, creat 80)

INR (6.2)

Resuscitation

Fluids (crystalloid)

Blood (XM BUT consider O neg)

Blood products (PCC- beriplex/octaplex) Important to involve haematology team

Upper GI bleed

Whilst on ward cover you are bleeped to see the 57F with decompensated ALD because she has become drowsy:

What do you want to know?

On arrival to ward what will you do?

Clinical case 2 cont…

Question 9:

The nurse on the phone is able to tell you she open her eyes when they tried to check a BM but that she seemed confused as she thought she was at the dentist. When they took the BM she withdrew her arm away.

What is her GCS?

a) 6

b) 10

c) 8

d) 15

e) 3

Clinical case 2 cont…

What is there GCS? This patient was 10 (E2, V4, M4)

< 8 may not be able to maintain airway AVPU

Encephalopathic

Bowels Nutrition

Intracrebral event

Any hx of fall Clotting and plts CT head

Blood sugar

Drowsiness in liver patient

Question 10:

A patient under your care requires an ERCP. They presented with cholangitis and a scan showed they have a gallstone stuck in their CBD. Which of the following do you need to do:

a) Let the patient know they are having the procedure

b) Put a form into endoscopy for them to organise it

c) Speak to the gastro consultant doing the procedure

d) Review the drug chart for any anti-coagulants

e) All of the above

Procedures

ERCP

Review drug chart (antiplt/heparin): 7 days off clopidogrel Hold heparin night before (if prophylactic)

OGD

Fasted for at least 6 hours Am list: from midnight Pm list: from 6 am

Colonoscopy

Try to avoid as IP procedure requires bowel preparation Have to be mobile!

Applicable to all IV access for sedation and analgesics Are they a diabetic? do they need a form 4 completing

Procedures

Any questions?

Discuss clinical scenarios within gastroenterology that you will be exposed to in FY1 doctor

acute presentations

procedures

Identify potential challenges in the clinical scenarios and formulate plans on how to manage them

Learning objectives

Documents

Gastroenterology: top tips for on calls