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ART OF MEDICINE
PRACTICE UPDATES
Can I have cheese on my
ham sandwich?
Whistleblowing in primary care
NHS England has published new guidance on supporting
whistleblowing in primary care. Each NHS primary care provider
should name an individual as the “Freedom to Speak Up
Guardian,” who can ensure that policies are in place and that
staff know who to contact if they have a concern. All primary
care providers should review and update their local policies
and procedures by September 2017, so that they align with this
new guidance. NHS England will provide easy access to learning
resources and will support a network of Freedom to Speak Up
Guardians in primary care.
“Can I have cheese on my
ham sandwich?”
My patient asked
me this question
several times
during the first
few weeks of my
employment
at a state
• http://bit.ly/gpwhistleblow
hospital. Although
dieticians provided
HIV testing: increasing uptake
recommendations, I was ultimately responsible
NICE and Public Health England have published new guidance on
for entering dietary orders. Like most patients on
the ward, my patient was prescribed psychotropic
HIV testing. In “high prevalence” settings, everyone admitted to
drugs that resulted in metabolic complications. As
hospital (including emergency departments) who is undergoing
a result, she required dietary restrictions. Despite
blood tests should be recommended an HIV test as well. In areas of
several explanations about these restrictions,
“extremely high prevalence,” everyone should be recommended
she continued to request cheese on her ham
HIV testing on admission to hospital. GP surgeries in areas of high
sandwiches. After I had denied her request on
or extremely high prevalence should recommend HIV testing to
numerous occasions, she finally said to me and
all new registrants and to all patients undergoing blood tests for
asked: “Why can’t I have cheese? I am stuck in a
another reason who have not been tested in the previous year.
hospital. I know I’m too sick to go home. I have
•http://bit.ly/HIVtestingNICE
nothing to look forward to except what I can eat.”
For many patients in an institutional setting,
days are regimented from the time of “lights
FAST FACT—DIAGNOSTIC CRITERIA FOR DIABETES
on” to “lights off.” They are told what activities
Diabetes UK supports the WHO diagnostic
to attend, when meals and snacks are served,
criteria for diabetes, which are:
and what they can eat. These patients have little
control over many aspects of their lives, but they
Glucose concentration in venous plasma
can choose what they put into their mouths.
– ≥7.0 mmol/L after fasting for ≥8 hours
Food is such a basic human need that we often
– ≥11.1 mmol/L on oral glucose tolerance
forget its psychological significance. In an
test
environment where most control is taken away,
– ≥11.1 mmol/L on random testing.
patients can exert an influence on food. Hence
For more information visit BMJ Learning
many patients insist on certain meals, purchase
• http://bit.ly/T1DMDiagnosis
“unhealthy” items from the canteen, and engage
in an “underground” snack distribution system.
Food serves as a mechanism to exert control in
You can gain CPD points from your reading
an environment where patients feel they have no
by recording and reflecting on what you have
influence.
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suggest
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Within reason, negotiating meals and snacks
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could provide patients with a sense of control and
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LEARNING
Kaustubh G Joshi, associate professor of clinical psychiatry,
Department of Neuropsychiatry and Behavioral Science, University
of South Carolina School of Medicine, Columbia, SC 29203, USA
[email protected]
We welcome contributions to this column via our online editorial
office: https://mc.manuscriptcentral.com/bmj.
Cite this as: BMJ 2016;355:i6024
log onto http://learning.bmj.com to
complete the online module.
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H OURS
We print a statement
financial interests and patient partnership with
each education article. We have resolved to reduce the involvement
LEARNING
of authors withMODULE
financial interests that The BMJ judge as relevant. We
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encourage and make clear how patients have been involved and shaped
our content. More details can be found on thebmj.com.
the bmj | 7 January 2017
29
GUIDELINES
End of life care for children:
summary of NICE guidance
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Gemma Villanueva,1 M Stephen Murphy,1 David Vickers,2 3 Emily Harrop,4 5 Katharina Dworzynski1
Children and young people can have a wide range
of life limiting conditions and may sometimes live
with such conditions for many years. This guideline
recommends that end of life care be managed
as a long term process that begins at the time of
diagnosis of a life limiting condition and entails
planning for the future. Sometimes it may begin
before the child’s birth. It is part of the overall care of
the child or young person and runs in parallel with
other active treatments for the underlying condition
itself.1 Finally, it includes those aspects related to the
care of the dying.
1
National Guideline Alliance, Royal College of Gynaecologists and Obstetricians, London
Cambridgeshire Community Services NHS Trust, St Ives
3
East Anglia’s Children's Hospices, Milton
4
Helen & Douglas House, Oxford
5
Oxford University Hospitals, Oxford
2
Correspondence to: K Dworzynski [email protected]
Further information about the guidance, a list of members of the guideline development group, and the
supporting evidence statements are in the full version on bmj.com.
SPENCER GRANT/SPL
How to plan care
• Recognise that children and young people with life
limiting conditions and their parents or carers have a
central role in decision making and care planning.
• Explain to children and young people and to their
parents or carers that their contribution to decisions
about their care is important, but they do not have to
make decisions alone and the multidisciplinary team
will be involved as well.
P
HOW PATIENTS WERE INVOLVED IN THE CREATION OF THIS ARTICLE
Patients were not directly involved in this article. Committee members involved
in this guideline included two patient representatives, who contributed to the
formulation of the recommendations summarised here. Children and young people
with life limiting conditions also contributed to this guideline by having their voices
heard by focus groups.
WHAT YOU NEED TO KNOW
• Involve children and young people with life limiting conditions
and their parents or carers in decision making and care planning
• An advance care plan is a core element of a child’s or young
person’s end of life care
• Be aware that other family members such as siblings and
grandparents, and others (such as friends, boyfriends or
girlfriends) may need support
• Name a medical specialist who leads on and coordinates the child
or young person’s care
• Decisions about care should always consider what is in the best
interest of the child
30
Advanced care planning
• Develop and record an advance care plan at an
appropriate time for the current and future care
of each child or young person with a life limiting
condition (see box, p 32).
– In some cases planning may begin antenatally.
• Share the advance care plan with the child or young
person and their parents or carers (as appropriate),
and think about which professionals and services
involved in the individual child or young person’s care
should also share it, for example:
– General practitioners
– Hospital consultants
– Hospices
– Respite centres
– Nursing services (community or specialist)
– School and other education services
– Ambulance services.
Multidisciplinary team working
• Depending on the needs of the child or young person,
the multidisciplinary team may include:
– Healthcare professionals
– Social care practitioners
– Education professionals
7 January 2017 | the bmj
Diagnosis of
life limiting
condition
Bereavement
Carry out wishes
expressed in ACP
Death
Organ/tissue donation
Care of body
Advance ACP
care plan
Child /
young
person
Rituals
Recording memories
End
of life
Plans for social media
Working together,
the young person,
their carers and
support team record
important information
and decisions.
Multidisciplinary
support team
Update treatments
Consider ending treatments
Condition specialists
Consider new invasive treatments
Other family and
important people
Consider nonpharmacological
treatments
Record
wishes + ambitions
Palliative care team
Siblings
Social care practitioners
Social activities
Education professionals
Religious/spiritual
Chaplains
Education
Allied health professionals
Family
Team
provides
ongoing care
and support
Friends
Spiritual/
religious
Social
Emotional/
psychological
Practical
Hospice professionals
Grandparents
Boy/girlfriends
Bereavement
support
Assemble
multidisciplinary
support team
Assign named medical
specialist to lead and
coordinate
care
Parents/
carers
Funeral
Help
family to
prepare
Early
stages
Establish
how a young
person and
carers want
to be involved
in decision
making
A living
document
Agree preferred
places for care
and death
Care
planning
ACP is updated as
needs change
and decisions
are made
Delivery
– Chaplains
– Allied health professionals (such as
physiotherapists, occupational therapists, and
psychological therapists).
E
very
child or young person with a life limiting
• condition should have a named medical specialist
who leads on and coordinates their care.
Emotional and psychological support
• Regularly discuss emotional and psychological
wellbeing with children and young people and their
parents or carers, particularly at times of change such as:
– When the life limiting condition is diagnosed
– If their clinical condition deteriorates
– If their personal circumstances change
– If there are changes to their nursery care, school, or
college arrangements, or their employment
– If there are changes to their clinical care (for example,
if their care changes focus from treating the condition
to end of life care).
Social and practical support
• Be aware that other family members and people
important to the child or young person may need
support, including social, practical, emotional,
psychological, and spiritual support.
the bmj | 7 January 2017
31
• Be aware that children and young people with life limiting
conditions and their parents or carers have varied social
and practical support needs, and that those needs may
change during the course of their condition. This may
include:
– Material support, such as housing or adaptations to the
home and equipment for home drug infusions
– Practical support, such as access to respite care
– Technical support, such as training and help with
administering drug infusions at home
– Education support, such as from hospital school
services
– Financial support.
EDUCATION INTO PRACTICE
•Has an advance care plan been developed and recorded, when appropriate, for the
children and young people with a life limiting condition in your care?
•Are there services in place that can provide round the clock care for a child or young
person with a life limiting condition who is approaching the end of life?
•Can patients and their families be cared for in their preferred place of care?
•Are children or young people with life limiting conditions receiving symptom
management that is adequate to maximise their quality of life?
Approaching the end of life
• When a child or young person is approaching the end of
life, discuss with their parents or carers what would help
them, for example:
– Important rituals
– Recording or preserving memories (for example,
photographs, hair locks, or hand prints)
– Plans for social media content.
• Agree the preferred place of care and place of death with
children and young people and their parents or carers,
taking into account:
– Their wishes, which are personal and individual
– Their religious, spiritual, and cultural values
– The views of relevant and experienced healthcare
professionals
– Safety and practicality.
• Explain that the place of care or place of death may
change, for example:
Components of an advance care plan for a child or young person with a life limiting
condition
•Demographic information about the child or young person and their family
•Up to date contact information for:
– The child or young person’s parents or carers
– The key professionals involved in care
•A statement about who has responsibility for giving consent
•A summary of the life limiting condition
•An agreed approach to communicating with and providing information to the child
or young person and their parents or carers
•An outline of the child or young person's life ambitions and wishes, such as on:
– Family and other relationships
– Social activities and participation
– Education
– How to incorporate their religious, spiritual, and cultural beliefs and values into
their care
•A record of significant discussions with the child or young person and their parents
or carers
•Agreed treatment plans and objectives
•Education plans, if relevant
•A record of any discussions and decisions that have taken place on:
– Preferred place of care and place of death
– Organ and tissue donation (see recommendation 1.1.19 in the full NICE
guideline2)
– Management of life threatening events, including plans for resuscitation or life
support
– Specific wishes, such as on funeral arrangements and care of the body
•A distribution list for the advance care plan
32
– If the child or young person and their parents or carers
change their minds or
– For clinical reasons or
– Due to problems with service provision.
• For children and young people with life limiting
conditions who are approaching the end of life and are
being cared for at home, services should provide (when
needed):
– Advice from a consultant in paediatric palliative care
(such as by telephone) at any time (day and night)
– Paediatric nursing care at any time
– Home visits by a healthcare professional from
the specialist paediatric palliative care team (see
recommendation 1.5.4 in the full NICE guideline2), for
example, for symptom management
– Practical support and equipment for interventions
including oxygen, enteral nutrition, and subcutaneous
and intravenous therapies
– Anticipatory prescribing for children and young people
who are likely to develop symptoms.
• Involve the specialist paediatric palliative care team
if a child or young person has unresolved distressing
symptoms as they approach the end of life.
• Think about non-pharmacological interventions for pain
management, such as:
– Changes that may help them to relax, for example,
environmental adjustments (for example reducing
noise), music or physical contact (such as touch,
holding or massage)
– Local hot or cold applications to the site of pain
– Comfort measures, such as sucrose for neonates.
• In addition to background analgesia, consider giving
anticipatory doses of analgesia for children and young
people who have pain at predictable times (for example,
when changing dressings or moving and handling). Do
not include anticipatory doses when calculating the
required daily background dose of analgesia.
• When a child or young person is approaching the end of
life, discuss with them and their parents or carers and
with relevant healthcare professionals:
– Any available invasive treatments that might be in their
best interest
– Any interventions they are currently receiving that may
no longer be in their best interest.
• Attempt resuscitation for children and young people with
life limiting conditions unless there is a “Do not attempt
resuscitation” order in place.
Competing interests: See bmj.com.
Cite this as: BMJ 2016;355:i6385
Find this at: http://dx.doi.org/10.1136/bmj.i6385
7 January 2017 | the bmj
CLINICAL UPDATES
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Ischaemic colitis
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J M Trotter,1 L Hunt,2 M B Peter1
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1
Department of Surgery, Scarborough General Hospital, Scarborough, UK
Department of Diabetes, Endocrinology and Metabolism, Sheffield Teaching
Hospitals, Royal Hallamshire Hospital, Sheffield, UK
Correspondence to: [email protected]
2
Marginal artery
of Drummond
LEARNING
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Vasa recta
This is an edited version; the full version is on bmj.com
The incidence of ischaemic colitis1 has risen from
6.1 cases/100 000 person-years in 1976-80 to
22.9/100 000 in 2005-09.2 Acute gastrointestinal
medical and surgical teams will see a few patients
with ischaemic colitis each month.
Prevalence increases with age and comorbidity,2
which might lead to an increase in the incidence of
ischaemic colitis as the population ages.3 A small
proportion of patients will present with a more
chronic form of ischaemic colitis.
Superior
mesenteric
arteryREADING
Middle
colic
artery
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Ileocolic
artery
Left
colic
artery
This article provides practical advice to non-specialists
regarding the diagnosis, management, and guideline
recommendations for ischaemic colitis in the acute
setting.
What is ischaemic colitis and what causes it?
Ischaemic colitis and mesenteric ischaemia are different
disorders but are often confused: the table (p 36)
highlights their differences. Ischaemic colitis occurs
when there is an acute, transient compromise in blood
flow, below that required for the metabolic needs of the
colon. This leads to mucosal ulceration, inflammation,
and haemorrhage. The duration and severity of
hypoperfusion determines whether the colonic injury
is predominantly ischaemic or as a consequence of
reperfusion.4 Figure 1 shows the arterial supply of the
colon and the most common sites for ischaemic colitis.
Ischaemic colitis often has a multifactorial origin, and
patients with extensive comorbidities are at particular
risk. The box lists common causes of ischaemic colitis.
What are the symptoms and signs?
Acute presenting symptoms are commonly diarrhoea,
rectal bleeding, and colicky abdominal pain.12
Examination typically reveals a soft abdomen with
tenderness and voluntary guarding over the affected
segment of colon. The presence of peritonitis suggests
full thickness ischaemia, perforation, or alternative
diagnosis. The acute onset of the symptoms is a useful
distinguishing factor between ischaemic colitis and
inflammatory or infective colitis, where abdominal
pain often has a more insidious onset.13 Symptoms of
ischaemic colitis manifest in a matter of hours and,
unlike infective or inflammatory colitis, continue to
worsen with systemic instability.
Inferior
mesenteric
artery
Marginal artery
of Drummond
Fig 1 | Arterial supply of the colon and the most common sites for
ischaemic colitis. The colon receives blood from both the superior
and inferior mesenteric arteries. However, there are weak points, or
“watershed” areas, at the borders of the territory supplied by each of
these arteries,5 such as the splenic flexure and the transverse portion
of the colon. These watershed areas are most vulnerable to ischaemia
when blood flow decreases, as they have the fewest vascular collaterals
WHAT YOU NEED TO KNOW
• Ischaemic colitis is different from mesenteric
ischaemia or “ischaemic bowel”
• Ischaemic colitis is typically acute in onset and has a
high mortality rate
• Patients with suspected ischaemic colitis need urgent
admission to a gastroenterological unit with specialist
surgical services
• Some patients with ischaemic colitis can be managed
conservatively
• Computed tomography is the investigation of
choice for initial diagnosis of ischaemic colitis,
using colonoscopy within 48 hours to give further
prognostic information and to confirm diagnosis
the bmj | 7 January 2017
33
Ischaemic colitis may result in systemic
inflammatory response syndrome (SIRS)
with associated observations of tachycardia,
hypotension, tachypnoea, and occasionally raised
temperature without an infective focus. Patients
can present in a state of shock, leading on to
multiorgan failure if not treated correctly.
Clinically, it is difficult to differentiate between
patients with possible infective, inflammatory,
or ischaemic colitis, and even with diagnostic
tests it is not always clear. Generalists need to be
equipped to recognise patients with symptoms of
colitis who are deteriorating and refer them for
specialist opinion.
How do you diagnose ischaemic colitis?
Investigate patients with possible ischaemic
colitis urgently. Computed tomography is the
diagnostic investigation of choice. Guidance
from the American College of Gastroenterology4
recommends that computed tomography is
performed within the first few hours of admission,
with care led by a senior clinician from this
point. Colonoscopic evaluation is recommended
within 48 hours to visualise mucosa and confirm
diagnosis.
There is no role for abdominal plain
radiographs or ultrasonography in diagnosing
ischaemic colitis, though these investigations
often used in practice in the assessment of
abdominal pain. They can give some information
about ischaemic colitis, such as “thumbprinting”
on x ray or mural thickening and blood flow on
ultrasonography and Doppler ultrasound.14‑17
However, the same, and more, information
is provided in greater detail on computed
tomography that is not user dependent and is
usually more readily available out of hours than
ultrasonography.
Common causes of ischaemic colitis
Physiological
Systemic—Heart failure, systemic inflammatory response syndrome (SIRS),
atherosclerosis
Embolic—Atrial fibrillation
Thrombotic—Concurrent malignancy and haematological disorders6
Iatrogenic
Pharmacological—Chemotherapy, sex hormones, interferon therapy,
pseudoephedrine, cardiac glycosides, diuretics, statins, non-steroidal antiinflammatory drugs (NSAIDS), immunosuppressive drugs, vasopressors6 7
Surgical—Abdominal aortic aneurysm repair8
Endoscopic—Colonoscopy and bowel preparation media for colonoscopy4‑11
HOW PATIENTS WERE INVOLVED IN THE CREATION OF THIS ARTICLE
No patients were involved in the creation of this article.
P
Laboratory tests
In the presence of rectal bleeding, perform
clotting studies and a haemoglobin level.
Inflammatory makers such as C reactive protein
and neutrophil count are likely to be raised.
Check renal function as patients are at risk of
acute kidney injury because of the inflammatory
response in ischaemic colitis.
Serum lactate levels may be raised as a result
of systemic dysfunction and hypoperfusion. The
role of lactate in this scenario is in monitoring
progress during resuscitation. Raised serum
lactate does not indicate gastrointestinal
ischaemia, and a normal lactate level does not
exclude full thickness ischaemia of the colon.18
Contrast enhanced computed tomography
Computed tomography gives prompt information,
with positive findings in ischaemic colitis in up
to 98% of cases.19 These include wall thickening,
34
Fig 2 | Computed tomographs of the abdomen (in axial and coronal views) showing fat
stranding (increased density of fat, a sign of inflammatory process) and thickening
(arrows) around the splenic flexure secondary to ischaemic colitis
7 January 2017 | the bmj
abnormal or absent wall enhancement, dilatation,
mesenteric stranding, venous engorgement,
ascites, pneumatosis (gas within the bowel wall),
and portal venous gas (fig 2).19 20 The CT findings
suggest a diagnosis of ischaemic colitis, but they
can be present regardless of severity,19 limiting
the prognostic value. The presence of such
features (particularly in the watershed between
the superior and inferior mesenteric artery)
will suggest a diagnosis of ischaemic colitis
but cannot absolutely distinguish it from other
types of colitis. CT can rule out other diagnoses
and complications such as perforation that will
change management.
Endoscopic evaluation
Early endoscopy can confirm the diagnosis by
direct visualisation4 and provides prognostic
information to help distinguish between cases
that may settle with conservative management
and those that may require emergency
resection.
Transient non-gangrenous features of
ischaemic colitis observed at colonoscopy
include:
• Petechial haemorrhages
• Oedematous and fragile mucosa
• Segmental erythema
• Scattered erosions
• Longitudinal ulcerations (colon single stripe
sign) (fig 3)
• A sharply defined segment of involvement.21
Cyanosis and pseudo-polyps suggest a
transmural ischaemia.
Colonoscopy is advocated by most studies, and
there is no evidence that its use in assessment
of ischaemic colitis is unsafe when performed
by experienced practitioners.4 22 Retrospective
studies of a total of 659 cases reported no cases of
perforation secondary to colonoscopy,23 24 in data
published in recent guidance.4
What treatment is available?
Initial resuscitation
There is no specific guidance for the resuscitation
of patients with ischaemic colitis. General
resuscitation principles apply, including
• Intravenous fluid resuscitation
• Fluid balance monitoring with bladder
catheterisation
• Assessment of acid-base status with arterial
blood gas sampling
• Blood glucose control and monitoring in
diabetic patients.
While there is no specific evidence regarding
fluid resuscitation in ischaemic colitis, aggressive
and prompt resuscitation of a patient with SIRS
has profound effects on outcomes, and specific
algorithms now exist for conditions such as sepsis
and pancreatitis.25 26
Fig 3 | Endoscopic findings of inflamed mucosa and single stripe sign (a single longitudinal
strip of ulcerated or inflamed colon (arrow)) in segment of ischaemic colitis (reproduced
with permission of www.natural-health-news.com)
With appropriate resuscitation measures, colonic
inflammation and associated symptoms settle in
some patients without the need for surgery. Data
on the proportion of patients who may be expected
to settle without surgical intervention vary widely,
reflecting the differences in clinical practice with
regards to ischaemic colitis and the current lack of
robust guidance.
Surgical intervention
Consider surgical intervention if there is
radiological evidence of perforation, generalised
peritonitis, or continuing haemorrhage causing
instability or repeated transfusion. For patients
without these features, decisions whether to
operate when conservative management fails are
made on an individual basis.
Factors associated with severe episodes that may
not resolve with conservative treatment include4‑27
• Right sided distribution of colitis
• Male sex
• Lack of rectal bleeding
• Renal dysfunction
• Colonic strictures
• Peritonitis.
Where one or more of these features exist,
provide senior review daily and be alert to signs
of development of full thickness ischaemia such
as worsening pain or peritonism. For patients
whose clinical condition is not improving,
consider further blood texts to review biochemical
markers. In the case of any clinical or biochemical
the bmj | 7 January 2017
35
QUESTIONS FOR ONGOING RESEARCH
•Does anticoagulation provide protection for recurrence of
ischemic colitis?
•Should Doppler ultrasound be more readily available in
centres dealing with ischaemic colitis?
•Should formal angiography and endovascular treatment
be performed in mesenteric stenoses found on computed
tomography of patients with ischaemic colitis?
Differences between mesenteric ischaemia and ischaemic colitis
Characteristic
Mesenteric ischaemia
(ischaemic bowel)
Ischaemic colitis
Symptom onset
Sudden
Hours
Cause
Embolic
Multifactorial
Blood supply
loss
Total to affected
segment
Transient
Presenting
symptoms
Abdominal pain out of Moderate abdominal pain and
proportion with clinical tenderness over affected segment,
findings
bloody diarrhoea
Management
Urgent surgery
Usually conservative, but surgery
needed in some cases
deterioration, consider the need for repeat imaging
and surgical intervention.
Patients who require surgical intervention
for ischaemic colitis have higher mortality
(37-48%4‑30) than those treated conservatively
(6.2% in a large systematic review17 22). Operative
intervention usually includes segmental resection
and colostomy formation. In unstable patients,
complex surgery can worsen outcome.31
Caring for patients with ischaemic colitis
Anticoagulation
Prophylactic anticoagulation is advocated, but
therapeutic anticoagulation is not indicated.
Current guidance from the National Institute for
Health and Care Excellence (NICE) advocates
mechanical and pharmacological prophylaxis
for venous thromboembolism for most groups
of patients who don’t have contraindications,
including those with ischaemic colitis.32 NICE
guidance recommends postoperative prophylaxis
for venous thromboembolism continues “until
mobility is no longer significantly restricted.”
Cardiac emboli
Cardiac emboli have been found in 43% of
patients with ischaemic colitis compared with
23% of matched controls.33 These findings may be
coincidental, but consider investigations in those
with cardiac symptoms or signs.33
Nutritional support
After admission for suspected ischaemic colitis,
most patients will be fasted until a decision is
made about surgery. There is a move away from
36
prolonged fasting in modern surgical practice in
acute and elective settings.25‑35
Offer a dietetic-led enteral diet to help restore
normal gut physiology and flora early. Parenteral
nutrition may be necessary in severe cases when
fasting is likely to exceed a week.
Antimicrobial therapy
The latest guidance on ischaemic colitis from the
American College of Gastroenterology recommends
antimicrobial therapy, although the evidence base
for this is poor.4 Consider which specific agents to
use with the help of microbiological guidance, taking
account of local protocols and microbial resistance.
What is the long term management of ischaemic colitis?
Ischaemic colitis is multifactorial in origin and often
occurs in a patient with multiple comorbidities. When
treating ischaemic colitis, offer support in lifestyle
modification to reduce recurrence or deterioration in
other conditions, including advice on
• Smoking cessation
• Alcohol intake reduction
• Increasing exercise.
There is no guidance or evidence to suggest that
antiplatelets are of benefit in treating ischaemic
colitis. It is not a purely atherosclerotic condition,
so, alone, it is not a reason to start antiplatelet
therapy.
Medication
Patients who have had ischaemic colitis may take
regular medication that can impair colonic blood
flow. These drugs are commonly prescribed for
primary or secondary prevention of ischaemic heart
disease such as angiotensin converting enzyme
inhibitors or β adrenoreceptor blockers. If cardiac
medications have been stopped temporarily during
the acute illness, reintroduce them with caution to
avoid periods of hypotension that might exacerbate
ischaemic colitis.
Follow-up care
Uncomplicated ischaemic colitis is usually followed
up once after admission by the surgical team, then
the patient discharged back to community care.
Chronic or recurrent ischaemic colitis occurs in 6.816% of patients.4 This can present as another acute
episode similar to the index admission. At the site
of previous ischaemic colitis stricturing can occur,
causing bloating, constipation, and colicky pain as
well as chronic ulceration prone to bleeding that may
manifest itself only as anaemia.
The chronic, more benign symptoms of
ischaemic colitis, although rare, are non-specific;
if encountered, they warrant prompt referral to
specialist services to confirm the diagnosis.
Competing interests: None declared.
Cite this as: BMJ 2016;355:i6600
Find this at: http://dx.doi.org/10.1136/bmj.i6600
7 January 2017 | the bmj
ENDGAMES For long answers go to the Education channel on thebmj.com CASE REVIEW A case of pulsatile tinnitus
A 32 year old man presented to his
primary care doctor with an eight month
history of hearing loss and a pulsatile
noise that sounded like a heartbeat in
his left ear. In the previous four months
he had experienced otalgia in the left ear
and headaches. On examination, the
doctor noticed a mass behind the left
tympanic membrane, with pulsation of the
membrane. Tuning fork tests identified
a conductive hearing loss in the left ear.
Other than headaches, there were no
red flag symptoms such as weight loss,
fever, or other signs of raised intracranial
pressure. The patient was referred to an
ear, nose, and throat specialist, who noted
that the left tympanic membrane was
intact and facial nerve function on both
sides was normal. There was an obvious
pulsating mass behind the left tympanic
membrane (fig 1). Endoscopic examination
of the larynx showed normal vocal cord
movement, but there was evidence of a
hypoglossal palsy on the left side, with
unilateral tongue wasting. The patient
had some difficulty articulating speech
but reported no dysphagia. Audiometry
confirmed a conductive hearing loss in
the left ear. Contrast enhanced computed
tomography (CT) and magnetic resonance
imaging (MRI) (fig 2) of the base of the
patient’s skull showed an enhanced
jugular fossa mass on the left side.
@bmj_latest
SPOT DIAGNOSIS
Abnormality on a skull
radiograph
1. What are the differential diagnoses for
pulsatile tinnitus?
2. What is the most likely diagnosis?
3. What are the management options?
Submitted by Karan Jolly, Pawanjit Hare, Richard Irving,
and Peter Monksfield
Patient consent obtained.
Cite this as: BMJ 2017;356:i6402
A 65 year old woman presented with a four week
history of increased fatigue, intermittent chest
pain, dyspnoea, and frequent constipation.
Biochemistry showed haemoglobin of 95 g/L
(baseline 130 g/L) and an estimated glomerular
filtration rate of 5 ml/min/1.73m2 (baseline
50 ml/min/1.73m2). Initial chest radiography
revealed multiple unexplained rib fractures,
which prompted a further skeletal survey,
including a radiograph of the skull (figure). What
does the skull radiograph show?
Submitted by Janice Ser Huey Tan and Timothy Shao Ern Tan
Patient consent obtained.
Cite this as: BMJ 2017;356:i6315
Fig 1
3 Three main treatment modalities exist: surveillance with repeat
imaging after an interval, surgical resection, and radiotherapy.
Treatment is guided by discussion between members of the skull base
multidisciplinary team.
1 Differential diagnoses include vascular stenosis due to atherosclerotic
plaques; arteriovenous fistula; vascular tumours (including
paragangliomas), and intracranial hypertension. Alternatively, the
tinnitus can result from increased sensitivity to normal bodily noises
such as blood flow. This can be due to conductive hearing loss caused
by wax obstruction or middle ear infection/effusion.
CASE REVIEW A case of pulsatile tinnitus
Lateral radiograph of
the skull showing focal
mandibular lucency
(*) on a background
of “pepper pot”
lucencies in the skull
vault (white arrow)
caused by myeloma
bone disease
SPOT
DIAGNOSIS
Abnormality on a
skull radiograph
the bmj | 7 January 2017 answers
2 Paraganglioma of the head and neck, more specifically known as a
glomus jugulare tumour.
FigFig
2 2
If you would like to write a Case Review
for Endgames, please see our author
guidelines at http://bit.ly/29HCBAL and
submit online at http://bit.ly/29yyGSx
41
MINERVA A wry look at the world of research
Cutaneous sarcoid granulomas within a cosmetic tattoo
A 40 year old man who had
known multisystem sarcoidosis
noticed the re-emergence of well
defined, non-tender papules
within the borders of his preexisting tattoo (figure). The
papules arose after his dose
of prednisolone was reduced
from 7 mg to 6 mg once daily,
and were associated with an
increase in serum angiotensin
converting enzyme activity, which
is a marker of sarcoid activity.
Invasion of cosmetic tattoos and
scars by sarcoid granulomas is
a well recognised phenomenon
of unknown pathophysiological
cause, and cutaneous
involvement occurs in up to
one third of patients. Currently,
patients with sarcoidosis are
not advised against having
cosmetic tattoos. Increasing the
prednisolone dose back up to 7
mg resulted in almost complete
resolution of the lesions within
three months.
Stephanie Laura Tanner
([email protected]);
Sarah Menzies, Wexham Park
Hospital, Slough
Patient consent obtained.
Cite this as: BMJ 2017;356:i6324
Don't blame the staff for staph
Lung transplant window opens
The idea that hospital
staff might go around
spreading infection arose
in the 1780s and took
about a hundred years to
sink in. Whole genome
bacterial sequencing can
now track how many bacteria
come to hospitals from outside and
how many are spread by healthcare
workers. Reassuringly, a study from
the intensive care unit at the Royal
Sussex Hospital, UK, found that in the
presence of standard infection control
measures, healthcare workers were
infrequently sources of transmission
of Staphylococcus aureus to patients
(Lancet Infect Dis doi:10.1016/S14733099(16)30413-3). Instead, the
epidemiology showed a continuous
ingress of distinct subtypes rather than
transmission of genetically related
strains.
Traditionally, the optimal time from lung
explantation to transplantation is 12 hours,
but this can be extended by splitting it into
two periods of cold ischaemia, separated by
a period of ex vivo lung perfusion. Looking
retrospectively at 906 patients on the
Toronto Lung Transplant Program database,
investigators found that extending graft
preservation time beyond 12 hours with
ex vivo lung perfusion does not negatively
affect early lung transplantation outcomes
(Lancet Respir Med doi:10.1016/S22132600(16)30323-X).
Bednets bomb in Haiti
Bednets treated with insecticide are
useful for preventing malaria when
the disease is spread by Anopheles
mosquitoes that bite in the night.
Unfortunately, the chief malarial
vector in Haiti, Anopheles albimanus,
bites primarily outdoors and often
when people are awake. A casecontrol study from 17 centres in Haiti
concluded that, despite a campaign
to encourage the use of bednets, the
nets did not statistically significantly
protect against clinical malaria (Lancet
Glob Health doi:10.1016/S2214109X(16)30238-8). The mosquitoes
all showed high susceptibility to the
bednet insecticide but they just fed too
early.
42
Know your genes, avoid diabetes?
Personal genetic testing is sold throughout
the world as a guide to preventing diseases
such as type 2 diabetes by enabling better
risk assessment and informing on lifestyle
change. The Fenland study, based in
Cambridge, UK, recruited 569 healthy
middle aged adults and randomised
them to receive either standard lifestyle
advice alone (control group n=190) or
in combination with a genetic (n=189)
or a phenotypic (n=190) risk estimate
for type 2 diabetes. After eight weeks,
there was no difference in health related
behaviours between the groups (PLOS Med
doi:10.1371/journal.pmed.1002185).
Stenting without a surgical safety net
Percutaneous coronary intervention
started cautiously in large hospitals that
had cardiac surgery teams on site in case
anything went wrong with the balloon or
the stent in the coronary artery. But in the
USA, the years 2003-12 saw a sevenfold
increase in the use of percutaneous
coronary intervention in smaller hospitals.
A survey covering nearly seven million
inpatient procedures shows that adjusted
in-hospital mortality does not differ
between hospitals with and without
surgical “rescue” teams. (JAMA Cardiol
doi:10.1001/jamacardio.2016.4188).
Inspecting skin in Queensland
White people living in sunny places get
skin cancers, but not always at the sites
on the body that are most exposed. A
survey of the anatomical location of basal
cell and squamous cell carcinomas in
Queensland, Australia, found the expected
predominance on the head and neck
for both (JAMA Dermatol doi:10.1001/
jamadermatol.2016.4070). But squamous
cell carcinomas were more common than
basal cell carcinomas on the arms, and
basal cell cancers were more common on
the hands and the buttocks.
Do benzos make nurses snore?
Minerva’s owl assures her that she never
snores. The Nurses' Health Study (USA,
2008), however, found that 10.6% of
its all female cohort aged between 62
and 86 snored regularly, increasing
to 11.4% if they took benzodiazepine
receptor agonists (JAMA Otolaryngol
Head Neck Surg.doi:10.1001/
jamaoto.2016.3174).
But after adjustment for
confounders, this small
difference disappeared. Use
of benzodiazepine receptor
agonists is not associated
with odds of snoring in
middle aged and elderly
women, and their
bedfellows have a nearly
nine out of 10 chance of
sleeping soundly.
Cite this as: BMJ 2017;
356:i6825
7 January 2017 | the bmj