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Yeah, wait for everyone to join. Yeah. Ok. I think we can start. Ok, so good evening everyone. Welcome back to the second episode of the series on emergency presentations for junior doctors. Today. Doctor Abraham and Doctor Hardwick will be teaching us about abdominal pain and coffee, ground vomit. Before we begin, we welcome our presenters, Doctor Abraham. Doctor Hardwick. We appreciate you taking up the time to be with us today. Um Thank you Rosa. So um I'll just start sharing the presentation um while we're doing that, I'll introduce myself. So um my name is Molly, I um trained in the UK and I'm currently um a working um as my second year as a doctor um in the UK and I work in the same hospital as John and we work up in Liverpool. So thank you for coming back or joining us for our um mini series on emergency presentations. And as we were saying on Monday, this series aimed at um getting you ready for what you're gonna need to know as a junior doctor um working as a first year junior doctor. So today I'm gonna be doing um a bit on abdominal pain and John is gonna be doing um a bit on coffee ground vomit. So without further ad we'll make a start. Um so mine is on acute abdominal pain. Obviously, this is so last time when we did chest pain similarly to this, this is a huge topic. And so we're going to focus mainly on history differentials. And then we, I've got a few very, very urgent courses of abdominal pain which will go through um you know, the initial management that you guys will be expected to do before cool or registers. But lots of this talk is about recognition because um with abdominal pain, it's important to be able to recognize the um serious stuff from the less serious stuff. So let's make a start. So as with any um condition, you're always gonna go to your patient, you're gonna take a history, do your a to assessment. And then at that point, once you've done your history and your um examination, you, you can start thinking about your list of differentials and then hopefully you'll be able to, based on the fact you've done everything you'll be able to um initiate some immediate investigations and interventions if needed. So anyone who remembers my talk from last time, remember our friend um Socrates, the philosopher. So we're gonna use him again. I use him pretty much in all my histories. So with your um abdominal pain history, use Socrates again. So just a quick recap for anyone who wasn't here. Last time that is the site onset character, radiation associated symptoms, timing, exacerbating or relieving factors and severity. And that will give you a really, really broad overview of the abdominal pain and help you work out what's going on some additional stuff for abdominal pain with the associated symptoms. I um find it easiest to work down the body. Um So I start off by um asking about swallowing, you know, are they having any difficulty swallowing? So I kind of follow the G I tract down. So difficulties with mouth with swallowing, nausea and vomiting. Like how much, how often the color the contents? So are they, are they vomiting blood? Are they vomiting? Bile? John's going to talk about um coffee ground vomit and vomiting blood later. So I'll leave that to him and then stay on the tummy. Talk about kind of like appetite and whether they've had any weight loss, appetite might suggest that they're really quite unwell if they don't want to eat anything. Whereas weight loss could suggest something underlying like cancer that's been going on for a long time, then you want to move on to the bowels. So are they opening their bowels? How much, how often color consistency contents you want to know, especially about blood and mucus and changes from their normal bowel habit. Um Nobody said that medicine was, was glamorous, did they? Um And then finally, it's really important to ask about flatus So if they've been passing wind when they last pass wind, um, and that's really important when you're thinking about obstruction. So the bowel not working properly. Um And then finally, there are a few other symptoms which also lie in the abdomen as well as the G I tract, which we need to consider. So, in everyone, we need to consider the urinary tract. So, um, we need to think about the symptoms of uti as I've got written there, you need to think about flank pain for the kidneys and anything that might indicate um you know, infection or problems with the urinary um tract. So, for example, if you had fever and rye or you might be thinking fever, you say if you have fever rye or and back pain, you might be thinking more about pyelonephritis. And then in women, we also need to think about um gyne. So we need to ask about bloating, which might um indicate ovarian pathology discharge, um bleeding, you know, are they a postmenopausal woman who's having um bleeding when she hasn't had a period for two years? So, you know, it's important to understand that there's other things apart from just the G I tract in the abdomen. So before we go any further, I thought it would be really useful to distinguish peritonitis and peronism. This is something that I um found quite confusing. And so I thought it would be good to just um establish the what they are and the differences between them. So, peritonitis, as you would kind of expect from, the name is inflammation of the peritoneum. And I'm sure you guys remember that you've got two linings of the peritoneum. One that lines the um the viscera, which is the visceral peritoneum and the other that lines the abdominal wall and that's called the parietal peritoneum. So, inflammation of either of the layers or both of the layers is called peritonitis and that's most commonly caused by a perforation of an abdominal viscus. So, viscus is an organ. So if you perforate your bowel, um and your bowel contents goes into your abdomen, that's going to irritate the peritoneum and cause peritonitis. And so, peronism is then the signs and symptoms of peritonitis, which we're gonna go through in the talk. Um And then if someone's peritonitis, they're displaying the signs of peronism. So they're displaying the signs and the symptoms of peritonitis, which then shows you that there's something going on in the abdomen. So that's just a bit of a few definitions for you. Um Something that I always found a bit confusing. So we've done our, so we, we've spoken about a few things to look out for in our site in the history, but specifically about peritonitis. So, II, I was talking to John room about this before we started, but um the innervation of the peritoneum um defines how pain is felt. So the v the parietal peritoneum which is adhered to the viscera, the the afferent. So the nerve signals going towards the spinal cord travel with the sympathetic nervous system and they produce a very dull and poorly localized pain. And because they're traveling with the autonomic nervous system, the sympathetic nervous system, they produce um kind of feelings of nausea. They can make people vomit and they can make people sweat, you know, all those kind of autonomic symptoms. Um and it produces dull, poorly localized pain, which is often um radiates to the midline of that dermatome. So, for example, um in the mid gut, you'll feel it in the umbilicus. The for gu you'll feel it in the epigastric region and the hindgut, you'll feel it in the suprapubic region. So it depends where um the pain is in the um gut will um determine where it's referred to. And then, so say you've got a perforated, basically say you've per to your appendix. So initially just the visceral peritoneum is gonna be painful. So we know the appendix lies in the mid gut. So you're gonna feel like a dull, poorly localized pain in the umbilicus. As the inflammation progresses to um the parietal peritoneum, the para perineum is stuck to the out to the inside of the abdominal wall and that is um innervated by the same nerves which are supplying the abdominal wall. So those afferent go with the somatic nerves and they are much more localized. So they will then produce a severe sharp localized pain. So that's kind of their and again, reflected in peritonitis. So as the inflammation um from se rupture, appendix travels and um the pri peritoneum starts to become involved in the inflammation. You then get the migration of the pain from the umbilicus to MC Burney point, which is two thirds of the way from the umbilicus to the um anterior superior iliac spine. So that's just a bit about Peric pain. So it means that it can move a bit. But uh a history of dull pain which progresses to a very severe sharp localized pain would suggest to you that, that um there is an element of peritonitis. So, yeah, so appendicitis, for example of that. Um So like we said, so with peritonitis, you can have pain which is localized or generalized. It's generally worse on movement because you're um moving the inflamed areas. It's like if you got an inflamed muscle and you move it, it's gonna hurt, same with the abdomen. So these people will generally try and stay quite still. So they'll be not wanting to move. They're not going to be rolling around the bed in pain. They're going to be lying really still. Um They might have some abdominal distension and they're gonna be feeling really unwell. So they're not gonna wanna eat, they're gonna be nauseous, they might be vomiting and they're probably gonna have a fever if they're developing an infection. If you have some sort of perforation. I was to be sweating. So you've done your history, you move on to your examination. Uh Hopefully you guys all have had it drawed into at UNI and we did it last session. But the A to E assessment is really important. And as we said, abdominal examination plus or minus pr lies within e exposure. And as is anything work from A to e initiate any interventions if required and once you have initiated, always go back and recheck after each intervention. So I at uni I was always taught this little acronym IP P A and I still use it today when I'm doing my examination. So it stands for inspection, palpation, percussion and auscultation. So when you're looking at the abdomen, it could be distended and you've got to think, OK, why is this descended? And one question that I find helpful is to ask the patient, does your abdomen look normal to you? You know, you've never, you might not have ever seen their abdomen before. You don't know what it looks like. So it's useful to get a gauge from them if it looks normal. And that's a fairly non offensive way to ask you to say, does your abdomen look normal to you? If they say, oh no doctor, it looks really distended. You can be thinking OK. So there's, there's something going on. It could be some fluid ascites, it could be gas suggesting they've got an obstruction, they could just be overweight, they might be pregnant or are they just have they just not been passing any stool? Are they really impacted with feces? So you also want to have a look for scars, hernias, see if you can see, maybe they've got a huge abdominal aortic aneurysm which you can see pulsating um and signs of liver disease like put me do say and then Cullen sign is a and gray turner signs are both signs of, I'll show you a photo of them in a second and it'll pop up. Um But they're both signs of um hemorrhages within the abdomen. This both both will appear with acute hemorrhagic pancreatitis and they're quite um patho pneumonic. So and they're good things to look out for when you're looking at the abdomen. Um So they look like this. So peen sign is bruising around the tummy button and gray turner sign. It's kind of in the flank area on the um lateral aspect of the abdomen. It's not that clear from where it is on that um photograph. But so they're both really useful when you're doing your abdo exam and you're doing your e part of exposure, have a look out for those because they're suggesting hemorrhage in the abdomen fine. So then we, so we've done inspection. So now we move on to palpation. So this is where we have our first poll. So um if Rimer or John is able to bring this up. I think the question is um what are um what did these three signs? Which disease did these three signs indicate if John Rasha just lets me know what the most common answer is. So, it seems like appendicitis is one with 68%. Yes, exactly. So, so these three signs um would be suggestive of appendicitis. So I've got some photos of what they are. So um roughing sign would be if you're palpating on the left side of the abdomen, you then because you're moving all of the, you know, you're moving all the abdominal, all the viscera. So where you're pressing, it's causing movement on the, on the right hand side where the appendix is, which is then gonna, because you're moving an inflamed area, it's gonna cause pain. So, pressing on the left hand side causes pain on the right hand side. So that's a resting sign. And then, so the pso A S sign and the obturator signs are painful because the inflammation of the appendix will then cause inflammation of the surrounding stuff as well. So, these are particularly um if the um appendix is lying posteriorly or Retroperitoneally, so it will um inflame the psoas muscle and the obturator internus muscle. So you've got um so the psoas muscle, you can either do a straight leg raise with the right leg or as they're showing you can bend the leg up. Um Alternatively, you can lie the patient on their left hand side and move the right leg back. Basically anything that's going to move the P OS muscle and then the obturator sign is similar. So you bend the leg up and you um kind of rotate the uh lower leg out and the upper leg in. So you rotate it around and that will cause pain um in the obturator muscle. So those are signs of appendicitis and then we've got another poll. So, what is Murphy's sign indicative of? Just let me know what everyone's saying to him? So, it seems like the most responses are for cholecystitis. Yes, exactly. Um, and just another note of palpation, if you feel a big abdominal aortic mass, that could be a AAA, but I'll show you a photo of, um, Murphy sign. So, so for anyone who doesn't know Murphy sign is when you are, um, it's palpating the upper right quadrant of the abdomen and you ask the patient to take a deep breath in. So that causes their lungs to expand and push the diaphragm down. And as the patient is, is breathing in, you push your hand into the, into the upright quadrant just at the, um, the bottom of the ribs. And if you're doing that, you're going to be hitting the gallbladder as it's moving down, your hands are going to be hitting the gallbladder and if it's inflamed, that's really going to hurt them and they'll, they'll flinch backwards. Um, so that would be Murphy's sign and that would um indicate cholecystitis. And then finally, so we've done inspection, palpation, percussion is next. So, um if your percuss in the abdomen, um it's gonna be tympanic, um it might, you might have a lot of gas. Um, if it really hurts when you're just, when you're tapping like that, that might indicate they're peritonitis and they could also have shifting illness such as ascites. And then finally you need to listen to the tummy. So if it's really tinkling obstruction, you can't hear anything at all. It's an ele or there's obstruction or you might hear some bruit, which would indicate AAA or renal artery stenosis. So we're onto our third pole now, which is a bit of a clinical scenario. So just let me know what everyone says, John, just waiting for the uh the responses to come in. That's fine. Yeah. So 67% of people voted for obstruction. Mhm. That's exactly right. So if you've got somebody who the abdomen is really distended, so you're thinking, ok, the five Fs, you then tap on it and it sounds really, really re that's making you think, ok? Is that fluid? Sorry? Is their gas is their latest? And then um, you listen and you hear tickly bowel sounds, that's gonna make you worried about obstruction. And then you can, um, you know, go through all the necessary steps that would involve probably getting an abdominal x-ray doing apr exam asking them, how, you know, when was the last time they opened their bowels and then you probably need to escalate it to a senior. So, just a bit of stuff on what a peritonitis abdomen is gonna be like. So they're gonna be really, really tender on palpation. It might be guarding, which means they're contracting the abdominal muscles to try and stop you pressing on the area that hurts what that could progress to is rigidity where the whole of the abdominal wall is just contracted, involuntary to try and prevent um anything moving the uh inflamed viscera underneath, you can have percussion tenderness. If you feel something that's painful, that could be an abscess. They might have reduced bowel sounds because sometimes you can get IES which is where the bowel goes on strike. If it becomes inflamed, they can also then have systemic features being unwell such as fever, tachycardia or shock. So I think time is moving on. So if you just take a moment just to try and remember which uh which organs are in each area of the body and we'll quickly go through this because it's quite important to when you're thinking that your differentials, it's quite important to think where all the organs are because it's pretty addictive. If you know where all the organs are, you can work out what's hurting underneath it. So just give me two minutes, just try and think of two organs which are in each region So, if we start with number one, so up in the right hand corner, I hope you guys will remembered. So you've got the liver and the gallbladder, like we just talked about, you've got at the back, you'll have your kidney and you've also got the small intestine up there. You've also, you'll also have your, um, your large bowel and you'll have the hepatic Flector. And then in the epigastric region you have the stomach, you'll have the, um, uh, the left lobe of the liver, the pancreas, duodenum spleen and adrenal glands. On the left hand side, you have the spleen and the colon, the left kidney at the back and then the tail of the spleen tickles, the pancreas, um, sorry, other way around the tail of the pancreas take of the spleen. Um, so the pancreas will come over and meet the spleen. Um, and then in the lumbar region, if you've got a large gallbladder, it'll be there. If you've got a large liver, it will be there. And the colon in the middle, you've got lots of your, um, small bowel, uh, and some of the duodenum on the other side, you've got your descending colon and your left kidney and the bottom in the right iliac. You've got the, um, appendix aum in the SUPT region, you have the bladder sigmoid and your female reproductive organs like the uterus. And in the left iliac, um, you'll have the descending colon and the sigmoid colon. So that's just useful to help you think. And then we go on to this slide which gives us some differential. So just take two minutes and just try and think of one differential for each of these regions. If someone has pain in each of these regions, just think of one differential because basically when you're on call and you're called to see someone with abdominal pain, you're gonna be examining their abdomen and as you're feeling, you're gonna think, oh gosh, they've got pain in the right hypochondrium. And you're going to be thinking, ok, is this something to do with their liver or their gallbladder or is it more bowel? So you might feel up there, you might be thinking gallstones, cholangitis, hepatitis liver, abscess, cardiac causes because sometimes, um, chest pain might actually present as like upper abdominal pain or um, similarly your lungs come down kind of more at the back. Um, and they can cause like upper abdominal pain. So these would kind of be all your differentials that you're thinking of. I appreciate there's loads to think of there, but it's, it's all about thinking what organ is in that area and how can it become inflamed at or you know, how can there be a problem with that organ and then you can go from there. So it's just really knowing your anatomy well, and then you can use that to work out what's going on. So, and general stuff you can do. So you've felt the abdomen, you felt the region and you, you're thinking, ok, this organ sits here and you can do some investigation to use some bloods. So it's always useful to get a BBg. You can see, you know, if they've got a metabolic lactic acidosis that's going to tell you. Ok. Well, they're not perfusing there. They might even be perfusing their abdomen enough. You know, it's something, something not getting enough blood supply. If their HBs dropped, you might be thinking about bleeding. It's always good to get a um, a set of bloods have a, just a thought. I haven't done this as a poll, but in hindsight, I should have done this as a poll. If, if somebody, if you're really worried about someone, you think they might have to go to theater, which set of these bloods do you think would be the most important to take John? Just let me, if you guys write it in the chat, John, just let me know what people are saying. I think everyone might be a little on the shy side. One that's came in. They, they've wrote, they're all coming in now. So it seems to be a toss up between group and save and coag. So, and I think that's, that's really good thinking about everyone. Um, and it's group and save because you always need to know their group and say before they go into theater and would you agree, John. Yeah, I, I definitely think so. It's actually going to be one of my questions. Sorry. Sorry. No, no, no. It's, it's an excellent point group and save is probably the most important of the lot um in that blood panel. So, and then you got to think about imaging. So if you, they're obstructed, you can get an x-ray, an abdominal x-ray, they're also useful for, if you can see free air under the diaphragm that suggests that they might have perforated because you shouldn't really have air under the diaphragm. The ultrasounds are really good for the liver and the gallbladder for Gyne, you might want a CT plus or minus contrast. And the key thing with all of these things is if you're, if you got an unwell patient, you've done the basic investigations and your a to inputs are not helping them get better. You've given them, you know, if you think they're septic, you've given them antibiotics, it's not improving. Call for senior health early because often surgical patients might require going like having urgent imaging, going back to theater and your seniors will need to know that because they're gonna be the ones who are going to be performing the surgery. You can think of yourself. Like in a little alarm bell, you're gonna go and assess and if you think gosh, this patient's really ill, you're gonna then alert someone who is going to be able to actually perform some surgery on them. So we're coming on to the last section now. So it's just some differentials which require really urgent intervention. So, are worth knowing about. So the acute bleeding perforated viscus ischemic bowel POSTOP leak and systemically unwell. So I'll talk about if you've got a POSTOP anastomotic leak. So this can happen any time POSTOP. But classically, it happens between 3 to 5 days POSTOP and this will present with a patient who um has got abdominal pain, it could be Peric and they could be becoming septic. So they're starting to become more unwell in their recovery period when they should be getting better. And it's at that point that if they're developing abdominal pain and sepsis. So that suggests that um the, the connection between the two loops of bowels not worked and all the contents are leaking out and causing them to become septic. So, so that will require really urgent intervention. So you need to assess them and as you would with your A T start them on fluids um and antibiotics and let your senior know because they'll need some urgent imaging. They'll need a CT to see if the um two sections of the bowel have come apart and then they, they might need to go back to theater and then if they're really unwell, um you know, they'll need some urgent intervention with, you know, your sepsis. Um What in the UK, we use something called the sepsis six. So that includes giving IV fluids, antibiotics and um oxygen if needed. So, yeah, so those two, we kind of sort of spoken about, so we'll move on to acute bleeding. So obviously there's loads of places you can bleed from in the abdomen. Really important ones would be AAA rupture, you know, that will kill you really quickly bleeding peptic ulcer. So, um, peptic ulcers can bleed a lot, especially if they erode backwards and they can cause bleeding to the, um, the arteries around the stomach, especially the gastroduodenal artery, traumatic injuries and ruptured ectopics also bleed a lot. So we present with a patient who is hypovolemic, they have, they might have abdominal pain, you know, if you've got a AAA rupture, you're very likely to have abdominal pain. Um, they will be, they have all the signs of hypokalemia when you're assessing them on their a to. So they'll be pale clammy hypo sensitive tachycardic and they'll have symptoms of end organ hypoperfusion. So they, they might be confused because they're not perfusing their brain enough, they might have very poor urine output, they're going to be cold. Um All of those things. So what you need to do as a junior, you need to go and examine them. What's really useful is if you take, you know, when you're doing your, um, C section of your A to when you're taking your bloods, if you take a VBG you, when you run the BBg, you'll very quickly know that the HB has dropped and you'll be able to see from their previous bloods and that will immediately get, get you on to thinking, gosh, is this patient bleeding? So you can start some emergency fluid resuscitation. So you know, as when you first work out they bleeding, you can give them fluid. But really you want to replace like for like, and if they're bleeding a lot, then you should activate the major hemorrhage protocol. So try and replace blood with blood. Um So in the UK, we have a major hemorrhage protocol that we can activate, which means that lots of blood comes up for the patient. Um And we can get that to them very quickly. They'll need an early ct to see where the blood is coming from, where they bleeding from. And then they're probably gonna need some sort of surgery to stop it bleeding. So really what you, what you, you guys should be doing as, as as new doctors is going to the patient recognizing they're unwell and they're bleeding at that point, you call for help while help is on its way, you can start with the fluids and order the blood. And then when help is there, you can start putting the blood in and start the investigations with the CT. So that's acute bleeding and this is a bleeding peptic ulcer and you can see that it's re you know, you can see the amount of blood that's coming out here. They can really, really spit. Um, so, and then next one is, um, perforated viscus. So, perforations again have loads of courses causes, um, peptic ulcers, obstructions that just get bigger and bigger and bigger. And then the bow just poops. Um, diverticular disease. You can get bursting of the diverticulum, uh, in inflammatory bowel disease. Um, again, ulcers and cancer can also cause perforations. So they'll present with peronism. So it can either be local. So if the omentum is gonna ward off the inflammation, then they'll just have an area where they're, they're just guarding in that area. Um, whereas if it's um perforated and there's um kind of like intra-abdominal contents within the, um, the whole of the abdomen, that'll be irritating the whole of the peritoneum. So then you've got peronism and they'll probably have signs of sepsis like hypertension, tachycardia fever. So for that, you're gonna want to assess them and do your seps six that we just talked about. And then you're going to call for help early because again, they're gonna need a CT to work out where they've perforated and then they, they're probably going to need surgery depending on, um, depending on what's happened. So again, you go to them, you assess them, you do the early interventions and then you call for help because these, these people need to get to theater first and here you can see part of the bowel that's perforated. So you can see the holes in the bowel. Um, so this is somebody who's gone to theater. And, um, to me, I'm not 100% sure because it didn't say, but this looks like, um, some sort of ulcer. So this could be maybe inflammatory bowel disease. Um, and then mesenteric ischemia is also important to know about. So this is where you get a lack of blood supply which causes infarction of the bowel. And if the blood supply is not, if, if the bowel is not res supplied with blood, it can become necrotic and perforate. So, again, really serious can be, um, caused by a thrombus. So similar to like a heart attack, you can have like a heart attack in the bowel is what, how we sometimes explain it to patients with a thrombus or it can be an embolus. If someone's got af and um, a clot is thrown off and goes, um, out of the, um, left ventricle through the aorta and then into the superior mesenteric artery, you can then get it in the, um sna and that will cause an infarction downstream from the embolus. So these people tend to have sudden onset really severe constant abdominal pain. So it's, it, you can think of it like a heart attack for the abdomen. Um, so you can have really, really bad abdominal pain. They could have, um, pr bleeding, um, or bloody diarrhea. And um, they can develop signs of shock peritonitis or sepsis if they go on, if the bowel is becoming necrotic or perforates. So, again, this is really important to recognize really quickly. So you're going to want to do bloods, your VBG is really important. That's going to show you if they've got a high lactate with or without a metabolic acidosis. And again, the high lactate is gonna make you think gosh, is, is this part, is this bowel not being perfused properly? And are they going to need, um, you know, have they got mesenteric ischemia? So, again, you're gonna want to call for help early because they're gonna need, um, a ct to see, um, where in the bowel is, um, becoming ischemic and then, um, they're gonna need surgical intervention and that what they do in the surgery is they restore the blood supply to the bowel and they look at the bowel and they take away any necrotic bowel because that would just perforate. So, so they, um, they might need surgery and I'll show you so on these pictures. So on the left hand side, you can see, um, towards the bottom right corner, you've got lots of nice pink bowel and then, um, the bowel by the hand is looking quite dusky. So that's bowel, that's, that's, um, ischemic and, you know, might be on its way to becoming necrotic. And then on the photo, on the right hand side, on the, um, kind of upper left corner, you've got some bowel, which is looking really quite black. So that is an aquatic bowel. So see that bowel is stuff that would have to be removed and wouldn't be able to be saved. Great. So that's the end of my talk. I'll hand over to John um good evening everyone. Um Nice to see all of you. Thank you so much for that talk um on the acute abdomen molly. Um We'll just give everyone probably 15, 30 seconds just to stretch their legs. Um And then we can talk about coffee ground vomit and thank you all for joining us today. I'm John. I'm one of the um medical doctors working in the northwest of England in the same hospital as Molly. Um I studied in Rigo and did my six years there. I think we a good group of people from the last talk that attended from RIGA. So really nice of you to join us from there and then all our colleagues around Europe. Um So we'll start off with coffee grand vomit as today's talk. Um I didn't put many um polls in for the last A two assessment, but we thought we'd loaded up this session with um as many polls so that it could be as interactive for all of you guys. So coffee ground vomit, we'll start off with the first poll. What are we concerned about when discussing coffee ground vomit? So um we'll we'll start with the first pole. Ok. So I can see the, the response is slowly coming in. Um So it's, yeah, so it's an upper G I bleed. Um So we'll just do the next poll straight off the bat. What do we think? Or, or where about in the body? Can we distinguish? Oh, this can be an upper G, I bleed from a lower G I bleed. So you've got four options right there. You've got ligament of trite DJ, flexure, splenic flexure and pyloric sphincter. Um This might be a little trickier than, than the last question. OK. So it looks like it's a toss up between the ligament of trites as well as pyloric sphincter. So, um the answer is ligament of trites, which is, um which is located just behind the duodenum. So it's basically a ligament that um it's a band like structure that supports the duodenum. And um it also helps facilitate the gastric contents to push through the G I tract. And now in regards to an upper G I bleed. So, in regards to an APP G I bleed, we're just concerned about bleeding that's taking place in the esophagus, in the stomach or in the duodenum. And anything below that um is considered AAA lower G I bleed. So you can have a quick look there with the red arrow is, is pretty much where the ligament of tri actually sits. It's just behind um the duodenum and just keeps it anchored in position in the G I tract. So, next poll, um, what do we have there? It's quite important when we talk about upper G I bleeds. Um, there are three options. Is it your good going regular stool? Uh Is it diarrhea or is it Melena? So, for those of you in final year, this is probably jogging your memory and, and for those of you who have probably just started med school, um, Melina might be a new sort of concept or something that you might not have heard of. But yes, we've got 96% that have picked Melina. So, yeah, um, we'll talk about upper G I bleed signs. So, um, there's three main ones that we're um, interested in. So the first one is coffee ground vomit. Um, so we're talking about coffee ground vomiting. Um, it's essentially, it's digested blood that's ended up um, in the stomach and it's been vomited out. Um, the next, uh, the next sign we have is Hammes. Um, and so that's throwing up, um, bright red blood and then the final sign we have is Melena. So Melena is the digested blood that ends up going through the um G I tract and comes out the other end. And when we talk about Melina, it's one of those things as a junior doctor and as a med student, it's something you'll read in your textbooks and it's often described as Tarry Black greasy, foul smelling stools. Um, the reality of it is as soon as you see it for the first time, um, you'll never really forget what it looks like a lens smells like. So it's something that you'll definitely come across when dealing with upper G I bleeds. So, um, the etiology behind an A G I bleed. Um So if we look at the, the four main causes, um, the four main causes, the first one is peptic duodenal ulcer. Um and that sort of constitutes the, the, the biggest risk factor behind the upper G I bleed. So it's secondary to H pylori or if you're taking nsaids. Um The second one is um I think the order is mallory wise is what we might have. Yeah. So this is usually includes forceful retching. Um and this is preceding any bleeding. Um The one after that is uh varices. So that's a result of portal hypertension. So with all our sort of G I organs, all the blood is being um taken back by the portal vein. And um we see portal hypertension where the blood's not able to be able to go through the portal vein. Um for whatever reason, this can be something like liver cirrhosis. And so we get a backflow of the blood um and as a result of hypertension and um collateral um circuits need to be made to get into the systemic circulation. So that's something that's seen in liver cirrhosis and a lot of these veins that ended up with um increased pressure. Um end up bulking in size becoming dilated and they can form viruses which can bleed at any point. And the last one is malignancy. So any of these gastric tumors, um it can be a bleeding tumor or erosion of any of the G I vessels. And the main one we see is the GD next slide. So I'm just going to go through this clinical case. Now, this is something that I actually dealt with a couple of weeks ago in A&E so patient was rolled into recess. So the story goes something like this. It's a 61 year old chap and what we know from the nurses that they've came in coffee ground vomits. It's happened twice and some dizziness. So um he was seen by the triage team um and then put back into the waiting room after they had taken some blood. So while he sat in the waiting room, he's had a further episode which is around half a liter projectile brand on it. And this is in the waiting room with there's tons of other people. Um and the medical team have now rushed him into um the resuscitation zone from what we know, pale sweaty clammy. Um but he's still talking in full sentences and um the coffee ground vomit looks a lot like the the image on the right hand side. So go approach the patient and then find out um what's been going on. So this is what he says, started vomiting brownish darkish red colored vomit yesterday, while walking in the park just before it happened, felt dizzy and quite shaky. So I sat on the ground and waited for the symptoms to subside 10 minutes later as I was resuming my walk, I vomited again. Don't feel very well, doctor. So alarm, alarm bells might be ringing a what do we think could be happening? Um, but compared to other sort of clinical situations or scenarios, um, we can't afford to take a full history, which is going to take a while. So we need to take something a bit more focused. So we use something called a sample history. So that is signs and symptoms, allergies, medications past medical history. The last time they've had anything to eat or drink. So that could be suppose they need to go to the theater. Um, are they fasted? Are we worried that if they've had any food recently, there's a chance they could aspirate, um, and then any events that could lead up to the presentation? So if we go to the next slide, so if we fill in this, we've got the sign. So at the moment, we know the hypotensive, the tachycardic in terms of symptoms as well. We've had coffee ground vomiting, they've been a bit dizzy, the patient's got no drug allergies. Um, and in terms of their past medical history, we can see that they've got hypertension hyperlipidemia, as well as liver cirrhosis. We've asked the chap, when is the last time they had anything to eat or drink? And it was around 12 hours ago. And in terms of events leading up to the event, like he had mentioned to us, he was walking in the park drinking a few cans of beer. So there's some extra questions we can ask because we're now starting to think, ok, maybe this is a potential upper G I bleed. And so we asked them, what did the, the blood look like? And we're told it's dark red, brownish in color. Um, have they had any coffee ground vomiting before? Um, and this gentleman says, ok, I had a, um, OGD a couple of years ago and I was told that it showed esophageal viruses, um, in terms of any changes in the color of his stool, he says that it's jet black and it smells quite offensive. Um, next question to ask. Are they on any regular medications? Um, he's not able to recall which ones he's currently on. Um, and then we press a little further and he says that he's not on any blood thinners or taking any nsaids like Ibuprofen that he's aware of, um, the medical conditions. We already know he's got liver cirrhosis hypertension and hyperlipidemia. And does the patient drink alcohol or smoke regularly? He says it's usually a bottle of wine per night and a few cans of beer while watching the football but he doesn't smoke. So this goes back to the last topic, what we want to do is you want to start our A two assessment? We've taken a focused history. So, um, airway patient, he's talking in full sentences. We're not worried about any airway compromise. So we move on to B which is breathing. So chest is clear. There's equal air entry, oxygen's floating around 93%. So we decide, ok, let's get some oxygen on start with 15 liters non rebreather. Um, and then wean our way down respirator 18. So we're not too concerned, move on to circulation. So heart sounds are normal. He's running quite tacky at 100 and 24. Um, capillary refill times less than three seconds. BP is slightly on the lower side. It's 100/56. Um The ECG shows sinus tacky. So it's what we want to do from there. So as we said, we want to be able to treat as we move along. So get some access early on, preferably for these upper G I bleeds, it's a medical emergency. So we want to be able to get some large vol Cannulas in there at least two and in regards to blood, we can save. Um So the lab knows, um, when we want to be able to um, give a transfusion and then we can also cross match which means that they can actually get blood specifically ready. So we can cross match two units and take a full blood count, buy a chem coagulation and a VBG. And as Molly had mentioned before, out of all those, the most important thing, we've got a patient that could be bleeding out um quite a lot so group and saves can be the most important. So we know what their blood type is. Um when it comes to um transfusing blood, it's going to take a long time in the lab. Um Molly had mentioned it before, but we've got something which is known as the major hemorrhage um protocol. So we can get blood to them quick and o negative is um typically what we um tend to give if we don't know their blood type, move on to disability. So the blood glucose is fine, temperatures are 37.6 G CS 15 and um pupils are equal and reactive to light and now we move on to e so exposure is something that we leave to the very end of a two and a lot of stuff can sort of get forgotten about. Um So we see there's some brown vomit at the side of his mouth and on his abdomen, his ascites, um calves are normal. And then um he had mentioned having um Tarry black stools. So we roll him over and we do apr exam and he um has got melena. So in this first image over here, um as you can see on the left, um his abdomen is there's ascites, but we also see this phenomena called Kappa medusa. So we can see these distended collateral veins around the umbilicus. And this is one of the telltale signs of um portal hypertension. You've got the coffee ground vomit as well as the melena. So first one that we do is VBG the bloods are going to take a bit of time. And um first thing we see is PH, which is 7.37. So that's all right. And then the HB um has taken a bit of a drop. So it's now 100 and five. and the lactate is 3.4. So we're a bit concerned, could there be some hyperperfusion? There's some ischemia. Um and then the blood slowly come back from the lab. So, as it was confirmed in the BG, there's a drop in the hemoglobin. And before we move on to the next one, we'll let pole um or cue the next pole, which is what would be altered in the biochemistry um in keeping with an upper G I bleed. So, is it sodium potassium urea or magnesium? So it looks like the, the vast majority have picked um urea and second place against the potassium. Um So, yeah, um So urea is actually the, the most common value that's um disproportionately increased um in the biochemistry, it's usually seen next to the creatinine. Um And we got to be quite care to look that um it is disproportionately um increased um as the patient because they're dropping a lot of um volume in terms of blood and they could be quite dehydrated, which is why um their renal function might be affected. Um sodium and potassium tends to, to stay the same CRP is less than five. And um the liver function enzymes are all deranged, which is in keeping with the liver cirrhosis, move on to the next slide. So why is the urea raised? Yeah, it's a good, it's a good point. So um it's one of the breakdown components of the blood. Um and uh once this gets absorbed into the intestines, uh it gets transferred over into the blood. And so we tend to see an increased amount of blood urea. So we'll pull this next one, which is what do we think is the cause of um upper G I bleed in this specific patient? Is this a potential peptic ulcer, gastric malignancy, varices or is it a mall wise tear? Yeah. So it looks like it is. Yeah, the most, the most voted one was um esophageal viruses, which is correct. So, um the reason why we're thinking about this is, yeah, the patient has liver cirrhosis, um signs of P hypertension. He's got the ascites, he's got the kapa medusa and on top of everything he had mentioned early on in the history that um he's got known esophageal viruses from this. Um OGD this upper endoscopy scope. He had a couple of years ago. So there's a high likelihood A K this is actually the same thing representing itself. Um But it's also important to, to mind um what other causes could be and be yet, what are the signs that could point us towards that direction instead? Um Next slide. So yes. So like we had mentioned before with the other um causes. So peptic ulcer, um typically we tend to see patients that have got um epigastric pain. They've got some dyspepsia, they've got a history of maybe using nsaids that's led to um bleeding of um of a stomach ulcer, et cetera or duodenal ulcer. Um With maori wise tests, they tend to involve um big episodes of binge drinking or gastroenteritis. And then for stomach cancer, we tend to see these constitutional symptoms at first. Um So weight loss, fatigue, anemia, just like we tend to see with a lot of other um malignancy, but it can also um manifest with epigastric pain, treatment, resistant dyspepsia. Um anemia like we've mentioned before, a raised platelet count. So, um when it comes to the actual management of upper G I bleeds, you know, it's a medical emergency, which means um it's one of those things where a patient can become very hemodynamically unstable and a lot of the time with these young adults where it can present, they're quite good at compensating for that. Um in terms of their physiological parameters and it can mask a lot of the time. And so it's very quickly the case that they can deteriorate. So, um escalate to your seniors quite early on and use this acronym of a basis. So um A is for the A two assessment which we've done B is for blood. So we've taken all the necessary bloods, um A for access, which we've got, we've got two cannulas in um T is for transfusions. So um blood platelets clotting factors. So we're thinking about either um transfusing, um fresh frozen plasma could be the case of fluids, um ease for endoscopy. So, chances are if we're worried about an A G I bleed and if they um if we use the GBS score, which I'll talk about in the next couple of slides, um if they score a one or above, then there are a high likelihood of an upper G I bleed, which means they've qualified to get an endoscopy um and the D is for drugs. So we got to make sure that um whatever is potentially causing this bleed, we don't want to be adding to that. So we stop any nsaids or any anticoagulation they're on um when it comes to variceal bleeding as well. Um There's a few more um measures that we can implement. So IV pressing is something um that we put on um which uh acts as a vasopressor and helps stop the bleeding and it's very common to have bacterial infections that um are in keeping with variceal bleeding, which is why we cover them with um IV antibiotics and they last for about a week or so. Um and they can become very systemically unwell and, and paint a bit of a septic picture. So, um it was before, for a, for a good, um, before the, the last set of guidelines came out, antibiotics weren't um actually on them along with um PPIs. And there's still a lot of research into whether um proton pump inhibitors are helpful before endoscopy. Currently, they're not indicated for non variceal bleeding before a patient gets scoped. Um If they're not on any warfarin and the inr is above 1.5 then we can give fresh frozen plasma. So Glasgow Blatchford score. So this is going to be one of the cornerstones of being able to assess and manage A G I bleed. And it's something that you're going to have to escalate when you speak to your seniors, whether it's the medical registrar or heaven forbid, you might have to speak to a consultant about getting an emergency scope. And one way to be able to calculate the risk of an upper G I bleeded is to use this score and you can use an online calculator. I think med CALC is, is one that's used a lot and it takes into account quite a few different values. So in that table, uh on the right hand, side, it takes into account their blood urea, their hemoglobin, their systolic BP, and then there's other markers. So that would be their heart race, whether they've got Melena, whether they've presented with CINO or they've got hepatic disease or cardiac failure. So, if we look on to um the next part, we're going to actually calculate the Glasgow Blatchford score um for this patient. So we'll let these values slowly trickle in. Um And um we'll put the table alongside next to it. So if we move to um if we click one more time, hopefully the table should pop up. Yes, bingo. So um what I'll ask you guys to do is to be able to calculate the G BS score for this patient and then we'll put a poll out. So we'll give you a bit of time. There's a few values you've got to take into consideration and top them all up and then we'll put out a poll so we can start the polling. I think there's a chance that maybe the, the right answer hasn't been put on there. Um But put the one closest to that um as it stands. So I think the, the responses are slowly trickling in. Um So we can all count it up together as such. So we've got the blood urea. So if we look on the table, it's 13. So as a result, we've got four points there, the HB is 105. So they've got one there. So total scores five for that side. The BP is um, 100 to 109. So we've got six points there. Pulse is over 100 so seven. they've got Melena which is eight. and they've got hepatic disease which is 10. Um, so we're looking at, yeah, well above 10 points for this. Um, so this instantly tells us a case patient definitely upper G I bleed and they're going to qualify for a emergency. Um OGD. So in terms of calculating score, this helps us decide. Ok. Can we discharge this patient with an outpatient endoscopy? Do they need to remain as an inpatient and get this scope within the next 24 hours or is it something that they need? And which is an emergency and they need to be scoped um within the next hour or two hours or so. So if the G BS score is zero, then we can consider an early discharge with an outpatient endoscopy if it's one or above. Um then they can um then they should be listed for an endoscopy within the next 24 hours. Um If it's around six or above, chances are this 50% needed um for an intervention and if a scoring um an eight or above, it's a big sign of a major bleed. And so you need to speak to the gastroenterologist on call um within an hour of this diagnosis. So that they can get scoped. So another um score calculate that we can use is rock all but that's used um after an endoscopy to estimate the risk of rebleeding and mortality. So it's, it's very much different to the, to the GBS score which is pre um but we can use um this rock or score after they've had um an endoscopy. So if we to up the scores here, patient, 61 the um systolic BP was 90/56 and they've got comorbidities of liver cirrhosis. So um if we have a look there, um it's one plus um two and they've got liver um liver failure. So we're looking at yeah, six points or so, which is a suspected variceal bleed, which is a high risk. So, but going to endoscopy, you've done your part as a junior doctor and this is all a bit of, I guess fun upper G I bleed trivia, but we'll do a poll really quickly. Does anybody, can anybody tell me um which grade varices we'd be looking at? So um you can an later by, you can click an later and then you can have a quick look at the images and then decide which grade um variceal bleed. We think it could be. Yes, most people click between grade two and three. And so um for this, um for this case with the images that you can see um it's, it's probably blocking around 50% or more of the Luminal diameter, um which is why we give it grade three. the patient that we actually saw a couple of weeks ago, which is this case, he was a known grade three esophageal viruses. And if we look where the arrow is pointed on the on the right hand side, um this is known as cherry spot sign and it's basically on the actual endoscopy, you can see what looks like a cherry spot, also known as whale sign, uh where an actual, where blood's basically um leaking out of from the actual viruses. So um for an actual um variceal bleed, what we tend to do the main cornerstone of treatment is band ligation. So um it works by capturing the virus with a small band resulting in inclusion in an occlusion from the thrombus. So to put it simply, we're essentially putting an elastic band around the actual um viruses and then this tissue becomes necrotic and then it sloughs off over a few days to weeks and you're left with uh what's probably a a superficial scar and it should heal um um over the next few weeks or so. So this is what it looks like in an OGD when they do banding. Now, for the last slide. So if we're not worried about varices and we're worried about a ulcer, for example, we can think about sclerotherapy in the form of thermal coagulations or we can put clips on and like we had mentioned with variceal bleeding. Um We can do this ligation, we can do tips which involves putting in shunts to divert the blood flow. Um The IVT depressant we had talked about before um if they've got definitive hemostasis, um we can stop it otherwise it can be stopped after five days and the IV antibiotics. So the car amoxiclav that we had prescribed, um that goes on for a full week. Um And that's all for today's A G I bleed um talk. Um We really appreciate this. It's a very quick lecture. I think there's a lot of information over the hour, but we hope you guys really liked it. Um If there's any questions in the chat, please feel free to, to ask. Thank you. So I think there are some questions in the chat just trying to go up to the top. Um So do you want to, should we do your questions first on? Uh Yeah, sure. I'm just uh reading, sorry. Um They said considering if their stats are a bit low. I think what the stats 93 why would do a BBg? Not an AB G consider? Yeah, there's definitely a claim to that. I think with 93% it's not something that we were particularly worried about in terms of their breathing was all right. And on paper, we always say 15 liters non re breed. In reality, we always just start off with nasal specs. Couple of leases and his oxygen picked up to, I think 95 96% and it wasn't something where, um, we are too worried about hypoxia but um, definitely true that we could, we could have taken an ABG um, as well. Um, so I think there's a lot of people saying thank you. We, we're a bit over time. So I don't know. Do you want to um, I can pick maybe one or two. Yeah. Do you want to pick one or two questions? And then yeah, so there's one about one ongoing acute virus you bleed present with fresh blood. Yeah. So um this is something that I asked the medical registrars with I said, OK, isn't this the case that we're getting it straight from the esophagus um outwards but a lot of the time the the blood in itself can be digested and go to the stomach and can also present as, as coffee ground vomit as well. Um So I think those are the ones the upper G I bleed. I think there's one for you. Maybe Molly. Yeah, it's quite a specific question. Um So it sounds like actually a clinical scenario um which maybe I don't think we have time to answer today, but just because we're already running out of time. Um So maybe, I mean, it sounds like a very specific situation. So if you've got a very specific clinical question, maybe ask somebody on the clinical team for that patient. Um unless you could see a different question for me, John at just I can't see anything related to acute abdomen. So that might be it for great. But thank you for everyone for joining us. Yeah, thank you so much, Doctor Abraham, Doctor Hardwick for the e engage in discussion. Uh We've learnt a lot and it was very informative and as you can see, everybody has been saying thank you in the chat box. Um, to all the participants. Uh Thank you for joining us today. We'll be looking forward to seeing you again on Monday for the third episode and to get your certificates, please check your emails, the feedback forms have been sent there. You must fill them out to get your certificates and we will see you all on 20.