OXFORD MEDICAL PUBLICATIONS Emergencies in Gastroenterology and Hepatology Published and forthcoming titles in the Emergencies in... series: Emergencies in Adult Nursing Edited by Philip Downing Emergencies in Anaesthesia Edited by Keith Allman, Andrew McIndoe, and Iain H. Wilson Emergencies in Cardiology Edited by Saul G. Myerson, Robin P. Choudhury, and Andrew Mitchell Emergencies in Children’s and Young People’s Nursing Edited by E.A. Glasper, Gill McEwing, and Jim Richardson Emergencies in Clinical Surgery Edited by Chris Callaghan, Chris Watson and Andrew Bradley Emergencies in Critical Care, 2e Edited by Martin Beed, Richard Sherman, and Ravi Mahajan Emergencies in Gastroenterology and Hepatology Marcus Harbord and Daniel Marks Emergencies in Mental Health Nursing Edited by Patrick Callaghan Emergencies in Obstetrics and Gynaecology Edited by S. Arulkumaran Emergencies in Oncology Edited by Martin Scott-Brown, Roy A.J. Spence, and Patrick G. Johnston Emergencies in Paediatrics and Neonatology, 2e Edited by Stuart Crisp and Jo Rainbow Emergencies in Palliative and Supportive Care Edited by David Currow and Katherine Clark Emergencies in Primary Care Chantal Simon, Karen O’Reilly, John Buckmaster, and Robin Proctor Emergencies in Psychiatry, 2e Basant Puri and Ian Treasaden Emergencies in Radiology Edited by Richard Graham and Ferdia Gallagher Emergencies in Respiratory Medicine Edited by Robert Parker, Catherine Thomas, and Lesley Bennett Emergencies in Sports Medicine Edited by Julian Redhead and Jonathan Gordon Head, Neck and Dental Emergencies Edited by Mike Perry Medical Emergencies in Dentistry Nigel Robb and Jason Leitch E mergencies in Gastroenterology and Hepatology Daniel Marks BSc MB PhD MRCP Wellcome Trust Postdoctoral Fellow University College London Hospital Marcus Harbord BSc MB PhD FRCP Consultant Gastroenterologist Chelsea and Westminster Hospital, London 1 3 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2013 The moral rights of the authors have been asserted First edition published in 2013 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer British Library Cataloguing in Publication Data Data available ISBN 978–0–19–923136–2 Special trade edition ISBN 978–0–19–968773–2 Printed in China by C&C Offset Printing Co. Ltd. Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-to-date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-pregnant adult who is not breastfeeding. Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work. v Foreword I am delighted to write a Foreword for this excellent practical book written by two young gastroenterologists. Each chapter is headed by a symptom or condition, and the reader is then led quickly into clear and up-to-date advice on managing them, without expanding into aetiology. I was particu- larly pleased to see useful advice on diffi cult-to-manage symptoms, such as nausea and vomiting and thoracic pain, and the inclusion of nutritional treatment. The chapter on HIV disease will be especially useful to the average gastroenterologist or general physician faced with the myriad of potential complications of this disease and side effects of treatment. The authors are to be congratulated. I predict this will be a handy refer- ence book (in the hand or on a screen), for all grades of doctors faced with these common problems. Sir Richard Thompson President Royal College of Physicians London, UK January 2013 This page intentionally left blank vii Preface This book focuses on managing the sick gastroenterology and hepatol- ogy patient, providing a point of rapid reference for use at the bedside. We make no apologies for covering a wide range of problems, as what may seem mundane to the visiting physician can be an emergency for the patient. Throughout, we have focused on giving practical advice, try- ing to answer the sorts of questions we have both faced over the years, as well as addressing emergency topics that are minimally covered or absent in other texts. This book provides contemporary guidance for doctors training in gastroenterology and hepatology, their seniors, and other team members responsible for the assessment and care of the acute medical patient. It complements the Oxford Handbook of Gastroenterology and Hepatology that one of us co-authored. We are grateful to its other co-authors Stuart Bloom and George Webster for their advice and friend- ship over many years. On a personal note, we would also like to thank the following experts, who have peer-reviewed many of the chapters or provided some of the images: Mike Anderson, Martyn Caplin, Tom Doherty, Matthew Foxton, Brian Gazzard CBE, John Karani, Aamir Khan, Nas Khan, Rob Miller, Iain Murray–Lyon, David Nott OBE, James O’Beirne, Alastair O’Brien, David Patch, and Stephen Wright. We are particularly grateful to Kevin Moore, editor of the Oxford Handbook of Acute Medicine, who was instrumental in this book’s early stages and who has contributed some content. We also thank our families for their support, and OUP for its patience. Finally, we thank you, the reader, without whom the written word has no purpose. We invite you to contact us with any suggestions to improve the text. Daniel Marks, BSc MB PhD MRCP University College London Hospital [email protected] Marcus Harbord, BSc MB PhD FRCP Chelsea and Westminster Hospital [email protected] This page intentionally left blank ix Contents Symbols and abbreviations xi 1 A cute upper gastrointestinal bleeding 1 2 Acute lower gastrointestinal bleeding 21 3 Severe iron defi ciency anaemia 35 4 Severe vomiting 45 5 Severe acute diarrhoea 61 6 Gastroenteritis 75 7 C omplications of infl ammatory bowel disease 91 8 A cute thoracic pain and dysphagia 109 9 A cute abdominal pain 125 10 Malnutrition and chronic gastrointestinal disease 157 11 Complications of nutritional support 171 12 HIV disease and the gastrointestinal tract 181 13 Assessment of liver function 193 14 Jaundice 207 15 Acute liver failure 235 16 Complications of cirrhosis and portal hypertension 251 17 Infections and the liver 273 18 Drug-induced liver injury 291 19 The liver in pregnancy 309 20 Hepatic trauma 319 21 Hepatic, neuroendocrine, and general oncological emergencies 329 22 Liver transplant patients 343 Appendix 357 Index 365