Editor:  Ken Liu, May Wong

Contributors: Ken Liu

Reviewed:  Janice Yeung

 

In a hurry? Make sure you know

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.

 

Information you should know: 

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

 

On top of this:

GI Bleed

History: 

  • 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?

 

Examination:

  • 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

 

Investigation:

  • 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

 

Other:

  • 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:

History:

  • 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

 

Examination:

  • Hydration status and vital signs
  • Gastrointestinal examination focusing on abdominal exam

 

Investigations:

  • 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

 

Percutaneous Endoscopic Gastrostomy (PEG) insertion request

  • 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

History:

  • 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

 

Examination:

  • Signs of cachexia, BMI
  • Connective tissue features e.g. scleroderma
  • Signs of infection e.g. oral thrush

 

Investigations:

  • Previous gastroscopy
  • Barium swallow
  • Blood tests including ANA if appropriate
  • CT chest if relevant

 

What additional information would impress you?

  • When you have thought about the problem yourself already and come up with a list of differentials or an interim management plan

 

What are common mistakes/omissions made by JMOs?

  • Not doing a per rectal examination
  • Not knowing the fasting status of a patient

 

Helpful resources

Life in the fast lane – Upper GI Haemorrhage

BMJ Journals – Non-variceal upper gastrointestinal haemorrhage: guidelines

BMJ Journals – Guidelines on the management of abnormal liver blood tests

American College of Gastroenterology – Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults

 

 

Podcasts

Lim, Peter.  (2014).  Upper GI bleeding.  [podcast].  Available at: https://onthewards.org/upper-gi-bleeding/  [Accessed 18 November 2014]

Volovets, Anastasia.  (2015).  Chronic liver disease.  [podcast].  Available at: https://onthewards.org/chronic-liver-disease/  [Accessed 3 February 2015]

Liu, Ken.  (2015).  Liver function tests.  [podcast].  Available at: https://onthewards.org/liver-function-tests/ [Accessed 2 September 2015]

Volovets, Anastasia.  (2017).  Upper GI bleeding.  [podcast].  Available at: https://onthewards.org/upper-gi-bleeding-2/  [Accessed 15 November 2017]

Volovets, Anastasia.  (2017).  Liver transplantation.  [podcast].  Available at: https://onthewards.org/liver-transplantation/ [Accessed 29 November 2017]

Volovets, Anastasia.  (2017).  Gastrostomy feeding tubes.  [podcast].  Available at: https://onthewards.org/gastrostomy-feeding-tubes/  [Accessed 6 December 2017]