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Stroke and transient ischaemic attacks

Essentials 1 Ischaemic strokes and transient ischaemic attacks (TIAs) are most commonly due to atherosclerotic thromboembolism of the cerebral vasculature or emboli from the heart. Other causes should be considered in younger patients, those presenting with atypical features or when evaluation is negative for the more common aetiologies. 2 Haemorrhagic and ischaemic strokes cannot be reliably differentiated on clinical grounds alone; therefore further imaging, most commonly…

Headache

Essentials 1 The pathophysiological basis of headache is understood to be traction or inflammation of extracranial structures, the basal dura or the large intracranial arteries and veins, dilatation/distension of cranial vascular structures or activation/sensitization of perivascular nerves. 2 Severity of headache is not a reliable indicator of the underlying pathology. 3 History is of paramount importance in the assessment of headache. 4 A normal physical examination…

Perianal conditions

Essentials 1 Anal pain, bleeding and masses are common symptoms in many different types of anorectal pathology. A careful history and anorectal examination are important in making the correct diagnosis. 2 Increasing fibre intake and reducing constipation are effective initial treatments for mild, uncomplicated haemorrhoidal disease and perianal fissures. 3 Anorectal abscesses require incision and drainage. In some cases, this can be done safely in the…

Haematochezia

Essentials 1 Haematochezia is a common presentation in patients aged over 50 years and can result in shock due to large-volume blood loss. 2 The most common cause of lower gastrointestinal bleeding (LGIB) in younger patients (<50 years of age) is anorectal disorders. In elderly patients, diverticular disease is the main cause. 3 Most cases of lower gastrointestinal (GI) haemorrhage are self-limiting and resolve spontaneously. 4…

Acute liver failure

Essentials 1 The diagnosis of acute liver failure (ALF) is based on the presence of worsening coagulopathy, hepatic encephalopathy and deepening jaundice. 2 In developing countries, viral causes predominate, with hepatitis E infection recognized as a common cause in many countries. 3 In developed countries, drug-induced liver injury (DILI) predominates, often from paracetamol. 4 Diagnosis of ALF must be considered in anyone presenting with the recent…

Inflammatory bowel disease

Essentials 1 The two major forms of inflammatory bowel disease (IBD) are Crohn’s disease and ulcerative colitis. The principal clinical features are diarrhoea and/or abdominal pain. 2 IBD is a chronic and relapsing condition. Patients may present to the emergency department with increased disease activity or with complications of the disease process or treatment. 3 Gastrointestinal complications may include dehydration, bleeding, strictures, obstruction, fistulae, sepsis, perforation,…

Acute appendicitis

Essentials 1 Appendicitis is the commonest cause of acute abdominal pain requiring surgical treatment. 2 The diagnosis is primarily clinical, but the absence of a pathognomonic sign or conclusive first-line diagnostic test can cause diagnostic difficulty. 3 Diagnostic delay is the primary cause of morbidity and mortality and a major source of litigation related to medical negligence in emergency departments. 4 Specialized imaging techniques enhance diagnostic…

Acute pancreatitis

Introduction The twin challenges of acute pancreatitis are to establish the diagnosis and stratify severity. The difficulty in diagnosing pancreatitis lies in its non-specific symptomatology, which is shared by a number of other gastrointestinal diseases. The 2012 revised Atlanta classification definition of acute pancreatitis requires two of the following three features: (1) abdominal pain consistent with acute pancreatitis; (2) serum lipase or amylase activity equal to…

Biliary tract disease

Essentials 1 More than 95% of biliary tract disease is attributable to gallstones. 2 Most patients with gallbladder disease present with abdominal pain. 3 Investigations are directed to confirming the diagnosis and detecting the presence of complications. 4 The management of acute biliary pain (biliary colic) is supportive and discharge from the Emergency Department is often possible. 5 The management of cholecystitis and other complications of…

Peptic ulcer disease and gastritis

Essentials 1 Helicobacter pylori is responsible for 70% to 90% of peptic ulcers, with non-steroidal anti-inflammatory drugs (NSAIDs) accounting for most of the remainder. 2 Emergency presentations of peptic ulcer disease vary from mild indigestion to severe life-threatening complications. 3 Endoscopy is the investigation of choice for definitive diagnosis. 4 Most patients can be managed medically with a combination of anti-secretory drugs and antibiotics as indicated.…

Haematemesis and melaena

Essentials 1 Resuscitation is the priority, with particular attention to restoring perfusion of vital organs by replacing intravascular volume. 2 Upper gastrointestinal (GI) endoscopy is the key investigation and frequently allows definitive therapy. It should be performed at the earliest opportunity. Introduction Upper gastrointestinal bleeding (UGIB) is a common medical emergency with substantial morbidity and mortality. Over the last two decades, there have been advances in…

Gastroenteritis

Essentials 1 Gastroenteritis is usually a benign, self-limiting disease that can be diagnosed clinically, warrants no specific investigation and settles spontaneously with symptomatic treatment and oral fluid therapy. 2 The cardinal clinical feature of gastroenteritis is diarrhoea, which may be accompanied by varying degrees of nausea and vomiting, abdominal cramping and pain, lethargy and fever. 3 The clinical examination is directed at confirming the diagnosis of…

Hernia

Essentials 1 A diagnosis of symptomatic herniae mandates early surgical repair to avoid life-threatening complications. 2 Herniae may present as a reducible lump or may incarcerate, strangulate and/or present as bowel obstruction. 3 Femoral herniae are often misdiagnosed and, when complicated, are associated with high morbidity. 4 All herniae presenting with a complication should undergo prompt surgical repair. Introduction A hernia is defined as the protrusion…

Bowel obstruction

Essentials 1 Small bowel obstruction is most often caused by adhesions, hernias or neoplasms. Large bowel obstruction more commonly results from neoplasms, volvulus or strictures. 2 The common clinical features of bowel obstruction are paroxysms of poorly localized abdominal pain, constipation/obstipation, abdominal distension, nausea, vomiting and hyperactive or high-pitched bowel sounds. Examination for hernias is essential. 3 On abdominal x-rays, dilated loops of bowel with multiple…

Approach to abdominal pain

Essentials 1 Abdominal pain accounts for 4% to 10% of all emergency department visits. 2 Abdominal pain most frequently arises from pathologies in the gastrointestinal and the genitourinary systems; however, it may also result from cardiovascular, pulmonary, metabolic, infective and/or toxic causes. 3 Special consideration should be given towards assessment of abdominal pain in elderly, immunocompromised or obese patients, women of childbearing age and children. These…

Dysphagia

Essentials 1 Dysphagia is a diagnostic challenge and a broad differential diagnosis should be considered. A carefully taken history will reveal the likely cause in most cases. 2 Dysphagia due to a new-onset stroke, pharyngeal or oesophageal disorder will increase the amount of food in the pharynx and may be complicated by aspiration. An assessment of that risk should be made before allowing the patient to…

Haemoptysis

Essentials 1 Most patients are stable and can be managed and investigated as outpatients. 2 It is essential to differentiate between haemoptysis, haematemesis and bleeding from the upper airway. 3 Chest x-ray is normal in 30% of patients with haemoptysis and misses 25% of malignancies. 4 High-resolution computed tomography is the investigation of choice if the chest x-ray cannot point to a cause of the bleeding.…

Pleural effusion

Essentials 1 In the majority of patients, a posteroanterior and lateral chest x-ray will confirm and localize an effusion. Ultrasound, lateral decubitus films and computed tomography scanning are more sensitive in diagnosing and localizing small effusions. 2 Pleural fluid analysis is the principal method of determining the underlying cause of an effusion. 3 Ultrasound-guided thoracocentesis is the recommended method for diagnostic or therapeutic fluid drainage. 4…

Pneumothorax

Essentials 1 Pneumothorax can occur spontaneously, as a result of trauma or iatrogenically. Spontaneous pneumothorax has traditionally been further subdivided into primary and secondary (related to underlying lung pathology). The utility of this distinction is being challenged, as there is increasing evidence of underlying lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax. 2 Clinical features are unreliable indicators of pneumothorax size. 3 The…

Chronic obstructive pulmonary disease

Essentials 1 Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation that is not fully reversible. 2 The majority of exacerbations of COPD are due to infection, but other important precipitants must be excluded. 3 It is prudent to control oxygen flow rate to achieve an arterial oxygen saturation of approximately 88% to 92% to ensure correction of hypoxia while avoiding the complication of hyperoxic…