scholarly journals P-EGS28 Management of obstructive jaundice secondary to gall stones in an ambulatory setting

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Katie Boag ◽  
Nasira Amtul ◽  
Pratik Roy ◽  
Rahulpreet Singh ◽  
Shivanthi Kandiah ◽  
...  
Keyword(s):  
Primary Care ◽  
Obstructive Jaundice ◽  
Epigastric Pain ◽  
Acute Cholangitis ◽  
Gall Stone ◽  
Ambulatory Setting ◽  
Mri Imaging ◽  
Surgical Service ◽  
Gall Stones ◽  
Patient Attendance

Abstract Background Our data from Leeds shows a 30% increase in patient attendance to the Surgical Assesment Unit (SAU) across a 5 year period, putting unprecedented demands on the acute surgical service. A new Ambulatory Surgical Centre (ASC) was established for the advancement of ambulatory care pathways that would ensure that acute patients are seen promptly and kept safe with monitoring in an appropriate setting without needing admission to the hospital bed base. Gallstone related disease accounts for a third of patient attendance to the emergency surgical services. We present our experience with an ambulatory pathway to manage patients with obstructive jaundice caused by gall stones, and propose a protocol driven pathway. Methods The ASC operates an acute, consultant led clinic, with access to urgent blood tests and dedicated USS, CT and MRI imaging capacity, and offers a direct referral service from Primary Care Networks (PCNs) through the Primary Care Access Line (PCAL). Patients referred with clinical jaundice or RUQ/Epigastric pain are investigated for derangement in their liver function, and assessed for the presence and severity of Acute Cholangitis (AC), according to the 2018 Tokyo Guidelines. Patients without evidence of cholangitis, or with AC Grade I are planned for management in the ambulatory setting, including investigations, monitoring and endoscopic/surgical intervention. Outcome data was collected retrospectively from PCAL data source, spanning from Oct 2020 till July 2021. Results A total of 98 patients were referred to the acute surgical service during this period. Out of these, 47% had Grade II (n = 35) or Grade III (n = 17) AC. 48% were suitable for ambulatory management, with no evidence of AC(n = 5) or Grade I AC(n = 43). 20% patients were found to have a cause other than gall stone disease. 55% have undergone intervention (33 Laparoscopic cholecystectomies, 22 ERCP) while 12 are on the waiting list for surgery. Conclusions Our protocol offers a safe, comprehensive and timely pathway for the management of patients with gall stone related obstructed jaundice in an ambulatory setting. This has helped reduce the demand on hospital beds for surgical patients.

scholarly journals Understanding the clinical reasoning processes involved in the management of multimorbidity in an ambulatory setting: study protocol of a stimulated recall research

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
M.-C. Audétat ◽  
S. Cairo Notari ◽  
J. Sader ◽  
C. Ritz ◽  
T. Fassier ◽  
...  
Keyword(s):  
Primary Care ◽  
Clinical Reasoning ◽  
Primary Care Physicians ◽  
Video Sequence ◽  
Structured Interview ◽  
Ambulatory Setting ◽  
Structured Interviews ◽  
Stimulated Recall ◽  
Study Results

Abstract Background Primary care physicians are at the very heart of managing patients suffering from multimorbidity. However, several studies have highlighted that some physicians feel ill-equipped to manage these kinds of complex clinical situations. Few studies are available on the clinical reasoning processes at play during the long-term management and follow-up of patients suffering from multimorbidity. This study aims to contribute to a better understanding on how the clinical reasoning of primary care physicians is affected during follow-up consultations with these patients. Methods A qualitative research project based on semi-structured interviews with primary care physicians in an ambulatory setting will be carried out, using the video stimulated recall interview method. Participants will be filmed in their work environment during a standard consultation with a patient suffering from multimorbidity using a “button camera” (small camera) which will be pinned to their white coat. The recording will be used in a following semi-structured interview with physicians and the research team to instigate a stimulated recall. Stimulated recall is a research method that allows the investigation of cognitive processes by inviting participants to recall their concurrent thinking during an event when prompted by a video sequence recall. During this interview, participants will be prompted by different video sequence and asked to discuss them; the aim will be to encourage them to make their clinical reasoning processes explicit. Fifteen to twenty interviews are planned to reach data saturation. The interviews will be transcribed verbatim and data will be analysed according to a standard content analysis, using deductive and inductive approaches. Conclusion Study results will contribute to the scientific community’s overall understanding of clinical reasoning. This will subsequently allow future generation of primary care physicians to have access to more adequate trainings to manage patients suffering from multimorbidity in their practice. As a result, this will improve the quality of the patient’s care and treatments.

scholarly journals Pilot study to build capacity for family medicine with abbreviated, low-cost training programme with minimal impact on patient care for a cohort of 84 general practitioners caring for Palestinian refugees in Jordan

BMJ Open ◽  
2019 ◽  
Vol 9 (8) ◽  
pp. e028240 ◽  
Author(s):  
Amjad Al Shdaifat ◽  
Therese Zink
Keyword(s):  
Primary Care ◽  
Patient Care ◽  
General Practitioners ◽  
Clinical Skills ◽  
Low Cost ◽  
Training Programme ◽  
Ambulatory Setting ◽  
Secondary Outcome ◽  
Intervention Programme ◽  
Minimal Impact

PurposeStudies document that primary care improves health outcomes and controls costs. In regions of the world where primary care is underdeveloped, building capacity is essential. Most capacity building programmes are expensive and take physicians away from their clinical settings. We describe a programme created, delivered and evaluated from 2013 to 2014 in Jordan.DesignCohort study.SettingPhysicians providing primary care in the United Nations Relief and Works Agency for Palestine Refugees clinics in Jordan.ParticipantsEighty-four general practitioners (GPs) were invited to participate and completed the training and evaluation. GPs are physicians who have a license to practice medicine after completing medical school and a 1 year hospital-based rotating internship. Although GPs provide care in the ambulatory setting, their hospital-based education provides little preparation for delivering ambulatory primary care.Intervention/ProgrammeThis three-stage programme included needs assessment, didactics and on-the-job coaching. First, the learning needs and baseline knowledge of the trainees were assessed and the findings guided curriculum development. During the second stage, 48 hours of didactics covered topics such as communications skills and disease management. The third stage was delivered one on one in the trainee’s clinical setting for a 4 to 6-hour block. The first, middle and final patient interactions were evaluated.Primary and secondary outcome measuresPreknowledge and postknowledge assessments were compared. The clinical checklist, developed for the programme, assessed eight domains of clinical skills such as communication and history taking on a five-point Likert scale during the patient interaction.ResultsPreknowledge and postknowledge assessments demonstrated significantly improved scores, 46% to 81% (p<0.0001). Trainee’s clinical checklist scores improved over the assessment intervals. Satisfaction with the training was high.ConclusionThis programme is a potential model for building primary care capacity at low cost and with little impact on patient care that addresses both knowledge and clinical skills on the job.

1425 A Stent Long-Forgotten: Obstructive Jaundice and Acute Cholangitis Due to Migrated Biliary Stent

2019 ◽  
Vol 114 (1) ◽  
pp. S791-S792
Author(s):  
Bobby Jacob ◽  
Kanak Das ◽  
Charudatta Wankhade ◽  
Stavros Stavropoulos ◽  
Kaleem Rizvon
Keyword(s):  
Obstructive Jaundice ◽  
Acute Cholangitis ◽  
Biliary Stent

scholarly journals How to decide adequately? Qualitative study of GPs’ view on decision-making in self-referred and physician-referred emergency department consultations in Berlin, Germany

BMJ Open ◽  
2019 ◽  
Vol 9 (4) ◽  
pp. e026786 ◽  
Author(s):  
Sarah Oslislo ◽  
Christoph Heintze ◽  
Martina Schmiedhofer ◽  
Martin Möckel ◽  
Liane Schenk ◽  
...  
Keyword(s):  
Primary Care ◽  
Decision Making ◽  
Qualitative Study ◽  
Qualitative Content Analysis ◽  
Wide Spectrum ◽  
Influencing Factor ◽  
Primary Care Providers ◽  
Ambulatory Setting ◽  
Care Providers ◽  
Registration Number

ObjectivesPatients with acute symptoms present not only to general practitioners (GPs), but also frequently to emergency departments (EDs). Patients’ decision processes leading up to an ED self-referral are complex and supposed to result from a multitude of determinants. While they are key providers in primary care, little is known about GPs’ perception of such patients. This qualitative study explores the GPs’ view regarding motives and competences of patients self-referring to EDs, and also GPs’ rationale for or against physician-initiated ED referrals.DesignQualitative study with semi-structured, face-to-face interviews; qualitative content analysis.SettingGP practices in Berlin, Germany.Participants15 GPs (female/male: 9/6; mean age 53.6 years).ResultsThe interviewed GPs related a wide spectrum of factors potentially influencing their patients’ decision to visit an ED, and also their own decision-making in potential referrals. Considerations go beyond medical urgency. Statements concerning patients’ surmised rationale corresponded to GPs’ reasoning in a variety of important areas. For one thing, the timely availability of an extended spectrum of diagnostic and therapeutic options may make ED services attractive to both. Access difficulties in the ambulatory setting were mentioned as additional triggers for an ED visit initiated by a patient or a GP. Key patient factors like severity of symptoms and anxiety also play a major role; a desire for reassurance may lead to both self-referred and physician-initiated ED visits. Patients’ health competence was prevailingly depicted as limited, with the internet as an important influencing factor. Counselling efforts by GP were described as crucial for improving health literacy.ConclusionsHealth education could hold promise when aiming to reduce non-urgent ED consultations. Primary care providers are in a key position here. Amelioration of organisational shortages in ambulatory care, for example, limited consultation hours, might also make an important impact, as these trigger both self-referrals and GP-initiated ED referrals.Trial registration numberDRKS00011930.

scholarly journals Measuring the Costs of Primary Care Education in the Ambulatory Setting

2000 ◽  
Vol 75 (5) ◽  
pp. 419-425 ◽  
Author(s):  
James R. Boex ◽  
Arthur A. Boll ◽  
Luisa Franzini ◽  
Andrew Hogan ◽  
David Irby ◽  
...  
Keyword(s):  
Primary Care ◽  
Ambulatory Setting ◽  
Care Education ◽  
Primary Care Education

scholarly journals Deciphering Autoimmune Pancreatitis, a Great Mimicker: Case Report and Review of the Literature

2015 ◽  
Vol 2015 ◽  
pp. 1-6
Author(s):  
Satya Allaparthi ◽  
Mohammed Sageer ◽  
Mark J. Sterling
Keyword(s):  
Obstructive Jaundice ◽  
Autoimmune Pancreatitis ◽  
Epigastric Pain ◽  
Hepatic Duct ◽  
Liver Function Tests ◽  
Pancreatic Disease ◽  
Common Hepatic Duct ◽  
Caucasian Woman ◽  
Distal Common Bile Duct ◽  
Biliary Sphincterotomy

Background. Autoimmune pancreatitis (AIP) is an atypical chronic inflammatory pancreatic disease that appears to involve autoimmune mechanisms. In recent years, AIP has presented as a new clinical entity with its protean pancreaticobiliary and systemic presentations. Its unique pathology and overlap of clinical and radiological features and absence of serological markers foster the disease’s unique position. We report a case of diffuse type 1 autoimmune pancreatitis with obstructive jaundice managed with biliary sphincterotomy, stent placement, and corticosteroids. A 50-year-old Caucasian woman presented to our hospital with epigastric pain, nausea, vomiting, and jaundice. Workup showed elevated liver function tests (LFT) suggestive of obstructive jaundice, MRCP done showed diffusely enlarged abnormal appearing pancreas with loss of normal lobulated contours, and IgG4 antibody level was 765 mg/dL. EUS revealed a diffusely hypoechoic and rounded pancreatic parenchyma with distal common bile duct (CBD) stricture and dilated proximal CBD and common hepatic duct (CHD). ERCP showed tight mid to distal CBD stricture that needed dilatation, sphincterotomy, and placement of stent that led to significant improvement in the symptoms and bilirubin level. Based on clinical, radiological, and immunological findings, a definitive diagnosis of AIP was made. Patient was started on prednisone 40 mg/day and she clinically responded in 4 weeks.

Massive left lobe primary hepatolithiasis with extremely high CA 19.9

2013 ◽  
Vol 19 (S4) ◽  
pp. 37-38
Author(s):  
A. Murinello ◽  
P. Guedes ◽  
A.M. Carvalho ◽  
J.S. Coelho ◽  
B.B. Leite ◽  
...  
Keyword(s):  
Bile Duct ◽  
Epigastric Pain ◽  
Acute Cholangitis ◽  
Intrahepatic Bile Duct ◽  
Left Lobe ◽  
Left Hepatectomy ◽  
Caroli Disease ◽  
Acute Calculous Cholecystitis ◽  
Ultrasound Study ◽  
Calculous Cholecystitis

Hepatolithiasis (HL) or intrahepatic calculi is an uncommon condition in Western countries, with a prevalence under 1%. It is much more frequent in East Asia, reaching 20% in China and Taiwan, up to 50% of which show associated cholelithiasis. The authors report a European patient with primary HL of the left hepatic lobe, 12 years after cholecystectomy for acute calculous cholecystitis, now successfully treated after left lobe hepatectomy.A 63-year-old caucasian man with a past medical history of hypertension, coronary artery disease, dyslipidaemia and urgent cholecystectomy 12 years ago (due to an acute calculous cholecystitis without ultrasonographic or perioperative evidence of bile duct dilation or choledocholithiasis, and with no cholangitis ever since) was now admitted to our ward following a 2-day course of fever (39ºC), epigastric pain, nausea, vomiting and tender right upper abdominal quadrant.Bloodwork showed mild leukocytosis with neutrophilia and low platelets; elevated C-reactive protein, γGT, alkaline phosphatase and LDH; normal AST, ALT, bilirubin and amylase. Negative HBV, HCV and HIV serologies. CA19.9 was notably high (7500 U/mL), 200x above normal range (N≤37). A diagnosis of acute cholangitis was assumed on clinical and laboratory basis, despite the absence of jaundice. The patient began therapy with iv ceftriaxone and improved clearly over the next few days. Raised CA19.9 in the setting of acute cholangitis, however, forced us into further study directed at the possibility of underlying biliary or pancreatic malignancy.Abdominal ultrasound disclosed multiple calcifications in the left lobe. CT displayed several left lobe intrahepatic bile duct dilations but no calcifications, thus suggesting intrahepatic cholesterol stones and cholangitis due to an obstacle before the hilum. MR-cholangiography was performed, showing marked dilation of the left intrahepatic bile duct and moderate dilation in the extrahepatic portion of the common bile duct (CBD). Neither exam showed any sign of cancer. Surgery was the therapeutic approach, and the patient underwent a left hepatectomy.Intra-operative ultrasound study unveiled severe dilation of the left intrahepatic bile duct, which was filled with gallstones, but no choledocholithiasis and no tumour whatsoever. Both the surgical procedure and the post-operative period were uneventful.Macroscopic liver section showed multiple dilated bile ductules containing fragile yellowish-green gallstones (Fig.1). Microscopy revealed cystic dilations of the left intrahepatic biliary tree packed with intraluminal gallstones (Fig.2), fibrosis and moderate chronic inflammatory infiltrate with lymphoid aggregates (Fig.3). Some areas of the epithelium displayed erosion and reactive changes. No biliary neoplasm was found.Immunocytochemistry for angiogenesis or lymphocyte membrane markers are not available in our Hospital. Soon after surgery, CA19.9 values decreased abruptly and just 4 months after the left hepatectomy they were back within reference range.Our working hypotheses were primary hepatolithiasis (HL), secondary HL and Caroli disease.Secondary HL, due to stone migration from the CBD, was discarded because calculi in the CBD were absent in the cholecystectomy 12 years ago and in ultrasonographic studies both then and now. Caroli disease, a congenital condition characterised by intrahepatic bile duct dilation, was contradicted by the ultrasonography in 2000 showing normal bile duct dimension. Excluding these two entities made primary idiopathic HL our final diagnosis.The patient is now asymptomatic, having returned to his normal life with no limitations.This report showcases a rare entity known as primary hepatolithiasis, usually causing recurrent cholangitis in older patients of Asian descent but seldom seen in Europe. The steep increase in CA19.9 related to cholangitis, although previously reported, is also very uncommon. Another interesting aspect is the conspicuous inexistence, over 12 years, of recurrent episodes of acute cholangitis (a traditional finding in hepatolithiasis). These three features help to compose this most peculiar case.

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