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Acute upper GIbleeds
(E OHAM4 p. 228.)
2Worrying features dGCS, iHR, dBP, postural BP drop, durine output,
frank haematemesis, frank PR blood, chest pain, coagulopathy, liver disease.
Think about Common Peptic ulcer (NSAIDs, H. pylori), Mallory– Weiss
tear, gastro- oesophageal varices, oesophagitis, swallowed blood (eg epi-
Other Oesophageal or gastric cancer, vascular malformations,
staxis);
underlying coagulopathy (Table0.4).
Ask aboutColour, quantity, mixed in or throughout vomit, frequency, onset,
stool colour and consistency (those on iron may have black stool but it should
not be tarry), chest pain, abdominal pain, dysphagia, dizziness, fainting, sweating,
SOB, weightloss;
DHNSAIDs, anticoagulants, steroids; SHAlcohol.
Obs Pay special attention for iHR, dBP; check postural BP,GCS.
Look for Continued bleeding, colour of vomit, cold extremities, sweating, pulse
volume, bruises, other bleeding (nose, mouth), abdominal tenderness ±peritonitis,
masses, signs of chronic liver disease (Epp. 327–31);
Investigations
platelets may indicate hypersplenism (?2° to portal hypertension/ chronic liver
disease); ii urea (out of proportion to icreatinine); check for coagulopathy;
ECG
?ischaemia;
resuscitation; timing guided by clinical assessment of severity.Risk scoring can be
useful in this regard (Table0.3), but does not replace clinical judgement. Discuss all
potential major bleeds with seniors and an endoscopist at an earlystage.
Table0.3 Rockall risk scoring system forGIbleeds
Clinical information allows initial risk stratication, to which endoscopic ndings (in
italics) are added for complete assessment. ≤2=low risk
Feature 0 2 3
Age <60yr 60– 79yr ≥80yr
Shock:systolic BP
and HR
Comorbidity Nil major Heart
Diagnosis Mallory– Weiss/ none All other Upper GI
Bleeding on OGD Nil recent Recent
Reprinted from The Lancet, 347: 9009, T.A. Rockall, H.B. Devlin, R.F.A. Logan, T.C.
Northeld), ‘Selection of patients for early discharge or outpatient care after acute upper
gastrointestinal haemorrhage’, 38–40, Copyright © 996, with permission from Elsevier.
The Rockall score was developed to predict risk of death or rebleeding based upon the
complete score calculated after endoscopy (eg will occur in % of those with Rockall=3).
3Suspicion of rebleeding requires urgent discussion with the endoscopist and surgeon on call
± interventional radiology. As an alternative, the Blatchford score was developed to predict those
not requiring intervention based upon admission parameters, marginally outperforming the Rockall
score in this regard. It is somewhat more complex and less widely used (online calculators available
eg Mwww.mdcalc.com). NICE has managed to end up recommending the use of both scores.
8
PMH Coagulopathy, liver problems (?varices), peptic ulcers;
PR
blds
FBC, U+E, LFT, clotting, G+S or 2– 4unit X- match; low
OGD
Allows diagnosis and denitive treatment only after adequate
>00mmHg
<00/ min >00/ min <00mmHg
failure, IHD
Fresh blood/ melaena.
Renal/ liver
failure
malignancy
Metastatic
disease
313ACUTE UPPER GIBLEEDS
8
NICE guidelines available at Mguidance.nice.org.uk/ CG4
314 CHAPTER0 Gastroenterology
Table0.4 Common causes ofupper GI bleeding
Peptic ulcers
Oesophagitis/
gastritis
Gastrooesophageal
varices
Mallory–
Weiss tear
History Examination Investigation
Epigastric/ chest pain,
heartburn, melaena,
previous ulcers,
NSAIDs, alcohol
Heartburn, NSAIDs,
alcohol, hiatus hernia
Frank haematemesis
previous liver disease,
alcohol
Forceful vomiting
precedes bloodstaining
Epigastric
tenderness, may
be peritonitic if
perforated
Epigastric
tenderness
Epigastric
tenderness, signs of
chronic liver disease
Epigastric
tenderness
Ulcer on OGD,
CLO test may
be +ve
Inammation/
erosions on OGD
iPT, deranged
LFT, varices on
OGD
Tear seen on OGD
if not resolving
Management Good resuscitation is paramount (and more urgent than any
OGD); O
postural BP, urine output); consider catheterization, CVC line, and HDU/
ICU; keep NBM until OGD (see also Box0.6):
, two large- bore cannulae. IV uids ±blood,9 regular obs (HR, BP,
2
Blood transfusion Often vital
and lifesaving but over- transfusion associated with imortality and rebleeding.
Agree transfusion targets with asenior;
PPIs Reduce rebleeding, surgery, and
transfusion, only when given after endoscopy to patients requiring endoscopic therapy (high- dose PO/ IV eg omeprazole 40mg BD as eective as
more cumbersome bolus/ 72h infusion);
Mallory– Weiss tears (E OHAM4
p. 240.) These occur after repeated forceful vomiting, often after alcohol excess. Bright red blood appears as streaks or mixed with vomit. Bleeding often
resolves spontaneously;
transfusion if active bleeding and plts <50 × 0
Clotting abnormalities (E p. 426.) Consider:platelet
9
/ L; FFP if PT/ APTT >.5 ×
control; prothrombin complex concentrate or recombinant clotting factors
if on warfarin/ DOAC; H.
pylori (E p. 308.) Test and eradicate if positive.
3Gastro- oesophageal varices (E OHAM4p. 236.)
Symptoms Symptoms of chronic liver failure (E pp. 327–31); known liver
disease, excess alcohol; varices are asymptomatic until theybleed
chronic liver failure (E pp. 327–31)
bleed
Resuscitate according to E p. 312then: Terlipressin 2mg/ over 5min IV if
not alreadygiven;
Antibiotics Cirrhotic patients have dimmune function; spon-
Investigations Varices seen on OGD Acute
taneous bacterial infections are associated with imortality (eg Tazocin
4.5g/ 8h IV);
(gastric);
OGD (urgent) For banding (oesophageal) or sclerotherapy
Bleeding still uncontrolled Consider a Sengstaken– Blakemore tube
and transjugular intrahepatic portosystemic shunting (TIPS);
controlled
Terlipressin – 2mg/ 6h over 5min IV, for up to 5d; treat cause of
liver failure; drisk of recurrent bleeding by dportal pressure (by TIPS or propranolol 40– 80mg/ 2h PO) or further banding.
T Box 0.6 What about otherdrugs?
Once haemostasis is achieved, continuation of aspirin where previously indicated (under PPI cover) is associated with reduced mortality (albeit at a higher
risk of rebleeding).
scribed. Data for other antiplatelet drugs and anticoagulants are more complex
and each case will need careful discussion between the relevant specialists.
9
Hb >7g/L is a better target than >9g/L; see Villanueva C, etal. NEJM 203;368: free at Mwww.
nejm.org/ doi/ full/ 0.056/ NEJMoa280;
0
NSAIDs should be stopped and alternative analgesics pre-
0
Sung JJY, etal. Ann Intern Med 200;52:.
SignsSigns of
Once bleeding
9
®
Acute lower GIbleeds
2Worrying features Continuous bright- red PR bleeding, iHR, dB P,
postural drop, dizziness, dGCS, abdominal pain, weight loss, vomiting.
Think about Common Polyps, diverticular disease, angiodysplasia, haem-
orrhoids, IBD, colon cancer, upper GI bleed (Epp. 313–14);
enteric stulae, ischaemic colitis, radiation proctitis, Meckel’s diverticulum.
Ask about Onset, quantity, colour (red, black, clots), type of blood
(fresh, mixed with stool, streaks on toilet paper), abdominal pain, vomiting
(colour), pain on opening bowels, straining, change in bowel habit, anorexia, weight loss, dizziness, SOB;
disease, IBD, peptic ulcer, liver disease, AAA;
steroids,iron;
FHIBD, bowel cancer; SHAlcohol. See also Box0.7.
PMH Previous bleeding, diverticular
DHNSAIDs, anticoagulants,
Obs HR, BP, postural BP, GCS, RR,sats.
Look for Pale and cold extremities, sweating, pulse volume, bruises,
other sources of bleeding (nose, mouth), abdominal tenderness
±peritonism, masses, signs of chronic liver disease (E pp. 327–31);
PRBlood, melaena, palpable mass, haemorrhoids. See Table0.5.
Investigations bldsFBC, clotting, U+E, LFT, G+S or X- match 2units;
ABGOnly if unwell; OGD To exclude upper GI bleed, urgent if shocked;
ECGIf age>50yr; Sigmoidoscopy/ colonoscopyFor investigation, biopsy, and
treatment; may require
bleeding source cannot be identied.
mesenteric angiography or capsule enteroscopy if
ManagementLower GI bleeding is traditionally managed by surgeons
while upper GI bleeding is usually a medical condition. Although 785% of
lower GI bleeds will settle with conservative management, always beware the brisk upper GI bleed presenting as PR bleeding.
Diagnosis It is rarely possible to tell the cause of signicant lower GI
bleeds from history and examination alone, investigations are essential.
Fresh blood ontoilet paperFresh blood or streaking stool only and patient
well:treat as haemorrhoids/ anal ssure, but arrange follow- up exible
sigmoidoscopy to rule out bowel cancer.
Mild bleeding(No evidence of shock.) Bleeding should usually settle with
conservative management. Consider early discharge and follow- up.
Moderate bleeding(Postural drop, iHR.) Secure IV access and uid resus-
citate ± blood until haemodynamically stable, catheterize, hourly uid
balance, senior review, may need urgent OGD if possibility of upper
GIsource
3Severe bleeding (Fresh bleeding/ clots, dBP.) Resuscitate according to
E p. 312, transfuse, call senior, on- call endoscopist, and surgical registrar.
75% of patients with acute, severe PR bleeding will have an upper
GI bleeding source identied on OGD. For the remainder, options include colonoscopic haemostasis, radiological embolization, or surgical
resection.
OtherAorto-
315ACUTE LOWER GIBLEEDS
316 CHAPTER0 Gastroenterology
Table0.5 Common causes oflower GI bleeding
History Examination Investigation
Upper GI
bleed
GI cancer or
polyps
Inammatory
bowel disease
Diverticular
disease
Bowel
ischaemia
Angiodysplasia
or radiation
proctitis
Haemorrhoids Painless, fresh red
Anal ssure Pain on defecating,
Haematemesis, fresh
PR bleeding, clots or
melaena, epigastric
pain
Change in bowel
habit, weight loss,
abdominal pain
Abdominal pain,
diarrhoea, weight
loss, mouth ulcers
Abdominal pain,
fever, change in
bowel habit
Abdo pain,
previous arterial
disease
Recurrent fresh
PR blood, old age,
previous pelvic
radiotherapy
blood on toilet
paper, perianal itch,
constipation
fresh blood on toilet
paper, constipation
Liver disease,
epigastric
tenderness, PR
blood or melaena
PR blood or
melaena, mucus,
palpable mass
itemp, abdo tender
±peritonitic, PR
blood, mucus,
melaena
Tenderness,
±peritonism, PR
blood, mucus
Shock, generalized
tenderness
PR blood or
melaena
Often not palpable
on PR, perianal tags,
may have rectal
prolapse
Posterior/ anterior
PR tear, perianal
tags, tenderness
dHb, iurea, lesion
on OGD
dHb ±dMCV, lesion
on sigmoidoscopy
or colonoscopy
dHb, iWCC,
iCRP, lesions on
sigmoidoscopy or
colonoscopy
dHb, diverticulae
on colonoscopy
iWCC, acidotic,
±AF or previous
MI on ECG
dHb, lesions on
colonoscopy,
consider argon
plasma coagulation
Lesions seen on
proctoscopy
Proctoscopy to
visualize lesions
Chronic GI bloodloss
Causes Oesophagitis, gastric erosions, gastritis, peptic ulcer, gastric/
bowel cancer, polyps, IBD, angiodysplasia, GI lymphoma.
Symptoms Anorexia, weight loss, tired, change in bowel habit, melaena,
vague intermittent abdopain.
Signs Pale/ anaemic, cachexic, mild abdo tenderness; PRBlood,mass.
Investigations StoolFaecal occult blood (FOB), ova, cysts, and parasites;
blds FBC (dHb, dMCV
), iron, ferritin, vitamin B2, folate, U+E,LFT;
OGD ± colonoscopyMay need a video capsule endoscopy or small bowel CT/
if small bowel disease suspected.
MRI
TreatmentInvestigate and treat the cause, treat anaemia with ferrous sul-
fate 200mg/ 8h PO, consider admission for transfusion if Hb <80g/ L or
if symptomatic with anaemia.
Those with a simultaneous iron deciency and vitamin B2 and/ or folate deciency may have a
normal or raised MCV; in this instance, signicant variation in red cell size will be reected in an
increased red cell distribution width(RDW).
Colorectal polyps(E OHCM1p. 609.)
$ A common nding at colonoscopy; their importance lies in the
premalignant potential of adenomatous polyps.
CausesVast majority sporadic; rare familial syndromes.
Symptoms Often none; intermittent abdo pain, altered bowel habit,
blood or melaena in stool, tenesmus, weightloss.
Signs PR Palpable mass if very distal, blood,mucus.
Investigations dHb, lesion on colonoscopy.
Treatment Polypectomy (send for histology), multiple polyps may need
colonic resection or regular colonoscopy follow- up.
2
Haemorrhoids(E OHCM1p. 624.)
$ Dilated and displaced perianal vascular tissue (anal cushions).
Symptoms Recurrent fresh red blood on toilet paper or streaking stools
±pain or pruritus ani (anal itch), constipation.
Risk factorsConstipation with straining, multiple vaginal deliveries.
SignsNot palpable unless prolapsed; PRBlood, otherwise normal.
Investigations Proctoscopy To visualize haemorrhoids; Sigmoidoscopy To
identify other pathology (eg malignancy).
Treatment High- bre diet, topical Anusol
®
, injection of sclerosants, band
ligation, coagulation, cryotherapy, may need haemorrhoidectomy.
Strangulated haemorrhoids Painful, tender mass, unable to sit down, treat
with ice packs, stool softeners, regular analgesia, and bed rest. Once
stable, inject piles and consider elective haemorrhoidectomy.
Anal ssure(E OHCM1p. 622.)
SymptomsNew- onset extreme pain ±fresh red blood on opening bowels,
history of constipation and straining (beware Crohn’s and cancer).
Signs Anal tear visible posteriorly on the anal margin (0% anterior),
perianal ulcers, stulae;
PRMay be impossible due topain.
Investigations SigmoidoscopyIf suspicious of pathology once pain controlled.
Treatment conservative High- bre diet; 5% lidocaine ointment, 0.2– 0.3%
GTN ointment, botulinum toxin injection all marginally better than
3
placebo;
internal sphincterotomy cure rate95%.
Angiodysplasia(E OHCM1p. 620.)
$ Submucosal arteriovenous malformation, often ascendingcolon.
Symptoms Elderly, recurrent blood in the stool, abdo pain israre.
SignsMay be normal, pallor; PRBlood or melaena.
InvestigationsFaecal occult blood, colonoscopy, mesenteric angiography.
Treatment Angiographic embolization if active bleeding; argon plasma co-
agulation (endoscopic); rarely resection; treat anaemia, eg ferrous sulfate.
317ACUTE LOWER GIBLEEDS
I Box 0.7 Causes ofrectal bleeding covered elsewhere
Inammatory bowel disease E p. 323 Upper GI bleed E pp. 313–14
Bowel ischaemia E p. 307 Diverticular disease E p. 309
Infective diarrhoea E p. 321
2
The British Society of Gastroenterology guidelines for colonoscopic follow- up are at Mww.bsg.
org.uk/clinical-resources/endoscopy/endoscopy-guidelines/
3
For a useful meta- anal ysis, see Mwww.cochrane.org/ CD00343
318 CHAPTER0 Gastroenterology
Nausea and vomiting
2Worrying features iHR, i/ dBP, dGCS, severe pain (head, chest,
abdomen), head injury, constipation, blood/ coee grounds, purpuricrash.
Think about 2Life- threatening Raised intracranial pressure (ICP), men-
ingitis, MI, bowel obstruction, acute abdomen, DKA;
pain, drug induced (opioids), gastroenteritis, other infection, alcohol;
Other Gastroparesis, paralytic ileus, pregnancy, electrolyte imbalance
2+
(Ca
, Na+), migraine, labyrinthitis, Ménière’s, chemotherapy, Addison’s,
eating disorder (Table0.6).
Ask about Frequency, timing, relation to food or medications, colour,
blood, coee grounds, melaena, dizziness, diarrhoea, constipation, atus,
pain, headaches, head trauma, visual problems, pregnancy;
surgery, migraines,DM;
DHOpioids, chemotherapy, digoxin; SHAlcohol.
Obs Temp, uid balance, HR, BP, blood glucose, GCS, stoolchart.
Look forand assess volume status (E p. 402), SOB, distended/ tender/
peritonitic abdomen, tinkling bowel sounds, hernias, surgical scars, mouth
ulcers, neck stiness, rash, photophobia, papilloedema.
InvestigationsVomiting without the worrying features usually does not
require urgent investigation. If recurrent, check U+E for dehydration or
electrolyte imbalance and
investigate according to related symptoms. Consider:
LFT, glucose, amylase, Ca
CT brain If head trauma (E p. 460); gastric emptying studies if suspect
gastroparesis.
AXR if bowel obstruction suspected. Otherwise
2+
,Mg2+; CXRAspiration; ABGIf acutely unwell;
Treatment Investigate and treat underlying disease; vomiting is
distressing— so E p. 84 for pharmacology and selection of appropriate
antiemetics.
Common Post-op,
PMH Previous
blds FBC, U+E,
Table0.6 Common causes ofnausea and vomiting
History Examination Investigations
Raised ICP/
meningitis
Bowel
obstruction
or ileus
Acute
abdomen
Upper GI
bleed
Gastroenteritis
Labyrinthitis Dizziness
Migraine Visual aura,
Hyperemesis
gravidarum
Drug induced Many medications can induce vomiting, particularly opioids,
Headache, blurred
vision, dizzy, feels ill,
drowsy
Colicky pain,
absolute
constipation, brown
vomit
Severe abdo pain Tender, rigid,
Blood/ coeeground vomit
Diarrhoea, feels
better after vomiting
predominant,
tinnitus
headache
♀ usually between
7– 2/ 40
chemotherapy, and digoxin toxicity
Febrile, sti neck,
photophobia, rash,
low GCS
Distended tender
abdomen, tinkling
bowel sounds
guarding, rebound
Tender abdomen,
PR melaena
Febrile, epigastric
tenderness, not
peritonitic
Unable to stand Acute investigations
Photophobia,
visual eld defects
Normal; palpable
uterus
iWCC/ NØ/ CRP,
abnormal CT brain or
CSF results
Distended bowel
loops on AXR
(E pp. 616–17)
Pneumoperitoneum
on CXR
dHb, iurea
iWBC, iLØ or NØ,
positive stool culture
normal (E p. 375)
Acute investigations
normal
β- hCG + TFTs often i,
iurea if dehydrated
319NAUSEA AND VOMITING
320 CHAPTER0 Gastroenterology
Diarrhoea
2Worrying features iHR, dBP, low urine output, PR blood,
weight loss, abdopain.
Think about AcuteGastroenteritis, antibiotics, laxatives, drugs, pseudo-
membranous colitis (E p. 322), overow diarrhoea (2° to constipation),
post- chemotherapy, bowel ischaemia;
diverticular disease, alcoholism, malabsorption disorders (eg coeliac,
chronic pancreatitis), thyrotoxicosis, bowel resection, parasitic/ fungal infections, autonomic neuropathy, carcinoid, Addison’s disease (Table0.7).
Traveller’s diarrhoea E.coli, Salmonella, Shigella, Campylobacter spp.,
giardiasis, amoebic dysentery, cholera, tropicalsprue.
Ask about Normal bowel habit and frequency, onset/ frequency of
diarrhoea, recent constipation, stool character (oating, greasy, bloody,
mucus), colour, abdominal pain, pain relief on opening bowels, nausea,
vomiting, atus, uid intake, weight loss, mouth ulcers;
cancer, IBD, diverticular disease, IBS, surgery;
suppression;
contacts, occupation (food, healthcare), alcohol.
SH Travel abroad, other household members aected/ sick
Medications causing diarrhoea Antibiotics, laxatives, colchicine,
digoxin, iron, NSAIDs, ranitidine, thiazide diuretics, propranolol,PPIs.
Obs Temp, HR, BP, postural BP, RR, sats, uid balance, stoolchart.
Look for Volume status (E p. 402), cachexia, mouth ulcers, clubbing,
jaundice, rashes, pale conjunctiva, thyroid mass, abdomen tenderness
±peritonitis, masses, distension, surgical scars;
colour, consistency; may reveal a rectum loaded with faeces suggesting
overow diarrhoea, particularly in the elderly, immobile patient with
poor diet and recent constipation— treat as constipation (Epp. 324–5).
Investigations StoolM,C+S × 3, C.dicile toxin, ova, cysts, and parasites;
calprotectin (?inammation) ±FIT test (?cancer) as appropriate;
U+E, glucose, LFT, Ca
transglutaminase (TTG) antibodies, bld cultures;
oedema, faecal impaction;
suspected IBD/ likely are);
2+
, TFT, CRP, vitamin B2, folate, iron studies, anti- tissue
Sigmoidoscopy If not improving (or within 24h if
ColonoscopyIf cancer suspected.
ManagementSee Box0.8.
K Box 0.8 General management ofdiarrhoea
• Conservative Increase uid intake, review drugs (consider
alternatives without GI side eects); start stool chart— this will
often be kept more accurately on a busy ward if you educate
patients to complete it themselves
• Infective Isolation and barrier nurse if infective source thought
possible, ABx if systemicallyunwell
• Medical Antimotility agents should be avoided in infective
diarrhoea, IBD, or pseudomembranous colitis.
ChronicIBD, IBS, colorectal cancer,
PMHColorectal
DH Recent ABx, immuno-
PR Pain, masses, stool
AXRObstruction, mucosal
blds FBC,
Table0.7 Common causes ofdiarrhoea
History Examination Investigation
Gastroenteritis Sudden onset,
Inammatory
bowel disease
Irritable bowel
syndrome
Malabsorption
disorders
Bowel cancer Abdo pain, weight
Diverticular
disease
Pseudomembranous
colitis
Overow
diarrhoea
±vomiting,
abdominal cramps
Crampy abdo pain,
weight loss, blood in
stool, mouth ulcers
Bloating, abdominal
cramps, relieved by
defecation
Weight loss, pale
greasy stools, tired,
anaemia
loss, fresh blood or
melaena
LIF pain, PR bleeding LIF tenderness,
Recent antibiotics
(days/ weeks),
crampy abdo pain,
green watery stool
Constipation, poor
mobility, abdominal
pain
itemp, sweating,
abdo tenderness
Abdo tenderness,
±peritonitis, PR
blood/ mucus,
eye/ skin/ joint
manifestations
Abdo tenderness,
non- peritonitic
Pale, abdo
tenderness,
oedema, bloating,
PR pale stool
PR blood or
melaena, mucus/
palpable mass
±peritonitis
itemp, abdo
tenderness,
PR green, foul
smelling, ±blood
Abdo distension
and tenderness,
PR palpable stool
iWCC, iCRP, +ve
microbiology on
stool sample
iWCC, iCRP;
mucosal oedema
or megacolon on
AXR; lesions seen on
sigmoidoscopy
Diagnosis of
exclusion; normal
investigations
dHb, dalbumin,
2+
dCa
±anti- TTG
or endomysial
antibodies
dHb, dMCV, lesion
on colonoscopy
iWCC, iCRP,
diverticulae on
colonoscopy
iWCC, iCRP, C.di
toxin +ve; AXR may
show toxic dilatation
AXR may show
faecal loading
321DIARRHOEA
Infective gastroenteritis(E OHCM1p. 424.)
$ Diarrhoea, accompanied by nausea, vomiting, ±abdominal pain; in most
cases due to viruses (including norovirus) but other infectious agents important.
Symptoms Rapid onset, recent vomiting and/ or diarrhoea, patient may
implicate a certain food, feels unwell, crampy abdominal pain, u- like
symptoms, pyrexia; other members of household/ contacts aected.
Appearance ofstoolBlood 2° colonic ulceration (typical for Campylobacter
or Shigella spp.); watery ‘rice’ stool suggests cholera.
Signs itemp, iHR, dehydrated, ushing, sweating, abdominal tender-
ness, general malaise;
PR tender, peri- anal erythema.
Investigations Stool culture Result may take ≥48h; C.di. toxin assays and
norovirus PCR where clinical suspicion;
prolonged, consider
sigmoidoscopy and discuss with microbiology.
blds iWCC, iCRP, iurea; if
Treatment Admit if clinical concern or not meeting uid needs orally; iso-
lation/ barrier nursing with rigorous hand- washing by nurses, doctors,
and visitors; push oral uids ±oral rehydration solutions, antiemetics
(E p. 84); IV uids if not tolerating oral uids. Surprisingly few indications
for antibiotics, even after identication of a causative bacterium— always
discuss with microbiology. Some causes are notiable (Ep. 491).
322 CHAPTER0 Gastroenterology
Pseudomembranous colitis
$ Overgrowth of Clostridium dicile, often following antibiotic use. Dicult
to treat, with a high mortality in vulnerable groups, always remember this
condition when tempted to start antibiotics on scanty evidence.
SymptomsUsually 3– 9d after antibiotic therapy (can be 24h– 6wk), rapid
onset of high- quantity green, foul- smelling stool, crampy abdopain.
Investigations blds ii WCC,dK
+
; Stool C.dicile toxin,M,C+S.
Treatment 2Stop unnecessary antibiotics; isolate and barrier nurse, rehy-
drate with PO/ IV uids and correct electrolyte abnormalities, metronidazole 400mg/ 8h PO and/ or vancomycin 25mg/ 6h PO (oral route targets
GI tract). For persistent or relapsing disease, consider IV metronidazole,
PR vancomycin, PO daxomicin, or stool transplantation as per ID advice.
Complications Toxic megacolon, perforation, high risk of spread to other
patients via hands of healthcare workers; spores not killed by alcoholgels.
Irritable bowel syndrome (IBS)(E OHCM1p. 264.)
$ Consider in those with >6mth abdo pain, bloating, or altered bowel habit.
Diagnostic criteriaCentral/ lower abdo pain at least d/ wk for past 3mth
associated with two or more of:() pain related to defecation, (2) altered bowel frequency, (3) altered stoolform.
Red ags These should prompt urgent consideration of other diagnoses
include unintentional weight loss, rectal bleeding, age >60yr, family history of bowel or ovarian cancer.
SignsOften normal or generalized abdo tenderness; exclude a pelvicmass.
InvestigationsIf ts diagnostic criteria and no red ags, exclude other path-
ology by checking for normal FBC, ESR, CRP, coeliac serology; CA25 if
♀ with persistent bloating/ pain; further tests only if suspicion this is not
IBS (eg TFT, faecal calprotectin, colonoscopy, OGD, parasites).
Treatment Reassure and explain; basic lifestyle, exercise, and dietary advice
including attention to regular meals and non- caeinated drinks, with limited
intake of foods high in insoluble bre (eg bran); consider dietician and/ or
psychology referral; mebeverine 35mg/ 8h PO, loperamide, or ispaghula
according to symptoms. Treat refractory constipation (E pp. 324–5).
Amitriptyline 0mg nocte or SSRIs (2nd line) have visceral analgesic eects.
Malabsorption disorders(E OHCM1p. 262.)
$ Impaired absorption of nutrients due to a wide range of GI pathology.
Causes Coeliac disease, chronic pancreatitis, tropical sprue, cystic -
brosis, small bowel/ gastric resection, bacterial overgrowth,IBD.
Symptoms Diarrhoea ±steatorrhoea, weight loss, tiredness, SOB, dizzi-
ness, bruising, swelling, vomiting, gluten intolerance, abdopain.
SignsCachexia, pale, dehydrated, mouth ulcers, sore tongue, abdo ten-
derness, oedema, bruises.
Investigations blds dHb, dMCV, dCa
2+
, dalbumin, diron, dfolate, iPT;
+ve anti- endomysial or anti- tissue transglutaminase antibodies sensitive
for coeliac disease;
Duodenal biopsyGold standard for coeliac diagnosis;
Stool Elastase for assessment of pancreatic function; Hydrogen breath
For small bowel bacterial overgrowth.
test
Treatment Refer to dietician and gastroenterologist, may need nutrient
±pancreatic supplements, gluten- free diet (coeliac).
4
5
4
See Mtheromefoundation.org for diagnostic resources. 5 NICE guidelines: Mguidance.nice.org.uk/ CG6