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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…

Influenza and emerging respiratory infections

Essentials 1 Influenza is infectious before symptoms appear. 2 Pneumonia and exacerbation of underlying chronic disease are the most common complications of influenza. 3 The sensitivity and specificity of clinical signs is poor. Testing by polymerase chain reaction (PCR) is essential for diagnosis. 4 The use of antiviral therapy is controversial; however, it has a role in the treatment of specific patient groups. 5 Nosocomial spread…

Community-acquired pneumonia

Essentials 1 The term community-acquired pneumonia refers to a syndrome of acute lower respiratory tract infection with a new infiltrate on chest x-ray (CXR) in a patient who has not been hospitalized in the preceding 14 days. 2 Recent studies have demonstrated that CXR is less reliable than previously thought for the diagnosis of pneumonia, particularly in the elderly and those with comorbidities such as congestive…

Asthma

Essentials 1 Asthma is a major health problem worldwide, resulting in significant morbidity and mortality. 2 Asthma is characterized by episodic bronchoconstriction and wheeze in response to a variety of stimuli. 3 Features suggesting an increased risk of life-threatening asthma include a previous life-threatening attack, previous admission to an intensive care unit (ICU) with ventilation, requiring three or more classes of asthma medication, heavy use of…

Upper respiratory tract

Essentials 1 Management of the airway, breathing and circulation (ABCs) takes precedence over the history, examination and specific treatment of upper airway obstruction. 2 Direct laryngoscopy can be an important technique for both the investigation and management of upper airway obstruction. 3 Chest thrusts and back blows can be useful first aid techniques in foreign-body upper airway obstruction. 4 Acute viral respiratory infections are a frequent…

Aneurysms

Essentials 1 Abdominal aortic aneurysms (AAAs) generally expand slowly and are asymptomatic. 2 Screening programs aim to detect their presence prior to rupture and promote early elective repair once their size is ≥5.5 cm. 3 Abdominal pain/back pain with hypotension should prompt a rapid search for an AAA in the age group of 65 years or above. 4 Aneurysmal rupture is a surgical emergency and requires…

Aortic dissection

Essentials 1 Untreated aortic dissection has a mortality rate of approximately 1% per hour for the first 48 hours and 90% at 3 months. Early diagnosis and aggressive management improve mortality rates to 20% to 40%. 2 Aortic dissection is a rare clinical diagnosis confirmed through focused investigation. A high index of suspicion is required. 3 Both false-negative and false-positive diagnoses of aortic dissection result in…

Hypertension

Essentials 1 Hypertension is defined as a systolic blood pressure ≥140 mm Hg and/or a diastolic blood pressure ≥90 mm Hg. 2 Hypertensive crises include both hypertensive emergencies and hypertensive urgencies. 3 A hypertensive emergency is characterized by end-organ damage (brain, cardiovascular system and kidney) and requires immediate treatment and admission. 4 Most patients presenting with a hypertensive emergency have chronic hypertension, although it can present…

Peripheral vascular disease

Essentials 1 With the continuing rise in the elderly population, the incidence of peripheral arterial and venous disease in the developed world continues to increase significantly. 2 Claudication is the most important symptom of arterial disease in an extremity, although a well-developed collateral circulation will delay the onset of symptomatic extremity ischaemia. 3 Acute arterial occlusion is usually associated with a number of classic symptoms and…

Heart valve emergencies

Essentials 1 Infective endocarditis is effectively a multiorgan disease and is an often missed diagnosis. 2 There has been a shift in the predominant organism in infective endocarditis from Streptococcus viridans to Staphylococcus aureus , and nosocomial infections are becoming more common. 3 Degenerative heart disease and the presence of prosthetic valves are currently the high-risk factors for infective endocarditis in developed countries. 4 Antibiotic prophylaxis…