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Developing people for health and healthcare
Update in Gastroenterology for the Acute Take
Kingston Hospital NHS Foundation Trust
24 July 2014
Dr Helen MatthewsConsultant Gastroenterologist
Developing people forhealth and healthcare
Summary• What’s new in gastroenterology?
Hepatitis C & Direct Acting Anti-virals
• Gastroenterology and AAU (Alcohol) GI Bleeds Paracetamol Overdose & ALF Anorexia and re-feeding
Developing people forhealth and healthcare
Developing people forhealth and healthcare
Gastroenterology & AAU
Developing people forhealth and healthcare
Alcohol & AAU
• Alcohol & brief intervention for hazardous & harmful drinking
AUDIT-C or FAST
• Wernicke’s Encephalopathy
Parenteral Thiamine 5 Days
• Delirium Tremens• Oral lorazepam
• Parenteral lorazepam/haloperidol/olanzapine
• Acute Alcohol Withdrawal Clinical Institute
Withdrawal Assessment – Alcohol, revised (CIWA-Ar)
Benzodiazepine (or carbamazepine, off label with informed consent….)
Symptoms triggered regimen
Alcohol-use disorders overview NICE 2014
Developing people forhealth and healthcare
Acute GI Bleeds
• Risk assessment: Initial Blatchford AND
Rockall Score after endoscopy
• History• Haematesis/Malaena?• PMH• Co-morbidities• Medication
Developing people forhealth and healthcare
Examination• Resting tachycardia =
Mild/moderate hypovol• Orthostatic hypotension =
blood loss 15%• Supine hypotension: >40%• PR!
Initial Resuscitation• Blood transfusion with
care• Platelets if platelets <50
AND actively bleeding/haemodynamically unstable
• FFP if fibrinogen <1g/Litre OR PT/INR or APTT >1.5 times normal
• Prothrombin complex concentrate (Beriplex) if taking warfarin and actively bleeding
Developing people forhealth and healthcare
• Controversial• Transfuse if Hb <70g/L, aim >70 g/L
Transfuse/aim Hb >90 g/L if unstable angina, elderly
• Avoid overtransfusion in variceal bleeds (and others?)
• Hypovolaemic patients with normal Hb may need blood
Blood Transfusion
Developing people forhealth and healthcare
Villaneuva et al. NEJM 2013
• 1610 presenting with UGI Bleed screened,
921 randomised• Restrictive (<70 g/L) versus Liberal (<90 g/L)• Survival (95 % vs 91%; HR death 0.55 ,95%
CI 0.33-0.92: p=0.02)• Further Bleeding (10% vs 16%;p=0.01)• Adverse events (40% vs 48%; p=0.02)
Developing people forhealth and healthcare
Medical Treatment Prior to Endoscopy
RESUSCITATION
NON-VARICEAL: PPI ?Hold off until after endoscopy (NICE 2012 versus ROW)Re-introduce aspirin ASAP
VARICEAL:Full septic screen and prophylactic antibioticsTerlipressin 2mg qds iv
Developing people forhealth and healthcare
When to call the GI Bleed SpR/Consultant?
• Endoscopy to unstable patients
with severe upper GI bleeding
immediately after resuscitation• Offer endoscopy within 24 hours
of admission to all other
patients with upper GI bleeding• Interventional radiology to all
patients who rebleed after
endoscopy• Surgery if IR not available• Consider early TIPS in varices
NICE Guidelines 2012
Developing people forhealth and healthcare
Paracetamol/APAP overdose: New Guidance on Treatment with Intravenous Acetyl Cysteine
• ALL patients with timed paracetamol level on or above a single treatment line receive acetylcysteine regardless of risk factors hepatotoxicity
MHRA Sept 2012
Developing people forhealth and healthcare
Paracetamol/APAP overdose: New Guidance on Treatment with Intravenous Acetyl Cysteine
• If in doubt (staggered overdose/timing) GIVE – do not use nomogram
•Administer initial dose of acetyl cysteine as an infusion over 60 minutes
•Hypersensitivity is no longer a contraindication
MHRA Sept 2012
Developing people forhealth and healthcare
Acute Liver Failure:Transplant Listing Criteria in UK – Superurgent #1
• Ph<7.25 after 24hrs and fluid resus
• PT>100s or INR >6.5 AND creat>300/anuria AND Gd3-4 enceph
• Lactate >3.5 after 24 hours on admission or >3 after resus
• or 2/3 from 2 with clinical deterioration (raised ICP, FiO2>50%, ↑inotropes)
NHSBT Liver Advisory Group 2013
1. Paracetamol poisoning (25%)
Developing people forhealth and healthcare
Subacute/Acute Liver FailureTransplant Listing Criteria in UK – Superurgent #2
2. Seroneg hepatitis, hep A/B, drug reaction (55%)
• PT>100s/INR>6.5 and any enceph
• Any enceph PLUS 3 of drug/seroneg; >40yrs; jaundice to enceph >7days; bili >300umol; PT>50s or INR>3.5
3. Acute Wilson’s/Budd Chiari and any enceph
4. HAT d0-21 post LT5. AST>10000 u/L; INR
>3; Lactate >3 d0-76. NHS Live liver donor,
severe liver failure <4/52
NHSBT Liver Advisory Group 2013
Developing people forhealth and healthcare
Survival % UK
Diagnosis 1 year 3 years
5 years
Elective LT 88 (92) 82 75
Superurgent LT 78 (88) 74 72
Data from RCS/NHSBT Liver transplant audit, 2012 (1994-2012)
Survival % by Aetiology
Diagnosis 1 year 3 years
5 years 10 years
Cirrhosis 83 76 71 60
Acute Liver Failure
68 63 61 55
Cancer 78 62 53 40
Data from European Liver Transplant Registry, 2008
MARSIPAN:Management of Really Sick Patients with Anorexia Nervosa2010
Re-Feeding including Anorexia Nervosa
Developing people forhealth and healthcare
Re-Feeding and Underfeeding
• Potentially fatal cardiac and neurological
abnormalities (WHO 1999; Mehanna et al. 2008)
• Early identification of high risk patients
• BMI <16, Rapid Weight Loss, ETOH abuse. NICE
2006
• PO4, K+, Mg2+,Vitamin, U&E, Glucose
Adapted from NICE 2006, BAPEN 2001
Developing people forhealth and healthcare
Summary
•Ask about alcohol use: FAST/AUDIT-C
•Don’t over transfuse especially the cirrhotics (but resuscitate!)
•Only one line for PODs
•Re-feeding versus underfeeding