Andrew Maurice

The Use of Gastrointestinal Cocktail for Differentiating Gastro-oesophageal Reflux Disease and Acute Coronary Syndrome in the Emergency Setting: A Systematic Review

BACKGROUND Differentiating acute chest pain caused by myocardial ischaemia from other, potentially more benign causes of chest pain is a frequent diagnostic challenge faced by Emergency Department (ED) clinicians. Only 30% of patients presenting with chest pain will have a cardiac origin for the pain, and gastro-oesophageal disorders are one of the common sources of non-cardiac chest pain, yet remain clinically difficult to differentiate from cardiac pain. AIM A systematic review of the literature was conducted to locate and evaluate clinical trials comparing the use of an oral gastrointestinal (GI) cocktail (oral viscous lidocaine/ antacid ± anticholinergic) to standard diagnostic protocols (serial electrocardiograms (ECGs), serial biomarkers, imaging and/ or provocative testing) to differentiate emergency patients presenting with acute chest pain caused by gastro-oesophageal disease from those with other aetiologies. METHODS Studies were identified by searching electronic databases, scanning reference lists of articles, and searching clinical trial databases for relevantly currently registered trials. The search included PubMed (1966 - present), Embase (1980 - present) and Cochrane Central Register of Controlled Trials (CENTRAL). The identified studies were evaluated with a modified QUADAS tool. RESULTS A total of four studies were identified for inclusion in the review. Studies were of low methodological quality with heterogeneous results. There were no adequately powered and appropriately designed studies identified. DISCUSSION Current diagnostic protocols for Acute Coronary Syndrome (ACS) revolve around early and serial ECG monitoring and cardiac biomarker testing, imaging and careful clinical examination. In patients with chest pain and suspected ACS, the use of a GI cocktail compared with standard diagnostic protocols (serial ECG and biomarkers and provocative testing or imaging) is not proven to improve accuracy of diagnosis, and cannot reliably exclude myocardial ischaemia.

Improving the quality of hospital discharge summaries utilising an electronic prompting system

The discharge summary (DS) is a summary of an inpatient admission, patients health state, and future treatment plans which is delivered to the patients primary care provider. The DS is often incomplete, inaccurate, or unclear. The aim of this project was to improve the quality of the DS through the use of an electronic prompting system. The electronic prompting system was implemented in the acute medical and surgical wards of the hospital as an adjunct to a pre-existing, widely used hospital program that documents all the patients in a ward or belonging to a particular treating team. When using the program, a doctor enters information (with the assistance of the treating consultant) from a drop-down menu and is prompted to include common, departmental specific diagnoses, co-morbidities, complications, and procedures that were commonly missed or documented incorrectly in the DS. Fifteen DSs were randomly selected from a two month period immediately prior to the intervention period and were rated by an external, experienced general practitioner (GP) using a scoring system consistent with the Australian Medical Association Guidelines for quality DSs. Fifteen random DSs from a two month period, four months post-implementation were also rated by the same GP. The quality of the DS improved in all categories evaluated. The overall quality improved from mean (± SD) 2.86 ± 1.64 to 4.13 ± 0.92 out of 5 (p = 0.031). Additionally the implementation of the system was associated with improvements in documentation of the diagnosis, co-morbidities and other relevant clinical information. In summary, electronic prompting systems can improve the quality of DSs to ensure the information contained within the DS is more accurate and complete.

Improving the efficiency of discharge summary completion by linking to preexisiting patient information databases

Abstract The discharge summary (DS) is a document that contains the diagnosis, comorbidities, procedures, complications, and future treatment plan for a particular patient after an inpatient hospital stay. The DS is completed by junior medical staff and is delivered to the general practitioner (GP). DS completion is time consuming and tedious, and DSs are usually not completed within the recommended time frame after a patient is discharged. Time spent completing DSs correlate to junior doctor overtime, which costs the hospital money in overtime pay. Information that is required in the DS is generally already entered into numerous electronic information systems in the hospital, including the “electronic patient journey board” which lists all the patients in a given ward with their clinical information. This information is constantly updated by all staff in the hospital. A program was developed that transferred this information directly into the patient DS. Ten junior doctors in two departments kept daily records for one week of the time spent compiling DSs, the time at work and the actual overtime claimed, before and after the introduction of the intervention. The mean (± SD) time for DS compilation per week reduced by 2.8 (± 2.4) hours from 10.0 (±3.5) hours (p<0.01) and the mean overtime worked per week reduced by 2.8 (± 3.1) hours from 8.5 (± 4.4) hours (p<0.05). The mean overtime claimed reduced by 1.8 (± 2.8) hours from 5.3 (± 5.4) hours per week (p<0.05), resulting in reduction in mean overtime payment of

Meckel's diverticulum enteroliths causing small bowel obstruction

114.95 from

Gastrointestinal mucormycosis in an immunocompromised host

290.57 per doctor, per week. Extrapolating to the 60 ward based junior doctors, the potential annual savings for the hospital budget are over

Campylobacter colitis: Rare cause of toxic megacolon

350,000. Additionally, the number of DSs completed within 48 hours increased from 45% to 58%. In summary, the transfer of electronic data from the electronic patient journey board to the discharge summary program has yielded improvements in DS completion rates and overtime worked by medical staff, resulting in significant reduction in overtime costs.

Stump appendicitis 5 years after laparoscopic appendicectomy

A 72-year-old man presented to the emergency department with 3 days of vague abdominal discomfort and increasing right-sided abdominal tenderness. He complained of nausea and had opened his bowels earlier that day. His past medical history included a total extraperitoneal bilateral inguinal hernia repair, dyslipidaemia, gastro-oesophageal reflux disease and previous excision of a giant cell tumour from his left radius, which required a bone graft from his right iliac crest. His abdominal X-ray at presentation revealed a circular opacity in the right upper quadrant consistent with a calcified gallstone and two further opacities in the right lower quadrant which had a similar lamellated appearance (Fig. 1). Computed tomography of the abdomen demonstrated a small bowel obstruction with a large lamellated mass within a Meckel’s diverticulum and an associated lamellated mass within the small bowel at the neck of the Meckel’s diverticulum: the latter mass was the transition point for the small bowel obstruction (Fig. 2). The right upper quadrant mass was confirmed to be a gallstone present within the gallbladder. As there was no evidence of pneumobilia and the liver function tests were normal, it was reasoned that a gallstone ileus was very unlikely. The patient was consented for laparotomy to manage his mechanical small bowel obstruction. Intra-operatively, a large stone was palpable within the Meckel’s diverticulum and a further stone was found within the adjoining small bowel, which appeared to cause the small bowel obstruction (Fig. 3). An enterotomy was performed at the tip of the Meckel’s diverticulum and both enteroliths were removed. On macroscopic examination, the enteroliths appeared smooth with a fractured edge, suggesting they were likely a single stone that fractured, with one fragment migrating, causing the small bowel obstruction. The Meckel’s diverticulum was resected using a stapler. Apart from an ileus, the patient made an unremarkable recovery and was discharged on post-operative day 8. Histology of the specimen demonstrated a Meckel’s diverticulum with acute inflammation, focal perforation and submucosal peridiverticular abscess formation. There was no evidence of heterotopic tissue or malignancy. Fig. 1. Abdominal radiograph. Two lamellated radiopaque masses (enteroliths) are visible in the right lower quadrant and a gallstone in the right upper quadrant.

PS01.025: CONSEQUENCES OF MUCOSAL PERFORATION FROM LAPAROSCOPIC HELLER MYOTOMY: A SYSTEMATIC REVIEW

A surgical consultation was requested for a 61-year-old immunocompromised male with worsening abdominal pain and increasing abdominal distension. This was in the setting of myelodysplastic syndrome treated with an allogenic haematopoietic stem cell transplant, complicated by graft versus host disease. There was no other surgical history. Upon review, the patient was haemodynamically stable and afebrile. A multiphase abdominal computed tomography scan was performed, which was suggestive of non-enhancing loops of distal ileum with associated mesenteric stranding and free fluid, concerning for ischaemia/infarction (Fig. 1). The remainder of small bowel was pathologically dilated, indicating obstruction. A laparoscopy was performed, which showed patchy necrosis of the small bowel and perforation of the distal ileum. A laparotomy was performed (Fig. 2) with resection of 110 cm of distal ileum; the ends were left stapled with a view to re-look in 48 h and reassess the remaining bowel to assure viability. At re-exploration, a further 50 cm of necrotic small bowel was resected and an end ileostomy and mucus fistula were fashioned. Histopathology revealed angioinvasive fungal organisms scattered amongst areas of necrotic bowel, with hyphae extending into the walls of regional blood vessels, with associated intestinal transmural infarction (Fig. 3). Tissue culture confirmed a diagnosis of mucormycosis secondary to Rhizopus species and amphotericin B was commenced. Two weeks following the operation, the patient developed worsening abdominal pain, vomiting and confusion. Computed tomography showed extensive small bowel ischemia, perforation and intra-abdominal free fluid. Given his complications from immunosuppression and the need for extensive bowel resection, the treating team and family decided against further surgical or therapeutic interventions. The patient was palliated and passed away several days later. We have reported a rare case of gastrointestinal mucormycosis, which clinically appeared to be ischaemic bowel, and have provided intraoperative, histological and radiological images. Risk factors, diagnosis and principles of treatment will be discussed. Mucormycosis refers to angioinvasive infections caused by fungi in the order of Mucorales. Of these, the most common genera are Rhizopus and Mucor, with Rhizopus oryzae being the most common pathogen accounting for more than 70% of cases. Mucormycosis is characterized by the invasion of blood vessels by fungal hyphae, leading to necrosis and infarction. Infection typically occurs in the presence of immunosuppression, including patients with haematological malignancies, uncontrolled diabetes and diabetic ketoacidosis, haematopoietic stem cell transplants and solid organ transplants. In haematopoietic stem cell transplants recipients, graft versus host disease and voriconazole therapy further increases the risk. Other predisposing factors include iron overload, especially those receiving desferrioxamine therapy; and wound contamination in the setting of penetrating trauma and blast injuries, which may present with a cutaneous manifestation of mucormycosis. Gastrointestinal involvement is rare and usually involves the stomach, colon or ileum. It is associated with a significant risk of mortality, which is up to 85%. Gastrointestinal cases may present with abdominal pain, gastrointestinal bleeding, perforation or unexplained sepsis. As this disease typically affects the

Functional outcomes ten years after lung volume reduction surgery

Highlights • Campylobacter colitis is usually self-limited but life-threatening toxic megacolon can occur.• Toxic megacolon is characterised by non-obstructive colonic dilatation, combined with evidence of systemic toxicity.• Early surgical consultation is recommended.• Indications for operation include perforation, uncontrolled bleeding, and worsening colonic dilatation and toxicity.• Despite treatment, toxic megacolon is associated with significant mortality.

Transcatheter aortic valve implantation in patients with percutaneous coronary intervention to the left main coronary artery

A 31-year-old healthy man presented with right lower quadrant pain and tenderness, mild neutrophilia and clinical presentation consistent with appendicitis, despite undergoing a laparoscopic appendicectomy 5 years prior. CT scan demonstrated a caecal phlegmon, in the expected region of the appendiceal stump. The patient was taken for laparoscopy and a 2 cm inflamed appendiceal stump was encountered. A distal caecectomy was performed and the patient made an unremarkable recovery. Histological examination was consistent with acute inflammation of the appendiceal stump. Only a small number of case reports of stump appendicitis have been published so far. Correct identification and ligation of the appendiceal stump is crucial to prevent this complication. Although normally it is treated with completion appendicectomy, the optimal treatment approach for this condition has not been well established.