Diarrhoea, Vomiting, Pelvic Pain & Vaginal Bleeding

“Approximately 1% of all Emergency Department consultations are for diarrhoea, but 87% of patients seen in the ED are hospitalised due to a complication of diarrhoea (Hospital episode statistics 2003).”

CAP 11 – Diarrhoea

CAP 26 – Pelvic Pain

CAP 34 – Vaginal Bleeding

CAP 36 – Vomiting and Nausea

EM Curriculum: (click to view)

Diarrhoea & Vomiting

Diarrhoea is one of the commonest causes for hospital admission. It can impact quality of life significantly, especially if it is chronic, and is of particular concern in the elderly regardless of the duration. Approximately 1% of all Emergency Department consultations are for diarrhoea, but 87% of patients seen in the ED are hospitalised due to a complication of diarrhoea (Hospital episode statistics 2003).

Vomiting is another very common presentation to the ED. Some causes of vomiting are be relatively benign, but vomiting can also represent serious pathologies such as raised intra-cranial pressure.

Recently, the UK has been hit by recurrent high numbers of presentations of vomiting caused by Norovirus. In 2012, over 1 million patients presented to the NHS with suspected vomiting secondary to Norovirus.

As with diarrhoea, vomiting can also lead to significant dehydration and eventually shock. This can be (although more rarely than diarrhoea) be a cause of mortality.

When reviewing a patient with diarrhoea or vomiting then always remember to consider a diagnosis of:

  • C.Difficile Colitis

  • Meningitis

  • Raised intra-cranial pressure

  • Inflammatory Bowel Disease

  • Diabetic Ketoacidosis

PV BLEEDING

Many women will experience symptoms of bleeding and pain in early pregnancy. Potential pathological causes for these symptoms include miscarriage, ectopic pregnancy and gestational trophoblastic disease.

Recurrent miscarriage affects 1% of couples (Stirrat, 1990) and is defined as the loss of three or more pregnancies.

Ectopic pregnancy occurs when the fertilised egg implants outside the uterine cavity. It is a common complication with an incidence of 1 in 100 conceptions. Women may present with shoulder pain due to blood irritating the diaphragm, fainting due to blood loss or occasionally with shock due to extensive intra-abdominal bleeding.

Abnormal bleeding may occur in around half of peri-menopausal women. Vaginal bleeding in post menopausal women bleeding can be caused by a range of conditions: One study (Van den Bosch et al) of 454 women found the following range of final diagnoses:

  • Carcinoma (6.6 percent)

  • Atypical hyperplasia (0.2 percent)

  • Hyperplasia without atypia (2.0 percent)

  • Polyp (37.7 percent); fibroid (6.2 percent)

  • Proliferative/secretory (14.5 percent)

  • Hypotrophy/atrophy (30.8 percent)

Learning Outcomes from completing the tasks

  • Recall the causes of diarrhoea and correlate these with other symptoms including abdominal pain, rectal bleeding and weight loss.

  • Specify the pathophysiology of nausea & vomiting.

  • Appreciate the role of the different classes of commonly used anti-emetics and their benefits and risks.

  • Recall the important differential diagnoses of vomiting in infants.

  • Know the causes of vaginal bleeding in different age groups, pre and post menopausal.

  • Understand the early complications of pregnancy and the pathophysiology of ectopic pregnancy.

  • Know which patients with vaginal bleeding can be discharged safely.

Learning Outcome from face-to-face teaching

  • Know the causes of pelvic pain and when to refer to surgeon, gynaecologist or GUM specialist.

  • Evaluate hydration and nutritional status of patients including children.

  • Demonstrate full examination of a patient presenting with pelvic pain including, vaginal, bimanual and pelvic examination.

Tasks

Complete the following before the face to face session:

Task 1: Acute Diarrhoea

Read the following article on an approach to Adults with acute diarrhoea - this link is via UpToDate, your trust may have an institutional login or you can login via Athens.

Task 2: Nausea, Vomiting and Fever

Duration: 30 mins

This article from EMJ refers to a pre-hospital assessment of patients with Nausea, Vomiting and Fever. However the risk assessment and range of conditions that can cause these symptoms equally apply to the in hospital setting. The main difference is that in hospital we have access to further diagnostics and treatments. It introduces the concepts of "Big Sick" and "Little Sick" and covers some pitfalls when assessing children or older patients.

Task 3: Physiology and Anti-emetics

Duration: 30 mins

These entries on FRCA.co.uk cover:

Task 4: Onthewards.org podcasts

Duration: 60 mins

These Australian Podcasts from @ontherwardsorg will provide a good grounding in PV bleeding for doctors in the ED.

#EM3 Content

Lightning Learning

Simulations

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“You are working in the ED and see a 29 year old woman with pelvic pain and wonder if she may have PID.”
“A 25 year old female presents to the ED complaining of LIF pain and PV bleeding. Her LMP was 8/52 ago. Urinary pregnancy test performed at triage was positive.”
“Mrs Brown is an 80 year old lady admitted from a residential home. She has had two days of profuse watery diarrhoea and her carers report she has not been eating or drinking much and generally not herself.
She finished a 5 day course of cefalexin for UTI yesterday.”

Additional Resources

Here are some extra resources to review if you want more information:

"Best Case Ever":

A short podcast from Canada discussing a case of a PV bleed at 18/40.

SPOTTING THE SICK CHILD:

A great website for the general approach to assessing a child. The dehydration section provides an in depth overview of assessing a child with potential dehydration and highlights some of the particular factors and diagnoses to consider in children.

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: