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Management Year 3 > Gastro > Flashcards

Gastro Flashcards

1
Q

What is the management plan for acute cholangitis?

A
  • 1st Line - ABC intensive care approach + IV Abx
    • cefuroxime + metronidazole
    • Plus biliary decompression non-surgical e.g. ERCP
  • 2nd Line - Biliary decompression surgical + IV Abx
    • Choledochotomy

Consider resusitation for some - SEPSIS 6

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2
Q

What is the management plan for Alcohol withdrawal?

A

All patients

  • 1st Line - Benzodiazepines (chlordiazepoxide) - reduces symptoms.
    • consider Barbiturates if servere/ delirium tremens
  • Plus pabrinex - prevents progression to Wernicke-Korsakoff
  • Consider propofol if admitted to ATU and very severe
  • If pyschotic symptoms e.g. delirium tremens add antipyschotic - haloperidol
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3
Q

What is the management plan for Alcoholic Hepatitis?

A
  • Alcohol abstinence + withdrawal management
    • lifestyle management e.g. smoking, weight
  • Nutrition + vitamin supplementation
    • Pabrinex + monitor and correct K+, Mg2+ and glucose
  • Consider corticosteroids - reduce hepatic encephalopathy
  • Consider furosemide/spironolactone - ascites
  • Consider pentoxifylline to reduce risk of hepatorenal syndrome - BMJ
    • Priya - Glypressin + N-acetylcystein
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4
Q

What is the management plan for Anal Fissure?

A

Acute

  • 1st Line - conservative - Increase fibre + fluid, laxatives
    • consider GTN ointment for symptom relief if persistent
    • Diltiazem if GTN headaches intolerable

Resistant fissures >8 weeks

  • 1st Line - botulinum toxin injection (no incontinence)
    • or surgical sphincterectomy, both have pros
  • 2nd Line - anal advancement flap
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5
Q

What is the management plan for Appendicitis?

A
  • Uncomplicated appendicitis:
    • Laparoscopy followed by appendicectomy
    • Abx for 24 hours post surgery - cefuroxime/metronidazole
  • If perforation of appendix
    • IV Abx + appendicectomy
  • If abscess
    • 1st Line - IV Abx + CT guided drainage of abscess
    • 2nd Line - Appendicectomy if symptomatic 6 weeks later
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6
Q

What is the management plan for Barrett’s Oesophagus?

A
  • Non-dysplastic = PPI (Omeprazole) + surveillance (every 2 yrs)
  • Low-grade dysplasia
    • non-nodular = radiofrequency ablation
    • nodular = endoscopic mucosal resection
  • High-grade dysplasia
    • 1st Line = Radiofrequency ablation +/- EMR + Omeprazole
    • 2nd Line = Oesophagectomy
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7
Q

What is the management plan for Cholecystitis?

A
  • In mild biliary colic - follow a low fat diet
  • Any symptomatic gallstones are removed
    • Initially remove CBD stones via ERCP
    • Then perform elective lap chole once LFT’s stablised
  • If LFT skewed/inflammation in severe or moderate cases
    • perform cholestectostomy if high risk of complications followed by elective cholecystectomy
  • If indicated in acute setting ideally cholecystectomy is performed <72 hours
  • Conservative and Medical management
    • Supportive -Admission, NBM, IV fluid, Abx + analgesia
      • If infective cause - IV Abx
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8
Q

What is the management plan for Inguinal Hernias?

A
  • Acute - incarcerated or strangulated bowel - Surgery
    • If bowel viable - laparoscopic mesh repair
    • If bowel gangrenous - bowel resection indicated
    • Consider prophylactic Abx
  • Ongoing
    • small asymptomatic - monitor and safety net
    • Large asymptomatic
      • if implicated - lap mesh repair + prophylactic Abx
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9
Q

What is the managament plan for Coeliac disease?

A
  • Conservative - strict, life-long gluten free diet + education
  • Medical - Vit supplementation (Vit D) + nutrients where necessary
    • 2nd Line - if unresponsive to diet restriction
      • refer to specialist and treat with prednisolone
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10
Q

What is the management plan for Crohn’s?

A
  • Acute
    • 1st Line - Corticosteroids used to induce remission
      • consider ASA-5 (less effective but less SE
    • If > 2 events in 12 months add Azathioprine/ mercaptopurine
    • If severe, acute events use infliximab
  • Chronic
    • Azathioprine/mercaptopurine to maintain remission
      • Avoid steroids for long-term therapy
    • Infliximab is reccomended in refractory Crohn’s or fistulating Crohn’s
  • Surgery - performed if medication fails, less effective than UC
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11
Q

What is the management plan for Diverticular Disease?

A
  • Asymptomatic - high fibre and fluid diet
  • Symptomatic Diverticular disease
    • Diet modification + oral Abx (cefuroxime and metronidazole)
  • Uncomplicated Diverticulitis
    • 1st Line - Simple analgesia + oral Abx + low-residue diet
    • 2nd Line - IV Abx
  • Symptomatic Diverticulitis
    • IV Abx + IV fluid + simple analgesia
    • If abscess 1st Line - drainage
    • If PR bleed - endoscopic haemostasis/ angiographic embolisation
  • Surgery - consider in recurrent events or severe complications
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12
Q

What is the management plan for IBS?

A

If Constipation predominant:

  • 1st Line - Lifestyle + dietary changes
      • laxatives > lubiprostone if unsucessful
  • If pain/ bloating - same + antispasmodics (dicycloverine)
    • 2nd Line - + CBT/ Hypnotherapy

If Diarrhoeal predominant:

  • 1st Line - Lifestyle + dietary changes
      • antidiarrhoeals
  • If pain/bloating - same + antispasmodics
    • 2nd Line - + TCA/SSRI +/- CBT or Hypnotherapy
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13
Q

What is the management plan for GORD?

A
  • Acute - Standard-dose PPI + Lifestyle changes
    • Decrease weight + smoking + fatty meals
    • Elevate head when sleeping
  • Ongoing - 1st Line - continued dose PPI
    • 2nd Line - High dose PPI + OGD - referrel
      • if nocturnal consider ranitidine
    • 3rd Line - surgery
      • Antireflux surgery - Nissen fundoplication
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14
Q

What is the management plan for Gastroenteritis?

A

In all patients

  • Fluid and electrolyte rehydration + bed rest
    • Consider Bismuth to reduce diarrhoea
  • 2nd Line - severe vomiting or diarrhoea consider IV fluid rehydration therapy

If suspected enterotoxigenic

  • Abx to non-self limiting causes if it will reduce recovery time
  • If EHEC notify health authorities
  • Treat botulinum toxin with botulinum antitoxin in ITU
  • C diff. - Isolate + oral metronidazole (14 days) -> Vancomycin
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15
Q

What is the management plan for GI perforation?

A
  • RESUS - medical emergency
    • IV Fluid + electrolytes + IV Abx (cefuroxime + metronidazole)
  • Surgery - perform peritoneal or pleural lavage
    • Large bowel - resection of perforated section using Hartmann’s
    • Gastroduodenal - perforation closed via omentum patch
      • Gastric ulcers are biopsied for malignancy
    • Oesophageal - Repair of ruptured oesophagus
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16
Q

What is the management plan for Haemorrhoids?

A
  • All patients - diet + lifestyle modification - Increase fibre + fluid
  • Grade 1 - consider topical corticosteroids - mild bleeding
  • Grade 2 - Rubber band ligation/ sclerotherapy or infrared photocoagulation
  • Grade 3 - Rubber band ligation
  • Grade 4 or persistent Grade 3 - Surgical Haemorrhoidectomy
    • Milligan Morgan or Stapled (better surgical prognosis)
17
Q

What is the management plan for Cirrhosis?

A
  • 1st Line - treat cause and manage complications
    • Portal Hypertension - consider Transjugular intrahepatic portosystemic shunt
      • Will increase risk of encephalopathy
    • SBP - Abx cefuroxime + metronidazole
    • Ascites - Oral spironolactone +/- furosemide
      • Sodium restriction in diet
    • Encephalopathy - treat infection if indicated
      • Use lactulose or phosphate enemas
    • Support nutrition + NG tube if indicated
    • Avoid alcohol, sedation, opiates, NSAIDs + Hepatotoxics
  • 2nd Line - Liver transplant if imminent death of serious liver decomponsation

If due to paracetomol OD - N-acetylcysteine

18
Q

What is the management plan for Femoral Hernias?

A
  • Surgical is the main management
    • Herniotomy - Ligation + excision of sac
    • Herniorrhaphy - Repair of femoral defect
19
Q

What is the management plan for Hiatus Hernia?

A
  • Acute - Symptomatic GORD
    • 1st Line - PPI + Lifestyle managememt
      • lose weight, elevate head, avoid large meals + alcohol
  • Ongoing - maintain PPI
    • Surgery performed if - severe complications, unresponsive to HD PPI or prophylactally Rolling Hernia
    • Nissen Fundoplication - 360 oesophageal stomach wrap
    • Belsey Mark IV - 270 degree wrap
20
Q

What is the management plan for Intestinal Obstruction?

A
  • General - drip + suck management
    • NBM + NG tube w/ gastric aspiration
    • IV Fluid + electrolyte replacement
    • Analgesia
    • Urinary catheter - monitor fluid balance + vitals
  • Ileus and incomplete SBO should be managed conservatively
  • Strangulation + LBO require surgery
  • Acute complete blockage + strangulation - emergency laparotomy
21
Q

What is the management plan for a Mallory-Weiss Tear?

A
  • 80-90% resolve on their own
  • 1st Line - Urgent evaluation + monitoring
    • Endoscopy with prophylactic PPI
    • Consider anti-emetics
  • 2nd Line - if bleeding doesnt resolve
    • Injection sclerotherapy
    • Thermocoagulation therapy
  • 3rd Line - in event of severe bleeding event
    • Laparoscopic surgery
    • Sengsteken-Blakemore tube if Boerhaave’s
22
Q

What is the management plan for NASH?

A
  • Mainly conservative to control RF
  • 1st Line - increase diet + exercise
    • Decrease alcohol consumption as it can excacerbate
    • Consider Vit E
    • If BMI >40kg/m2 consider bariatric surgery
  • Manage dyslipidaemia and diabetes medically
23
Q

What is the management plan for Acute Pancreatitis?

A

Assess severity using SIRS>APACHE II

  • 1st Line - Fluid Resus immediately + analgesia (pain ladder)
    • consider antiemetic, O2, Ca2+ or Mg2+ therapy
    • NG tube - aim to resume regular diet <24hrs
  • If gallstone cause with BDO or cholangitis - ERCP <72 hours
  • If gallstone cause without cholangitis - cholecystectomy
    • consider prophylactic Abx

If no change seen >5 days perform Contrast Enhanced CT then FNA to check for necrosis/infection

  • If pancreatic necrosis refer - necresectomy may be necessary
24
Q

What is the management plan for Chronic Pancreatitis?

A
  • Treat acute episodic pain w/ analgesia (pain ladder)
    • In chronic pain - refer to pain specialist
  • 1st Line - alcohol/smoking cessation + lifestyle modification
    • Consider analgesia, Creon + PPI
  • 2nd Line - in event of complications
    • Pseudocyst - ERCP drainage
    • Biliary compression - Stenting + dilation of strictures
    • Calcification - Extracorporeal Shock Wave Lithotripsy (ESWL)
  • Consider resection or prancreatectomy if indicated
25
Q

What is the management plan for Peptic ulcer disease?

A

All patients - drug review, stop NSAIDs, aspirin, bisphosphonates

  • Active bleeding ulcer
    • 1st Line - endoscopy +/- blood transfusion if severe loss
        • IV bolus omeprazole
    • 2nd Line - surgery or embolisation via laser coagulation/electrocoagulation
  • H.Pylori - no bleeding
    • 1st Line - triple (omeprazole + clarithryomicin + amoxicillin
      • consider alternate regimen if fails
  • Not H.Pylori associated - no bleeding
    • 1st line = omeprazole > ranitidine

If recurrent - oral PPI daily or misoprostol if NSAID related

26
Q

What is the management plan for Perineal Abscesses and Fistulae?

A

Requires surgical treatment

  • Abscess - open drainage immediately
  • Fistulae - Probe inserted to explore + dye into external opening to identify internal opening
    • Low Fistula - Fistulotomy
    • High Fistula - Seton performed - suture that allows drainage
      • Avoid fistulotomy due to incontinence complication
27
Q

What is the management plan for Peritonitis?

A
  • Localised - depends on the cause:
    • Appendicitis - surgery
    • Salpingitis - Abx
  • Generalised - medical emergency risk of sepsis or death
    • Resus - IV fluids + IV abx
    • Catheter, NG tube and central line
    • Primary - should resolve with Abx
    • Secondary - laparotomy may be indicated
  • Spontaneous Bacterial Peritonitis
    • 1st Line - ciprafloxacin + vancomycin
    • Or cefuroxime + metronidazole
28
Q

What is the management plan for Pilonidal sinus?

A
  • Asymptomatic - hair removal + local hygeine
  • Symptomatic - without abscess
    • 1st Line - Karydakis surgery under LA
      • Consider co-amoxiclav before surgery + 5 day course
  • Symptomatic - without abscess
    • 1st Line - Surgery and drainage of abscess under LA
      • Consider co-amoxiclav before surgery + 5 day course + paracetomol
  • If recurrent - consider more complex exploration surgery under GA
29
Q

What is the management plan for Ulcerative Colitis?

A

Acute exacerbations

  • IV rehydration + prophylactic Abx/DVT
  • Bowel rest and parenteral nutrition if indicated
  • 1st Line - topical 5-ASA for 4 weeks
  • 2nd Line - Oral 5-ASA + 4-8 week corticosteroids
  • 3rd Line - infliximab - good at inducing remission if severe
  • If toxic megacolon - consider emergency colectomy

Maintaining remission - no steroids

  • Moderate - Oral or rectal 5-ASA
  • Severe or 2nd Line moderate - oral Azathioprine/Mercaptopurine
    • consider Infliximab if unresponsive
  • Surgery - elective colectomy if unresponsive or frequently relapsing
30
Q

What is the management plan for Viral Hepatitis A?

A
  • Initially - unvaccinated OR following recent exposure
    • IM human globullin - recommended for >40 yrs, shorter effectiveness
    • Active attenuated HAV - for <40 yrs, longer effectiveness
    • Prophylaxis HAV - shown to have some efficacy
  • Management
    • 1st Line - Supportive care e.g. bed rest
      • Symptomatics - antipyretic, anti-emetics
    • 2nd Line - 1% get Fulminant course of virus
      • Potentially require liver transplant
31
Q

What is the management plan for Vitamin Deficiencies?

A
  • Vitamin A
    • Diet education - chicken, eggs and leafy greens
    • Vitamin A supplements if indicated
  • Vitamin B
    • Pabrinex (Thiamine) - oral initially then IV
      • Done to present transition to Wernicke-Korsakoff
    • Ensure thiamine given before glucose in hypoglycaemia
  • Vitamin C
    • Diet education - citrus fruits
    • Absorbic acid >250mg/24hr orally
  • Vitamin D
    • Ergocalciferol + calcium carbonate
    • Ensure adequate sun/ UV-B exposure
    • If malabsorbtion - calcitriol e.g. CKD
  • Vitamin E - supplementation
  • Vitamin K - supplementation
32
Q

What is the management plan for Viral Hepatitis B?

A
  • Prevention: blood screening, safe sex, instrument sterilisation
  • Immunisation -
    • Passive - IM human immunoglobulin - at risk individuals + neonates w/ mother HbeAg+
    • Active - same as above - protects against HDV too
  • Acute - 1st Line - Support care + antipyretics, anti-emetics
    • Notifiable disease to report to health authorities
    • Add antiviral in children or severe cases
    • 2nd Line - very severe needs assessment for liver transplant
  • Chronic HBV infection
    • 1st Line - antiviral therapy - e.g. tenofovir
      • if HDV co infection - peginterfeon alpha
    • 2nd Line - decomponsating cirrhosis - liver transplant
33
Q

What is the management plan for Viral Hepatitis C?

A
  • Prevention: blood screening, safe sex, instrument sterilisation
    • No vaccination available for Hep C
  • Acute - monitor for 12 weeks to allow for spontaneous clearance
    • Support care +antipyretics/ antiemetics + cholecystyramine
  • Chronic - use antivirals - mainly protease inhibitor +/- ribavirin
    • Treatment duration 8-16 weeks depending on Genotype and presenting complications
    • If cirrhosis is present regular liver USS is indicated
  • Ongoing - referal to specialist to assess liver transplant
34
Q

What is the management plan for Portal Hypertension?

A
  • Immediate = IV terlipressin + prophylactic Abx
    • Injection sclerotherapy or band ligation - endoscopy
    • 2nd Line = Sengstaken–Blakemore tube
  • TIPPS to prevent further rebleed
  • Prophylactic BB

Management Year 3 (13 decks)

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