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Y3 Charis > Gastro - mx use this > Flashcards

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
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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
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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
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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
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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
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6
Q

Oesophageal spasm treatment

A

CCB

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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)

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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
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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
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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)
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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

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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
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13
Q

Constipation

Give examples of stool softeners

A

Sodium docusate, liquid paraffin, arachis oil enema, poloxamer

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14
Q

Constipation

Give examples of osmotic laxatives

A

Lactulose, macrogols (Movicol), polyethylene glycols (e.g Laxido), magnesium salts

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15
Q

Constipation

Give examples of peristalsis stimulants

A

Senna, docusate, glycerol suppositories, bisacodyl, dantron

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16
Q

Constipation

Give examples of bulking agents

A 
Ispaghula husk (Fybogel)
Methycellulose

contraindicated in patients with
intestinal obstruction
faecal impaction
swallowing difficulty

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17
Q

ConstipationGive examples ofdrug used for opioid induced constipation

A

Methylnaltrexone

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18
Q

ConstipationWhat kind of drug is co-danthamer

A

Dantron (peristalsis stimulant) + poloxamer (stool softner)

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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
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20
Q

Mild gallstone pancreatitis management

A
  • IVF

- Supportive care

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21
Q

ERCP assosciated pancreatitis management

A
  • IVF
  • Analgesia
  • Bowel rest
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22
Q

Asymptomatic cholelithiasis management

A

Observation

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23
Q

Symptomatic cholelithiasis management

A

Laparoscopic cholecystectomy

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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)

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25
Q

Cholecystitis management

A
  • 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
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26
Q

Acute cholangitis mx

A
  • 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
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27
Q

Mallory Weiss tear management

A
  • 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

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28
Q

Toxic megacolon mx

A
  • 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)
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29
Q

Acute exacerbation of UC treatment

A
  • IVF
  • IV steroids
  • Abx
  • Bowel rest
  • TPN might be required
  • DVT prophylaxis
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30
Q

Mild UC

What does it mean (6)
Management

A 
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)

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31
Q

Moderate UC

What does it mean (6)
Management

A 
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)

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32
Q

Severe UC

What does it mean (6)
Management

A 
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)

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33
Q

Surgical UC therapy

A

Past: protocolectomy with ileostomy

Now: IPAA - ileal-pouch anal anastomosis

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34
Q

Acute exacerbation of Crohn’s disease management

A
  • IVF
  • IV steroids
  • 5-ASA (mesalazine, sulfalazine, olsalazine)
  • Analgesia
  • TPN might be necessary
  • Monitor markers of disease activity
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35
Q

To induce remission in Crohn’s

A

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
Q

Crohn’s first, second, third line treatment

A

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
Q

Cirrhosis management

A

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
Q

Ascites management

A

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
Q

UCrole of

corticosteroids
aminosalicyltes
thiopurines
Ciclosporin
TNFa antibodies
A

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
Q

Mx of liver failure for all patients

A

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
Q

Management of causes of liver failure

Acute hepatitis B
Autoimmune hepatitis
Herpes Simplex hepatitis
Budd-Chiari syndrome
Wilson's disease
A
  • 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
Q 
Management of complications of liver failure
•	To decrease ammonia production 
•	ICP  
•	Cerebral oedema 
•	AKI
•	Treat + prevent abnormal clotting 
•	Paracetamol overdose 
•	Monitor glucose 
•	Liver transplantation
A
  • 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
Q

SBO-partial or complete or complicated poor surgical candidate management

A
  • 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
Q

SBO-complete or complicated, surgical candidate

A
  • IVF + correct electrolyte imbalances
  • Emergency laparotomy
  • Abx – ampicillin + gentamicin or cefoxitin
  • NG decompression
  • Analgesia
  • Correction of underlying cause
45
Q

LBO-Acutely ill

A

• 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
Q

HAV mx

A
  • 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
Q

HBV mx

A
  • 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
Q

HCV mx

A
  • Acute - supportive care
  • Chronic - Oral direct-acting antiviral therapies – elbasvir (NS5A inhibitors) + grazoprevir (NS3/4 protease inhibitors)

,

49
Q

HDV mx

A
  • Supportive care
  • Pegylated interferon alfa
  • Liver transplantation
50
Q

HEV mx

A

Supportive care

51
Q

Autoimmune hepatitis mx

A
  • 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
Q

AAA seen on US (AA >3cm in diameter) + patient has abdominal pain mx

A

Stable patient
- CT aortogram

Unstable patient
- Surgery to rule out ruptured AAA

53
Q

Perforated peptic ulcer emergency mx (resuscitation + treatment until surgery)

A
  • 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
Q

Acute pancreatitis management

A
  • 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
Q

Chronic pancreatitis management

Acute episodic pain
Chronic management

A

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
Q

How to manage Pancreatic endocrine insufficiency

Pancreatic exocrine insufficiency

as a result of chronic pancreatitis

A

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
Q

Which enzymes does pancreatic include?

A

Amyalse
Protease
Lipase

58
Q

Peritonitis managment

A
  • IVF
  • Analgesia
  • Broad spectrum abx
  • NG tube
  • Blood transfusion
  • Surgery

Exploratory laparotomy
Correct cause of peritonitis

59
Q

If you suspect varices you should include the following in your initial (pre-endoscopy) management

A
  • 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
Q

Alcoholic hepatitis mx

A 
•	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
Q

NASH/NAFLD ix

A

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
Q

Which antibiotic is the first line treatment for C. difficle infection?

A

Metronidazole

Can also use vancomycin (2nd line if allergic to metronidazole, if C difficile is resistant to metronidazole)

63
Q

How to maintain remission in UC?

A
  • low dose oral ASA (e.g. melsalazine)

- oral azathioprine/mercaptopurine if severe

64
Q

What is the critical view cholecystectomy?

A

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
Q

Diverticular disease mx

A

• 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
Q

Hernia mx

A

• 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
Q

Intestinal obstruction mx

A 
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
Q

Management of acute alcoholic hepatits

A
  • Thiamine
  • Vitamin C and other multivitamins (can be given asPabrinex)

• 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
Q

Hiatus hernia mx

A

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
Q

Gastroenteritis mx

A
  • 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
Q

Which class of drugs increases risk of bleeding form diverticular disease?

A

NSAIDs

72
Q

Encephalopathy mx

A
  • Place on a low protein diet

- Lactulose enemas to decrease transit time and decrease GI absorption

73
Q

Oesophageal varices mx

A
  • 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
Q

UC

Induction of remission
Maintenance of remission

A

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
Q

Crohn’s

Induction of remission
Maintenance of remission

A

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

76
Q

IBS mx

A

• 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

77
Q

Coeliac disease mx

A

• 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

78
Q

Coeliac crisis mx

A

Coeliac crisis – hypovolaemia, severe watery diarrhoea, acidosis, hypocalcaemia, hypoalbuminaemia
• Rehydration + correction of electrolyte abnormalities
• Corticosteroid (budesonide or prednisolone)

79
Q

Boerhaave’s perforation mx

A
  • IVF
  • Abx
  • Prompt surgical repair (within 12h)
80
Q

Why are PPIs prefered to H2 receptor antagonists for the mx of GORD?

A

H2 receptor antagonists suffer from tachyphylaxis - their utility diminishes with time
therefore they are often stopped after 2 weeks

81
Q

AAA mx

A

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
Q

Methotrexate SE

A

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
Q

Bowel obstruction general management

A

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
Q

Different procedures - what are they used for

Left colectomy
Anterior resection 
Abdominoperineal resection 
Delorme's procedure
Hartmann's procedure
Primary anastomosis
A

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
Q

Describe the process in

Left colectomy
Anterior resection
Abdominoperineal resection

A

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
Q

Drugs known to cause cholestasis

A 
Clavulanic acid
Penicillin 
Co-amoxiclav
Erythromycin 
Chlorpromazine
Oetrogens
87
Q

AAA monitoring + mx

A

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

Y3 Charis (35 decks)

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