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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Table26.1HbA1ctargets
Management TargetHbA1c
LifestyleanddietaryORsinglemedicationnotassociatedwithhypoglycaemia 48mmol/mol
Medicationassociatedwithhypoglycaemia 53mmol/mol
Source:datafromNICENG28.
Complications
Macrovascularcomplications Autonomicandsensoryneuropathy(Box26.2)(seeChapter25) Diabeticnephropathy Diabeticretinopathy(Box26.2).
Box26.2Peripheralneuropathy
Startsinthetoesandsolesofthefeetandspreadsuptheshinssymmetrically Resultsin↓vibrationperception,finetouch,pin-prick,andtemperaturesensation ↓vibrationsensationandabsentanklereflexesareoftenfirsttoappear Moreseverecasesoccurinthefingersandhands Painfulneuropathymayoccurwithsharp,burning,stabbingpains.
Box26.3Diabeticretinopathy
UponT2DMdiagnosis,patientsshouldbereferredforroutineretinopathyscreening Intheeventofsuddenvisuallossoracutevisualsymptoms,patientsshouldhaveanemergency ophthalmologyreview.
Diabeticfootproblems
ThecombinationofneuropathyandperipheralvasculardiseaseinT2DMleadstodiabetic footproblemswhicharetheleadingcauseofmorbidity.
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Approximately6000peoplewithdiabetesundergolowerlimbamputationannually,withdiabetic footulcerationpreceding80%ofamputations Patientsshouldbeexaminedatdiagnosisandatleastannuallythereafter,includingoneachnew hospitaladmission Skin care and nail care should be discussed during clinical reviews to reduce the riskof foot problemsdeveloping Thehighestriskpatientsmayneedweeklyfootchecks.
Assessingriskofdiabeticfootlesions
Examinefeetfor:
Neuropathy(use10gmonofilament) Limbischaemia(useankle–brachialpressureindex(ABPI)) Ulceration Callus Inflammationorinfectedareas Deformity Gangrene Charcotarthropathy:
If a patient with T2DM fractures their foot or ankle, this may develop into Charcot’s arthropathy Suspect Charcot arthropathy if there is redness, warmth, or swelling, especially in the presenceofrenalfailureandperipheralneuropathy.
Use Table 26.2 to assess the risk of developing a diabetic foot problem based on examinationfindings.
Table26.2Riskofdevelopingadiabeticfootproblem
Lowrisk Moderaterisk Highrisk
Noriskfactorsasidefrom callus
FootdeformityOR PreviousulceroramputationOR
NeuropathyOR OnrenalreplacementtherapyOR
Non-criticallimb ischaemia
Twoof:neuropathy,callus/deformity,andnon-criticallimb ischaemia
Source:datafromNICENG19.
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Ifmoderateorhighriskofdevelopingadiabeticfootproblem,refertoaspecialistteam Diagnoseanactivediabeticfootproblemifthereis:
lcerationOR SpreadinginflammationOR CriticallimbischaemiaOR GangreneOR
SuspicionofCharcotarthropathy TheSINBADscoring system(Fig.26.2) may be used toclassify theseverityof a diabetic foot ulcer.Bealerttooflife-orlimb-threateningproblemsin Box26.4.
Fig.26.2SINBADscoringsystemtoidentifyseverityofdiabeticfootulcer.
Source:datafromInceP,etal(May2008)UseoftheSINBADClassificationSystemandScorein comparingoutcomeoffootulcermanagementonthreecontinents.DiabetesCare.31(5):964–967.
Box26.4Life-orlimb-threateningdiabeticfootproblems
Lookoutforlife-or limb-threateningdiabeticfootproblemswhichrequire immediate referraltoacuteservices:
Ulcerationwithfever,signsofsepsisorlimbischaemia Clinicalconcernofdeep-seatedsofttissueinfectionorosteomyelitis Gangrene(withorwithoutulceration).
Source:datafromNICENG19.
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Managementofdiabeticfootulcers
Offloadwithnon-removablecastingforneuropathic,non-infectedulcers Treatinfectionorischaemia Usepressureredistributingdevices,e.g.inflatablefootprotectors Wounddebridementfollowedbynegativepressurewoundtherapy Refer toMDT foot care service (this may include a podiatrist, nurse, orthotist, microbiologist,
diabetologist,interventionalradiologist,andvascular,orthopaedic,andplasticsurgeons1).
Managementofdiabeticfootinfection
SuspectosteomyelitiseveninthepresenceofnormalinflammatorymarkersandX-ray Takeculturesideallyfromthebaseofadebridedwound ConsiderMRItoconfirmosteomyelitis Followlocal antibiotic guidelines—formildinfections,initially useoralantibioticswithGram­positive cover.Formoderatetosevereinfections,useantibioticswithGram-positive,-negative, andanaerobiccover Ifosteomyelitisispresent,theantibioticcourseshouldbeprolonged(6weeksminimum).
ManagementofCharcot’sarthropathy
RefertoMDTfootcareservicewithin1workingdayofsuspecteddiagnosis Offernon-weight-bearingdeviceuntildiagnosisisconfirmed Takeweight-bearingX-rayofthefootandankle Offernon-removable(ifsuitable)offloadingdevicefortreatment ContinuousmonitoringoftreatmentefficacywithtemperaturechecksandserialX-rays.
Monitoringandfollow-up
Afulldiabetesreviewshouldtakeplaceatleastannuallyincludingafootexamination
If thereisasuddendecreasein HbA1cto lessthanthe targetlevel,considerpossible causes including improved diabetic control, deteriorating renal function, or sudden weightloss.
Ifatmoderateorhighriskofadiabeticfootproblem,reassessmorefrequently For patients on insulin therapy, review injection technique and confirm understanding of hypoglycaemiaandhyperglycaemiaandself-managementoftheseconditions.Ensurethepatientis awareofDVLAguidance(seeChapter115) Measure HbA1c every 3–6 months until the HbA1c and doses of antidiabetic medication are stable.MeasureHbA1cevery6monthsthereafter.
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Emergencyreferral
Arrangeemergencyreviewbyanophthalmologistifthereissuddenlossofvision,rubeosisiridis, preretinalorvitreoushaemorrhage,orretinaldetachment.
Specialconsiderations
Pregnancy
Fordetailsaboutdiabetesinpregnancy,seeChapter59.
Surgery
SeeChapters92and93forthemanagementofdiabetesinpatientsundergoingsurgery.
Furtherreading
1.WassJ,OwenK(eds)(2014).Diabetes.In:OxfordHandbookofEndocrinologyandDiabetes,3rded (pp. 683–822). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199644438.003.0013
2. Diabetes UK (2019). Diabetesand emotional health. A practical guide for healthcare professionals supporting adults with type 1 and type 2 diabetes, 2nd ed. Available at:
https://www.diabetes.org.uk/resources-s3/2019­03/0506%20Diabetes%20UK%20Australian%20Handbook_P4_FINAL_1.pdf
1Huang DY, WilkinsCJ,EvanDR,etal.Thediabeticfoot:the importanceofcoordinatedcare. Semin
InterventRadiol.2014;31:307–12.
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Part4
Gastrointestinal
Acuteuppergastrointestinalbleedingandvaricealbleeding
Coeliacdisease
Crohn’sdisease
Gastro-oesophagealrefluxdiseaseanddyspepsia
Irritablebowelsyndrome
Ulcerativecolitis
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Chapter27
Acuteuppergastrointestinalbleedingandvaricealbleeding
Guidelines:NICECG141(Acuteuppergastrointestinalbleedinginover16s:
management):https://www.nice.org.uk/guidance/cg141
Baveno VI Faculty (Expanding consensus in portal hypertension):
https://www.journal-of-hepatology.eu/article/S0168-8278%2815%2900349­9/fulltext
British Society of Gastroenterology (UK guidelines on the management of variceal haemorrhage in cirrhotic patients):
https://gut.bmj.com/content/64/11/1680.long
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Anuppergastrointestinalbleed(UGIB)referstobleedingfromtheoesophagus,stomach, or duodenum, andcanrangefromminortolife-threateninginseverity.Avaricealbleed mustalwaysbeconsideredinbleedingpatientswithchronicliverdisease,astheyrequire specificmanagementandhaveamortalityrateof10%.CausesofUGIBarelistedinBox
27.1.
Box27.1CausesofUGIB
Duodenalulcer(prevalence40%) Erosivegastritis/duodenitis(20%) Oesophagealvarices(15–20%) Gastriculcers(10–20%) Mallory–Weisstear(5–10%).
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Diagnosis
History
Presentingcomplaint
Haematemesis ‘Coffee-groundvomit’:duetoironinhaemoglobinbeingoxidizedbygastricacid.Notallbrown vomitsareaGIbleed! Melaena:offensive,black,tarrystool Abdominalpain Symptomsofbloodloss:syncope,fatigue,shortnessofbreath,chestpain.
Pastmedicalhistory
Gastricorduodenalulcers,orpreviousbleed Liverdisease.
Drughistory
NSAIDs Anticoagulants(warfarin,DOACs) Antiplatelets(aspirin,clopidogrel) AlcoholexcessorIVDU
Examination
Initialexaminationshouldfocusonvitalsigns,lookingforsignsofhaemorrhagicshock (syncope,hypotension,pallor,tachycardia,tachypnoea,alteredGCSscore).
Bloodpressureandheartrate:inyoung patients,tachycardia(heartrate>100bpm)maybethe onlysignofbloodloss Temperature: infection should always be suspected in a UGIB, particularly in patients with chronicliverdisease
Digitalrectalexamination(DRE):lookformelaenaand/orfreshblood Signs of chronic liverdisease: e.g.fingerclubbing,spider naevi, gynaecomastia,jaundice,and
palmarerythema.Thesearesuggestiveofavaricealbleedbeingtheunderlyingcause,
Investigations
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FBC:↓haemoglobin/↓platelets(seeninalcoholexcess,cirrhosis) U&E: ↑urea:creatinineratio (suggestbleeding intotheupper GItractas ureais producedfrom digestedblood) LFT:chronicliverdisease Coagulationprofile: impairmentimplies possibleliverdisease,howeverneedstobe interpreted withcaution;INRisnotareliableindicatorofcoagulationprofilestatusincirrhosis.
Management
Fig.27.1isaflowchartprovidinganoverviewofmanagement.
CalculateaGlasgow-Blatchfordscore forallpatientsonadmission(see‘Further
reading’)1—patients with a score of 0 may be considered safe for discharge without
furtherinvestigations.Carefulsafetynettingisrequired.
Resuscitation
Table27.1describestheABCDEapproachtotheresuscitationofapatientwithUGIBor
varicealbleeding.
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Table27.1Resuscitationinacuteuppergastrointestinalorvaricealbleeding
A Patientsatriskofaspirationshouldbeconsideredforearlyintubationforairwayprotection
C Insertatleasttwolargecannulae(consideracentrallineifdifficultaccess)
IVfluidresuscitation,aimingtomaintainsystolicbloodpressure≥100mmHg Bloodproducts(seeChapter94):
Patients with significant ongoing haemorrhage should be transfused in line with local protocols. Consider activatingamajorhaemorrhagepathway Givepacked red bloodcells as required, aimingfor a haemoglobinof 70–80g/L.Over-transfusionof stable patients (i.e. >80g/L) has been shown to be harmful. Consider patient’s age, cardiovascular disease, and whetherbleedingisongoing
Considerplateletsifactivelybleedingandplateletcount<50×109/L Consider fresh frozen plasma (FFP) if actively bleeding and prothrombin time (PT)/INR/activated partial thromboplastintime(APTT)>1.5×normal.Iffibrinogenremains<1.5g/LdespiteFFP,givecryoprecipitate. CautionisadvisedwiththeuseofFFPinvaricealhaemorrhageasexcessivevolumeexpansioncanprecipitate furtherbleeding If taking warfarin, reversalismandatory ifactively bleeding. Follow local protocolswhichusually includes prothrombincomplexconcentrateand10mgIVvitaminK
IftakingDOACs,e.g.apixaban, rivaroxaban,dabigatran,andthereissignificantbleeding,useBeriplex®and specificreversalagents(e.g.idarucizumab) For appropriate use of platelets, FFP, prothrombin concentrate, and other specific reversal agents, seek advicefromahaematologist
Balloontamponade(Sengstaken–Blakemoretube)mayoccasionallybeusedinsignificantbleedsto temporarilystopbleedingandallowthepatienttobestabilized
Source:datafromNICECG141.
Oesophagogastroduodenoscopy(OGD)
Shouldoccurimmediatelyafterresuscitationinunstablepatientsandwithin24hoursforallUGIB Calculate a post-endoscopy Rockall score (calculates mortality risk following upper GI
bleeding).1 Variables include age, presence of shock, comorbidities, diagnosis on OGD, and whethertherewasevidenceofbleedinginthestomach Donotgiveacidsuppressiondrugspriortoendoscopyinnon-varicealbleeds.
Pharmacologicalmanagement
Non-varicealbleed
Giveaprotonpumpinhibitor(PPI)topatientswithnon-varicealbleedafterendoscopy, ifevidenceofrecenthaemorrhageisseen.
Varicealbleed
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