Abdo Flashcards
management for H Pylori
Triple eradication therapy 7d
1) high dose PPI taken 30 mins before meals
2) amoxicillin
3) clarithromycin or metronidazole
Management of Ascites
Fluid restrict Sit up SAAG and signs of SBP MR diuretics > loop diuretics Ascitic drain TIPS ABx if peritonitis: cef
Management of Variceal Bleed
Fluids resus
NBM for OGD
Terlipressin on presentation + PPI
Try and reverse coagulopathy e.g. packed cells, vit K, FFP
Oesophageal varices: band ligation
Gastric varices: Endoscopic scleroptherapy injection of N-butyl-2-cyanoacrylate
IV antibiotics (tazocin) offer TIPS if not controlled
consider Sengstaken-Blakemore tube as last resort
AI hep management
high dose steroids
azathioprine after
2 y duration
Management of peptic stricture
Balloon dilatation
PPI if caused by GORD
Management of Wilson’s disease
Penicillamine
Crohn’s induce remission
mild: oral pred
severe: IV hydrocortisone
consider elemental diet
if first mild presentation in 12m consider 5-asa or budesonide
Crohn’s maintain remission
DMARDs: azathioprine (check TPMT first) biologic therapies e.g. infliximab biologic screen before starting STOP SMOKING = as good as steroids elemental diet 2nd-line: methotrexate
consider surgery
UC induce remission
mild: topical aminosalicylates, oral salicylates, oral steroids
consider elemental diet
Severe: IV hydrocortisone +/- ciclosporin/infliximab if ciclo CI
consider surgery
Add LMWH and D3 for bone protection
UC maintain remission
mild/moderate: topical ASA +/- oral
biologic screen before starting
consider azathioprine/mercaptopurine after 2 or more exacerbations in 12m or severe
IBS management
lifestyle (stress, depression, diet diary)
mostly diarrhoea/bloating: reduce insoluble fibre
if diarrhoea persists: loperamide
mostly constipation: increase fibre/laxatives
if severe constipation >12m: trial linaclotide
if pain: antispasmodic e.g. mebeverine or alverine citratre, consider trial TCA
Haemorrhoids management
medical: increase fibre/stool softener, topical analgesia
non-operative: rubber band ligation, sclerotherapy
operative: haemorrhoidectomy, HALO procedure
Decompensated Liver failure management
Empirical antibiotics e.g. tazocin
Laxatives e.g. lactulose aiming for BO 3x/24h (also helps with encephalopathy)
Pabrinex/chlordiazepoxide if alcohol
Diuretics/paracentesis if ascitic
Consider if variceal bleed or renal failure
optimise nutrition +/- NG
Coeliac management
remove gluten dietician referral consider e.g. iron, vitamin D etc. monitor tTG Consider repeat endoscopy
Management for Appendicitis
Prophylactic antibiotics
laparoscopic appendectomy
if perforated: abdominal lavage
if appendix mass: broad spectrum abx, consider drainage and interval appendectomy
investigation for appendicitis
CT
consider USS for pregnancy, children, breastfeeding
MRI if pregnant and USS not diagnostic
Management of Acute Cholecystitis
IV Abx
Severe pain: Diclofenac or opioid
mild/moderate: paracetamol or NSAID
laparoscopic cholecystectomy on admission OR after 6w
consider percutaneous cholecystostomy if surgery contraindicated at presentation + conservative management unsuccessful
Management of Ascending cholangitis
IV Abx
ERCP within 24-48h for placement of stent and removal of stone
Management of gallstones
asymptomatic in gallbladder/biliary tree: nothing
asymptomatic in CBD: offer lap cholecystectomy
Difference between biliary colic, acute cholecystitis and cholangitis
colic: steady non-paroxysmal pain in epigastrium >30 mins
Acute cholecystitis: + fever and tenderness in RUQ pain
Cholangitis: fever + rigors, jaundice, RUQ pain
Reynold pentad: + neuro and shock
management acute pancreatitis
Fluid resus (3-6L)
analgesia
oxygen
IV Abx if infected/associated cholangitis
Enteral nutrition (start oral feeding if possible, otherwise NG tube)
ERCP within 72h
Blood gas for Glasgow-Imrie scoring
consider cholecystectomy if no cholangitis/bile duct obstruction
consider replacing Ca/Mg
Management of chronic pancreatitis
acute intermittent: no alcohol/smoking + analgesia
Persistent: as above +
Pancreatin enzyme replacement AND omeprazole
pseudocyt/biliary complications: endoscopic decompression under USS
intractable pain and pancreatic duct calcifications: ESWL
pancreatic head enlargement: distal pancreatectomy
management of acute diverticular disease
mild/moderate: 5d co-amoxiclav
if allergic: cefalexin with metronidazole
Paracetamol (avoid NSAIDs and opioids)
fluid replacement
clear liquids only, with a gradual reintroduction of solid food if symptoms improve over the following 2–3 days
investigations for acute diverticular disease
lactate
USS abdo pelvis
CT scan (contrast or non-contrast)
urgent colonoscopy if haemorrhage
Management for diverticular disease complications
Percutaneous drainage of large abscesses
peritoneal lavage in perforation
sigmoid resection and colostomy formation
GORD indications for 2ww OGD
GI bleed (same day) dysphagia upper abdo mass >55y AND weight loss AND dyspepsia/reflux/upper abdo pain
Management for dyspepsia
review medications
H pylori testing
trial full dose PPI
management for GORD
PPI for 4-8w
if stricture/recurrence continue PPI
2nd line H2RA therapy
Nissen fundoplication if severe
management of colorectal cancer
resection of bowel
heparin for 28d post-surgery
+/- chemoradiotherapy
management for volvulus
sigmoid: therapeutic sigmoidoscopy decompression with rectal flatus tube insertion
surgery: Hartmann’s
caecal volvulus: laparotomy (often right hemicolectomy and ileocaecal resection)
management for Bowel Obstruction
?fluid resus
if ischaemia/strangulation, surgery within 6h
no peritonitis: Drip and suck + conservative management for 72h
can consider adhesiolysis, but causes more adhesions later
hernia management
strangulated/incarcerated = emergency surgery
inguinal: conservative/routine repair
femoral: urgent repair
hernia approaches
lockwood = low, elective McEvedey = high, emergency
incision: Gridiron/Mcburney’s or Lanz
Lichtenstein mesh repair
SBP management
resus if septic
empirical Abx e.g. gen 3 ceph
large volume paracentesis and albumin replacement
perforated peptic ulcer manage
CT scan/ABG
CXR if CT not immediate
NO endoscopy
resuscitation + G&S
laparoscopic surgery as soon as possible (open if unstable patients) for primary repair +/- omental patch
Antibiotics
bleeding peptic ulcer management
G&S and ABG
Blatchford score
Endoscopy ASAP
Rockall score after endoscopy
CT if endoscopy not available
resuscitation
Antibiotics, IV PPI
endoscopy can be diagnostic and therapeutic adrenaline + either: mechanical clips thermal coagulation fibrin/thrombin
start propranolol for prophylaxis
H pylori eradication
Abdominal presentations of IBD
diarrhoea + constipation + bleeding pancreatitis gallstones kidney stones bowel cancer PSC
What is the Travis score
if CRP is >45 72h after steroids treatment for IBD, 85% need colectomy
Management of Boerhaave’s
ALL: fluid resuscitation, antibiotics
Primary oesophageal repair through open thoracotomy
VATS with fundic reinforcement
3 types of ischaemic bowel disease
acute mesenteric
chronic mesenteric
colonic (most common)
3 types of acute mesenteric ischaemia
venous
embolic
thrombotic
Management of ischaemic bowel disease
resus
empirical antibiotics
open embolectomy OR arterial bypass +/- bowel resection
investigation of ischaemic bowel disease
CT with contrast/angio lactate bloods sigmoid/colonoscopy will show ischaemia mesenteric angio
Creatinine changes after starting drug before stopping
> 30%
management of chronic diverticulosis
increase fluids and fibre
add laxative
lose weight
avoid NSAID and opiates
diverticulitis complications
haemorrhage abscess formation perforation/peritonitis stricture and fistula obstruction sepsis
oesophageal cancer management
non-metastatic/regional spread only: oesophagectomy
severe: stent, laser treatment
palliative chemoradiotherapy
sigmoid volvulus X ray
upturned U shape of dilated bowel (coffee bean)
severity score for UC
Truelove and Witts Frequency of stool blood in stool fever tachycardia anaemia raised ESR
investigations for flare up of IBD
Blood culture
Stool culture
Sigmoidoscopy (not colonoscopy as risk of perforation)
abdominal radiograph
Ulcerative colitis associations
non-smokers (smoking makes better)
PSC
arthritis
colon cancer
post splenectomy cautions
vaccines: pneumococcus, meningococcus, hib
long term Pen V
risk of malaria
investigations achalasia
barium swallow
upper GI endoscopy (esp for malignancy)
manometry needed to confirm diagnosis
management of achalasia
balloon dilatation
Surgical cardiomyotomy
Botox injections
Per-oral endoscopic myotomy
Barrett’s oesophagus treatment
conservative: avoid triggers, lose weight, smaller meals, stop smoking, reduce alcohol, sleep with head raised
PPI
ranitidine if PPI not helping
Surgery: laparoscopic fundoplication
radiofrequency ablation
glasgow-imrie score
Pancreatitis Pao2 Age Neutrophils Calcium Renal function Enzymes Albumin Sugar
what to monitor in TPN
glucose
4h temp
daily electrolytes, inspection of line/dressing
fluid balance
diagnosis of PSC
history
MR cholangiopancreatography (beading of bile duct)
Biopsy
No specific antibody, but may be ANCA+ will be AMA negative (that’s PBC)
PSC management
Conservative lifestyle optimisation cholestyramide for pruritis Vitamin supplements (D, calcium) bisphosphonates ERCP of any strictures Liver transplant
difference between femoral and inguinal hernia
femoral hernia is inferior and lateral to pubic tubercle
inguinal is superior and medial
difference between indirect and direct inguinal hernia
reduce hernia and press on deep ring (midpoint of inguinal ligament)
if direct it will protrude on coughing
is very inaccurate
artery supply of abdomen Stomach and liver Duodenum Ascending colon Transverse Descending/colon
Stomach and liver: coeliac trunk (L/R gastrics and hepatic artery)
Duodenum: SMA
Ascending colon: SMA
Transverse: proximal 2/3 SMA distal 1/3 IMA
Descending/colon: IMA
Acute diverticulitis investigations
No bleeding: contrast CT
Bleeding: Urgent colonoscopy
Acute diverticulitis management
Admission and supportive treatment
Analgesia: Paracetamol
ABx: Co-Amoxiclav or metro+another Abx (e.g. cef)
?Clear liquid diet/low residue diet
ERCP complications
pancreatitis
cholangitis
haemorrhage
duodenal perforation
