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Abdominalpain
2Worrying features Sudden onset, iHR, dBP, dGCS, massive
distension, peritonism, expansile mass, persistent vomiting, haematemesis, massive PR bleeding; if life- threatening E p. 302.
Think about Pain by anatomical structure, see Fig. 0.; Common
Gastroenteritis, peptic ulcer, gastro- oesophageal reux disease
(GORD), constipation, inammatory bowel disease (IBD), irritable
bowel syndrome (IBS), diverticular disease, adhesions, mesenteric
adenitis, renal colic, UTI/ pyelonephritis, urinary retention, biliary colic/
sepsis, pancreatitis, bleeding AAA, incarcerated hernia, ischaemicbowel;
Obs/ gynae Ectopic pregnancy, ovarian cyst, ovarian torsion, PID, endo-
metriosis, labour;
psoas abscess, porphyria. See Table0. and Box0.2.
Ask about Nature of pain (constant, colicky, changes with eating/
vomiting/ bowels), duration, onset, frequency, severity, radiation to the
back, dysphagia, dyspepsia, abdominal swelling, nausea and vomiting, stool
colour, change in bowel habit, urinary symptoms, weight loss, breathlessness, rashes, lumps, chest pain, recent surgery, last period;
IBD, IHD, jaundice, gallstones, pancreatitis, previous abdo surgery;
DHNSAIDs; SHAlcohol.
Obs Temp, HR, BP, RR, sats, nger- prick glucose, urine output.
Look forJaundice, sweating, pallor, pulse volume, clubbing, leuconychia
(white nails), lymphadenopathy (Virchow’s node), abdominal scars, distension, ascites, visible peristalsis, tenderness, peritonitis (tenderness with
guarding, rebound, or rigidity), loin tenderness, hepatomegaly, splenomegaly, masses (?expansile/ pulsatile), check hernial orices, examine external genitalia (♂: testicular vs epididymal tenderness), femoral pulses,
bowel sounds, lung air entry;
ness, masses, prostate hypertrophy, stool, check glove for blood, mucus,
melaena, and stool colour.
Investigations Urine Dipstick, β- hCG in all pre- menopausal women
of reproductive age,MSU;
±cardiac markers, venous lactate, clotting, bld cultures if pyrexial;
unwell;
ECG To exclude MI; Erect CXR To exclude perforation; Plain
To exclude bowel obstruction,or KUBFor renalcolic; USS Especially
AXR
if hepatobiliary cause suspected;
TreatmentGive all patients O
catheter if unwell. Keep NBM until urgent surgery is ruledout.
•
Shocked IV uids 3urgent seniorreview
Peritonitic With IV uids, IV antibiotics 3urgent seniorreview
•
>50yr in severe pain ?AAA, IV uids 3urgent seniorreview
•
Abdo pain and vomiting Consider obstruction, IV uids, NG tube, AXR
•
(E pp. 616–7) 3urgent seniorreview
•
GI bleed Resuscitate with IV uids (E p. 312) 3urgent senior review.
Other Trauma, MI, pneumonia, sickle- cell crises, DKA,
PMHDM,
PR Perianal skin tags, ssures, warts; tender-
bldsFBC, U+E, LFT, amylase, Ca
CT abdoDiscuss with senior.
, analgesia ±antiemetics; insert a urinary
2
2+
, glucose,
ABGIf
303ABDOMINALPAIN
304 CHAPTER0 Gastroenterology
Table0. Common causes ofabdominalpain
History Examination Investigations
3Perforation
Bowel
obstruction
Bowel ischaemia/
infarction
Appendicitis RIF pain (initially
Strangulated
hernia
GORD/ peptic
ulcer
Gastroenteritis Rapid onset,
Inammatory
bowel disease
Diverticular
disease
3Acute
pancreatitis
3Abdominal
aortic aneurysm
(AAA)
Renal colic Sudden severe colicky
Hepatobiliary
disease
Obs/ gynae
disease
3Testicular
torsion
Rapid onset, severe
abdominal pain
Pain, distension,
nausea, vomiting,
constipation
Sudden onset, severe
pain, previous arterial
disease, ±AF
periumbilical),
anorexia, nausea,
vomiting
Sudden-onset pain,
previous hernia
Dyspepsia, heartburn,
anorexia, NSAIDs
vomiting, diarrhoea
Weight loss, mouth
ulcers, PR blood
±mucus, diarrhoea
Pain, diarrhoea,
constipation, PR
bleeding
Constant epigastric
pain radiating to back,
vomiting, anorexia,
ialcohol or gallstones
Abdominal and
back pain, collapse,
previous heart
disease/ iBP, age
>50yr, ♂
ank pain, radiates
to groin, nausea/
vomiting
Constant or colicky
RUQ pain, gallstone
Lower abdo pain, PV
bleeding, irregular/
absent periods
Sudden- onset severe
unilateral groin pain
Peritonitis,
±bowel sounds
Distension,
tenderness,
tinkling bowel
sounds
Shock,
generalized
tenderness
Slight temp, RIF
tenderness,
±peritonitic
Tender hernial
mass
Epigastric
tenderness
itemp, epigastric
tenderness, no
peritonitis
Tender ±mass
±peritonitis
Tenderness,
±peritonitis
Shock,
epigastric
tenderness,
dbowel sounds
Expansile mass,
unwell, often
dBP, dleg
pulses
Sweating,
restless, loin
tenderness
RUQ
tenderness,
±jaundice
Lower abdo
tenderness, PV
exam abnormal
Tender testicle,
±swelling
Gas under
diaphragm, acidotic
Dilated loops of
bowel on AXR
iWCC, ilactate/
acidotic, ±AF or
previous MI on
ECG
iWCC, iCRP
Needs urgent
surgery
Consider need for
OGD
iWCC, iCRP
iWCC,
iCRP, iplts,
oedematous
bowel on AXR,
lesions on
colonoscopy
iWCC, iCRP,
diverticulae on
colonoscopy
iii amylase,
iWCC, iCRP,
iglucose, dCa
Urgent USS
(bedside if
possible);
immediate surgery
if leaking
60% of stones
visible on KUB;
>99% on noncontrast CT
Deranged LFTs;
dilated CBD on
USS
β- hCG +ve,
lesions seen on
USS
2+
Urgent surgery
Fig.0. Abdominal organs and pain, by region.
I Box 0.2 Causes ofabdominal pain inthis chapter
and elsewhere
Bowel
Adhesions/ ischaemia E p. 307 Appendicitis E p. 307
Diverticular disease E p. 309 Dyspepsia/ peptic ulcers E p. 308
Gastroenteritis E p. 321 Hernias E p. 521
Inammatory bowel disease E p. 323 Irritable bowel syndrome E p. 322
Obstruction E p. 306 Perforation E p. 305
Hepatopancreatobiliary
Biliary colic/ cholecystitis E p. 309 Hepatitis E p. 329
Pancreatitis (acute/ chronic) E pp. 310–11
Genitourinary
Ectopic pregnancy E p. 500 Endometriosis E p. 530
Ovarian cyst E p. 530 Pelvic inammatory disease E p. 530
Testicular torsion E p. 520
Other
Abdominal aortic aneurysm E p. 477 Renal colic E p. 304
305ABDOMINALPAIN
3Perforation (E OHCM1p. 698.)
Causes Peptic ulcer, appendicitis, diverticulitis, inammatory bowel
disease, bowel obstruction, GI cancer, gallbladder.
Symptoms Acute abdominal pain worse on coughing or moving;
PMH Peptic ulcer, cancer,IBD; DHNSAIDs; SHAlcohol.
Signs iHR, ±dBP, iRR, peritonism (abdo tenderness, guarding, rebound,
rigidity), reduced or absent bowel sounds.
Investigations blds iWCC, dHb, iamylase, ilactate; CXR Erect lm shows
air under the diaphragm, ±obstruction onAXR;
ABGAcidosis.
Management 2Seek senior review; resuscitate with IV uids, 5L/ min O
good IV access (large ×2), analgesia (eg morphine 5– 0mg IV with cyclizine
50mg/ 8h IV), NBM, and urgent X- match 4units; IV antibiotics (eg coamoxiclav .2g/ 8h IV), insert NG tube and urinary catheter, consider emergency CT once stable, prepare for emergency laparotomy (Ep. 0).
,
2
306 CHAPTER0 Gastroenterology
Bowel obstruction(E OHCM1p. 602.)
Box 0.3 Causes ofintestinal obstruction
Outside thebowelAdhesions, hernias, masses, volvulus.
Within thebowel wall Tumours, IBD, diverticular disease, infarction, con-
genital atresia, Hirschsprung’s disease.
Inside thebowel lumenImpacted faeces, FB, intussusception, strictures,
polyps, gallstones.
Paralytic ileus (pseudo- obstruction) Post- op, electrolyte imbalance, ur-
aemia, DM, anticholinergicdrugs.
Symptoms Vomiting (may be faeculant), colicky abdo pain, pain may
improve with vomiting, constipation (±absolute— no atus or stool),
bloating, anorexia, recent surgery.
Signs iHR ±dBP, iRR, distended abdomen, absent or tinkling bowel
sounds, peritonitis, scars from previous surgery, hernias.
Investigations bldsMild iWCC and iamylase ±acidosis; AXRLook for dilated
bowel (?small or large) or volvulus (E pp. 616–17);
Erect CXR?freeair.
Management Bowel obstruction may need uid resuscitation and anal-
gesia, treat according to the type and location of the obstruction:
•
Strangulated Constant severe pain in an ill patient with peritonitis
(acute abdomen); can be small or large bowel. This will require urgent
surgery especially if caused by ahernia
•
Small bowel Early vomiting with late constipation, usually caused by
hernias, adhesions, or Crohn’s. Treat conservatively with NBM, a NG
tube, and IV uids (E pp. 402–5)— often referred to as drip and suck—
until the obstruction resolves; surgery if patient deteriorates. K
lost into the bowel and needs to be replaced in uids (eg 20mmol/ L)
•
Large bowel Early absolute constipation with late vomiting, usually
caused by tumours, diverticulitis, volvulus (sigmoid or caecal), or faeces.
IV uids, NBM, and refer to a senior surgeon. Urgent surgery may
be required if the caecum is >0cm across on AXR otherwise a CT,
colonoscopy, or water- soluble contrast enema may be requested to
investigate the cause. Surgery is usually required exceptfor:
•
sigmoid volvulus— sigmoidoscopy and atus tube insertion
•
faecal obstruction— laxative enemas (Ep. 204)
•
colonic stenting— may be oered for tumour palliation
•
Paralytic ileus Loss of bowel motility can mimic the signs and symptoms of a
mechanical blockage. It is a response of the bowel to inammation locally
(eg surgery) or adjacently (eg pancreatitis). The main distinguishing feature
is the relative lack of abdo pain, although the pathology responsible for the
ileus may cause abdo pain itself. USS abdo, contrast enema, or CT may
be required to exclude mechanical obstruction. Treat conservatively with
NBM, NG tube, IV uids (E pp. 402–5) until the underlying pathology
improves. Check and correct electrolyte abnormalities, including K
2+
Mg
both of which may need to be replaced.
Complications Strangulation, bowel infarction, bowel perforation, dK
hypovolaemia.
+
is often
+
and
+
,
Adhesions
Causes Previous surgery, abdominal sepsis, IBD, cancer, endometriosis.
Symptoms and signsChronic intermittent abdominal pain and tenderness,
may develop bowel obstruction (distension, vomiting, constipation).
ManagementAnalgesia and stool softeners; may need operative division
of adhesions, but this may lead to new adhesions forming.
Bowel ischaemia/ infarction(E OHCM1p. 617.)
Symptoms Unwell, sudden- onset severe constant abdominal pain, PR
blood;
PMHAF, MI, polycythaemia.
Signs iHR (?irregular), ±dBP, iRR, itemp, cold extremities, generalized
tenderness but few specicsigns.
Investigations blds iWCC, iamylase, metabolic/ lactic acidosis;
Sigmoidoscopy ±biopsy may show pale, ulcerated mucosa.
Management NBM, resuscitate with IV uids; analgesia, IV ABx (eg
co- amoxiclav .2g/ 8h IV), consider anticoagulation with LMWH (Epp.
428–30), surgical resection is often necessary. Very poor prognosis—
clarify premorbid state and consider ICU care as appropriate.
Appendicitis(E OHCM1p. 600.)
$ A common diagnostic challenge
— complications can be severe if left
untreated, but 5– 40% of appendicectomy specimens are normal. Can
occur in any age group; classical cases are easy enough to spot, variable
anatomy and extremes of age can make presentation atypical.
DierentialUTI, diverticulitis, gastroenteritis, mesenteric adenitis, perfor-
ated ulcer, IBD, diverticulitis;
Gynae Ectopic pregnancy, ovarian torsion,
ruptured ovarian cyst, salpingitis.
Symptoms Central, abdominal colicky pain worsening over – 2d then
developing into constant RIF pain (sensitivity and specicity of 780%
2
worse on moving, anorexia, nausea, vomiting, may have constipation,
diarrhoea, dysuria, oliguria (all non- specic and common).
Signs itemp, iHR, ±dBP, RIF tenderness ±guarding/ rebound/ rigidity,
RIF pain on palpating LIF (Rovsing’s sign), PR tender on right (there is no
evidence that this has diagnostic utility in adults, but failure to perform
PR still considered negligent).
Investigations iWCC, neutrophilia >75%, iCRP (a useful triad with negative
predictive value >97% in adults, but beware children and elderly); bld cultures
(if pyrexial), G+S; US and contrast- enhanced CT reduce laparotomy rates, but
this must be balanced against risks of radiation exposure and local resources.
ManagementSurgery— NBM, IV uids, analgesia, IV ABx (eg co- amoxiclav
.2g/ 8h IV). Laparoscopic approaches reduce scarring, postoperative
pain, recovery time, and incidence of wound infections, but require
more operative time and higher skill levels than open appendicectomy.
If peritonitic, send for immediate surgery, otherwise reassess regularly
while awaiting surgery. If diagnostic uncertainty, a short period of safe
observation ±imaging can be informative.
And hence an all too common source of tension between ED sta and junior surgical doctors—
try to avoid becoming part of this seemingly perpetual cliché when your turncomes.
2
See Yeh B. Ann Emerg Med 2008;52:30 for an excellent review of the clinical utility of signs and
symptoms in adult appendicitis:Mwww.annemergmed.com/ ar ticle/ S096- 0644(07)0732- 5/ fulltext
307ABDOMINALPAIN
),
308 CHAPTER0 Gastroenterology
Dyspepsia(E OHCM1p. 248.)
$ Any persistent symptom referable to the upper GI tract. This will in-
clude patients with peptic ulcer disease, GORD, oesophagitis, and rare
upper GI malignancies, as well as those without signicant endoscopic
changes. Aim to identify those at risk of signicant pathology, and control symptoms in those without.
SymptomsBurning retrosternal or epigastric pain, worse on bending and
3
lying, waterbrash (excess saliva), acid reux, nausea, vomiting, nocturnal
cough, symptoms improved by antacids; symptom patterns are poorly
predictive of endoscopic ndings.
Signs Epigastric tenderness (no peritonitis), rarely epigastricmass.
Common risk factorsSmoking, alcohol, obesity, pregnancy, hiatus hernia, medica-
tions (bisphosphonates, calcium antagonists, nitrates, corticosteroids, NSAIDs).
InvestigationsUrgent endoscopy if ‘red ag’ symptoms (chronic GI bleeding/
iron deciency anaemia, unintentional weight loss, progressive dysphagia,
persistent vomiting, epigastric mass) or ≥55yr and persistent/ unexplained
dyspepsia. Else test and treat for H.pylori (Box 0.4). Some reserve testing
for those who fail empirical treatment with mth full- dose PPI. Consider
low- dose maintenance or as- required PPI for those who respond. If symptoms persist, consider endoscopy or 24h ambulatory pH monitoring.
Management Lifestyle adviceWeight loss, smoking cessation, alcohol reduc-
tion, avoid foods/ drugs which exacerbate symptoms, especially NSAIDs.
•
GORD Antacids (E p. 83) PRN if mild; full- dose PPI for – 2mth,
then low- dose or PRN PPI; H
eective than PPI, but individual patients may respond better; surgical
receptor blockers (eg ranitidine) less
2
fundoplication (rarely) ifsevere
•
Oesophagitis As for GORD; frequency of surveillance if Barrett’s
oesophagus detected requires specialist guidance
•
Peptic ulcer – 2mth full- dose PPI. 95% of duodenal and 80% of gastric ulcers
are related to H.pylori, therefore ensure eradication (Box 0.4). Gastric
ulcers are also associated with malignancy, therefore repeat endoscopy at
6wk to conrm healing. If symptom recurrence, retest, since eradication
may require dierent or prolonged antibiotics, and re- infection canoccur
•
Gastric/ oesophageal malignancy Urgent multidisciplinary team referral
for surgery/ palliation.
K Box 0.4 H.pylori infection and eradication
• 3C- urea breath testing reliably detects infection or conrms
eradication and is widely used in secondary care; faecal antigen
tests are used in primarycare
• CLO tests require a biopsy taken at OGD and rely upon pH
indicator changes
• A‘wash- out’ period of 2wk o PPI is needed for these tests;
serological tests are less reliable, but can be used in a patient onaPPI
• Treatment is with triple therapy for wk, eg lansoprazole 30mg/
2h PO, amoxicillin g/ 2h PO, clarithromycin 500mg/ 2hPO
• Regimens containing metronidazole may increase resistance and
may be better reserved for 2nd- line therapy
• 2wk courses increase eradication rates by 0%, but are not cost- eective.
3
NICE guidelines available at Mguidance.nice.org.uk/ CG84
Diverticular disease(E OHCM1p. 620.)
$ Diverticulosis = diverticulae (out pouchings) in the largebowel.
$ Diverticulitis = inammation of diverticulae; acutely symptomatic.
Symptoms Abdominal pain/ cramps (usually left sided, improves with
bowel opening), irregular bowel habit, atus, bloating, PR bleeding.
Signs itemp, iHR, ±dBP, LIF tenderness, ±peritonitis, distension.
Investigations blds iWCC,iCRP; CT/ colonoscopyFor indirect/ direct visu-
alization (necessary only to exclude other causes of symptoms).
Management Diverticulosis High- bre diet, antispasmodics (eg
mebeverine), laxatives (eg senna, E p. 204);
Diverticulitis NBM, anal-
gesia, uids, and ABx (eg co- amoxiclav .2g/ 8hIV).
Complications Obstruction, perforation, abscess, adhesions, strictures,
stula, PR bleeding (usually painless).
Renal colic(E OHCM1p. 630.)
$ Always consider other causes of abdominal pain, including AAA,
especially if no previous renal stone disease.
SymptomsAcute- onset severe unilateral colicky pain radiating from loin to
groin, nausea and vomiting, sweating, haematuria, dysuria, strangury (frequent, painful passage of small volumes of urine with sensation of incomplete emptying); iliac fossa or suprapubic pain suggests another pathology.
Signs iHR, sweating, patient restless and in severe pain, usually no ten-
derness on palpation unless superimposed infection.
Investigations Urine Hb on dipstick (790% cases), nitrates suggest UTI;
β
- hCGIf♀; bldsFBC, U+E, Ca
ManagementAnalgesia (NSAID rst, then opioids), if <5mm should pass
2+
,urate; CT- KUBDetects >99% stones.
spontaneously; larger stone will require urology opinion. If evidence of
infection give IV ABx (check local policy). If evidence of infection or
hydronephrosis refer urgently to urologist for nephrostomy orstent.
Complications Pyelonephritis, renal dysfunction.
Biliarycolic
$ Contraction of the gallbladder or cystic duct around gallstones.
Symptoms Recurrent colicky or constant RUQ/ epigastric pain (especially
on eating fatty foods), nausea, vomiting, bloating.
Signs RUQ tenderness, non- peritonitic, not jaundiced.
Results bldsNormal; USSGallstones.
ManagementAnalgesia, dietary advice, and elective cholecystectomy.
Complications Passage of stone into common bile duct may cause
cholestatic jaundice, cholangitis, or acute pancreatitis.
Acute cholecystitis
$ Gallbladder inammation, eg 2° to cystic duct occlusion by gallstone.
SymptomsContinuous RUQ/ epigastric pain, unwell, vomiting.
Signs itemp, RUQ tenderness and peritonitis, Murphy’s sign (pain and ces-
sation of deep inspiration during palpation in RUQ, not present inLUQ).
Results blds iWCC,iCRP; USSGallstones and thickened gallbladder.
ManagementNBM, analgesia, ABx (eg co- amoxiclav .2g/ 8h IV); consider
urgent cholecystectomy vs interval procedure. ERCP if distal CBDstone.
309ABDOMINALPAIN
310 CHAPTER0 Gastroenterology
3Acute pancreatitis (E OHCM1p. 628.)
$ Varies from a mild self- limiting illness to severe and life- threatening.
4
Causes‘I GET SMASHED’:Idiopathic, Gallstones (50%), Ethanol (25%),
Trauma, Steroids, Mumps, Autoimmune, Scorpion bites (rare),
Hyperlipi daemia, Hypercalcaemia, Hypothermia, ERCP, Drugs (eg thia-
zide diuretics).
SymptomsConstant severe epigastric pain radiating to the back, improved
with sitting forward, nausea, vomiting, anorexia.
Signs iHR, ±dBP, itemp, cold extremities, epigastric tenderness with
peritonitis, abdominal distension, dbowel sounds, mild jaundice, Cullen’s
(bruised umbilicus) or Grey Turner’s (bruised anks)sign.
Results blds dHb, iWCC, iii lipase (or amylase),
deranged clotting (±DIC),LFT;
ManagementIV uid resuscitation,
USS?gallstones; CTIf diagnosis indoubt.
7
O2, analgesia, urinary catheter, NBM,
6
iglucose, dCa2+,
NG tube. If severe (Table0.2) involve ICU and plan ERCP if gallstone
aetiology. Monitor uid balance, obs, glucose. Daily U+E, FBC, CRP;
prophylactic LMWH (Epp. 428–30).
Complications DIC, renal failure, respiratory failure, haemorrhage,
thrombosis, sepsis (infected necrosis), pseudocysts, abscess, chronic
pancreatitis.
Table0.2 Modied Glasgow score forpredicting acute pancreatitis severity
Variable Criteria In 974 Ranson developed a scoring system,
Age
PaO
2
WCC
2+
(uncorr)
Ca
Glucose
ALT
LDH
Urea
Albumin
Score point for each parameter present on admission or within the rst 48h. Ascore
of ≥3 predicts an episode of severe pancreatitis and should prompt ICU/ HDU refer ral.
Reproduced from Gut, Blamey S.L., etal., 25, 340– 6, 984, with permission from BMJ
Publishing Group Ltd.
*Original article available free at Mwww.ncbi.nlm.nih.gov/ pmc/ articles/ PMC42097
>55yr
<8.0kPa
>5 ×0
<2mmol/ L
>0mmol/ L
>00u/ L
>600u/ L
>6mmol/ L
<32g/ L
validated for use in alcohol- induced acute
pancreatitis; this remains widely used. The
modied Ranson criteria (979) have been
9
/ L
validated for gallstone- related disease. In
984, Blamey etal.* at the Royal Inrmary
in
Glasgow modied 8 of the Ranson
criteria and validated these for prognostic
use in both alcohol and gallstone induced
acute pancreatitis.
5
4
British Society of Gastroenterology guidelines at Mgut.bmj.com/ content/ 54/ suppl_ 3/ iii.full
5
Case series available free at Mwww.ncbi.nlm.nih.gov/ pmc/ articles/ PMC700547
6
Lipase slightly more specic. Overall trend in relation to pain is more important than absolute values.
7
WATERFALL trial showed that less aggressive uid resuscitation with bolus of 0mL/kg onl y if
hypovolemia then .5mL/kg in all associated with similar clinical outcomes but less uid overload
than more aggressive regiments. Mwww.nejm.org/doi/full/0.056/NEJMoa2202884
Chronic pancreatitis(E OHCM1p. 262.)
Causes Usually alcohol, but can be due to gallstones (which
may also cause recurrent pancreatitis), familial, cystic brosis,
hyperparathyroidism,iCa
2+
.
Symptoms General malaise, anorexia, weight loss, recurrent epigastric
pain radiating to back, steatorrhoea, bloating,DM.
SignsCachexia, epigastric tenderness.
Investigations blds Glucose (?DM, E pp. 342–4); Stool delastase;
USS (±endoscopic); CT/ MRCP May show characteristic changes, eg
microcalcication.
Management Analgesia, advise to stop drinking alcohol; Diet Refer to
dietician: low fat, high calorie, high protein, with fat- soluble vitamin
supplements;
Pancreatic enzymes Eg Creon
®
before eating; SurgeryCoeliac-
plexus block, stenting of the pancreatic duct, pancreatectomy.
311ABDOMINALPAIN
312 CHAPTER0 Gastroenterology
2GI bleeding emergency
2 Airway
2 Breathing
2 Circulation
Check airway is patent; consider manoeuvres/ adjuncts
If no respiratory eort—
If no palpable pulse—
CALL ARREST TEAM
CALL ARREST TEAM
3Call for senior help early if patient deteriorating.
• Lay the patient
5L/ min O
•
Monitor pulse oximeter, BP, debrillator ECG leads ifunwell
•
• Obtain a full set of
• Two good (large) sites of
•
FBC, U+E, LFT, clotting, urgent 4unit X- match
0.9% salineLIV
•
• Take brief
Examine patient: condensed CVS, RS, and abdoexam
•
Correct clotting abnormalities if present (Ep. 426)
•
Arterial blood gas, but don’t leave the patientalone
•
• Initiate
• Consider
on their side if vomiting
if SOB or sats<94%
2
observations includingtemp
venous access, take bloods:
history if possible/ check notes/ ask wardsta
further treatment, see following sections
serious causes (Box 0.5) and treat if present
• Seniors may consider giving terlipressin 2mg IV over 5min if
oesophageal varices
suspected (Ep. 314)
If bleeding is severe and the patient haemodynamically unstable:
• Call for
seniorhelp
• Give O– ve blood, request X- matchedunits
• Contact the on- call endoscopist and alert
surgeons
• 2Reassess, starting with A, B, C…
Box 0.5 Life- threateningcauses of GI bleeding
• Pepticulcer
• Vascular malformations
• Gastro- oesophageal varices
• Upper GI malignancy.
gastro-