Gastro - mx use this Flashcards
1
Q
Portal HTN management
A
- Lifestyle advice
salt restriction
stop drinking + smoking - Keep BP low
To minimise chance of oesophageal varices bleeding
Propanolol, Carvediol
Isosorbide mononitrate - TIPPS (transjugular intrahepatic portosystemic shunt) Passing a catheter down the jugular vein + creating a shunt from the hepatic vein to the portal vein to relieve portal HTN
Ascites, oesophageal variceal bleeding refractory to medical treatment, bleeding from non-oesophageal varices e.g. gastric varices
2
Q
Barrett’s oesophagus management
A
- Regular endoscopic surveillance
- High grade dysplasia –> Radiofrequency ablation (downgrades the dysplasia) + PPI
- Nodule –> Endoscopic mucosal resection + PPI
- Oseophagectomy - if high-grade dysplasia persists after intensive acid suppression
- Aspirin
Controversial treatments
- Life-long PPIs
- Anti-refulx surgery
3
Q
Gastritis management
A
- PPI (omeprazole, lansoparazole) or ranitidine (H2 antagonist)
- Triple therapy for H. pylori (PPI + 2 abx)
PPI + clarithromycin + Amoxicillin/metronidazole
or
PPI + Clarithormycin + metronidazole
Repeat endoscopy to show resolution of the ulcer - Antacids (MgHCO3, AlOH, alginates)
- Lifestyle modification Stop alcohol Stop smoking Reduce stress Smaller + more frequent meals
4
Q
Peptic ulcer disease management
A
Active bleeding ulcer - ABC - NBM - OGD Adrenaline injection /thermal coagulation/endoclips/haemostatic powder spray - PPI IV - +/- Blood transfusion
Healing ulcers
H pylori +ve
Triple therapy
PPI + clarithromycin + Amoxicillin/metronidazole or
PPI + Clarithormycin + metronidazole
Repeat endoscopy to show resolution of the ulcer
H pylori -ve
- Stop NSAIDs
- Full dose PPIs for 2 months (or H2 antagonist (e.g. cimetidine, ranitidine )
Lifestyle modification
- Stop/replace drugs that cause peptic uclers
- Stop smoking
- Stop alcohol
- Weight reduction
Perforated peptic ulcer
- NBM
- IV abx
- IV PPI
- Surgery
5
Q
GORD mx
A
Lifestyle
- Lose weight
- Stop smoking
- Stop alcohol
- Small, regular meals
- Avoid hot drinks/alcohol
- Raise head at night
- Avoid drugs which a) affect oesophageal motility (nitrates, CCBs, anticholinergics, TCAs), b) damage the mucosa (NSAIDs, potassium salts, alendronate)
Pharmacological treatment
- PPI (more effective + safer than H2RA)
- Prokinetic drugs (metoclopramide) - promote gastric emptying, increase tone of cardiac sphincer
- Antacids (MgHCO3, AlOH)
- Alginates
Surgical treatment
- Laparoscopy fundoplication (magnetic beads at gastro-oesophageal juntion)
- Nissen fundoplication if hiatus hernia is the problem
6
Q
Oesophageal spasm treatment
A
CCB
7
Q
Acute severe ulcerative colitis management
A
IV hydrocortisone to induce remission
ciclosporin in pt who cant tolerate IV steroids
(infliximab in pt who cant tolerate ciclosporin)
8
Q
Leaking AAA emergency management
A
- 2 large bore IV cannulae
- Cross-match 10 units of blood (=5L, enough to replace the entire circulating volume)
- Urinary catheter (to monitor renal function) - urine output is a very sensitive marker of renal perfusion
- Immediately notify the vascular surgeon + anaesthetist on call
9
Q
Anal fissures management
Conservative Medical Surgical On presentation Resistant fissures
A
Conservative management
- High fibre diet
- Hydration
- Softening the stool (e.g. sodium docusate)
- Warm baths
Medical management
- High fibre diet +/- laxatives +/- non-constipaating analgesics
- Topical anaesthetics (e.g. lidocaine)
- GTN - increases local blood flow + relaxes internal anal sphincter
- Diltiazem (CCB) - relaxes anal sphincter
- Chronic fissures –> Botox injections into anal sphincter –> relieve spasm
Surgical management
- Lateral internal sphincterectomy (need to check integrity of external anal sphincter first)
- Anal advancement flap
Adjacent well vascularised tissue advanced into the defect following fissure excision
- Fissurectomy
On presentation
- Conservative treatment alone (1st line)
- Topical GTN
- Topical diltiazem
Refractory fissures
- Botulinum toxin injection (1st line)
- Surgical sphincterectomy (1st line)
- Anal advancement flap
10
Q
Haemorrhoids management
Conservative
Medical
Non-surgical
Surgical
A
Conservative
- Lifestyle modification
- Increase dietary fibre
- Keep well hydrated
- Avoid straining at stool
Medical management - Local anaesthetics (e.g. lidocaine) - Steroid creams/suppositories - decrease local inflammation - Laxative if constipation causes straining, hard stool, bleeding Lactulose Sodium docusate Ispaghula husk Sterculia
Non-surgical management - Grade 2
- Rubber band ligation
- Injection sclerotherapy
- Infrared coagulation/photocoagulation
Surgical management- large symptomatic haemorrhoids
- Haemorrhoidectomy
- Staplex haemorrhoidopexy
- Haemorrhoidal artery ligation (doppler guided) + rectoanal repair (DG-HAL-RAR)
11
Q
Summary of management of haemorrhoids for Grade 1, 2, 3, 4
A
Grade 1
Dietary + lifestyle modifications
Topical corticosteroids
Grade 2
Dietary + lifestyle modifications
Rubber band ligation/sclerotherapy/infrared photocoagulation/ staplex haemorrhoidopexy/ haemorrhoid arterial ligation
Grade 3
Dietary + lifestyle modifications
Rubber band ligation
Grade 4
Dietary + lifestyle modifications
Surgical haemorrhoidectomy
12
Q
Appendicitis mx
A
- IVF
- Analgesia (opioids)
- Antiemetics
First line treatement - Appnedicectomy NBM solids - 6h NMB clear fluids - 2h - Abx after surgery (Cef+Met - Cefotaxime, Metronidazole) - DVT prophylaxis
13
Q
Constipation
Give examples of stool softeners
A
Sodium docusate, liquid paraffin, arachis oil enema, poloxamer
14
Q
Constipation
Give examples of osmotic laxatives
A
Lactulose, macrogols (Movicol), polyethylene glycols (e.g Laxido), magnesium salts
15
Q
Constipation
Give examples of peristalsis stimulants
A
Senna, docusate, glycerol suppositories, bisacodyl, dantron
16
Q
Constipation
Give examples of bulking agents
A
Ispaghula husk (Fybogel) Methycellulose
contraindicated in patients with
intestinal obstruction
faecal impaction
swallowing difficulty
17
Q
ConstipationGive examples ofdrug used for opioid induced constipation
A
Methylnaltrexone
18
Q
ConstipationWhat kind of drug is co-danthamer
A
Dantron (peristalsis stimulant) + poloxamer (stool softner)
19
Q
Severe acute gallstone pancreatitis with evidence of biliary obstruction +/or cholangitis management
A
- IVF
- Analgesia
- ERCP + sphincterectomy + stone extraction within 72h of admission
20
Q
Mild gallstone pancreatitis management
A
- IVF
- Supportive care
21
Q
ERCP assosciated pancreatitis management
A
- IVF
- Analgesia
- Bowel rest
22
Q
Asymptomatic cholelithiasis management
A
Observation
23
Q
Symptomatic cholelithiasis management
A
Laparoscopic cholecystectomy
24
Q
Choledocholithiasis +/- symptoms management
A
ERCP with biliary sphincterotomy + stone extraction
If stone is large (>1.5cm) –> Lithotripsy, papillary balloon dilation, long-term biliary stenting
Following extraction, cholecystectomy represents definitive treatment to reduce the risk of recurrent biliary events (e.g. cholangitis, pancreatitis)
25
Cholecystitis management
- NBM
- IVF
- NSAID Analgesia (diclofenac, indometacin)
- Abx IV (ampicillin/ceftriaxone/ertapenem)
- Antiemetics
- Early laparoscopic cholecystectomy if surgically high risk patient
- Pre-cutaneous transhepatic gallbladder drainage
26
Acute cholangitis mx
- IV abx - piperacillin/tazobactam or imipenem/cilastatin
- IVF
- Opioid analgesia (morphine sulphate)
- Biliary decompression
ERCP (+/- sphincterotomy +/- placement of stent +/- stone extraction) - FIRST LINE
Pre-cutaneous trans-hepatic cholangiography - SECOND LINE
27
Mallory Weiss tear management
- IVF
- Blood transfusion if
Hb <80g/L
Hb <100 g/L + comobidities
- Platelet transfusion
if Plt <50
- FFP transfusion
If prolonged PT/INR
- OGD
Adrenaline + thermocoagulationb/band ligation
Haemoclip +/- adrenaline
If bleeding can't be stopped using endoscopic treatments
- Angiography with VP injection or embolization
28
Toxic megacolon mx
- IVF
- IV steroids
- NG decompression
- Abx (broad spectrum - piperacillin/tazobactam) (If C.difficile suspected/confirmed - vancomycin)
- IV ciclopsorin
- Total Colectomy with end-ileostomy (if no imporvement with medical treatment after 72h)
29
Acute exacerbation of UC treatment
- IVF
- IV steroids
- Abx
- Bowel rest
- TPN might be required
- DVT prophylaxis
30
Mild UC
What does it mean (6)
Management
```
Mild UC
<4 stools per day
no more than small amount of blood in stools
no anaemia
pulse rate <90
no fever
N ESR/CRP (<30)
```
oral/rectal 5-ASA derivatives (melsalazine, olsalazine, sulfalazine)
+/- rectal steroids (predinisilone, methylpredinisilone)
500 SBAs mentions that you also give oral steroids (gastro Q36)
31
Moderate UC
What does it mean (6)
Management
```
Moderate UC
4-6 stools per day
more blood than for mild
no anaemia
pulse rate <90
no fever
N ESR/CRP (<30)
```
oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine)
+ oral steroids (predinisilone, methylpredinisilone) + immunosuppresants (azathioprine, mercaptupurine, cyclosporin, infliximab)
500 SBAs didnt mention immunosuppresants but mentioned topical steroids (gastro Q36)
32
Severe UC
What does it mean (6)
Management
```
Severe UC
>6 stools per day
Visible blood in stools
+ 1 or more systemic upsets:
anaemia
pulse rate >90
fever >37.8
ESR >30
```
oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine)
+ oral steroids (predinisilone, methylpredinisilone)
+ immunosuppresants (azathioprine, mercaptupurine, cyclosporin, infliximab)
methotrexate if unable to tolerate azathioprine or mercaptopurine
ciclosporin -p w severe refractory colitis, rapid onset of action, reduces colectomy rate by 50%
500 SBAs mentions that severe UC is treated w admission for IVF + IV steroids (gastro Q36)
33
Surgical UC therapy
Past: protocolectomy with ileostomy
Now: IPAA - ileal-pouch anal anastomosis
34
Acute exacerbation of Crohn's disease management
- IVF
- IV steroids
- 5-ASA (mesalazine, sulfalazine, olsalazine)
- Analgesia
- TPN might be necessary
- Monitor markers of disease activity
35
To induce remission in Crohn's
IV/oral corticosteroids
2nd line Mesalazine (5-ASA), azathioprine/mercaptopurine, infliximab
Budesonide less effective than conventional steroids but fewer SE
In 1000 SBA's+EMQ they say that to induce remission in Crohn's flare up you use steroids
36
Crohn's first, second, third line treatment
1st line
Budesonide +/or 5-ASA (melsalazine, olsalazine) or oral corticosteroids (prednisolone, 2nd line)
2nd line
Immunomodulator therapy (azathioprine, mercaptopurine) + oral corticosteroids
Methotrexate second line if unable to tolerate azathioprine or mercaptopurine
3rd line
Biological therapies anti-TNFa (infliximab, adalimumab) - used in refractory Crohn's +/- azathioprine +/- oral corticosteroids
37
Cirrhosis management
1st line
- Treatment of underlying liver disease
Hep C - oral antivirals [elbasvir + grazoprevir]
- Prevention of superimposed hepatic insult
No alcohol, hepatotoxic drugs
Immunisation against hep A, B, influenza, pneumococci
Management of metabolic RF
- prevention of osteoporosis
- Maintenance of adequate nutrition
-Regular exercise to prevent muscle wasting
- Monitoring for complications
- Na restriction + diuretic therapy for ascites
Spironolactone
Frusemide - if they dont respond to spirnolocatone
2nd line- Liver transplantation
38
Ascites management
Treatment of underlying cause
Medical treatment – sodium restriction + diuretic therapy
• Restricted salt intake <90mmol/day (<5.2 g salt/day)
• Spironolactone - increase Na excretion + increase K absorption (with potassium sparring diuretics, sodium reabsorption and potassium excretion are prevented)
o Needs monitoring bc of risk of hyperkalaemia
• Loop diuretics (e.g. frusemide) – if pt don’t respond to spironolactone
o Higher doses cause severe electrolyte disturbance, particularly hyponatraemia
Therapeutic paracentesis
• Large/refractory ascites
• Large-volume paracenteses should be followed by volume expansion using human albumin solution
Surgical
• TIPS (transjugular intrahepatic portosystemic shunt) – refractory ascites needing frequent paracentesis
39
UCrole of
```
corticosteroids
aminosalicyltes
thiopurines
Ciclosporin
TNFa antibodies
```
corticosteroids - to induce remission in acute UC
aminosalicyltes - 5-ASA to induce and maintain remission (1ST LINE) (mild to moderate)
Mesalazine - to maintain remission
thiopurines (azathioprine, 6-mercaptopurine) - if intolerant to coricosteroids
Ciclosporin - severe refractory colitis, rapid onset of action
TNFa antibodies (infliximab, adalimumab, golimumab) - severely active UC in adults whose disease has responded inadequately to conventional therapy (moderate to severe UC)
40
Mx of liver failure for all patients
o ICU – mandatory once hepatic encephalopathy is present
o Intubation once advanced encephalopathy develops
o Neurological status monitoring for advanced encephalopathy – associated with a greater risk of cerebral oedema + intracranial HTN
o Monitoring of blood glucose, electrolytes, cultures (high risk of bacterial + fungal infection)
o Liver transplantation assessment (all pt should be considered for liver transplantation )
41
Management of causes of liver failure
```
Acute hepatitis B
Autoimmune hepatitis
Herpes Simplex hepatitis
Budd-Chiari syndrome
Wilson's disease
```
* Acute hepatitis B – entecavir or tenofovir disoproxil (oral nucleoside or nucleotide analogue)
* Autoimmune hepatitis - methylprednisolone
* Herpes Simplex hepatitis – acyclovir
* Budd- Chiari syndrome – anticoagulation (LMWH), TIPS
* Wilson’s disease – measures to decrease serum copper (plasmapheresis, continuous veno-venous hemofiltration, album dialysis, plasma exchange, chelation therapy for Wilson’s in the setting of AFP is generally ineffective + may be associated with hypersensitivity)
42
```
Management of complications of liver failure
• To decrease ammonia production
• ICP
• Cerebral oedema
• AKI
• Treat + prevent abnormal clotting
• Paracetamol overdose
• Monitor glucose
• Liver transplantation
```
* To decrease ammonia production – Lactulose (w neomycin)
* ICP – Mannitol
* Cerebral oedema – therapeutic hypothermia (when medical treatments are not successful)
* AKI – haemodialysis, hemofiltration
* Treat + prevent abnormal clotting – FFP, platelet concentrates, antifibrinolytic drugs, prothrombin complex concentrates, recombinant activated factor 7
* Paracetamol overdose – acetylcysteine therapy should be administered in all suspected cases, regardless of the dose/timing of paracetamol ingestion
* Monitor glucose – IV glucose may be required
* Liver transplantation – all patients should be considered
43
SBO-partial or complete or complicated poor surgical candidate management
* IVF + correct electrolyte imbalances
* NG decompression
* Analgesia – morphine sulfate
* Anti-emetic – ondansetron (metoclopramide is contraindicated in patients with bowel obstruction as it’s a pro-kinetic)
* Correction of underlying cause
44
SBO-complete or complicated, surgical candidate
* IVF + correct electrolyte imbalances
* Emergency laparotomy
* Abx – ampicillin + gentamicin or cefoxitin
* NG decompression
* Analgesia
* Correction of underlying cause
45
LBO-Acutely ill
• Supportive measures
o NBM
o O2
o IVF + correct electrolyte imbalances
o NG decompression
o Abx pre-operatively (broad spectrum: amoxicillin, metronidazole, gentamycin) +/-
o Blood transfusion to correct anaemia +/- coagulopathy
• Emergency surgery – if suspected/impending perforation, peritonitis, irreducible hernia
46
HAV mx
* Supportive treatment (no specific anti-viral available)
* Post-exposure (<2 weeks) prophylaxis in unvaccinated people - Active/passive immunisation
* With worsening jaundice and encephalopathy - liver transplant
47
HBV mx
* Supportive care – most will achieve seroconversion with appearance of ab to HBsAg in the absence of treatment
* Chronic hepatitis B – 1) peginterfeon alpha 2a, 2) tenofovir disoproxil or entecavir
* Anti-viral therapy (entecavir, tenofovir disoproxil) – not indicated for acute hepatitis B except in cases of fulminant hepatitis
* Liver transplant
48
HCV mx
* Acute - supportive care
* Chronic - Oral direct-acting antiviral therapies – elbasvir (NS5A inhibitors) + grazoprevir (NS3/4 protease inhibitors)
,
49
HDV mx
* Supportive care
* Pegylated interferon alfa
* Liver transplantation
50
HEV mx
Supportive care
51
Autoimmune hepatitis mx
- Corticosteroids - if treatment <6m
Prednisolone
Budesonide if intolerant to prednisolone
- Corticosteroids + immunosuppressants - if treatment >6m (immunosuppresants have steroid sparring effects), if pt at high risk of corticosteroid-related SE (post-menopausal women, pt w osteoporosis, DM, glaucoma, cataracts, arterial HTN, major depression, emotional lability)
Prednisolone/Budesonide + Azathioprine/mercaptopurine *
- Liver transplantion
Pt with advanced liver disease who are refractory/intolerant to corticosteroid therapy
*methotraxare is 2nd line if unable to tolerate azathioprine/mercaptopurine
52
AAA seen on US (AA >3cm in diameter) + patient has abdominal pain mx
Stable patient
- CT aortogram
Unstable patient
- Surgery to rule out ruptured AAA
53
Perforated peptic ulcer emergency mx (resuscitation + treatment until surgery)
- IVF
- Oxygen
- Analgesia
- NBM
- Abx
- NG tube (so that the gastric contents can come up the NG tube rather than then perforated ulcer)
- Monitor urine output (may require urinary output)
Surgical emergency
54
Acute pancreatitis management
- IVF
- Analgesia (morphine sulfate, fentanyl)
- Oxygen
- Anti-emetics (ondansentron)
- DVT prophylaxis
- Nutritional support (low fat diet, might need an NJ tube)
- Tight glucose control (might need to give insulin)
- ERCP if severe
55
Chronic pancreatitis management
Acute episodic pain
Chronic management
No definitive therapy
Acute episodic pain
- analgesics (paracetamol/ibuprofen + tramadol)
Chronic symptoms
Lifestyle modifications - decrease smoking + alcohol
Dietary modifications (e.g. low fat diet) + enteral feeding
Analgesia - Octreotide - SS analogue, may relieve pain
Pancreatic enzymes (pancreatin) + PPI (omeprazole) - Acid inhibition increases enzyme activity by decreasing luminal inactivation
Glucose control - insulin
Pancreatic calcification- curative resection + adjuvant chemo-radiation
56
How to manage Pancreatic endocrine insufficiency
Pancreatic exocrine insufficiency
as a result of chronic pancreatitis
Pancreatic endocrine insufficiency (DM) - insulin
But be careful - chronic pancreatitis patients are at risk of hypoglycaemia due to impaired hepatic gluconeogenesis and hypoglycaemia
Pancreatic exocrine insufficiency (enzymes e.g. lipase, amylase, protease) - pancreatic enzyme supplementation (e.g. pancreatin)
57
Which enzymes does pancreatic include?
Amyalse
Protease
Lipase
58
Peritonitis managment
- IVF
- Analgesia
- Broad spectrum abx
- NG tube
- Blood transfusion
- Surgery
Exploratory laparotomy
Correct cause of peritonitis
59
If you suspect varices you should include the following in your initial (pre-endoscopy) management
- Terlipressn
ADH agonist, causes splanchnic vasoconstriction and decreases mesenteric blood flow and portal pressure
- Prophylactic antibiotics
Increased risk of translocation of bacteria from gut into the systemic circulation
60
Alcoholic hepatitis mx
```
• Alcohol abstinence + alcohol withdrawal management
o Benzodiazepines (oxazepam, diazepam, lorazepam)
Long acting (diazepam) – provide greater protection against seizures + delirium
Short acting (oxazepam, lorazepam) – safer in older adults + those with hepatic dysfunction
```
• Weight reduction + smoking cessation
o Careful with orlistat – might lead to acute liver failure, cholelithiasis, cholestatic hepatitis
• Nutritional supplementation + multivitamins
o Protein restriction only considered if pt is encephalopathic
o Vitamins (B group, thiamine) - should be started parenterally + continued orally
o At risk of developing “re-feeding syndrome” --> Monitor for hypokalaemia, hypophosphatemia, hypomagnesaemia
• Immunisationon
o Influenza + pneumococcal vaccine recommended in patients with chronic ALD
o Hep A + Hep B vaccination if Anti-HBs (Hep B surface antibody) + HAIgG are negative
• Corticosteroids
o Prednisolone
o If patients have hepatic encephalopathy
• Sodium restriction +/- diuretics
o Frusemide + spironolactone
o Treatment for ascites
• Liver transplant
o Second line
o For patients with end-stage ALD
61
NASH/NAFLD ix
With no end-stage liver disease
• Lifestyle modification – first line therapy
o Weight loss through diet + exercise
o Diet should have a high protein: calorie ratio
o Exercise with diet increases muscle mass + insulin sensitivity
o Abstinence from alcohol + hepatotoxic drugs
• Vitamin E (alpha tocopherol)
o Vitamin E significantly improves liver function + histological changes in patients with NASH
• Gastric bypass with Roux-en-Y
o Patients with a BMI >40 kg/m² or
o Patients with a BMI >35 kg/m² and at least one or more obesity-related comorbidity
With diabetes
• Insulin sensitiser
o Metformin – does not improve histological scores or fibrosis but leads to weight reduction, reduced HbA1c, reduced plasma glucose
With dyslipidaemia
• Statins
With end-stage liver disease secondary to NASH
• Liver transplantation
• TIPS
62
Which antibiotic is the first line treatment for C. difficle infection?
Metronidazole
| Can also use vancomycin (2nd line if allergic to metronidazole, if C difficile is resistant to metronidazole)
63
How to maintain remission in UC?
- low dose oral ASA (e.g. melsalazine)
| - oral azathioprine/mercaptopurine if severe
64
What is the critical view cholecystectomy?
The critical view of safety (CVS) technique is a means of target identification, the targets being the cystic duct and artery
This is important to avoid injury to the hepatic artery, hepatic duct or CBD
65
Diverticular disease mx
• Chronic asymptomatic diverticulosis
Soluble high fibre diet (20-30g/day)
Anti-inflammatories (e.g. Melsalazine)
• Acute symptomatic diverticular disease
IVF
Bowel rest
Analgesia (paacetamol, tramadol, morphine sulfate)
Dietary modification + fibre supplementation
Abx if evidence of infection+/or suspicion of bacterial overgrowth
• Surgery
Primary anastomosis
- One stage resection of affected bowel + anastomosis
- Proximal loop ileostomy (diverts contents before they pass via primary anastomosis - protects the primary anastomosis)
Hartmann's procedure - if presentation is ACUTE because the bowel needs to rest + inflammation needs to go down before primary anastomosis
- Proctosigmoidectomy + Formation of an end colostomy with anorectal stump
- Used when primary anastomosis is not possible due to e.g. inflammation
o Endoscopic haemostasis/angiographic embolization - In cases of acute rectal bleeding
o Oral Abx – bc diverticulitis might be caused by infection, in some patients
66
Hernia mx
• Treatment options
o Watchful waiting
o Open mesh repair – unilateral primary hernia
o Laparoscopic repair – recurrence after open-mesh, bilateral hernias, abx prophyaxis not recommended
o Truss
Femoral hernias
o Elective repair ASAP (high risk of stangulation)
o No truss
o Reinforce abdominal wall with stitches or use of mesh
Inguinal hernias
- Reassurance
• Direct inguinal hernias
o Have a wider neck - less risk of strangulation - can adopt a conservative approach
o If patient is obese ask them to lose weight
o Ask patient to wear a truss – prevents bowel obstruction !!you should never put a truss over an irreducible hernia!!
- Elective surgery
• Lichtenstein’s technique
o Most commonly performed open mesh repair
o Piece of open-weave polypropylene mesh is used to repair + reinforce the abdominal wall
• Bilateral hernias
o Best repaired laparoscopically (TAPP (transabdominal periperitoneal), TEP (totally extraperitoninal))
• Incarcerated or strangulated hernia
o Surgical repair
o Prophylactic Abx therapy
o In the absence of necrosis or contamination – bowel can be reduced + hernia repaired with a mesh
o If gangrenous bowel or contamination – bowel resection required + non-mesh primary tissue repair of hernia (mesh repair avoided as there is risk of mesh infection)
67
Intestinal obstruction mx
```
Medical mx
• IVF + correct electrolyte imbalances
• NG decompression
• Analgesia – morphine sulfate
• Anti-emetic – ondansetron (metoclopramide is contraindicated in patients with bowel obstruction as it’s a pro-kinetic)
• NBM
• O2
• Correction of underlying cause
```
Surgical - esp if peritonitic
• Emergency laparotomy
• Abx – ampicillin + gentamicin or cefoxitin
* Adhesions – conservative treatment, endoscopy
* Sigmoid volvulus – flexible/rigid sigmoidoscopy (1st line), surgery (2nd line)
* Caecal volvulus, colorectal malignancy, diverticular disease - surgery
* Monitor urine output – oliguria is an important sign of early dehydration
68
Management of acute alcoholic hepatits
* Thiamine
* Vitamin C and other multivitamins (can be given as Pabrinex)
• Encephalopathy - oral lactulose or phosphate enemas
• Ascites
Diuretics (spironolactone with/without furosemide)
Therapeutic paracentesis
• Hepatorenal syndrome
Glypressin and N-acetylcysteine
* Monitor and correct K+, Mg2+ and glucose
* Ensure adequate urine output
69
Hiatus hernia mx
Acute symptomatic GORD
• PPIs
• Lifestyle modifications – lose weight, elevate the head of the bed, avoid large meals, alcohol, acidic foods
Ongoing
• Surgical repair +/- anti-reflux procedure
o Laparoscopic fundoplication = mobilisation of the distal oesophagus, reduction of the associated hiatus hernia after complete (Nissen’s) or partial (modified) wrapping of the fundus of the stomach around the oesophagus (fundoplication)
70
Gastroenteritis mx
* No systemic signs - Bed rest, IVF + electrolyte replacement – no stool culture needed
* Systemic signs [>39 or dehydration, visible blood or >2 weeks] – admit + give oral fluids (IV rehydration if severe vomiting)
* Abx if severe/if the infective organism has been identified (E.g. ciprofloxacin against – Salmonella, Shigella, Campylobacter)
– direct faecal smear then culture
```
invasive diarrhoea (causing bloody diarrhoea and fever) - ciprofloxacin
Clarithromycin - traveller's diarrhoea and non-invasive diarrhoeal illnesses when treatment is necessary
```
71
Which class of drugs increases risk of bleeding form diverticular disease?
NSAIDs
72
Encephalopathy mx
- Place on a low protein diet
| - Lactulose enemas to decrease transit time and decrease GI absorption
73
Oesophageal varices mx
- Combination of endoscopic variceal ligation (Band ligation)* + terlipressin** is first line
- ABCDE approach
- Fluids, regular monitoring
- Reduce portal HTN: Terlipressin
- OGD
* Alternatives include sclerotherapy + balloon therapy
* *Alternatives to terlipressin include vasopressin octreotide
prophylaxis for the prevention of varicieal bleeidng - propanolol, endoscopic band ligation, TIPPS
74
UC
Induction of remission
Maintenance of remission
Induction
- Melsalazine (5-ASA)
- IV steroids if severe
Maintenance
Mild --> oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine)
+ rectal steroids (predinisilone, methylpredinisilone)
Moderate/severe --> oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine)
+ oral steroids (predinisilone, methylpredinisilone)
+ immunosuppresants (azathioprine, mercaptupurine, cyclosporin, infliximab)
75
Crohn's
Induction of remission
Maintenance of remission
Induction of remission
- IV steroids
Maintenance of remission
- Azathioprine, mercaptopurine
+ oral corticosteroids
- Methotrexate second line if unable to tolerate azathioprine or mercaptopurine
Biological therapies anti-TNFa (infliximab, adalimumab) - used in refractory Crohn's +/- azathioprine +/- oral corticosteroids
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IBS mx
• Conservative – increase fibre to prevent constipation, probiotic, special diet, low caffeine/alcohol/fizzy drinks
• Medical
o Anti-spasmodics – mebeverin (anti-ach), buscopan
o Prokinetic agents – domperidone, metoclopramide
o Antidiarrheals – loperamide
o Laxatives – lactulose
o Low dose TCAs – may decrease visceral awareness – amitriptyline
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Coeliac disease mx
• Strict, lifelong gluten-free diet
• Calcium + vitamin D supplementation +/- iron (ergocalciferol + calcium carbonate +/- ferrous sulfate)
o All pt with coeliac disease should take calcium + vitamin D supplements
o Iron should only be given to individuals with iron deficiency
• Pneumococcal vaccine every 5 years due to hyposplenism
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Coeliac crisis mx
Coeliac crisis – hypovolaemia, severe watery diarrhoea, acidosis, hypocalcaemia, hypoalbuminaemia
• Rehydration + correction of electrolyte abnormalities
• Corticosteroid (budesonide or prednisolone)
79
Boerhaave's perforation mx
* IVF
* Abx
* Prompt surgical repair (within 12h)
80
Why are PPIs prefered to H2 receptor antagonists for the mx of GORD?
H2 receptor antagonists suffer from tachyphylaxis - their utility diminishes with time
therefore they are often stopped after 2 weeks
81
AAA mx
Normal diameter of aorta - 2cm
<4 cm - annual US
4-5.5cm - US every 3 months
>5.5cm - elective intervention
3-4.5 cm – every year
4.5-5.4cm – every 3 months
```
Early intervention
rapidly expanding (>1cm/year)
tender
symptomatic
suspected rupture
```
82
Methotrexate SE
Pulmonary fibrosis – need a baseline CXR
Hepatic fibrosis – LFTs monitored weekly, followed by fortnightly, then every 4-6 weeks
Neutropenia + myelosuppression – FBC
Folate antagonist – contraindicated in pregnancy
83
Bowel obstruction general management
Surgical emergency – drip + suck (IVF + NG to decompress)
Conservative mx for 48h (in 75% of the cases, adhesions resolve spontaneously)
If pt don’t improve/have signs of peritonism/have a palpable mass/have a virgin abdomen - surgery
From RevMed
84
Different procedures - what are they used for
```
Left colectomy
Anterior resection
Abdominoperineal resection
Delorme's procedure
Hartmann's procedure
Primary anastomosis
```
Left colectomy - cancer localised to the descending colon
Anterior resection - high lying rectal tumours
Abdominoperineal resection - low lying rectal tumours
Delorme's procedure - full thickness rectal prolapse
Hartmann's procedure - acute perforated diverticulitis
Primary anastomosis - sigmoid tumours, when inflammation goes down after Hartmann's procedure as a result of perforated diverticulitis
from RevMed 5, 16 p. 129
85
Describe the process in
Left colectomy
Anterior resection
Abdominoperineal resection
Left colectomy
Removal of 2/3 of the way along the transverse colon up to the start of the sigmoid colon
https://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/08/26/10/38/my00141_im00232_c7_left_hemicolectomythu_jpg.jpg
Anterior resection
Removal of part of the sigmoid colon + the upper 2/3 of the rectum
Anal sphincter remains intact + an anastomosis is formed
https://www.ccalliance.org/all-in-the-recovery/image-thumb__2459__auto_055d3e6a07d8271f4ca923e2e4c9b72e/Low-anterior-resection-LAR.png
Abdominoperineal resection
Removal of the distal sigmoid colon, rectum, anus + formation of an end colostomy
https://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_and_medical_reference/cancer/abdominoperineal_resection.jpg
86
Drugs known to cause cholestasis
```
Clavulanic acid
Penicillin
Co-amoxiclav
Erythromycin
Chlorpromazine
Oetrogens
```
87
AAA monitoring + mx
Normal diameter of aorta - 2cm
<4 cm - annual US
4-5.5cm - US every 3 months
>5.5cm - elective intervention
3-4.5 cm – every year
4.5-5.4cm – every 3 months
```
Early intervention
rapidly expanding (>1cm/year)
tender
symptomatic
suspected rupture
```
