Upper Gastrointestinal
CASE 31: poStoperative ConFuSion
history
As the junior doctor on call, you are asked to review a 75-year-old woman who has become confused on the ward. She is 5 days post an emergency femoral hernia repair. The operation was straightforward and there are no complications from the surgery. Her past medical history includes osteoarthritis of her right knee, for which she is taking diclofenac. She is a non-smoker and drinks two units of alcohol per week. She lives on her own with no support from social services.
examination
She is disorientated in time, place and person. You notice that she is pale and tachypnoeic. Her blood pressure is 90/70 mmHg with a pulse rate of 110/min. Her chest is clear with oxygen saturations of 97 per cent on air. On palpation of her abdomen, you note vague upper abdominal tenderness. Bowel sounds are present and the urinalysis is clear. The wound site is clean and there is no evidence of a haematoma.
INVESTIGATIONS
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Normal |
haemoglobin (hb) |
6.2 g/dl |
11.5–16.0 g/dl |
mean cell volume |
86 fl |
76–96 fl |
White cell count |
9 × 109/l |
4.0–11.0 × 109/l |
platelets |
250 × 109/l |
150–400 × 109/l |
Sodium |
132 mmol/l |
135–145 mmol/l |
potassium |
3.5 mmol/l |
3.5–5.0 mmol/l |
urea |
16 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
79 μmol/l |
44–80 μmol/l |
electrocardiogram shows sinus tachycardia
Questions
•What are the most common causes of postoperative confusion?
•What is the most likely diagnosis in this patient?
•What are the common causes?
•Which further clinical examination would you perform to help confirm this?
•How would you manage this patient?
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100 Cases in Surgery
ANSWER 31
Postoperative confusion is common in surgical patients. Causes include infection (urinary tract, chest, wound sepsis) myocardial infarction, pulmonary embolism, opiate medication and alcohol withdrawal. In this case, it is most likely that the patient has become confused as a result of acute blood loss. The stress from her recent emergency surgery and the nonsteroidal anti-inflammatory (NSAID) medication has resulted in an upper gastrointestinal bleed.
A rectal examination is an important part of the clinical assessment. The presence of melaena on the glove would indicate an upper gastrointestinal source of bleeding. Melaena is abnormally dark tarry faeces caused by the action of stomach acid on blood. The normocytic anaemia (Hb 6.2 g/dL) shows that a large acute bleed has occurred. The rise in urea (16 mmol/L) indicates protein absorption from blood in the gastrointestinal tract. A systolic blood pressure of 90 mmHg and tachycardia suggest the patient is in hypovolaemic shock and requires urgent resuscitation.
!Causes of upper gastrointestinal bleeding
•Duodenal/gastric ulcer
•gastritis/gastric erosions
•mallory–Weiss tear
•Duodenitis
•oesophageal varices
•gastrointestinal tract malignancy
•medication (nSaiDS, steroids)
!Acute management of a gastrointestinal bleed
1protect airway and administer high-flow oxygen.
2insert two large-bore (14–16 g) cannulae and take blood for full blood count, renal function, liver function, clotting and crossmatch 4–6 units.
3replace fluid, until blood is available.
4insert a urinary catheter and a central venous line with strict fluid balance monitoring.
5transfer to an appropriate level of care, i.e. a high-dependency unit.
6arrange an urgent endoscopy: less than 24 h if stable, immediate if unstable despite appropriate resuscitation.
7if you suspect variceal bleeding (signs chronic liver disease or previous variceal bleed), then perform endoscopy within 4 h.
8Start high-dose intravenous proton pump inhibitor.
9Surgical or radiological intervention will be required if endoscopic therapy fails to control the bleeding.
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Upper Gastrointestinal
KEY POINTS
•nSaiDs should be used cautiously in the elderly.
•patients with bleeding peptic ulcers should have a repeat endoscopy to check that the ulcer has healed and to exclude underlying malignancy.
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100 Cases in Surgery
CASE 32: ChroniC epigaStriC pain
history
A 50-year-old man is referred to the surgical outpatients with a 6-month history of epigastric pain, weight loss and altered bowel habit. The epigastric pain is present throughout the day and is not relieved by food. He has noticed that his bowels have been opening more frequently and that the stools are bulky, pale and malodorous. His appetite has been poor over the last couple of months and he has lost 2 stone in weight. His previous medical history includes treatment for alcohol dependence. He still drinks at least ten units of alcohol per day and is a heavy smoker. Prior to his referral, his GP organized an oesophagogastroduodenoscopy and ultrasound of the abdomen, both of which were normal.
examination
The patient is pale, thin and unkempt. There is no jaundice or supraclavicular lymphadenopathy. The abdomen is soft and non-tender with no palpable masses or organomegaly. The patient has previously had a plain abdominal film, which is shown in Figure 32.1.
Figure 32.1 plain x-ray of the abdomen.
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Upper Gastrointestinal |
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INVESTIGATIONS |
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Normal |
haemoglobin |
13.0 g/dl |
11.5–16.0 g/dl |
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mean cell volume |
108 fl |
76–96 fl |
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White cell count |
10 × 109/l |
4.0–11.0 × 109/l |
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platelets |
210 × 109/l |
150–400 × 109/l |
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Sodium |
137 mmol/l |
135–145 mmol/l |
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potassium |
3.6 mmol/l |
3.5–5.0 mmol/l |
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urea |
6 mmol/l |
2.5–6.7 mmol/l |
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Creatinine |
112 μmol/l |
44–80 μmol/l |
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amylase |
222 iu/dl |
0–100 iu/dl |
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aSt |
30 iu/dl |
5–35 iu/l |
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ggt |
235 iu/l |
11–51 iu/l |
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albumin |
32 g/l |
35–50 g/l |
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bilirubin |
12 mmol/l |
3–17 mmol/l |
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glucose |
12 mmol/l |
3.5–5.5 mmol/l |
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total serum calcium |
2.36 mmol/l |
2.12–2.65 mmol/l |
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QuESTIONS
•What does the x-ray show?
•What is the likely diagnosis?
•What are the common causes?
•What investigations are required to confirm the diagnosis?
•How should the patient be managed?
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