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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2683_Библиотеки_им_академика_М_И_Перельмана.pdf
Gastrointestinal bleed
Bedside investigations
• Observations: heart rate, blood pressure, respiratory
rate, oxygen saturations, temperature.
Blood tests
• Full blood count: haemoglobin level may be normal
in the acute phase, despite a large GI bleed, as it
takes some hours for haemodilution to occur. Low
haemoglobin level on initial presentation and/or mean
corpuscular volume suggests chronic blood loss. White
cell count may be raised after a GI bleed. Platelet count
may be reduced (acute bleed) or increased (chronic
blood loss). A very low platelet count should raise
suspicion of a bleeding diathesis.
• Any actively bleeding patient should have a blood
‘group and save’ taken and sent to the laboratory. Blood
should be cross-matched if a need for transfusion is
li k ely.
• Clotting screen: prothrombin time is raised in liver disease.
More specific investigations may be indicated (e.g. in
patients with haemophilia or von Willebrand disease).
• Urea level is raised because of the absorption and
subsequent breakdown of protein when blood reaches
the small bowel. Intravascular volume depletion
causing prerenal impairment also contributes.
Further investigations
• Erect chest X-ray, for pneumoperitoneum suggestive of
bowel perforation.
• Endoscopy. Urgent in unstable patients or those with
significant comorbidity. It allows direct visualization of
the disease and provides a diagnosis in around 90% of
cases. This will determine the most appropriate form of
medical therapy. The risk of rebleeding (the major cause
of death) may be estimated. Treatment may be given
endoscopically (e.g. banding or sclerosing a bleeding
varix, or adrenaline injection into a bleeding vessel). If
endoscopy findings are negative, colonoscopy should be
performed to rule out a proximal colonic bleed.
• Rockall score: a scoring system that helps to identify
high-risk patients presenting with an upper GI tract
bleed. It is used to predict the risk of death (before and
after endoscopy) (Tables 11.2 and 11.3). A score of less
than 3 carries good prognosis (Table11.3).
Most patients do not require further tests, but occasionally
these are performed under the guidance of a specialist when
the diagnosis remains uncertain (see Fig.11.2):
• Isotope studies: abdominal gamma scanning can detect
extravasation of radioisotope-labelled red blood cells
if active bleeding is present. Such studies are now very
rarely undertaken.
• Mesenteric angiography requires significant, active
bleeding to localize the source. It can also be used to
visualize the portal venous system.
• CT/MRI with or without capsule endoscopy to
investigate disease of the small intestine.
• Diagnostic laparoscopy before laparotomy and surgically
assisted enteroscopy are occasionally performed.
Table11.3 Prediction of rebleeding and mortality from
the Rockall score
Score Initial score (%)
0 0.2 0
1 2 0
2 6 0.2
3 11 2.9
4 25 5.3
5 40 10.8
6 50 17.3
7 50 27
8+ — 41.1
Final score after
endoscopy (%)
Table11.2 Rockall score
Score
Variable
Age (years) <60 60–79 80
Shock No shock Pulse >100 SBP
Comorbidity Nil major CHF, IHD, major morbidity Renal or liver failure,
Diagnosis Mallory–Weiss tear All other diagnoses GI malignancy
Evidence of
bleeding
CHF, Congestive heart failure; GI, gastrointestinal; IHD, ischaemic heart disease; SBP, systolic blood pressure.
0 1 2 3
SBP <100 mmHg
>100 mmHg
None Blood, adherent clot,
spurting vessel
metastatic cancer
78
Investigations
1111
Despite extensive investigation, a small minority of patients
will remain undiagnosed. If bleeding is severe, laparotomy
may be required, but if it is mild, the patient may attend hospital for ‘top-up’ transfusions or iron infusions as required
while investigations continue.
HINTS AND TIPS
Elevated blood urea level with normal serum
creatinine level suggests gastrointestinal blood loss.
Chapter Summary
• Haematemesis and melaena are signs of gastrointestinal bleeding.
• Melaena suggests a bleed originating above the hepatic flexure.
• ‘Coffee grounds’ vomiting suggests a lower gastrointestinal tract bleed.
• Endoscopy is the main diagnostic and therapeutic investigation in this presentation and
should not be delayed.
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Change in bowel habit
12
INTRODUCTION
Always ask about the patient's normal bowel habit because
there are considerable differences between people. Change
in bowel habit is an important symptom and may suggest
an underlying disease. Constipation is defined as abnormally delayed or infrequent passage of dry hardened stool.
Diarrhoea is defined as abnormally frequent intestinal evacuations with stools which are mostly fluid. Tables 12.1 and
12.2 summarize the causes of diarrhoea and constipation,
respectively.
HINTS AND TIPS
Note the features of acute gastrointestinal
obstruction: absolute constipation (no passage of
either faeces or gas), vomiting, pain and abdominal
distension.
HISTORY AND EXAMINATION FINDINGS
History
COMMUNICATION
Make sure that by ‘constipation’ and ‘diarrhoea’
you and the patient mean the same thing.
Table12.1 Differential diagnosis of diarrhoea (see Chapter29)
Causes Examples
Infective Bacterial: Campylobacter (poultry), Salmonella (meat, poultry and dairy), Shigella (faecal–
oral transmission)
Viral: rotavirus, Norwalk virus, cytomegalovirus
Protozoa: Giardia lamblia, Cryptosporidium, Entamoeba histolytica
Inflammatory Inflammatory bowel disease
Malignancy
Radiation enteritis
Ischaemic Emboli or mesenteric atheromatous disease
Functional Irritable bowel syndrome
Secretory Infection (e.g., cholera)
VIPoma/Zollinger–Ellison/carcinoid
Villous adenoma
Factitious diarrhoea (e.g., laxative abuse)
Bile salt malabsorption (disruption of enterohepatic circulation)
Osmotic Medications (e.g. antacids and lactulose)
Disaccharidase deficiency
Factitious diarrhoea
Malabsorption See Chapter29 for causes
Systemic illness Hyperthyroidism, diabetes mellitus, Addison disease (see Chapter33)
Overflow diarrhoea Faecal impaction in elderly patients
Drugs Alcohol, digoxin, metformin, neomycin, proton pump inhibitors, bisphosphonates
Ask about.
• Normal bowel habit and diet.
• Onset: sudden or chronic. Infectious diarrhoea is
usually of acute onset. Has the patient been in contact
with anyone with diarrhoea? Recent foreign travel?
81
Change in bowel habit
Table12.2 Differential diagnosis of constipation (see
Chapter29)
Causes Examples
Congenital Hirschsprung disease
Mechanical
obstruction
Lifestyle Diet
Pain Fissure-in-ano
Metabolic/
endocrine
Drugs Opiates, anticholinergics, diuretics
Neurological Paraplegia (see Chapter32)
Functional Irritable bowel syndrome
Inflammatory stricture (e.g., Crohn
disease, diverticulitis)
Neoplasm
Extraluminal mass (e.g., pelvic)
Rectocele
Dehydration
Immobility
Lack of privacy (e.g., hospital ward)
Thrombosed haemorrhoids
Postoperative
Hypothyroidism (see Chapter33)
Hypercalcaemia
Diabetic neuropathy
Multiple sclerosis
Idiopathic megacolon/rectum
• Frequency of defecation.
• Stool appearance: formed, loose or watery; colour—
normal, red (blood from low in the gastrointestinal
tract), black (melaena), yellow (high fat content, or
mucus and slime), ‘redcurrant jelly’ (intussusception),
putty coloured (obstructive jaundice); volume; do the
stools float? (high fat content—malabsorption).
• Associated features (e.g., pain, fever, vomiting, weight
loss, extraintestinal manifestations of inflammatory
bowel disease) (see Chapter29).
• Nocturnal symptoms: these go against a functional
disorder.
• Tenesmus (a sense of incomplete evacuation).
• Smell: offensively malodorous in malabsorption;
melaena has a particularly offensive characteristic smell.
• Symptoms of thyrotoxicosis.
• Relationship to food.
• Stress.
• Drugs: antacids, laxatives, cimetidine, digoxin,
antibiotics, alcohol.
• Surgical history (e.g., multiple bowel resections for
Crohn disease can result in malabsorption).
Examination
The examination approach in the patient with a change in
bowel habit is given in Fig.12.1.
INVESTIGATIONS
The wide range of possible diagnoses in patients with altered bowel habit is reflected by the large number of tests
that may be performed. Some of these are used commonly,
whereas others are used much less frequently and only under the guidance of specialists.
Bedside investigations
Blood tests
• Full blood count: anaemia of chronic disease, raised
white cell count in infections.
• Urea and electrolytes, including calcium: acute kidney
injury secondary to dehydration.
• Thyroid function tests: constipation in hypothyroidism
and diarrhoea in hyperthyroidism.
• Blood glucose: diabetes.
• Liver function tests: pale stools in obstructive or
posthepatic jaundice.
• Albumin: level decreased in malabsorption, proteinlosing enteropathies, inflammatory diseases.
• In malabsorption: anaemia—vitamin B12, folate, iron;
hyponatraemia in profound secretory diarrhoea;
reduced absorption of fat-soluble vitamins—prolonged
prothrombin time (vitamin K), hypocalcaemia (vitamin
D), visual impairment (vitamin A).
• Antitissue transglutaminase antibodies if suspected
coeliac disease.
• Inflammatory markers (erythrocyte sedimentation
rate and C-reactive protein)—levels raised in infection/
inflammation. Many centres now measure plasma viscosity.
Imaging
Noninvasive
• Abdominal X-ray: distended intestinal loops and fluid
levels suggest obstruction, pancreatic calcification
suggests chronic pancreatitis, and gross dilatation
of the colon suggests Hirschsprung disease (rare).
Featureless colon, with loss of haustral markings, may
indicate colitis.
• Abdominal ultrasound scan and/or CT for suspected
masses and pancreatitis. Occasionally MRI enterography
is used for detailed visualization of the small bowel.
• Videocapsule endoscopy for small bowel disease.
Invasive
• Rigid sigmoidoscopy—performed without sedation
(e.g., in an outpatient setting); allows inspection and/or
biopsy of rectal mucosa.
• Flexible sigmoidoscopy/colonoscopy—examination of
the large bowel; allows biopsies (even if the large bowel
is macroscopically normal to exclude microscopic
82
manifestations of IBD
manifestations of IBD
— Appearance of faeces
Eyes
— Anaemia
— Features of thyrotoxicosis
(e.g., lid lag, exophthalmos)
— Extraintestinal
manifestations of IBD
Abdomen
— Distension
— Masses
— Tenderness
— Bowel sounds
Hands
— Clubbing
Investigations
Skin
— Flushing (carcinoid
syndrome)
— Rashes
— Extraintestinal
Lymph nodes
— Lymphadenopathy
(infections,
tuberculosis,
lymphoma)
Hernial orifices
1212
Rectal examination
— Faecal impaction
— Perianal disease
— Fistulae (Crohn
General
— Temperature and other
signs of infection
— Nutritional status
Fig.12.1 Examining the patient with a change in bowel habit. IBD, Inflammatory bowel disease.
colitis). Flexible sigmoidoscopy examines the colon
up to the sigmoid, whereas colonoscopy examines the
whole large bowel.
• Endoscopy and duodenal (D2) biopsy for
malabsorption.
• Magnetic resonance cholangiopancreatography,
endoscopic retrograde cholangiopancreatography or
endoscopic ultrasonography for suspected biliary and
pancreatic pathology.
Further investigations
• Stool microscopy, culture and detection of Clostridium
difficile toxin if infection is suspected.
• Faecal calprotectin as a means of differentiating
inflammatory from noninflammatory diarrhoea.
• Faecal elastase test for pancreatic exocrine function.
• Assessment of bile salt absorption using radioisotopelabelled bile acids (SeHCAT scan).
• Faecal clearance of α1-antitrypsin to investigate
protein-losing enteropathy.
• Laxative screen.
• Colonic transit study: to confirm constipation and
measure the transit time.
• Studies of pelvic floor function: defecating
proctography and anal manometry.
• Fasting gut hormones: serum vasoactive
intestinal polypeptide (VIPoma); serum gastrin
(Zollinger–Ellison syndrome); chromogranin
calcitonin (medullary thyroid carcinoma);
cortisol (Addison disease); 24-hour urinary
5-hydroxyindoleacetic acid (carcinoid syndrome).
disease)
Joints
— Extraintestinal
83
Change in bowel habit
Chapter Summary
• Change in bowel habit can indicate serious disease; if indicated, patients presenting with
this symptom should undergo full assessment to exclude a sinister cause.
• Local or systemic causes can be the reason for the presentation. In most cases, careful
history taking and examination will lead to the correct diagnosis. Occasionally specialized
testing is necessary.
84
Weight loss
13
INTRODUCTION
Weight loss is due to either decreased energy intake or
increased energy output, or both. Distinguish deliberate weight loss from involuntary weight loss. Involuntary
weight loss is a common manifestation of physical or psychological illness and always warrants further investigation.
It can be a manifestation of disease in any system.
Table 13.1 summarizes the differential diagnosis of
weight loss.
Table13.1 The differential diagnosis of weight loss
Causes Examples
Psychiatric/psychological Anorexia nervosa
Depression or agitation
Catatonia
Schizophrenia
Laxative or diuretic abuse
Neglect (e.g. ‘tea and toast’ diet in widowhood)
Drugs Alcohol, tobacco, laxatives or diuretics, opiates, amphetamines
Infections Tuberculosis
HIV infection
Other chronic infections and infestations
See Chapter37
Chronic inflammation Inflammatory bowel disease
Connective tissue disease
See Chapters29 and 35
Malignancy Almost every type of malignancy is associated with weight loss
Chronic illness Cardiac failure (‘cardiac cachexia’)
Chronic obstructive pulmonary
disease
Chronic renal failure
See Ch. 27, 28 & 29
Endocrine Uncontrolled diabetes mellitus
Hyperthyroidism and rarely hypothyroidism
Adrenal insufficiency
Phaeochromocytoma
Hypopituitarism
Severe diabetes insipidus
See Chapter33
Gastrointestinal Peptic ulcer disease
Dysphagia
Malabsorption liver disease
See Chapter29
Neurological Motor neurone disease
Myopathies
Poliomyelitis
See Chapter32
HIV, Human immunodeficiency virus.
HINTS AND TIPS
Malignancy must be excluded in patients with
unexplained weight loss. In cancer, weight loss
occurs secondary to increased metabolic rate and/
or reduced oral intake.
85
Weight loss
HISTORY AND EXAMINATION FINDINGS
History
Try to confirm weight loss objectively with records of previous weights.
Ask about:
• The amount of weight lost, over what period the
weight was lost and if the weight loss was
intentional.
• Diet: detailed intake and any recent changes
in diet history. Assess alcohol intake and illicit
drug use.
• Physical activity: any changes in level.
Systems review:
• Symptoms of chronic infection, inflammation or
malignancy: fever and sweats, rashes, general malaise,
lethargy, anorexia, easy bruising.
• Cardiorespiratory: shortness of breath, cough,
haemoptysis.
• Gastrointestinal: dysphagia, change in bowel habit,
melaena, rectal bleeding, change in stool consistency,
haematemesis.
• Genitourinary: polyuria and polydipsia (diabetes),
haematuria, obstructive urinary symptoms (prostate),
menstrual history.
• Neurological: vitamin and mineral deficiencies
can result in neurological symptoms such as
paraesthesia.
• Endocrine: assess the patient for thyrotoxicosis (tremor,
heat intolerance, palpitations); adrenal insufficiency
(skin pigmentation, weakness); phaeochromocytoma
(headache, sweating and tachycardia is the classic
triad); panhypopituitarism (pallor, dizziness, loss of
body hair, loss of libido, visual field defects, symptoms
of hypothyroidism).
• Psychiatric: depression screen and assessment for
anorexia nervosa.
COMMUNICATION
Many patients with unexplained weight loss fear an
underlying malignancy. It is important to make time
to address this concern.
Examination
The examination approach in the patient with weight loss
is given in Fig.13.1. Does the patient look as if he or she
has lost weight (loose skin, loose clothes)? Does the patient
look well or ill? Is the patient pyrexial? The patient's weight,
height and body mass index should be documented.
Check for:
• Clubbing: malignancy, cirrhosis, inflammatory bowel
disease and infections (chronic suppurative lung
disease, infective endocarditis, COPD).
• Leuconychia and palmar erythema: liver
disease (leuconychia reflects
hypoalbuminaemia).
• Koilonychia: iron deficiency anaemia.
• Pigmentation: increased in Addison disease
(particularly in palmar creases) but decreased in
anaemia.
• Joint swelling and decreased range of movement:
connective tissue diseases.
• Tremor, goitre and eye signs: hyperthyroidism
(see Chapters 17 and 33).
• Jaundice and other signs of liver failure (e.g. spider
naevi) (see Chapter14).
• Muscle wasting.
• Rashes.
• Raised blood pressure: phaeochromocytoma.
• Mouth changes: infections and malignancies.
• Lymphadenopathy.
The following individual systems should be examined:
• Cardiorespiratory.
• Gastrointestinal: including careful palpation
for abdominal masses, rectal examination and
organomegaly (e.g. liver metastases). Always do a
digital rectal examination.
• Neurological system: motor neurone disease,
myopathy, paraneoplastic or metastatic manifestations
of malignancy.
• Breast lumps.
INVESTIGATIONS
As the potential causes of weight loss are multiple, investigations need to be tailored to the history and clinical examination findings. Nonetheless, the following investigations
should be performed.
Blood tests
• Full blood count: anaemia with malignancy, iron
deficiency, vitamin B12 deficiency or folate deficiency,
with inadequate dietary intake.
• Urea and electrolytes for uraemia and chronic
kidney disease; calcium, magnesium and
potassium.
• C-reactive protein: level raised in infection and
inflammation but also in myeloma and other
malignancies.
• Blood cultures if indicated (e.g. in sepsis or
endocarditis).
86
Neurological system
— Effects of malignancy
Eyes
— Jaundice, anaemia
— Lid lag, retraction,
— Exophthalmos
Breast
— Lumps
Lungs
— Effusions
— Crepitations
Hands
— Clubbing
— Leuconychia
— Pigmentation
— Stigmata of endocarditis
— Nail fold infarcts
J
oints
— Swelling
— Inflammation
Investigations
— Primary illness
Mouth
— Infections
— Malignancy
Thyroid
— Infections
— Malignancy
Lymph nodes
— Lymphadenopathy
Abdomen
— Masses
— Ascites
Rectum/vagina
— Masses
Skin
— Rashes
1313
Fig.13.1 Examining the patient with weight loss.
• Liver function tests and clotting: liver failure.
• Blood glucose: diabetes, low glucose level in liver
failure, Addison disease.
• Thyroid function tests.
Chapter Summary
• Unintentional weight loss is a nonspecific symptom that may be a manifestation of
sinister pathology such as malignancy.
• It occurs with inadequate energy intake, increased energy expenditure, malabsorption
and/or increased metabolic rate.
• The history and examination and good clinical reasoning should guide the choice of
investigations.
Imaging
• Chest X-ray: infection or tuberculosis, and malignancy.
• CT/MRI/ultrasound scan.
General
— Nutritional status
87