About Dr Chris Hair

1. About Dr Chris Hair • Gastroenterology and Endoscopy • Colonoscopy, Crohns disease, ulcerative colitis, coeliac disease and IBS • Clinical Teaching • -Clinical senior lecturer Deakin University • -Director of National training in capsule endoscopy (small intestine) • -Co-director of gastroenterology training in Suva, Fiji • -International Trainer, Solomon Islands, Fiji • -Founding member, Australia and New Zealand Gastroenterology International Training Association (ANZGITA) • -Member of World gastroenterology Organisation (WGO) training committee www.drchrishair.comwww.anzgita.org

2. The yellow man in pain • Dr Chris Hair • Gastroenterologist • Epworth Private Hospital, Geelong

3. Case Presentation • 65 yo man presents to Belmont GP • Crampy Epigastric pain overnight • Shivers and shakes • Single vomit • PHx • Stable angina, • Mild COPD • A few stubbies per night • Metoprolol, perindopril, aspirin • 37.5 C • P 110 regular • BP110/80 • RUQ palpation, seems very tender

4. presentation • No stigmata of chronic liver disease • Whilst examining him he offers: • - no alcohol use • No recent travel or unwell contacts • No recent antibiotic use or new medications • No injecting drug use • No family history of liver problems

5. Review the stigmata of chronic liver disease

6. Painful Jaundice • What are the clinical and examination features that help us to define the urgency and severity Urgent case comorbidity Pain severity Older Age Fever Onset acute Hemodynamic stability

7. DDx The medical emergency cases are acute cholecystitis, ascending cholangitis, and liver abscess – prompt referral and managment Jaundice

8. Clinical Clues in the clinic

9. Dx: Ascending cholangitis – the not quite peritonitic abdomen… • Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture. • The most common organisms isolated in bile: • Escherichia coli (27%), • Klebsiella species (16%), • Enterococcus species (15%), • Streptococcus species (8%), • Enterobacter species (7%), and Pseudomonas aeruginosa (7%).

10. Ascending cholangitis • Symptoms include the following: • Charcot triad: right upper quadrant (RUQ) pain, fever, and jaundice (15-20% ) • Fever is present in approximately 90% of cases. • Jaundice is thought to occur in 60% of patients. • Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection. • Consider cholangitis in any patient who appears septic, especially in patients who are elderly, jaundiced, or who have abdominal pain.

11. Ascending cholangitis • Prognosis • The prognosis depends on several factors, including the following: • - Early recognition and treatment of cholangitis • - Response to therapy • - Underlying medical conditions of the patient • Mortality rate ranges from 5-10%, with a higher mortality rate in patients who require emergency decompression or surgery. • The following patient characteristics are associated with higher morbidity and mortality rates: • Hypotension , renal failure, abscess, cirrhosis, older age and multiple comorbidity, fail to respond early to antibiotics

12. Pre hospital management • Mild cholangitis may present with abdominal pain, jaundice, and fever. • When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous (IV) line (can rapidly deteriorate) • In unstable patients with cholangitis, prehospital care should include the following: • - Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement) • - Stabilization (eg, oxygen, placement of large-bore IV, administration of IV fluids to unstable patients) • - Rapid transport • - Empirical antibiotics (?after blood culture) (Amp/Gent/Metronidazole) (timentin)

13. TAKE HOME MESSAGE; painful jaundice Urgent case comorbidity Pain severity Older Age Fever The medical emergency cases are acute cholecystitis, ascending cholangitis, and liver abscess – prompt referral and managment Onset acute Hemodynamic stability

14. The Pale Woman Dr Chris Hair, Gastroenterologist

15. Presentation • A elderly woman presents tired and pale • Fatigue, lethargy 2 months • Sleeping a lot more 1 month • Off food last few days, had occasional dark stool • PHx: • CAD and stents, AF • Mild CVA and DM • Ticagrelor, warfarin, metformin, lipitor

16. Which dark colour stool has you worried? A C B

17. Investigating pallor • Afebrile, BP 130/90, P 80 reg, good JVP, lungs clear, abdomen soft n/t • Sent for investigations: • Hb 99, urea 12.9, Creatinine 98, INR 1.2 • Blood film: microcytic anaemia: • ddx IDA, • Thalassemia, • acquired microcytosis (anaemia chronic disease) What to do next?

18. Interpreting iron studies

19. Medical Care • Starts with the investigation of the cause of IDA • Commence oral iron supplementation immediately • Referral to specialist with expertise in upper and lower endoscopy +/- capsule endoscopy • refer all male patients and post-menopausal woman • refer pre-menopausal with severe iron deficiency anaemia • consider early referral of pre-menopausal woman with recurrent anaemia or failure to respond to oral iron

20. How to manage IDA Crohns, UC, coeliac (early) Iron polymaltose 1% allergic reactions, cheap, slow infusion Iron carboxymaltose 0.5% allergic reactions, more expensive, IV push

21. Returns for review to clinic • Collapses in the waiting room toilet and calls for help, • P 120, BP 60/40 • Transferred to clinic treatment room • Large coffee ground vomit and then large malena • What Management? • A: call ambulance • B: insert cannula if avail, apply oxygen, and ECG monitoring (if avail) • C: Fluid support (eg 1L IV saline stat) • D: administer maxalon 10 mg IV

22. Who to call • All cases of suspected or confirmed acute UGIB (hematemesis or malena) to an emergency dept after initial management • Patients with ‘subacute’ presentation who are not unstable can be discussed with specialist and baseline investigations sent • Patients with chronic UGIB symptoms can be investigated and managed as outpatients unless there is severe anaemia present.