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

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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

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Gastroenterology & AAU

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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

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Acute GI Bleeds

• Risk assessment: Initial Blatchford AND

Rockall Score after endoscopy

• History• Haematesis/Malaena?• PMH• Co-morbidities• Medication

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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

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• 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

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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)

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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

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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

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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

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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

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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%)

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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

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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

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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

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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