Overview of clinical approach to acute gastroenterological presentations.

1. CORE CASES IN
GASTROENTEROLOGY
Dr. Anahita Sharma
Academic FY1,Aintree University Hospital

2. CASE 1

3. • A 45 year old gentleman, normally fit and
well, is brought in by ambulance to the
Accident & Emergency department.
• He complains of an abdominal pain that
began 2 days ago.
• Right upper quadrant of abdomen
• Colicky at first, and now constant – attempted
to manage symptoms by taking paracetamol
• Developed chills, fevers and rigors overnight
• Passing dark urine and pale stools
• Vomiting this morning
• Wife noticed he was jaundiced today
• Today, he felt lethargic and unable to get out
of bed.
• His wife, who was anxious about his state,
called an ambulance.

4. EXAMINATION (1)
• He arrived in the department, and you notice he looks unwell.
• His observations are as follows:
• HR: 110
• BP 110/70
• RR: 22
• T: 38.9°C
• GCS = 15
• Last passed urine last night
• SpO2: 96% on room air

5. EXAMINATION (2)
• You feel his hands, which are clammy and warm. His pulse is
bounding.
• You look into his eyes; the scleral conjunctiva appears yellow.
• There are no peripheral stigmata of chronic liver disease.
• Chest is clear on auscultation.
• On palpation of his abdomen, you elicit severe tenderness in the
right upper quadrant with associated guarding.

6. QUESTIONS (1)
• What is your working diagnosis?
• Biliary sepsis (↑ ↑ probability)
• Cholangitis 2° to gallstone obstruction
• Cholecystitis (↓ probability)
• Obstructive jaundice secondary to malignancy
(cholangiocarcinoma, pancreatic carcinoma; ↓
probability)

7. BLOOD TESTS 💉
• FBC
• Hb 135 g/L
• WCC 18.5 x 109/L
• Platelets 200 x 109/L
• U&Es, amylase and clotting
function
• Normal
• CRP
• 156 mg/dL
• LFTs
• Bilirubin 185 uM ↑
• ALT 120 IU/L (↑)
• ALP 1506 IU/L (↑ ↑)
• Albumin 36 g/L
• Lactate
• 6.9 mM ↑

8. QUESTIONS (2)
• What do his LFTs suggest?
• Obstruction / cholestasis
• What management will you initiate immediately?
• IV antibiotics 💊 💊 💊 (as per Trust policy!)
• IV fluids (HR) 💦 💦 💦
• Routine bloods, and blood cultures – blood, urine
• Urinary catheter
• Chest X-ray
• Further imaging

9. QUESTIONS (3)
• What imaging would you like to order?
• 1st-line: US abdomen
• Common bile duct (CBD) dilatation > 7 mm → suggestive of
obstruction
• May or may not visualize a gallstone directly
• Thickening of gallbladder wall and presence of sludge → suggests
cholecystitis
• A CT scan may be appropriate in some cases, particularly if you suspect
malignancy (N.B. the ‘double duct’ sign, which means dilatation of both pancreatic and common
bile ducts, is highly suspicious for a pancreatic cancer)

10. IMAGING RESULTS
• Dilated CBD @ 12 mm
• What intervention would you like
to order next?

11. ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREATICOGRAPHY (ERCP)
• Gallstones retrieved by ‘balloon trawling’
• Insertion of biliary stent to maintain patency
of CBD
• Sphincterotomy → cutting sphincter at
base of CBD to allow future stones to fall out
• N.B.The pancreas is very close to these
structures, so consider post-ERCP pancreatitis in
any patient who develops severe abdominal pain
after ERCP
• The gallbladder should be removed at
distance from the infection, so refer the
patient for consideration of a laparoscopic
cholecystectomy

12. TAKE-HOME MESSAGES (1): KEY
FEATURES IN HISTORY
• Presence of abdominal pain
• Painful, colicky → Gallstones? Cholangitis?
• Absence → Cholangiocarcinoma/pancreatic malignancy?
• Obstructive symptoms
• Pale stools (↓ stercobilinogen in stool)
• Dark urine (↑ urobilinogen from bloodstream)
• Pruritis
• Systemic symptoms
• Fever, chills and rigors → Cholangitis? Biliary sepsis? Hepatitis?

13. TAKE-HOME MESSAGES (2): ‘PATTERNS’ OF LIVER FUNCTION
TESTS
‘Hepatitic’
• Hepatocellular damage →
hepatocyte release of
enzymes
• Transaminitis ↑ ALT ↑ AST
‘Cholestatic’
• Obstructed outflow
• ↑ ALP ↑ yGT
A ‘mixed’ picture is also possible
e.g. hepatitic liver damage can lead to obstruction

14. TAKE-HOME MESSAGES (3): ASCENDING CHOLANGITIS

15. CASE 2

16. • A 75-year old lady, normally independent,
presented to her G.P. after vomiting blood
twice that morning.
• She has a background of ischemic heart
disease, hypertension and gastro-
oesophageal reflux disease. She had been
started on antiplatelet agents to treat an
NSTEMI 2 weeks ago.
• She is sent to A&E.
• She complains of worsening abdominal
pain which began a week ago.
• High up in her abdomen
• Stabbing in character
• Radiating to the back
• She states she had vomited fresh red
blood.
• She has also been passing black stools, and
does not take iron tablets.

17. EXAMINATION (1)
• You notice she appears unwell and rather pale.
• Her observations are as follows:
• HR: 105, irregular
• BP 95/60
• RR: 28
• T: 36.5°C
• GCS = 14 (E4,V4, M6; due to slightly confused speech)
• Has not passed urine in the past 12 hours
• SpO2: 96% on room air

18. EXAMINATION (2)
• Her hands feel cold. Her radial pulse is thready but palpable, and
irregular.
• There are no peripheral stigmata of chronic liver disease.
• On examination of her abdomen, she has marked epigastric
tenderness with associated guarding. She is not peritonitic.
• On per-rectal examination, you note the presence of melaena
(dark, offensive smelling stool).
• She has another episode of haematemesis in the department.

19. QUESTIONS (1)
• What is your working diagnosis?
• Upper GI bleed 2° to peptic
ulceration/gastritis/oesophagitis/malignancy (↑ ↑ probability)
• Upper GI bleed 2° to oesophageal varices (↓ probability)
• Lower GI bleed 2° diverticular disease, colorectal cancer (↓
probability)
• Aortic aneurysm rupture, aortic dissection, pancreatitis (↓ ↓
probability)

20. BLOOD TESTS 💉
• FBC
• Hb 75 g/L, MCV normal
• WCC 14.0 x 109/L
• Platelets 240 x 109/L
• U&Es
• Na+ 136 mM
• K+ 4.6 mM
• Urea 9.1 mM (↑)
• Creatinine 75 uM (baseline 83)
• LFTs, amylase
• Normal
• Lactate
• 4.3 mM ↑

21. QUESTIONS (2)
• What type of anaemia does she have?
• What management will you initiate immediately?
• Resuscitation
• IV crystalloids (normal saline, saline-dextrose or PlasmaLyte) STAT – but be careful in
patients with known ischemic heart disease!
• IV access, Group & Save, and X-match 4 units RBC and FFP each
• Erect CXR – to rule out a perforation
• IV PPI – omeprazole 40 mg STAT
• IV tranexamic acid 1 g STAT
• SUSPEND ANTICOAGULANTS / NEPHROTOXIC AGENTS / ANTI-HYPERTENSIVES
(restarting should be a risk/benefit decision)
• Urgent referral for endoscopy

22. QUESTIONS (3)
• What is her Glasgow-Blatchford score?
• Urea scores 3
• Hb scores 6
• Systolic BP scores 2
• Scores 4 on other parameters
• Total score = 15
• High risk are GBS > 0
• GBS > 6 indicates that she is likely to
require intervention

23. ENDOSCOPY
• She is adequately resuscitated.
• She is transferred and scoped by the
gastroenterologist on-call, who finds an oozing
duodenal ulcer.
• This is injected with adrenaline and
thermally coagulated, with application of an
“endoclip”.
• She is subsequently maintained on an infusion
of IV omeprazole and admitted for further
observation and monitoring.

24. TAKE-HOME MESSAGES (1)
• In a patient with known or
suspected chronic liver
disease, haematemesis is due to
a variceal bleed until proven
otherwise.
• Give a STAT dose of 1–2 mg of IV
terlipressin, which lowers portal
pressure.
• If there is suspected or confirmed
coagulopathy, consider
administering Vitamin K.

25. TAKE-HOME MESSAGES (2)
• The presence of a
pneumoperitoneum is
indicative of free air in the
abdomen and a perforated
ulcer.
• The patient should urgently be
referred to the general
surgeons on-call for
consideration of a laparotomy.

26. CASE 3

27. • A 52-year old retired army major,
with a background of alcoholic liver
cirrhosis and Type II diabetes
mellitus, is brought to A&E by his
family.
• He presents with worsening jaundice
and ascites.
• They are concerned he is becoming
increasingly confused.
• He goes to the pub every evening,
and drinks approximately 10–12
pints of cider. His last drink was over
12 hours ago.

28. EXAMINATION (1)
• He appears jaundiced. He is tremulous and quite agitated.
• His observations are as follows:
• HR: 100, regular
• BP 110/60
• RR: 20
• T: 36.5°C
• GCS = 14 (E4, V4, M6; due to confused speech)
• Has passed urine whilst in the department
• SpO2: 98% on room air

29. EXAMINATION (2)
• There are several peripheral stigmata of chronic liver
disease, including the presence of spider naevi and
gynaecomastia.
• A flapping tremor (asterixis) is present.
• On examination of his abdomen, he has marked
ascites and pitting oedema to his calves.
• Physical examination is otherwise unremarkable.

30. BLOOD TESTS 💉
• FBC
• Hb 110 g/L, MCV 110 fl (↑)
• WCC 6.0 x 109/L
• Platelets 90 x 109/L (↓)
• U&Es
• Normal
• CRP
• 5 mg/dL
• LFTs, amylase
• Bilirubin 212 uM ↑
• ALT 300 IU/L (↑)
• ALP 100 IU/L ↑
• yGT 320 IU/l ↑
• Albumin 32 g/L (mildly ↓)
• INR
• 1.8

31. CHILD-PUGH SCORE
• This is a useful scoring
system for prognostication
of chronic liver disease.
• What is his CHILD-PUGH
score?
• Encephalopathy = 2
• Ascites = 2
• Bilirubin = 2
• Albumin = 2
• PT = 2
• Total = 12

32. QUESTIONS (1)
• What are your working diagnoses?
• Decompensated alcoholic liver disease (↑ ↑
probability) 2° to alcoholic hepatitis
• Alcohol withdrawal (↑ ↑ probability)

33. QUESTIONS (2)
• What type of anaemia does he have?
• Why is he thrombocytopaenic?
• What do his LFTs show?
• How would you manage this patient?

34. ALBUMIN
• Marker of synthetic function of liver
• But also, a…
• Marker of nutritional status
• Marker of inflammation/disease severity
• Negative acute phase protein
• ↓ production by liver so more amino acids available for
production of positive acute phase proteins
• ↑ proteolysis (catabolism)
• ↑ transcapillary escape rate

35. MANAGEMENT (1) – GENERAL
MEASURES
• Tap his ascites – why?
• Rule out spontaneous bacterial peritonitis
• Treatment of alcohol withdrawal (at high risk of delirium
tremens,Wernicke’s encephalopathy and withdrawal seizures):
• IV Pabrinex for 3 days, followed by oral thiamine
supplementation
• PRN chlordiazepoxide (or ‘Librium’), dose titrated by
symptoms of withdrawal

37. ASCITIC TAP
• EVERY PATIENT PRESENTING TO
HOSPITAL WITH ASCITES SHOULD
HAVE AN ASCITIC TAP.
• This is to rule out SPONTANEOUS
BACTERIAL PERITONITIS, which can
be asymptomatic.

38. MANAGEMENT (2) – GENERAL
MEASURES
• Ultrasound abdomen
• To evaluate extent of cirrhosis/exclude biliary
obstruction/screen for hepatocellular carcinoma

39. MANAGEMENT (3) – SPECIALIST
• Treatment of hepatic encephalopathy:
• Lactulose 10-20 mL TDS (aim BO 3 x / day)
• Rifaximin 550 mg TDS
• Prophylaxis for variceal bleeding (non-selective beta-blocker if BP
stable):
• Carvedilol 6.25 mg OD or propanolol 40 mg BD
• Consider inpatient gastroscopy for prophylactic banding
• Treatment of ascites (N.B. should be tapped on admission!):
• Spironolactone 50 mg BD
• Paracentesis, if required

40. MANAGEMENT (4) – SPECIALIST
• Treatment of alcoholic hepatitis
• If bilirubin significantly elevated and associated
with coagulopathy, the patient may be a
candidate for treatment with oral
prednisolone and IV N-acetylcysteine
• This depends on the patient’s Maddrey
score

41. TAKE-HOME MESSAGES (1)
• Symptoms of ‘decompensated’ chronic liver disease
(N.B. < 7 days: hyperacute liver failure; 5–12 weeks: subacute liver failure)
• Abdominal swelling (= ascites)
• Episodes of confusion (= encephalopathy)
• Easy/abnormal bruising (= coagulopathy)
• Haematemesis/malaena (= bleeding varices 2° to portal hypertension)
• Past medical history
• Known chronic liver disease? Known cirrhosis?
• Known alcohol excess? High risk of hepatitis exposure?

42. CASE 4

43. • A 36-year old lady, with a
background of ulcerative colitis,
present to A&E with a 2-day history
of bloody diarrhoea.
• She complains of a diffuse and
spasmodic abdominal pain associated
with the diarrhoea.
• She states she has opened her
bowels 6–7 times on each day, when
she normally opens them twice a
day.
• She has no recent travel history or
history of trying new foods.

44. EXAMINATION (1)
• She appears dehydrated and looks to be in pain.
• His observations are as follows:
• HR: 105, regular
• BP 130/50
• RR: 18
• T: 37.4°C
• GCS = 15
• Has passed urine whilst in the department
• SpO2: 99% on room air

45. EXAMINATION (2)
• On examination of her abdomen, she is markedly
tender over the entire abdomen, but more so on
the left side.
• Her abdomen is distended but there are no signs
of peritonism.
• She cannot tolerate a per rectal examination.

46. BLOOD TESTS 💉
• FBC
• Hb 130 g/L
• WCC 14.0 x 109/L (↑)
• Platelets 450 x 109/L
• U&Es
• Normal
• LFTs, amylase
• Normal
• CRP
• 45 mg/dL (↑)
• Lactate
• 2.7 mM (↑)

47. QUESTIONS (1)
• What are your working diagnoses?
• Flare-up of ulcerative colitis (↑ ↑ probability)
• Infectious or ischemic colitis (↓ probability)

48. TRUELOVE &
WITTS’
CRITERIA
N.B. Patients
with IBD will
not always
mount a ‘high’
CRP response

49. MANAGEMENT – GENERAL
MEASURES
• What specific imaging would you initially request?
• Abdominal X-ray – to exclude toxic megacolon
• How would you manage this patient?
• High-dose steroids – IV hydrocortisone 100 mg TDS
• Stool cultures MC&S, incl. C. difficile toxin test
• IV fluids
• IV antibiotics, if indicated
• Stool chart (give to patient to record output)
• VTE prophylaxis (pro-thrombotic state ++)
• Inpatient flexible sigmoidoscopy (no bowel prep required)

50. MANAGEMENT – SPECIALIST
• Remission:
• Topical therapies – 5-aminosalicylates (mesalazine)
or corticosteroid suppositories
• Oral therapies – 5-aminosalicylates (avoid steroids
due to long-term effects)
• Consideration of biologic therapy (e.g. infliximab);
biologics can also be used when patients do not
respond to steroids (induction regime over 1, 3
and 6 weeks)

51. TOXIC
MEGACOLON

53. CROHN’S VS. ULCERATIVE COLITIS

54. CROHN’S DISEASE –
ADDITIONAL
CONSIDERATIONS
• Always define the extent of
inflammatory bowel disease (i.e.
pancolitis, right- or left-sided, ileo-
caecal, perianal) as this influences
management.
• Steroids may not always be
appropriate.
• In fistulating Crohn’s disease,
further imaging with CT and MRI
of pelvis and rectum may be
required, with possible involvement
of a colorectal surgeon.

55. CASE 5

56. • A 36-year old businessman, with a
history of intravenous drug use,
presents with a 2 day history of
jaundice, fever, chills and general
malaise.
• He does not complain of
abdominal pain.
• He has a past history of sexual
intercourse with other men, and
has previously been diagnosed
with HIV (on antiretroviral
therapy).

57. EXAMINATION (1)
• He appears jaundiced, but observations are otherwise
normal.
• On inspection, there are no peripheral stigmata of liver
disease.
• On palpation of his abdomen, a liver edge is palpable. He
is mildly tender in the right upper quadrant.

58. BLOOD TESTS 💉
• FBC
• Hb 145 g/L
• WCC 5.4 x 109/L
• Platelets 220 x 109/L
• U&Es, CRP and lactate
• Normal
• LFTs
• Bilirubin 110 uM ↑
• ALT 1430IU/L (↑)
• ALP 150 IU/L ↑
• yGT 800 IU/l ↑
• Albumin 37g/L
• Clotting
• INR 1.2

59. QUESTIONS (1)
• What pattern do the LFTs show?
• Hepatitic
• What is your differential diagnosis?
• Viral hepatitis (Hepatitis A-E, CMV, EBV)
• Ischemic hepatitis
• Autoimmune hepatitis
• Drug-induced liver injury
• Acute alcoholic hepatitis
• Biliary obstruction
• Primary or secondary hepatocellular carcinoma
• Other congenital causes: Wilson’s disease, haemochromatosis, etc.

60. QUESTIONS (2)
• What further tests would you like to
perform?
• US abdomen (?cirrhosis)
• Full liver screen, including viral serology

65. N.B. HbeAg (the envelope antigen) and anti-HbeAg play an important role in indicating
disease activity in patients with chronic hepatitis.

67. RESULTS (2)
Marker Result
HbsAg +
Anti-HBs (total) -
Anti-HBc IgM ++
Anti-HBc Ig (total) +
In keeping with acute hepatitis B
Next investigations worth ordering would be HbeAg, HBV PCR to
determine viral load, and HBV genotyping.

68. CASE 3 (CONT.)
• This man was referred to a liver specialist for
consideration of antiviral therapy and liver
transplantation.
• Treatment for Hepatitis C is otherwise conservative.
Patients commenced on antiretroviral therapy are high
risk (e.g. pregnant), have high viral loads and/or a marked
transaminitis.

69. IMPORTANT CONSIDERATIONS
• Recurrent episodes of acute-on-chronic hepatitis
B can lead to cirrhosis.
• Note that the majority of patients will be
asymptomatic, and that a recent multi-centred
RCT trial (HepFREE) demonstrates significant
cost-effectiveness to primary-care level
screening of hepatitis B and C in high-risk migrant
populations.

70. TAKE-HOME MESSAGES (1)
• Risk factors for hepatitis
• Travel history
• Sexual history
• Intravenous drug use
• Risk factors for acute/chronic liver injury
• Alcohol
• Paracetamol
• Other drugs e.g. amoxicillin, flucloxacillin

71. TAKE-HOME MESSAGES (2)
• If paracetamol overdose is
suspected as the cause for acute
liver failure, treat using IV N-
acetylcysteine.
• Use the King’s College criteria to
identify candidates for liver
transplantation.

72. ONE LAST POINTER
• Asymptomatic iron-deficiency anaemia in the
older patient requires exclusion of a bowel
malignancy.
• Always request haematinics (B12/folate/ferritin) and
iron studies, as you cannot make a diagnosis of iron
deficiency using the FBC alone.
• (Your consultants will thank you for it!)