Standards & guidelines for daily practice
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Mistakes in acute jaundice and how to avoid them
Jaundice—one of the major signs in medicine—can result from numerous conditions
Jaundice or icterus (derived from the ancient Greek word ikteros that described the yellow-breasted oriole bird) is not a diagnosis in itself but constitutes one of the major signs in medicine. Jaundice refers to the yellowish discoloration of tissue that occurs as a consequence of the deposition of bilirubin. This discoloration is a physical manifestation of a marked increase in serum bilirubin levels. Normal serum bilirubin values are <17 μmol/L; for jaundice to be perceived visually serum bilirubin levels need to be elevated to >40 μmol/L (equivalent to 2.5 mg/dL).1Most serum bilirubin is formed from the breakdown of the haem contained in senescent red blood cells by the reticuloendothelial system. Thus, unconjugated bilirubin is released in the bloodstream, where it is bound by albumin. Through the blood circulation bilirubin is moved to liver hepatocytes, where it undergoes further processing. In brief, bilirubin becomes conjugated in the hepatocytes through glucuronidation, which allows it to be excreted from the body (unconjugated bilirubin is water insoluble and cannot pass into the urine). Conjugated bilirubin forms one of the main components of bile and most of it passes through the biliary tree to the intestine. Unconjugated and conjugated bilirubin are reported in laboratory measurements as indirect and direct bilirubin, according to their chemical properties (i.e. reaction with reagents).1 Jaundice can be caused by abnormalities in any of the steps comprising the formation, metabolism and excretion of bilirubin. In addition, these processes may be functioning properly, but jaundice can be seen because of an obstruction of the biliary tree at any point, from its intrahepatic origins to its end at the ampulla of Vater. For this reason, it is clear that numerous conditions can result in jaundice. When faced with a patient presenting with jaundice a reasonable and careful diagnostic approach is, therefore, warranted to elucidate the underlying cause of this sign. Conventional wisdom may be that “jaundice by itself never killed anyone,” but it is imperative to find the cause as soon as possible, as prompt intervention saves lives in many cases. Here, we outline several of the mistakes made when approaching a patient presenting with acute jaundice based on our clinical experience and published data.
Congress experience for half-price
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Hereditary Gastrointestinal Polyposis Syndromes
Improve your understanding of Hereditary Gastrointestinal Polyposis Syndromes
ESGAR/ESCP Bowel Imaging Workshop (Multidisciplinary)
Learn about new imaging methods, clinically relevant questions and more.
Mistakes in capsule endoscopy and how to avoid them
Wireless technology means capsule endoscopy is well tolerated, but it is also a drawback
Capsule endoscopy is a noninvasive technique intended for studying the small bowel and/or colon. The capsule endoscope consists of a small, wireless, pill-sized camera that can be swallowed and allows direct visualization of the gastrointestinal mucosa. The design of the capsule differs depending on the part of the gastrointestinal tract to be studied. The small-bowel capsule has one optical dome and is generally used in patients who have suspected bleeding or to identify evidence of active Crohn’s disease. By contrast, the colon capsule has two optical domes, a higher frame rate and can be considered as an alternative to conventional colonoscopy, especially for cases when the examination was incomplete. There is also a new capsule with two optical domes that is designed for the panendoscopic study of both the small bowel and colon.The main characteristic of capsule endoscopy is the wireless technology, which enables it to be very well tolerated. However, this feature is also one of its drawbacks, as the capsule cannot be directly controlled by the physician. The capsule moves through the gut depending solely on intestinal motility, and the examiner is not able to drive it back and forth or to stop it to look more carefully at any finding. Moreover, the visualization relies heavily on the adequacy of intestinal cleansing as rinsing with water and aspiration are not possible. Capsule endoscopists should be aware of these shortcomings, as they directly affect the reading and diagnosis. Here we discuss frequent errors that are made when performing capsule endoscopy, based on the published literature and more than 15 years’ experience
A not-so-black-and-white case of gastrointestinal bleeding
What's causing the black tarry stool, episode of coffee-ground emesis and epigastric pain?
A 60-year-old woman presents at the Emergency Department complaining that she has been passing black, tarry stool since yesterday and had an episode of coffee-ground emesis some hours ago. It is the first time she has noticed these kinds of symptoms. Moreover, she reports episodes of epigastric pain on and off during the past week.The patient has never undergone endoscopy. Her medical history includes diabetes mellitus, hypertension, hyperlipidaemia, gastro-oesophageal reflux disease (GORD), osteoarthritis and alcohol abuse. She admits that she occasionally uses nonsteroidal anti-inflammatory drugs (NSAIDs) to cope with episodes of pain caused by her osteoarthritis and that she took some in the past week. On physical examination she is tachycardic (92 beats per minute) and hypotensive (82/57 mm Hg), but afebrile and her oxygen saturation level is normal. Her abdomen is mildly distended, with some tenderness during deep palpation and increased bowel sounds. Her blood test results at presentation are shown in Table 1. A variceal bleed was suspected, and an emergency upper gastrointestinal endoscopy was performed (see video). Case Question 1 WHAT IS YOUR CLINICAL DIAGNOSIS? A. Oesophageal melanoma
B. Oesophageal infection (e.g. CMV, HSV, Candidiasis)
C. Acanthosis nigricans
D. Acute oesophageal necrosis (AEN) Case Question 2 WHICH OF THE CONDITIONS FROM THE PATIENT’S MEDICAL HISTORY IS NOT ASSOCIATED WITH THEIR DIAGNOSIS?
A. Diabetes mellitus
B. NSAID use
C. Alcohol abuse
Case Question 3 WHICH OF THE FOLLOWING MEASURES IS NOT RECOMMENDED FOR THE MANAGEMENT OF THIS PATIENT?
A. Nil per os
B. Aggressive fluid resuscitation
D. IV acid suppression with PPIs
E. Glycaemic control
Personalised nutrition - food for thought
Developing tailored eating advice based on individual nutritional needs
‘Personalised nutrition’ represents any attempt to provide tailor-made healthy eating advice based on the nutritional needs of an individual, as dictated by their behaviour, phenotype and/or genotype and their interactions. Increasing evidence has shown the potential for integrating lifestyle habits, physiology, nutraceuticals, the gut microbiome and genetics into nutritional solutions, specific to the needs of each individual, for maintaining health and preventing disease.
- 200 µg folic acid
- 40 mg vitamin C
- No more than 6 g salt
- At least five portions of a variety of fruit and vegetables
- No more than 11% of energy from saturated fat
- Fenech M, El-Sohemy A, Cahill L, et al. Nutrigenetics and nutrigenomics: Viewpoints on the current status and applications in nutrition research and practice. J Nutrigenet Nutrigenom 2011; 4: 69–89.
- Food Standards Agency. Nutrient and food based guidelines for UK institutions. https://www.ptdirect.com/training-design/nutrition/national-nutrition-guidelines-united-kingdom. (2007, revised October 2007, accessed 11 May 2018).
- Blumeberg JF, Bailey RL, Sesso HD, et al. The evolving role of multivitamin/multimineral supplement use among adults in the age of personalized nutrition. Nutrients 2018; 10: 248.
- Kohlmeier M, De Caterina R, Ferguson LR, et al. Guide and position of the International Society of Nutrigenetics/Nutrigenomics on personalized nutrition: Part 2 – Ethics, challenges and endeavors of Precision Nutrition. J Nutrigenet Nutrigenom 2016; 9: 28–46.
- Liew SC and Gupta ED. Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism: Epidemiology, metabolism and the associated diseases. Eur J Med Genet 2015; 58: 1–10.
- Görman U, Mathers JC, Grimaldi KA, et al. Do we know enough? A scientific and ethical analysis of the basis for genetic-based personalized nutrition. Genes Nutr 2013; 8: 373–381.
- Davis CD and Milner JA. Nutrigenomics, vitamin D and cancer prevention. J Nutrigenet Nutrigenom 2011; 4: 1–11.
This was Basic Science Course 2018
Read what happened this year or watch the recordings to learn about research in motility & neurogastroenterology.
Please sign-in and access the BORN module to begin interactive web-based training for endoscopists in the detection and delineation of Barrett´s Oesophagus Related Neoplasia now.
Over the last decade this training module has been developed and validated by members of the International Working Group for the Classification of Oesophagitis.
Find out more
This was Summer School 2018
158 trainees from 29 countries met for a weekend full of lectures and hands-on training.
Mistakes in clinical investigation of gastrointestinal motility & function
Symptoms related to abnormal motility and function are very common.
Symptoms related to abnormal gastrointestinal motility and function can occur from the moment food is swallowed to the time stool is passed into the toilet. A recent UEG survey indicated that dysphagia, heartburn, bloating, abdominal pain and changes to bowel habit are each reported by 5–15% of the general population.1 These symptoms are frequent reasons for seeking medical attention from general physicians and for referral to specialist gastroenterologists. Most patients with these symptoms do not have neoplasia, infection or inflammation on initial investigation, but rather so-called functional gastrointestinal symptoms.2,3For patients with mild symptoms, negative tests provide reassurance and simple, symptomatic management might be all that is required (e.g. acid suppression, stool regulation). However, for those with severe symptoms that persist on therapy, ruling out life-threatening disease is not sufficient, and referral to the neurogastroenterology and motility (NGM) laboratory for physiological measurements is often indicated.
Clinical investigations aim to explain the cause of symptoms and establish a diagnosis that can guide rational treatment. Until recently, it could be argued that manometry, scintigraphy, breath tests and related tests rarely provided this information. As a result, only patients with suspected major motility disorders (e.g. achalasia, severe reflux disease or faecal incontinence) were routinely referred to the NGM laboratory for tests. Technological advances, such as high-resolution manometry (HRM), now provide objective measurements not only of motility, but also of function in terms of the movement (and digestion) of ingested material within the gastrointestinal tract. Furthermore, the ability to associate events (such as bolus retention, reflux or gas production) with symptoms provides an indication of visceral sensitivity and can identify what is causing patient complaints. Here, I discuss frequent mistakes in clinical investigation of gastrointestinal motility and function based on a series of consensus documents published by members of the International Working Group for Disorders of Gastrointestinal Motility and Function.
3rd EDS Surgical Skills Course (SSC)
Improve your surgical skills & register for this course on minimally invasive management of critically ill GI patients until July 1.
Enhance your knowledge with the UEG Library!
Find new educational online content from UEG Week 2017 subtitled into Spanish.
Mistakes in the endoscopic diagnosis and management of Barrett’s oesophagus and how to avoid them
Barrett’s oesophagus is the precursor to oesophageal adenocarcinoma, which carries a poor prognosis,1 and it is likely that all endoscopists and gastroenterologists will encounter Barrett’s oesophagus in their clinical practice.Careful assessment and management of patients who have Barrett’s oesophagus with endoscopic surveillance and endoscopic endotherapy aim to reduce the risk of progression to invasive adenocarcinoma. Advances in endoscopic diagnosis and therapy should, therefore, help to reduce the risk of progression. As with all premalignant conditions and surveillance programmes,2 careful multidisciplinary management of the patient is important to reduce the risk of causing them to become unduly concerned. Here, we present some mistakes that in our experience are commonly made in the endoscopic diagnosis and management of Barrett’s oesophagus and give advice on how to avoid them.
This was the YIM 2018
30 participants from 11 countries met for a 3-day basic research training in Vienna.