Page 149 - Medicine and Surgery

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Chapter 4: Clinical 145

paralysis of gut motility leading to dilation. Fluid ac- Aetiology
cumulation within the lumen of the bowel may result in The most common cause is peptic ulcer disease (35–
fluid and electrolyte imbalances. This may further exac- 50%) often exacerbated by the use of nonsteroidal
erbate the paralytic ileus. anti-inflammatory drugs.
Acute gastroduodenal erosions can follow any major

Clinical features illness (8–15%).
There is abdominal distension with little evidence of re- Oesophagitis (5–15%).
bound or guarding. If patients are not nil by mouth they Mallory Weiss tears of the oesophagus resulting from
develop copious vomiting. Patients do not pass stool or vomiting (15%).
flatus and bowel sounds are characteristically absent. Oesophageal varices may cause torrential bleeding (5–
10%) (see page 199).
Investigations Rarer causes include upper gastrointestinal malig-
Abdominal X-ray shows gaseous distension with multi- nancy and vascular malformations.
ple fluid levels in the lumen of the bowel. This may be
optimally seen on an erect film.
Clinical features
Haematemesis is vomiting of blood. It may appear fresh
Management
redoras‘coffee ground’ altered blood. Melaena is the
It is treated conservatively with i.v. fluids and nasogastric
passage of black tarry stool due to at least 50 mL of
tube (drip and suck). Fluid and electrolyte imbalances
digested blood; however, if there is very fast gut transit
should be corrected. Any underlying cause should be
time or rapid bleeding, bright red blood may be passed
identified and treated.
rectally. It is essential to identify any coexistent medical
conditions especially renal or liver disease and those with
Pseudo-obstruction widespread malignancy, as these patients (along with the
Definition elderly) are at greatest risk of mortality.
Arareconditioninwhichsymptomssuggestobstruction
but where no obstruction is present. The condition is Investigations
seen following major respiratory or renal disease and/or Urgent full blood count, U & Es, LFTs, coagulation
after major trauma. screen and cross match specimens should be sent.
The haemoglobin level may not be low despite severe
Clinical features blood loss until fluid redistribution or resuscitation has
Symptoms are similar to those of intestinal obstruction, occurred.
with distension and tinkling bowel sounds.

Investigations and management Management
Abdominal X-ray reveals gas extending to the rec- The initial management is to correct fluid loss and hy-
tum, which may be useful to differentiate from true potension. All patients require large bore cannulae ide-
obstruction. It is managed conservatively, any under- ally in the anterior antecubital fossae. A central line may
lying cause should be identified and treated. also be necessary for measurement of the central venous
pressure. If the patient is in a state of shock they should
be catheterised for accurate hourly fluid balance. Any
Acute upper gastrointestinal bleed
coagulopathies should be corrected, e.g. with vitamin K
Definition and fresh frozen plasma.
Acute upper gastrointestinal bleeds arise from the stom- Young patients with minor bleeds and no comorbid-
ach, duodenum and oesophagus. ity should be observed and undergo an elective en-
doscopy.
Incidence Patients with more severe bleeding, particularly older
50–150 per 100,000 population per year. patients or those with comorbidity, require urgent