Managing gastroenterology patients
Gastroenterology is a wonderful specialty, however it is quite different than what we see back home.
I am going to go through the common cases and how we manage them.
Please note that this is only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust/ when you work in this specialty.
Also read the junior doctors handbook here:
https://www.bsg.org.uk/bsg-sections/trainees/online-learning.html
Here are a few common cases we see:
PARACETAMOL OVERDOSE
https://cks.nice.org.uk/poisoning-or-overdose#!scenario
We see this all the time. Each trust has a paracetamol overdose pathway. Follow it and remember to escalate if their bloods are deranged:
https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity
Refer them to the mental health team even if their bloods are normal. Be very careful of what you say to these patients. They are very vulnerable. It is important that they are seen by the professionals who deal with these cases day in and day out ( ie the psychiatry team) and are given advice by them.
Monitoring their bloods is important and if possible, get a collateral history to ensure they have not overdosed on anything else.
Usually, they take a good amount of alcohol with this so manage that accordingly ( as explained below).
I am going to go through the common cases and how we manage them.
Please note that this is only for educational purposes and if in doubt, kindly refer to your local guidelines and ask your seniors. Please remember that these guidelines vary from trust to trust which you will be introduced to during your induction and your first few days in your trust/ when you work in this specialty.
Also read the junior doctors handbook here:
https://www.bsg.org.uk/bsg-sections/trainees/online-learning.html
Here are a few common cases we see:
PARACETAMOL OVERDOSE
https://cks.nice.org.uk/poisoning-or-overdose#!scenario
We see this all the time. Each trust has a paracetamol overdose pathway. Follow it and remember to escalate if their bloods are deranged:
https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity
Refer them to the mental health team even if their bloods are normal. Be very careful of what you say to these patients. They are very vulnerable. It is important that they are seen by the professionals who deal with these cases day in and day out ( ie the psychiatry team) and are given advice by them.
Monitoring their bloods is important and if possible, get a collateral history to ensure they have not overdosed on anything else.
Usually, they take a good amount of alcohol with this so manage that accordingly ( as explained below).
Alcohol
This may vary from alcohol toxicity to full blown hepatic encephalopathy secondary to alcoholic liver disease.
This may vary from alcohol toxicity to full blown hepatic encephalopathy secondary to alcoholic liver disease.
It is very important to get a detailed history of how many units the patient usually drinks, what the reason behind the increased alcohol intake was and if the patient took anything else ( like overdose of medication - especially paracetamol). If it doubt, do paracetamol levels and salicylate levels.
Examination:
Look for features of chronic liver disease - palmar erythema, jaundice, heaptic flap, parotitis, ascites, spider naevi
Investigations:
Routine bloods: FBC, U and E's( be aware of pseudohyponatremia), LFTs, bone profile, magnesium, phosphate, clotting, blood cultures ( if they are septic). USS abdomen if they have deranged LFTs (if they have not had one in the past).
CXR, urine dip and MSU.
CT head if their confusion is out of proportion ( if they do not look "encephalopathic")
Management:
Simple ETOH excess:
Each trust has an alcolohol withdrawal pathway. We usually start patients on Pabrinex ( high potency vitamin B and C ) as they are at risk of vitamin deficiency causing Wernicke's, prescribe PRN chlordiazepoxide/ another alternative (and then see how much PRN they require over 24 hours then decide about a reducing regime).
Refer them to substance misuse.
Refer them to the gastro team if they have deranged LFTs ( they may need regular follow up)
Decompensated liver disease:
This includes ascites to SBP to upper GI bleeds.
SPONTANEOUS BACTERIAL PERITONITIS
https://www.nice.org.uk/search?q=spontaneous+bacterial+peritonitis
The most important thing is to rule out spontaneous bacterial peritonitis (bacterial infection of their ascitic fluid). Therefore we should do a ascitic tap. Usually, core medical trainees are expected to be signed off. Registrars can definitely do it. Therefore if you have not done one before, take this oppurtunity to explain the procedure to the patient:
I will be taking out some fluid from your tummy and send it to the lab to ensure there are no bugs in it. I usually explain the pathophysiology behind it as well.
I will be inserting a needle attached to a syringe and will draw up some fluid.
I will be cleaning the area with alcohol swabs before this.
There are some risks associated with it:
- Bleeding, infection, pain, failure of procedure, multiple attempts, injury to surrounding structures.
Some trusts suggest to sign a consent form. Some trusts are happy with an informed consent with documentation of the aforementioned conversation in the notes.
I will not be explaining the procedure here as I would expect you to know. And if you do not know, your registrar should be guiding you through it.
Send the sample for
Culture and sensitivity
Protein
Glucose
LDH
If there is no clear cause of ascites, you may want to send it for cytology looking for atypical cells ? malignancy. However be careful that if this is the case, the ?malignant ascitic fluid may seed into the skin and surrounding tissue therefore ask a senior if they are happy for you to go ahead.
Remember, if you suspect SBP, you should start patients on antibitiotics immediately ( this varies from trust to trust - in mine it is STAT tigecycyline 100 mg then 50 mg BD). Remember to do an ascitic tap and blood cultures ( however this should not delay treatment).
ASCITES
Ascitic drains:
If a patient has massive ascites, the acute/gastro team may want to consider draining it. This has its own risks:
- Sudden drop in blood pressure- which is why we always give Human Albumin Solution (HAS 20%- 100 ml) to patients for every 1.5 to 2.5 liters drained.
- Bleeding, infection, pain, failure of procedure, multiple attempts, injury to surrounding structures.
We always consent patients for this. If they have capacity, we use a consent form 1. If they do not, we discuss this with their next of kin and use a consent form 4.
Again, I will not be explaining the procedure here as I would expect you to know. And if you do not know, your registrar should be guiding you through it.
However you may be expected to collect the relevant equipment which may differ from trust to trust. This includes:
1. Consenting the patient ( the person doing this procedure should be consenting).
2. Arrange HAS - It is usually the blood transfusion team. You do not need a group and save for this.
You will need to prescribe this as well (usually on a blood transfusion form). Inform the nursing staff as they will have to collect it and ensure that it is ready to go by the time 1-1.5 liters is drained.
3. Ascitic tap trolley:
- 1% Lidocaine
- Orange needles
- Green needles
- Wound care pack which contains gauzes, sterile sheets, etc
- Ascitic drain kit which includes a Banano Catheter, needle and stopper.
- Urine catheter bag (which is sealed)
- Sterile gloves.
- 2 white top pots in case we need to send a sample to the lab
(Remember to keep an extra pair of everything - especially the ascitic drain kit).
- Ideally an assistant. However, after a few procedures you can do it on your own ( as long as you remember to open the lidocaine vial beforehand and prepare your trolley BEFORE you put your sterile gloves on). I always have an assistant - as they get to learn as well and can hold the patients hands if need be.
4. You are now ready to go ahead with the procedure.
5. Document everything after the procedure.
6. Usually the drain is left in for 6 hours however the reg/consultant may have a limit to how much fluid (s)he wants to be drained.
7. Keep an eye on the patients OBS. Ensure that the nurse informs you if there is any change.
Medical management of ascites:
Patients with ascites secondary to decompensated liver disease are usually started on spironolactone 100 mg OD which is uptitrated.
Monitor U and Es daily
Monitor daily weights
Ensure that the patient is not drinking a lot of fluid.
UPPER GI BLEEDS
https://www.nice.org.uk/guidance/cg141/chapter/1-Guidance
These are a medical emergency if the patient is actively bleeding, has hemodynamic instability and is becoming more drowsy. When it doubt, always escalate because this is a potentially reversible condition and warrants urgent endoscopy.
You should inform the registrar immediately who should inform the on call endoscopist- who is usually a gastro/surgical consultant.
Get 2 large bore cannulas.
Remember to send an urgent group and save (x2) in addition to the aforementioned investigations (call transfusion immediately).
However nothing should delay discussion with the on call endoscopist.
From a junior doctors point of view, you must ensure that :
1. The on call endoscopist knows about it (The registrar should be doing this)
2. All relevant investigations have been sent.
3. Medication history- ensure the patient was not on warfarin, NOACs, etc and consider reversal if appropriate ( NOAC reversal may need discussion with the on call haematologist).
4. DO NOT START THE PATIENT ON IV PPI unless the registrar/on call endoscopist suggests this.
5. Calculate the Blatchford score.
6. Sometimes, the gastroenterology consultant may suggest doing a TEG, which stands for thromboelastography which gives the team an idea about which blood products the patient needs to receive other than packed red cells. This is particularly helpful in cirrhotic patients as their clotting is markedly deranged.
The process varies from trust to trust. In my trust, a sample is taken in a citrated bottle ( the blood sample bottle used to send a clotting profile in ), it is taken to theaters where one of the ODPs (operating department practitioner) runs the sample. It takes 30 minutes for the sample to be analyzed - which is a graph. This graph is interpreted by the gastroenterology team and they decide if it is normal, whether the patient needs FFP, platelets, cryoprecipitate, tranexamic acid or a combination.
Remember- not everyone can interpret it so always ask the gastroenterology consultant on call. In some trusts, the haematologists might be able to help.
TEGs should ONLY be done if the gastroenterology consultant/registrar have suggested to do this.
Once the patient has been scoped and the bleed has been managed - ie, banding of the bleeding varices, adrenaline injections/gluing to the bleeding point, (s)he may be transferred to the ward/ITU depending on how well (s)he is.
Post OGD management:
Always read the report. The on call endoscopist would have given recommendations. Just follow them. If any doubt, discuss this with the registrar/on call endoscopist.
These patients have a rescope in 24 to 48 hours to ensure that the bleeding has settled.
The underlying cause is then managed. If it was variceal bleeding secondary to decompensated liver disease due ETOH excess then the ETOH excess is managed by referring to substance misuse, gastro F/U on a regular basis, etc.
ENCEPHALOPATHY
https://www.evidence.nhs.uk/search?q=hepatic+encephalopathy
This is the most challenging part of decompensated liver disease.
These patients are very confused, have poor nutrition and need extra care.
The most important management here is to ensure they are not consipated and they are fed properly.
Most encephalopathic patients have a NG tube and are seen by dieticians as they cannot eat and drink like normal people. If they are very confused, a DOLS (https://www.scie.org.uk/mca/dols/at-a-glance) is put in and hence the medical team can treat them in their best interests which involves inserting a bridle to keep the NG tube in place ( there are plenty of videos on inserting a bridle on YouTube however you should do this under supervision if you have not done it before).
Ensure the DOLS is valid at all times.
Once the NG tube (and if required bridles AND/OR mittens) is in place, their feed is started so that they meet the daily caloric requirements.
They may need a 1:1 care if they are very confused ( They are at high risk of falls).
From a junior doctors point of view, these are the important points:
1. They should have daily refeeding bloods ( U and E's, Magnesium and phosphate)- these should be replaced accordingly. Some consultants like to send off trace minerals (copper, zinc, selenium) however this is a senior led decision.
Also monitor their routine FBC, CRP, LFTs, clotting to ensure they are not developing an infection.
2. They should have daily blood sugars checked- EVEN if they are not diabetic.
3. Make sure their feed is running ( usually it is overnight) and they are not lying flat when it is running ( there is a high risk of aspiration)- ensure they are sitting/lying with their head-end rasied.
4. Ensure they are opening their bowels - they may need an enema daily.
5. Ensure they take their medications. On a busy ward, the nursing staff may leave medications on the side without realizing how confused these patients are so ensure that the patients actually take their medications.
6. Advanced care planning - ask your registrar/consultant to think about DNARs. Observe them discussing this with their families so that you can do this (initially under supervision) the next time.
7. Discharge planning - these may be suitable for a nursing home/24 hour care package and this needs to be started once they are a bit stable.
8. Check for bruises. These patients can get bruised easily given their coagulopathy and can injure themselves in their confusion.
9. These patients may be started on rifaximin which may be stopped if there is no change in their clinical condition in 10 days to 2 weeks. We have different techniques to check if it is working ( ie by doing a number joining test a week after starting them on rifaxamin - the tests used may vary from trust to trust)
( https://www.nice.org.uk/guidance/ta337 )
ALCOHOLIC HEPATITIS
https://pathways.nice.org.uk/pathways/alcohol-use-disorders/alcohol-related-liver-disease
Some patients who come in with deranged LFTs may be considered for steroids - This is usually a consultant/registrar decision.
From a junior doctors point of view, these are the important points:
1. Send FBC, U and E's( be aware of pseudohyponatremia), LFTs, bone profile, magnesium, phosphate, clotting, blood cultures. USS abdomen if they have deranged LFTs (if they have not had one in the past).
CXR, urine dip and MSU.
2. Calculate their Lille Score:
http://www.alchepscores.com/
Print out the results and put them in the patients notes
3. Monitor BMs- they are on steroids.
4. Consider PPI - they are at a high risk of bleeding anyway.
5. Check Lille score at 7 days.
6. Monitor CRP, FBC ( remember, the neutrophils will be high anyway due to steroids).
7. Examine them for any infection everyday given that they are on steroids.
DERANGED LFTs.
We see these cases from time to time. The patient is not an excessive drinker and we need to find the cause.
These are the tests we do:
NILS (Non invasive liver screen)
https://www.tsft.nhs.uk/media/61359/Taunton-GP-NILS-vOct11.pdf
USS abdomen
Here are some common causes:
1. Drug induced
These patients may be considered for steroids after ruling out other causes
2. Viral Hepatitis
We have specialist nurses who come see the patients if they have HCV or HBV, request specialist tests ( ie genotyping) , give advice, do screening of sexual contacts if necessary and then follow them up with management.
3. Ischemic insults - such myocardial infacrtions, etc.
4. Parastic infections
If they have been travelling abroad. The infectious diseases team may be involved in this.
5. Cancer
They will have a CT of their neck, chest, thorax, abdomen and pelvis and will be discussed in the cancer MDT.
LIVER BIOPSIES
Sometimes, when no cause of deranged LFTs is found a liver biopsy is warranted.
This is done by the hepatologist consultants/registrars/specialist radiologists.
As junior doctors we may need to consent them. Before we do so, we need to take a full history to rule out any infections/ if they are on any NOACS/warfarin/blood thinners.
Once you have "clerked" them and know what the indication for the liver biopsy is ( check previous letters from the hepatology clinic), have made sure that their bloods are normal (including clotting), have not been on any blood thinners since 5 days ( this varies from trust to trust and from patient to patient- the hepatology letters will clearly state when the patient was supposed to stop them), have had group and saves (x2), you can consent them.
Please note that you should ONLY consent patients when you are aware of the procedure- if you are not, then ask your registrar to consent the patient. The patients usually receive a leaflet on this ( if not, then give them one- each trust has its own patient information leaflet).
These are the risks:
Bleeding, infection, pain, failure of the procedure, pneumothorax ( air entering into the lining of the lungs which may warrant inserting a drain to remove it), failure of procedure, multiple attempts, failure to get a diagnosis of what has caused the derangement in LFTs, death
(This may vary from trust to trust).
Usually patients need to stay in overnight after the procedure but this varies.
From a junior doctors point of view, these are the important points to remember:
1. Full clerking - ensure there is no active infection, blood thinners were stopped at the right time.
2. Bloods are normal. Group and Save has been sent.
3. OBS are stable
4. You know the procedure and can hence constent the patient.
5. Post procedure pain - this is very important. I ensure that the nurses know to contact me in case the patient is in any pain. The liver is highly vascular and hence there is a high risk of bleeding. Therefore I avoid prescribing PRN analgesia so that I can review the patient myself if (s)he is in any pain post procedure.
If there is any pain post procedure, I immediately repeat all bloods (incl clotting) and do a VBG (gives me an immediate result for Hb - if there is any drop and lactate). I contact my consultant and then discuss this with the consultant radiologist for a CT scan to rule out bleeding.
Remember, when in doubt always escalate.
CANCERS
This is the most unpleasant part of this specialty. Pancreatic cancer, liver cancers are getting more and more common. These patients need extra support and they should be referred to the cancer specialist nurses and teams immediately.
As junior doctors, our most important role is to be human. Sit with them if you have time and talk to them. Ask them how they are feeling and ALWAYS open the curtains in their dark room to let sunlight in. They need you the most. So be their pillar of support. The earlier they tell their families, the better it is for them. This way they can have extra support. Offer to tell the family if they do not wish to.
CHRONIC DIARRHOEA
https://cks.nice.org.uk/diarrhoea-adults-assessment
There are many causes of this:
1. Infective - make sure the patients stool sample has been sent for C diff, C+S, microscopy.
2. Medications - metformin and other medications are common culprits.
3. Coeliac disease - send coeliac screening tests
4. IBD - faecal calprotectin
5. Pancreatic insufficiency- Fecal elastase.
6. IBS
7. Laxatives - make sure you have stopped these.
8.Overflow diarrhoea - Always do a PR!
Usually these patients end up having a flexible sigmoidoscopy or colonoscopy.
IBD:
https://cks.nice.org.uk/ulcerative-colitis
https://cks.nice.org.uk/crohns-disease
Given that we have an amazing service for management of IBD as an outpatient/day unit, we hardly see these patients anymore. However they may be admitted with a flare up.
These patients need high dose steroids ( after ruling out sepsis, infective diarrhea ) and may be considered for steroid sparing agents ( usually the IBD nurses and consultants decide about this).
From a junior doctors point of view, it is important that these patients
1. Have an AXR as soon as possible - to rule out toxic megacolon
2. Have their BMs monitored if they are on steroids
3. Daily bloods to ensure their inflammatory markers are improving
4. Have a stool chart - this will give an idea of how well the treatment is working
5. Have had a full septic screen.
PANCREATITIS
These patients are admitted under surgeons but at times, the gastroenterology team takes over care if they are not for surgery.
https://cks.nice.org.uk/pancreatitis-acute
This is a very painful condition therefore needs to be well managed with analgesia. These patients also need adequate hydration.
IBS
https://cks.nice.org.uk/irritable-bowel-syndrome
These patients are very tricky. They are known to a particular consultant as an outpatient and when they come in with abdominal pain, once we have done the necessary investigations ( bloods, amylase, VBG, CXR, AXR), we always ask the consultant they are well known to to see the patient.
The most important thing to realize is that we should never label a patient as "functional". We should always rule out potentially life threatening and reversible causes first and ensure that we treat the patient like anyone else. They notice our facial expressions so be an empathetic and kind doctor. Listen to their concerns and manage them accordingly. Avoid giving high dose opiates and go up the pain ladder gradually.
LIVER TRANSPLANT PATIENTS
If a patient meets the criteria for liver transplant, they are referred to specialist centers ( For York, it is Leeds) for a liver transplant.
They have a very detailed liver transplant checklist which the registrars/consultants fill and email to the specialist teams.
Usually, these patients are referred as an outpatient basis however paracetamol OD ( if they meet King's Criteria) and alcohol liver disease patients ( if they have been abstinent for long enough) are also referred. It is very important to transfer all the images, investigations, medication history across to the specialist centers so that they have all the information.
ANOREXIA NERVOSA
These are complex patients usually managed by the psychiatry team. They may be admitted for NG tube feeding.
They are managed according to the MARSIPAN guidelines. It is important for all members of the team to have one view on feeding regimes rather than conflicting views. Usually, it is the psychiatry team who is the best team to advise on everything about these patients as they know them really well.
From a medical point of view, they need daily refeeding bloods including blood sugars.
THE GASTRO/HEPATOLOGY MDT
This is a huge team and everyone plays a very important role:
1. Consultants - they all have specialist interests ( in luminal pathology or hepatology).
2. Registrars
3. Junior doctors - foundation trainees, core trainees and trust grades.
4. ACPs - who have been nurses and have then trained to learn a specialist skill like endoscopies
5. PA's- Physician associates
6. Nurse specialists - they have a particular specialty role like endoscopy, IBD, IBS, Substance misuse, HCV/HBV, fibroscan, etc.
7. Dieticians - They play an important role in monitoring nutrition.
8. Specialist OT/PTs who can help with discharge planning.
9. Research specialists
This list is in no way complete. Overall it is an amazing team of experts. They all share their advice and experience.
THE GASTROENTEROLOGY WARD:
I have worked in a few gastroenterology wards in the NHS and they have not been very organized. This is because of lack of teamwork and unavailability of senior support. However the gastro team in York is amazing and I wish all other trusts follow this same principle which works really well:
1. An active WhatsApp group. We know where the consultants and registrars are. Rather than bleeping one another we update each other on the group if we need help ( we never share confidential data).
2. Active consultants - we have a consultant of the week who does a ward round in the morning and then meets the team at costa at 11 AM (where we are all treated to coffee) and then again at 4 PM.
Even if they are not available, we know where to find them.
3. Amazing registrars - they are very supportive and given that they have a dedicated rota for scopes and clinics, they do not leave the juniors alone fending for themselves.
4. An active rota team. When we are understaffed, the rota team preempts this and makes sure there is adequate cover ( we have a few excellent trust grade SHOs who help in cross covering).
5. Adequate handover to the nursing staff. The nurses and discharge coordinators inform us of any sick patients / potential discharges at 0900 therefore we can prioritize our tasks accordingly.
We also have a "Huddle" at 1430 in which we go through all of the patients with the nurses, OTs, PTs and dietitians to address any outstanding concerns.
6. Escalation plans - All patients have a clear escalation plan and the consultants actively discuss this ( and let us juniors do this).
7. Weekend ward round - The gastro consultants on call for that week come on weekends and see the sick patients from the week to ensure that the FY1 on call does not have to deal with them on their own.
8. Approachable on call gastro consultants - All our gastro consutlants do on calls and are on call 24/7. They can easily be approached out of hours to discuss scopes/sick admitted patients under their care.
9. Training - all our FY1s can do ascitic drains (under supervision) and can be signed off. They are also encouraged to pass NG tubes and bridles. Both core trainees and foundation trainees are encouraged to observe scopes, ERCPs, attend clinics, work on QIPs and hence get the maximum out of their placement.
10. A detailed handover from consultant of the week to the next - we have a meeting in the education center ( usually complimented with free food) which is attended by all members of the MDT and every patient under care of the gastro team is discussed.
11. Seeing referrals appopriately. There is always a gastro registrar who carries a "gastro phone". (S)he takes calls from GPs, other specialties including A and E ( if they are worried about someone). All referrals are seen the same day.
12. Ensuring that we leave on time. Everyone works as a team. The consultants do not hand over jobs unnecessarily and if we are really swamped, they actually help us by discussing scans with the radiologists, talking to relatives, etc.
I cannot praise the gastroenterology team at York Hospital enough. The members of the team are more or less the same as in any other trust but because of team work and leadership, everyone enjoys their placement here and learns something new making them a better doctor.
This is no way a complete list of gastro/liver patients we see as junior doctors.
Here are some useful resources:
https://www.bsg.org.uk/
https://www.yorkhospitals.nhs.uk/our-services/a-z-of-services/gastroenterology/
Look for features of chronic liver disease - palmar erythema, jaundice, heaptic flap, parotitis, ascites, spider naevi
Investigations:
Routine bloods: FBC, U and E's( be aware of pseudohyponatremia), LFTs, bone profile, magnesium, phosphate, clotting, blood cultures ( if they are septic). USS abdomen if they have deranged LFTs (if they have not had one in the past).
CXR, urine dip and MSU.
CT head if their confusion is out of proportion ( if they do not look "encephalopathic")
Management:
Simple ETOH excess:
Each trust has an alcolohol withdrawal pathway. We usually start patients on Pabrinex ( high potency vitamin B and C ) as they are at risk of vitamin deficiency causing Wernicke's, prescribe PRN chlordiazepoxide/ another alternative (and then see how much PRN they require over 24 hours then decide about a reducing regime).
Refer them to substance misuse.
Refer them to the gastro team if they have deranged LFTs ( they may need regular follow up)
Decompensated liver disease:
This includes ascites to SBP to upper GI bleeds.
SPONTANEOUS BACTERIAL PERITONITIS
https://www.nice.org.uk/search?q=spontaneous+bacterial+peritonitis
The most important thing is to rule out spontaneous bacterial peritonitis (bacterial infection of their ascitic fluid). Therefore we should do a ascitic tap. Usually, core medical trainees are expected to be signed off. Registrars can definitely do it. Therefore if you have not done one before, take this oppurtunity to explain the procedure to the patient:
I will be taking out some fluid from your tummy and send it to the lab to ensure there are no bugs in it. I usually explain the pathophysiology behind it as well.
I will be inserting a needle attached to a syringe and will draw up some fluid.
I will be cleaning the area with alcohol swabs before this.
There are some risks associated with it:
- Bleeding, infection, pain, failure of procedure, multiple attempts, injury to surrounding structures.
Some trusts suggest to sign a consent form. Some trusts are happy with an informed consent with documentation of the aforementioned conversation in the notes.
I will not be explaining the procedure here as I would expect you to know. And if you do not know, your registrar should be guiding you through it.
Send the sample for
Culture and sensitivity
Protein
Glucose
LDH
If there is no clear cause of ascites, you may want to send it for cytology looking for atypical cells ? malignancy. However be careful that if this is the case, the ?malignant ascitic fluid may seed into the skin and surrounding tissue therefore ask a senior if they are happy for you to go ahead.
Remember, if you suspect SBP, you should start patients on antibitiotics immediately ( this varies from trust to trust - in mine it is STAT tigecycyline 100 mg then 50 mg BD). Remember to do an ascitic tap and blood cultures ( however this should not delay treatment).
ASCITES
Ascitic drains:
If a patient has massive ascites, the acute/gastro team may want to consider draining it. This has its own risks:
- Sudden drop in blood pressure- which is why we always give Human Albumin Solution (HAS 20%- 100 ml) to patients for every 1.5 to 2.5 liters drained.
- Bleeding, infection, pain, failure of procedure, multiple attempts, injury to surrounding structures.
We always consent patients for this. If they have capacity, we use a consent form 1. If they do not, we discuss this with their next of kin and use a consent form 4.
Again, I will not be explaining the procedure here as I would expect you to know. And if you do not know, your registrar should be guiding you through it.
However you may be expected to collect the relevant equipment which may differ from trust to trust. This includes:
1. Consenting the patient ( the person doing this procedure should be consenting).
2. Arrange HAS - It is usually the blood transfusion team. You do not need a group and save for this.
You will need to prescribe this as well (usually on a blood transfusion form). Inform the nursing staff as they will have to collect it and ensure that it is ready to go by the time 1-1.5 liters is drained.
3. Ascitic tap trolley:
- 1% Lidocaine
- Orange needles
- Green needles
- Wound care pack which contains gauzes, sterile sheets, etc
- Ascitic drain kit which includes a Banano Catheter, needle and stopper.
- Urine catheter bag (which is sealed)
- Sterile gloves.
- 2 white top pots in case we need to send a sample to the lab
(Remember to keep an extra pair of everything - especially the ascitic drain kit).
- Ideally an assistant. However, after a few procedures you can do it on your own ( as long as you remember to open the lidocaine vial beforehand and prepare your trolley BEFORE you put your sterile gloves on). I always have an assistant - as they get to learn as well and can hold the patients hands if need be.
4. You are now ready to go ahead with the procedure.
5. Document everything after the procedure.
6. Usually the drain is left in for 6 hours however the reg/consultant may have a limit to how much fluid (s)he wants to be drained.
7. Keep an eye on the patients OBS. Ensure that the nurse informs you if there is any change.
Medical management of ascites:
Patients with ascites secondary to decompensated liver disease are usually started on spironolactone 100 mg OD which is uptitrated.
Monitor U and Es daily
Monitor daily weights
Ensure that the patient is not drinking a lot of fluid.
UPPER GI BLEEDS
https://www.nice.org.uk/guidance/cg141/chapter/1-Guidance
These are a medical emergency if the patient is actively bleeding, has hemodynamic instability and is becoming more drowsy. When it doubt, always escalate because this is a potentially reversible condition and warrants urgent endoscopy.
You should inform the registrar immediately who should inform the on call endoscopist- who is usually a gastro/surgical consultant.
Get 2 large bore cannulas.
Remember to send an urgent group and save (x2) in addition to the aforementioned investigations (call transfusion immediately).
However nothing should delay discussion with the on call endoscopist.
From a junior doctors point of view, you must ensure that :
1. The on call endoscopist knows about it (The registrar should be doing this)
2. All relevant investigations have been sent.
3. Medication history- ensure the patient was not on warfarin, NOACs, etc and consider reversal if appropriate ( NOAC reversal may need discussion with the on call haematologist).
4. DO NOT START THE PATIENT ON IV PPI unless the registrar/on call endoscopist suggests this.
5. Calculate the Blatchford score.
6. Sometimes, the gastroenterology consultant may suggest doing a TEG, which stands for thromboelastography which gives the team an idea about which blood products the patient needs to receive other than packed red cells. This is particularly helpful in cirrhotic patients as their clotting is markedly deranged.
The process varies from trust to trust. In my trust, a sample is taken in a citrated bottle ( the blood sample bottle used to send a clotting profile in ), it is taken to theaters where one of the ODPs (operating department practitioner) runs the sample. It takes 30 minutes for the sample to be analyzed - which is a graph. This graph is interpreted by the gastroenterology team and they decide if it is normal, whether the patient needs FFP, platelets, cryoprecipitate, tranexamic acid or a combination.
Remember- not everyone can interpret it so always ask the gastroenterology consultant on call. In some trusts, the haematologists might be able to help.
TEGs should ONLY be done if the gastroenterology consultant/registrar have suggested to do this.
Once the patient has been scoped and the bleed has been managed - ie, banding of the bleeding varices, adrenaline injections/gluing to the bleeding point, (s)he may be transferred to the ward/ITU depending on how well (s)he is.
Post OGD management:
Always read the report. The on call endoscopist would have given recommendations. Just follow them. If any doubt, discuss this with the registrar/on call endoscopist.
These patients have a rescope in 24 to 48 hours to ensure that the bleeding has settled.
The underlying cause is then managed. If it was variceal bleeding secondary to decompensated liver disease due ETOH excess then the ETOH excess is managed by referring to substance misuse, gastro F/U on a regular basis, etc.
ENCEPHALOPATHY
https://www.evidence.nhs.uk/search?q=hepatic+encephalopathy
This is the most challenging part of decompensated liver disease.
These patients are very confused, have poor nutrition and need extra care.
The most important management here is to ensure they are not consipated and they are fed properly.
Most encephalopathic patients have a NG tube and are seen by dieticians as they cannot eat and drink like normal people. If they are very confused, a DOLS (https://www.scie.org.uk/mca/dols/at-a-glance) is put in and hence the medical team can treat them in their best interests which involves inserting a bridle to keep the NG tube in place ( there are plenty of videos on inserting a bridle on YouTube however you should do this under supervision if you have not done it before).
Ensure the DOLS is valid at all times.
Once the NG tube (and if required bridles AND/OR mittens) is in place, their feed is started so that they meet the daily caloric requirements.
They may need a 1:1 care if they are very confused ( They are at high risk of falls).
From a junior doctors point of view, these are the important points:
1. They should have daily refeeding bloods ( U and E's, Magnesium and phosphate)- these should be replaced accordingly. Some consultants like to send off trace minerals (copper, zinc, selenium) however this is a senior led decision.
Also monitor their routine FBC, CRP, LFTs, clotting to ensure they are not developing an infection.
2. They should have daily blood sugars checked- EVEN if they are not diabetic.
3. Make sure their feed is running ( usually it is overnight) and they are not lying flat when it is running ( there is a high risk of aspiration)- ensure they are sitting/lying with their head-end rasied.
4. Ensure they are opening their bowels - they may need an enema daily.
5. Ensure they take their medications. On a busy ward, the nursing staff may leave medications on the side without realizing how confused these patients are so ensure that the patients actually take their medications.
6. Advanced care planning - ask your registrar/consultant to think about DNARs. Observe them discussing this with their families so that you can do this (initially under supervision) the next time.
7. Discharge planning - these may be suitable for a nursing home/24 hour care package and this needs to be started once they are a bit stable.
8. Check for bruises. These patients can get bruised easily given their coagulopathy and can injure themselves in their confusion.
9. These patients may be started on rifaximin which may be stopped if there is no change in their clinical condition in 10 days to 2 weeks. We have different techniques to check if it is working ( ie by doing a number joining test a week after starting them on rifaxamin - the tests used may vary from trust to trust)
( https://www.nice.org.uk/guidance/ta337 )
ALCOHOLIC HEPATITIS
https://pathways.nice.org.uk/pathways/alcohol-use-disorders/alcohol-related-liver-disease
Some patients who come in with deranged LFTs may be considered for steroids - This is usually a consultant/registrar decision.
From a junior doctors point of view, these are the important points:
1. Send FBC, U and E's( be aware of pseudohyponatremia), LFTs, bone profile, magnesium, phosphate, clotting, blood cultures. USS abdomen if they have deranged LFTs (if they have not had one in the past).
CXR, urine dip and MSU.
2. Calculate their Lille Score:
http://www.alchepscores.com/
Print out the results and put them in the patients notes
3. Monitor BMs- they are on steroids.
4. Consider PPI - they are at a high risk of bleeding anyway.
5. Check Lille score at 7 days.
6. Monitor CRP, FBC ( remember, the neutrophils will be high anyway due to steroids).
7. Examine them for any infection everyday given that they are on steroids.
DERANGED LFTs.
We see these cases from time to time. The patient is not an excessive drinker and we need to find the cause.
These are the tests we do:
NILS (Non invasive liver screen)
https://www.tsft.nhs.uk/media/61359/Taunton-GP-NILS-vOct11.pdf
USS abdomen
Here are some common causes:
1. Drug induced
These patients may be considered for steroids after ruling out other causes
2. Viral Hepatitis
We have specialist nurses who come see the patients if they have HCV or HBV, request specialist tests ( ie genotyping) , give advice, do screening of sexual contacts if necessary and then follow them up with management.
3. Ischemic insults - such myocardial infacrtions, etc.
4. Parastic infections
If they have been travelling abroad. The infectious diseases team may be involved in this.
5. Cancer
They will have a CT of their neck, chest, thorax, abdomen and pelvis and will be discussed in the cancer MDT.
LIVER BIOPSIES
Sometimes, when no cause of deranged LFTs is found a liver biopsy is warranted.
This is done by the hepatologist consultants/registrars/specialist radiologists.
As junior doctors we may need to consent them. Before we do so, we need to take a full history to rule out any infections/ if they are on any NOACS/warfarin/blood thinners.
Once you have "clerked" them and know what the indication for the liver biopsy is ( check previous letters from the hepatology clinic), have made sure that their bloods are normal (including clotting), have not been on any blood thinners since 5 days ( this varies from trust to trust and from patient to patient- the hepatology letters will clearly state when the patient was supposed to stop them), have had group and saves (x2), you can consent them.
Please note that you should ONLY consent patients when you are aware of the procedure- if you are not, then ask your registrar to consent the patient. The patients usually receive a leaflet on this ( if not, then give them one- each trust has its own patient information leaflet).
These are the risks:
Bleeding, infection, pain, failure of the procedure, pneumothorax ( air entering into the lining of the lungs which may warrant inserting a drain to remove it), failure of procedure, multiple attempts, failure to get a diagnosis of what has caused the derangement in LFTs, death
(This may vary from trust to trust).
Usually patients need to stay in overnight after the procedure but this varies.
From a junior doctors point of view, these are the important points to remember:
1. Full clerking - ensure there is no active infection, blood thinners were stopped at the right time.
2. Bloods are normal. Group and Save has been sent.
3. OBS are stable
4. You know the procedure and can hence constent the patient.
5. Post procedure pain - this is very important. I ensure that the nurses know to contact me in case the patient is in any pain. The liver is highly vascular and hence there is a high risk of bleeding. Therefore I avoid prescribing PRN analgesia so that I can review the patient myself if (s)he is in any pain post procedure.
If there is any pain post procedure, I immediately repeat all bloods (incl clotting) and do a VBG (gives me an immediate result for Hb - if there is any drop and lactate). I contact my consultant and then discuss this with the consultant radiologist for a CT scan to rule out bleeding.
Remember, when in doubt always escalate.
CANCERS
This is the most unpleasant part of this specialty. Pancreatic cancer, liver cancers are getting more and more common. These patients need extra support and they should be referred to the cancer specialist nurses and teams immediately.
As junior doctors, our most important role is to be human. Sit with them if you have time and talk to them. Ask them how they are feeling and ALWAYS open the curtains in their dark room to let sunlight in. They need you the most. So be their pillar of support. The earlier they tell their families, the better it is for them. This way they can have extra support. Offer to tell the family if they do not wish to.
CHRONIC DIARRHOEA
https://cks.nice.org.uk/diarrhoea-adults-assessment
There are many causes of this:
1. Infective - make sure the patients stool sample has been sent for C diff, C+S, microscopy.
2. Medications - metformin and other medications are common culprits.
3. Coeliac disease - send coeliac screening tests
4. IBD - faecal calprotectin
5. Pancreatic insufficiency- Fecal elastase.
6. IBS
7. Laxatives - make sure you have stopped these.
8.Overflow diarrhoea - Always do a PR!
Usually these patients end up having a flexible sigmoidoscopy or colonoscopy.
IBD:
https://cks.nice.org.uk/ulcerative-colitis
https://cks.nice.org.uk/crohns-disease
Given that we have an amazing service for management of IBD as an outpatient/day unit, we hardly see these patients anymore. However they may be admitted with a flare up.
These patients need high dose steroids ( after ruling out sepsis, infective diarrhea ) and may be considered for steroid sparing agents ( usually the IBD nurses and consultants decide about this).
From a junior doctors point of view, it is important that these patients
1. Have an AXR as soon as possible - to rule out toxic megacolon
2. Have their BMs monitored if they are on steroids
3. Daily bloods to ensure their inflammatory markers are improving
4. Have a stool chart - this will give an idea of how well the treatment is working
5. Have had a full septic screen.
PANCREATITIS
These patients are admitted under surgeons but at times, the gastroenterology team takes over care if they are not for surgery.
https://cks.nice.org.uk/pancreatitis-acute
This is a very painful condition therefore needs to be well managed with analgesia. These patients also need adequate hydration.
IBS
https://cks.nice.org.uk/irritable-bowel-syndrome
These patients are very tricky. They are known to a particular consultant as an outpatient and when they come in with abdominal pain, once we have done the necessary investigations ( bloods, amylase, VBG, CXR, AXR), we always ask the consultant they are well known to to see the patient.
The most important thing to realize is that we should never label a patient as "functional". We should always rule out potentially life threatening and reversible causes first and ensure that we treat the patient like anyone else. They notice our facial expressions so be an empathetic and kind doctor. Listen to their concerns and manage them accordingly. Avoid giving high dose opiates and go up the pain ladder gradually.
LIVER TRANSPLANT PATIENTS
If a patient meets the criteria for liver transplant, they are referred to specialist centers ( For York, it is Leeds) for a liver transplant.
They have a very detailed liver transplant checklist which the registrars/consultants fill and email to the specialist teams.
Usually, these patients are referred as an outpatient basis however paracetamol OD ( if they meet King's Criteria) and alcohol liver disease patients ( if they have been abstinent for long enough) are also referred. It is very important to transfer all the images, investigations, medication history across to the specialist centers so that they have all the information.
ANOREXIA NERVOSA
These are complex patients usually managed by the psychiatry team. They may be admitted for NG tube feeding.
They are managed according to the MARSIPAN guidelines. It is important for all members of the team to have one view on feeding regimes rather than conflicting views. Usually, it is the psychiatry team who is the best team to advise on everything about these patients as they know them really well.
From a medical point of view, they need daily refeeding bloods including blood sugars.
THE GASTRO/HEPATOLOGY MDT
This is a huge team and everyone plays a very important role:
1. Consultants - they all have specialist interests ( in luminal pathology or hepatology).
2. Registrars
3. Junior doctors - foundation trainees, core trainees and trust grades.
4. ACPs - who have been nurses and have then trained to learn a specialist skill like endoscopies
5. PA's- Physician associates
6. Nurse specialists - they have a particular specialty role like endoscopy, IBD, IBS, Substance misuse, HCV/HBV, fibroscan, etc.
7. Dieticians - They play an important role in monitoring nutrition.
8. Specialist OT/PTs who can help with discharge planning.
9. Research specialists
This list is in no way complete. Overall it is an amazing team of experts. They all share their advice and experience.
THE GASTROENTEROLOGY WARD:
I have worked in a few gastroenterology wards in the NHS and they have not been very organized. This is because of lack of teamwork and unavailability of senior support. However the gastro team in York is amazing and I wish all other trusts follow this same principle which works really well:
1. An active WhatsApp group. We know where the consultants and registrars are. Rather than bleeping one another we update each other on the group if we need help ( we never share confidential data).
2. Active consultants - we have a consultant of the week who does a ward round in the morning and then meets the team at costa at 11 AM (where we are all treated to coffee) and then again at 4 PM.
Even if they are not available, we know where to find them.
3. Amazing registrars - they are very supportive and given that they have a dedicated rota for scopes and clinics, they do not leave the juniors alone fending for themselves.
4. An active rota team. When we are understaffed, the rota team preempts this and makes sure there is adequate cover ( we have a few excellent trust grade SHOs who help in cross covering).
5. Adequate handover to the nursing staff. The nurses and discharge coordinators inform us of any sick patients / potential discharges at 0900 therefore we can prioritize our tasks accordingly.
We also have a "Huddle" at 1430 in which we go through all of the patients with the nurses, OTs, PTs and dietitians to address any outstanding concerns.
6. Escalation plans - All patients have a clear escalation plan and the consultants actively discuss this ( and let us juniors do this).
7. Weekend ward round - The gastro consultants on call for that week come on weekends and see the sick patients from the week to ensure that the FY1 on call does not have to deal with them on their own.
8. Approachable on call gastro consultants - All our gastro consutlants do on calls and are on call 24/7. They can easily be approached out of hours to discuss scopes/sick admitted patients under their care.
9. Training - all our FY1s can do ascitic drains (under supervision) and can be signed off. They are also encouraged to pass NG tubes and bridles. Both core trainees and foundation trainees are encouraged to observe scopes, ERCPs, attend clinics, work on QIPs and hence get the maximum out of their placement.
10. A detailed handover from consultant of the week to the next - we have a meeting in the education center ( usually complimented with free food) which is attended by all members of the MDT and every patient under care of the gastro team is discussed.
11. Seeing referrals appopriately. There is always a gastro registrar who carries a "gastro phone". (S)he takes calls from GPs, other specialties including A and E ( if they are worried about someone). All referrals are seen the same day.
12. Ensuring that we leave on time. Everyone works as a team. The consultants do not hand over jobs unnecessarily and if we are really swamped, they actually help us by discussing scans with the radiologists, talking to relatives, etc.
I cannot praise the gastroenterology team at York Hospital enough. The members of the team are more or less the same as in any other trust but because of team work and leadership, everyone enjoys their placement here and learns something new making them a better doctor.
This is no way a complete list of gastro/liver patients we see as junior doctors.
Here are some useful resources:
https://www.bsg.org.uk/
https://www.yorkhospitals.nhs.uk/our-services/a-z-of-services/gastroenterology/
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