About Dr Chris Hair Gastroenterology and Endoscopy Colonoscopy
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 BP 110/80 Single vomit RUQ palpation, seems very tender PHx Stable angina, Mild COPD A few stubbies per night Metoprolol, perindopril, aspirin 3
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 4
Review the stigmata of chronic liver disease 5
Painful Jaundice What are the clinical and examination features that help us to define the urgency and severity Pain severity Urgent case comorbidity Older Age Fever Hemodynamic stability Onset acute 6
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 • Viral hepatitis, typhoid • Cholangitis, Cholecystitis • Abscess • Rarer; alcoholic hepatitis, drug reaction (hepatitis), portal pyemia Fever patient • Severe Infections • Acute cholecystitis and ascending cholangitis Jaundice 7
Clinical Clues in the clinic Cholangitis Cholecystitis Viral hepatitis Alcoholic hepatitis Liver abscess pain 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 Mild Unstable Potentially No No potentially onset Acute Subacute 8
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%). 9
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. 10
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 11
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) 12
TAKE HOME MESSAGE; painful jaundice Urgent case 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 13
The Pale Woman Dr Chris Hair, Gastroenterologist 14
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 15
Which dark colour stool has you worried? A B C 16
Investigating pallor Afebrile, BP 130/90, P 80 reg, good JVP, lungs clear, abdomen soft n/t o d o t t a h W Sent for investigations: ? t x e n Hb 99, urea 12. 9, Creatinine 98, INR 1. 2 Blood film: microcytic anaemia: ddx IDA, Thalassemia, acquired microcytosis (anaemia chronic disease) 17
Interpreting iron studies 18
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 19
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 20
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 1 L IV saline stat) D: administer maxalon 10 mg IV 21
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. 22
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