Guideline for Acute Upper Abdo pain 2.0 FINAL. Guideline adopted from the Bedside Clinical Guideline Partnership

Transcription

1 Guideline for Acute Upper Abdo pain 2.0 FINAL Guideline adopted from the Bedside Clinical Guideline Partnership EQUALITY IMPACT The Trust strives to ensure equality of opportunity for all both as a major employer and as a provider of health care. This policy has therefore been equality impact assessed by the authorising body to ensure fairness and consistency for all those covered by it regardless of their individual differences, and the results are shown in Appendix 1. Version: 2.0 Final Authorised by: Surgery DMT Date authorised: April 2013 Next review date: April 2015 Document author: Mr C Pratap

2 VERSION CONTROL SCHEDULE Upper abdo pain Version :2.0 Final Version Number Issue Date Revisions from previous issue 1.0 final May FInal April 2013 amendments

3 INDEX/ TABLE OF CONTENTS EQUALITY IMPACT... 1 INTRODUCTION... 4 PURPOSE... 4 SCOPE... 4 DEFINITIONS... 4 DUTIES... 4 GUIDELINE STATEMENT... 5 GUIDELINE DEVELOPMENT AND REVIEW... 7 IMPLEMENTATION... 5 MONITORING... 5 REVIEW... 5 REFERENCES AND BIBLIOGRAPHY... 6 THE GUIDELINE... 6 EQUALITY IMPACT ASSESSMENT TOOL... 11

4 INTRODUCTION This clinical guidance document produced by the Bedside Clinical Guidance Partnership has been amended and adopted for local use by Tameside Hospital NHS Foundation Trust. PURPOSE This clinical guideline is a systematically developed statement designed to assist practitioners in deciding appropriate health care for specific clinical circumstances. The guideline is intended to provide guidance for staff in the diagnosis and management of a particular condition, and provides indication of the best choices for the clinical management of the patient. SCOPE This guideline is to be used by staff or professional groups involved in the diagnosis management of the condition to which to the document relates in all areas within Tameside Hospital NHS Trust. DEFINITIONS The definitions of key words, terms and concepts used in the policy document will be clearly defined within the body of the guideline where necessary. DUTIES Chief Executive The Chief Executive is responsible and accountable for ensuring that clinical guidelines are in place and that implementation of the guidelines is undertaken and monitored. Medical Director The Medical Director is responsible for overseeing that minated Divisional Leads implement guidelines according to the Bedside Clinical Guideline Policy and for ensuring that specifics of this guideline are implemented and monitored as appropriate. minated Divisional Leads for Clinical Guidelines Will ensure that guidelines adopted by their specialty or Division are appropriately scrutinised and amended where applicable and that they are subject to adoption and ratification by the Division at the Divisonal DMT meeting or other appropriate Committee as specified in the Trusts Controlled Documents Policy. Clinical Risk Officer for General CNST and Elective Services Is responsible for facilitating the implementation of clinical guidelines by liaison with minated Divisonal Leads. The Clinical Risk Offcier is also responsible for the review of the overarching Bedside Clinical Guidelines policy and guideline template and for producing monitoring reports for the Medical Director on

5 progress of the implementation, review and monitoring of clinical guidelines adopted from the Bedside Partnership. These monitoring reports will be on an annual basis. Local Implementation Author The person submitting the ratified guideline for publishing on the Intranet is considered the local implementation author and will be responsible for any subsequent review process and for ensuring that guidelines are implemented and monitored where appropriate, e.g. through their inclusion in the annual Clinical Audit Plan for the Division. All staff All staff have a duty to follow this guideline unless there are sound clinical reasons for not doing so which can be supported by evidence. Junior Staff should discuss any proposed deviation with their senior colleagues, and gain their approval prior to implementation. Junior doctors should document the discussion with the Consultant and reasons for deviation in the Health records. Where consultants choose to deviate from agreed practice stated in the guideline this should also be documented. GUIDELINE STATEMENT The guideline is presented using set headings in the body of the guideline which provide structure to the guideline and a methodical order The guideline subheadings will differ dependening on the topic of the guideline but will given structured guidance to staff on treatment and management of the specific clinical condition or procedure. GUIDELINE DEVELOPMENT & CONSULTATION This guideline has been developed by the Bedside Guidelines Partnership and has been amended to reflect local implementation processes by a consultative process within the division responsible for delivering care. Where appropriate consultation with other stakeholders within the Trust was appropriate this has taken place before final ratification at the Divisional DMT or other approved Committee or Group stated on the cover page table. IMPLEMENTATION This guideline has been distributed to main stakeholders and members of the ratifying Committee for dissemination and uploaded to the Trust s intranet in the clinical guidelines section MONITORING Monitoring of this guideline is the responsiblitiy of the Surgical Division REVIEW This guideline will be formally reviewed at a minimum of every 2 years. The date of review is stated on the title page. The guideline may be reviewed earlier

6 depending on the results of monitoring, recommendations from recognised bodies or as a result of incident complaint or claim review REFERENCES AND BIBLIOGRAPHY Extensive reference material and evidence base is provided by the Bedside Clinical Guidelines Partnership for each individual guideline and is accessible on the TIS site, under the section Policies and Procedures entitled Bedside Clinical Guidelines Reference section.

7 THE GUIDELINE ACUTE UPPER ABDOMINAL PAIN RECOGNITION AND ASSESSMENT Symptoms and signs Pain may be constant or colicky may radiate to back or chest Pyrexia, particularly in acute cholecystitis Vomiting of food, dark brown, denatured blood ( coffee-grounds ) or fresh blood (haematemesis) Melaena (black, tarry, smelly stool containing digested blood) suggests peptic ulcer Previous history Enquire about: peptic ulceration ulcerogenic medication (particularly non-steroidal anti-inflammatory drugs) gallstones alcohol intake weight loss liver disease Examination Pulse, BP, temperature Anaemia Jaundice (suggests gallstones, cholangitis, or severe hepatic or pancreatic disease) Abdominal tenderness Rebound tenderness Guarding/rigidity Mass (including palpable gall bladder) Differential diagnosis Biliary colic Acute cholecystitis Pancreatitis/carcinoma pancreas Acute peptic ulceration (including perforation) Hiatus hernia Perforation lower oesophagus (spontaneous/iatrogenic/foreign body) Traumatic ruptured spleen/liver/bowel/diaphragm Ruptured or dissecting abdominal aortic aneurysm see Acute abdominal aortic aneurysm guideline Referred chest pain in association with: myocardial infarction pulmonary embolus pleurisy

8 pericarditis Investigations FBC U&E Serum amylase If jaundiced, LFT and INR If pyrexial, blood cultures Plain abdominal X-ray If suspecting: upper GI perforation erect chest X-ray biliary colic or acute cholecystitis ultrasound scan of abdomen malignancy CT scan of abdomen acute abdominal aortic aneurysm see Acute abdominal aortic aneurysm guideline peptic ulcer upper GI endoscopy IMMEDIATE TREATMENT Baseline observations: temperature, pulse, blood pressure Establish IV access and administer fluids see Fluid resuscitation and Maintenance fluid therapy guidelines If infective cause suspected (e.g. cholecystitis/cholangitis), give appropriate antibiotic (see table) Insert nasogastric tube if required Seek senior help (at least SpR) consider transfer to SSCU/HDU for resuscitation and invasive monitoring if emergency surgery anticipated see Arranging a theatre list guideline

9 Antimicrobial therapy Acute Cholecystitis Treatment First line Alternative (penicillin allergy) 1 For uncomplicated cases: Co-amoxiclav 625 mg orally 8 hrly For complicated cases (e.g. severe acute cholecystitis with possible gangrenous gallbladder or perforation): Following blood culture: Co-amoxiclav 1.2 g IV 8 hrly plus gentamicin IV single dose (see Prescribing regimens and nomograms Gentamicin). Only give further dose of IV gentamicin after appropriate interval (see prescribing regimen) if blood culture has become positive for Gram Negative Bacillus Urgent surgical intervention likely to be required Gentamicin IV (see Prescribing regimens and nomograms gentamicin*) plus metronidazole 500 mg IV by infusion (or 400 mg orally) 8 hrly *Monitor U&E and serum gentamicin. Discuss with consultant microbiologist, consultant in infectious diseases, pharmacist or medicines information if there are any concerns regarding gentamicin toxicity Oral step-down: Co-amoxiclav 625 mg orally 8 hrly If tagged on EPR for ESBL: Check previous sensitivities for ESBL and choose empirical treatment based on these results Duration Review IV route after hr only give further dose of IV gentamicin if blood culture has become positive for Gram Negative Bacillus. Convert to oral therapy, if available and tolerated Usually 5 7 days total (including IV treatment) Continue until resolution of clinical signs of infection (including normalization of temperature and WCC) If persistent or recurrent evidence of infection after 5 7 days treatment, discuss with consultant surgeon and consider appropriate diagnostic investigations 1 Assume penicillin allergy only if convincing history of either rash within 72 hr of dose or anaphylactic reaction. If any doubt about whether patient truly allergic to penicillin, seek advice from a microbiologist (4666) or a consultant in infectious diseases (2299)

10 Acute Cholangitis Treatment First line Alternative (penicillin allergy) 1 Biliary drainage by either urgent ERCP or PTC is likely to be necessary Following blood culture Gentamicin IV (see Co-amoxiclav 1.2 g IV 8 hrly Prescribing regimens and plus nomograms Gentamicin*) gentamicin IV single dose (see plus Prescribing regimens and metronidazole 500 mg IV by infusion (or 400 mg orally) 8 hrly nomograms Gentamicin). Only give further dose of IV gentamicin after appropriate interval (see prescribing regimen) if blood culture has become positive for Gram Negative Bacillus Oral step-down: Co-amoxiclav 625 mg orally 8 hrly *Monitor U&E and serum gentamicin. Discuss with consultant microbiologist, consultant in infectious diseases or pharmacist or medicines information if there are any concerns regarding gentamicin toxicity If tagged on EPR for ESBL: Check previous sensitivities for ESBL and choose empirical treatment based on these results Duration Review IV route after hr only give further dose of IV gentamicin if blood culture has become positive for Gram Negative Bacillus. Convert to oral therapy, if available and tolerated Usually 5 7 days total (including IV treatment) Continue until resolution of clinical signs of infection (including normalization of temperature and WCC) If persistent or recurrent evidence of infection after 5 7 days treatment, discuss with consultant surgeon and consider appropriate diagnostic investigations 1 Assume penicillin allergy only if convincing history of either rash within 72 hr of dose or anaphylactic reaction. If any doubt about whether patient truly allergic to penicillin, seek advice from a microbiologist (4666) or a consultant in infectious diseases (2299) SUBSEQUENT MANAGEMENT Dependent on clinical response of patient and findings of the investigations DISCHARGE AND FOLLOW-UP Patients with neoplasia may need further investigation and treatment discuss with upper GI team cancer nurse specialist (3101) Patients with H. pylori-positive peptic ulceration should have faecal antigen test to confirm eradication of H. pylori >4 weeks post therapy Patients with investigations pending must have outpatient appointments made anticipating when results will be available Arrange appropriate follow-up at discretion of consultant in charge

11 EQUALITY IMPACT ASSESSMENT TOOL. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? N/A 5. If so can the impact be avoided? n/a 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? n/a n/a