Gastroenterology consult guide

Gastroenterology consult guide

Aug 31, 2018 0
onthephones

Editor:  Ken Liu, May Wong

Contributors: Ken Liu

Reviewed:  Janice Yeung

The only time to “hurry” is in the event of GI bleeding in which case, the most important things to know are the 4 H’s:

  • How much blood loss?/How long they have been bleeding?
  • Haemodynamics – symptoms, blood pressure, heart rate?
  • Hb (if available)?
  • Hungry? (I.e. fasted?)

For the other consults, they can generally wait until you have collected the other information as detailed below.

  • Patient details: age, medical record number, location in the hospital.
  • Main comorbidities?
  • Reason they are in hospital?

On top of this:

GI Bleed

  • Bleeding:
    • Type: melaena, haematemesis/coffee ground vomit, haematochezia.
      • Note: lower GI bleeding may be a surgical consult in some hospitals.
    • Volume, frequency and duration?
  • Evidence of haemodynamic compromise:
    • Syncope, ischaemic sounding chest pain, new AF.
  • History Risk factors: NSAIDS, aspirin, anti-coagulation, previous ulcers, cirrhosis, excessive chronic alcohol use.
  • Fasted? When did they last eat?
  • Blood pressure, heart rate, postural blood pressure.
  • Gastrointestinal examination – signs of chronic liver disease, abdominal examination?
    • For patients with dark/”coffee ground” vomit exclude signs of bowel obstruction causing faeculent vomiting (which is not upper GI bleeding).
  • PR exam for melaena.
  • FBC, EUC, coagulation studies, Group and Hold.
    • If a patient is having obvious gastrointestinal bleeding – call for the consult before the blood tests come back! We like to know sooner rather than later so we can arrange theatres/endoscopy unit for a gastroscopy.
  • Commence a stool chart.
  • Get IV access.
  • If the patient has limited life expectancy, e.g. dementia, advanced cancer etc. it would be useful to know what the patient/family/NOK’s wishes are regarding invasive investigations such as endoscopy.

Diarrhoea:

  • Character of the diarrhoea: frequency, consistency, volume, blood?
  • Associated symptoms: vomiting, abdominal pain, fever
  • Medication history – recent medications esp. antibiotics
  • Infectious contacts, suspicious foods, overseas travel
  • Hydration status and vital signs.
  • Gastrointestinal examination focusing on abdominal exam.
  • FBC looking for leukocytosis.
  • Electrolytes and renal function (may need K replacement).
  • Inflammatory markers: CRP.
  • Send stool culture.
  • Thyroid function tests almost always normal. Do not order unless clinical suspicion of thyrotoxicosis is high.
  • Reason for PEG insertion:
    • in a transient purpose when patients are getting chemoradiotherapy.
  • Previous abdominal surgery which would be a relative contraindication.
  • Are they on any antiplatelets or anticoagulants which would need to be withheld or reversed prior to procedure?

Dysphagia

  • Duration (acute vs chronic)?
  • Solids vs liquids or both?
  • Location of pain?
  • Weight loss?
  • Prior investigations:  endoscopy, barium swallow.
  • Associated symptoms, e.g. connective tissue features in scleroderma.
  • Signs of cachexia, BMI.
  • Connective tissue features e.g. scleroderma.
  • Signs of infection e.g. oral thrush.
  • Previous gastroscopy.
  • Barium swallow.
  • Blood tests including ANA if appropriate.
  • CT chest if relevant.
  • When you have thought about the problem yourself already and come up with a list of differentials or an interim management plan.
  • Not doing a per rectal examination.
  • Not knowing the fasting status of a patient.

Helpful resources

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Tags: #consult guide,#Diarrhoea,#dysphagia,#gastroenterology,#gastrointestinal infections,#GI bleeding,#junior doctors,#Percutaneous Endoscopic Gastrostomy,#requesting a consult

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