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

 

 

onthewards podcasts

Liver function tests with Dr Ken Liu

Gastrostomy feeding tubes with Dr Anastasia Volovets

Upper GI bleeding with Dr Anastasia Volovets