Gastro/renal Flashcards
Acute pancreatitis management
Fluid resuscitation and analgesia
- aggressive early hydration with crystalloids
- pain may be severe - key priority of care. use ladder but may need IV opioids
NICE states do not offer prophylactic antimicrobials to people with acute pancreatitis
What are the outcomes/actions for screening for AAA
Aorta width
<3cm - normal, no further action
3-4.4cm - small aneurysm, rescan every 12 months
4.5-5.4cm - medium aneurysm, rescan every 3 months
>/= 5.5.cm - large aneurysm. refer within 2 weeks to vascular surgery for probably intervention
Which AAAs have a low rupture risk?
asymptomatic, aortic diameter <5.5cm (i.e. small and medium aneurysms)
- abdominal US surveillance, and optimise cardiovascular risk factors (e.g. stop smoking)
Which AAAs have high rupture risk
SYMPTOMATIC (ie pain), aortic diameter >/=5.5cm or rapidly enlarging (>1cm/year)
Refer within 2 weeks to vascular surgery for probable intervention
Treat with elective endovascular repair (EVAR) or open repair if unsuitable.
What is an inguinal hernia?
What is a strangulated inguinal hernia?
Protrusion of viscera or abdominal contents through the superficial inguinal ring.
Hernia should be reducible. If it cannot be reduced it is referred to as an incarcerated hernia, these are at risk of strangulation.
Strangulation - surgical emergency where blood supply to the herniated tissue is compromised - leads to ischaemia or necrosis.
- pain, fever, increase in hernia size or erythema of the overlying skin. peritonitic features, bowel obstruction, bowel ischaemia .
Repair involves immediate surgery either form an open or laparoscopic approach with a mesh technique.
Causes of hydronephrosis (unilateral and bilateral)?
Unilsteral (PACT)
- Pelvic ureteric obstruction (congenital or acquired)
- Aberrant renal vessels
- Calculi
- Tumours of renal pelvis
Bilateral (SUPER)
- Stenosis of the urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-peritoneal fibrosis
Hydronephrosis investigations and management?
Ix - ultrasound (1st line)
- IVU assess position of obstruction
- antegrade/retrigrade pyelography- allows treatment
- if suspect renal colic - CT scan
Management
- Remove the obstruction and drainage of urine
- Acute upper urinary tract obstruction: nephrostomy tube
- Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
Which stomas are spouted and why?
Ileostomy is spouted to prevent the skin from coming into contact with the enzymes in the small intestine.
They are usually on the right side of the abdomen but not always.
Colonic stomas don’t need to be spouted as their contents are less irritant
What do you see on imaging in bowel obstruction?
Small bowel obstruction
- maximum normal diameter - 35mm
- valvulae conniventes extend all the way across
Large bowel
- maximum normal diameter - 55mm
- haustra extend about a third of the way across
Acute management of renal colic?
IM diclofenac
IV paracetamol if NSAIDs contraindicated or ineffective
Management of renal stones
<5mm will usually pass spontaneously
Lithotripsy/nephrolithotomy if severe cases
Stone burden of less than 2cm in aggregate - Lithotripsy
Stone burden of less than 2cm in pregnant females
- Ureteroscopy
Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy
Ureteric calculi less than 5mm
- Manage expectantly
How to prevent renal stones?
Calcium stones
- may be due to hypercalciuria
- high fluid intake
- low animal protein, low salt diet
- thiazide diuretic (increases distal tubular calcium resorption)
Oxalate stones
- cholestyramine reduces urinary oxalate secretion
- pyridoxine reduces urinary oxalate secretion
Uric acid stones
- allopurinol
- urinary alkalinisation e.g. oral bicarb
Classic triad of intestinal angina?
Severe, colicky, post-prandial abdominal pain
Weight loss
Abdominal bruit
(Intestinal angina is also known as chronic mesenteric ischaemia)
- by far the most common cause is atherosclerotic disease in arteries supplying the GI tract
What are the differences between acute mesenteric ischaemia, chronic mesenteric ischaemia?
Acute - typically caused by an embolism resulting in the occlusion of an artery which supplies the small bowel e.g. the superior mesenteric artery. Pts usually have a history of Atrial fibrillation
- abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
- management: urgent surgery is usually required. poor prognosis, esp if surgery delayed
Chronic - relatively rare clinical diagnosis due to it’s non-specific features and may be thought of as ‘intestinal angina’. Colickly, intermittent abdominal pain occurs.
What is ischaemic colitis and how to manage?
Acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage. It is more likely to occur in ‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.
Ix: ‘thumbprinting’ may be seen on AXR due to mucosal oedema/haemorrhage
Mx: usually supportive, surgery may be required if eg peritonitis, perforation or ongoing haemorrhage
Management of coeliac disease
Gluten free diet
Patients with coeliac disease often have a degree of functional hyposplenism
For this reason, all patients with coeliac disease are offered the pneumococcal vaccine
UTI tx
- Non pregnant women
- pregnant women
- men
Non pregnant women
- local guidelines
- trimethoprim or nitrofurantoin for three days
- send a culture if aged >65
- or if visible or non visible haematuria
Pregnant women
- if symptomatic:
- urine culture
- first-line: nitrofurantoin (should be avoided near term)
- second-line: amoxicillin or cefalexin
- if asymptomatic - immediate 7 day course of nitrofurantoin, amoxicillin or cefalexin
Men
- 7 day course of trimethoprim or nitrofurantoin (unless prostatitis suspected)
Catherised patients
- do not tx asymptomatic
- if symptomatic they should get 7 days abx
What scores are used for risk assessment of acute upper GI bleeds
Blatchford score at first assessment
Full Rockall score after endoscopy
What are the components of the Blatchford score?
Urea (mmol/l) 6·5 - 8 = 2 8 - 10 = 3 10 - 25 = 4 > 25 = 6
Haemoglobin Men 12 - 13 = 1 10 - 12 = 3 < 10 = 6
Women
10 - 12 = 1
< 10 = 6
Systolic BP
100 - 109 = 1
90 - 99 = 2
< 90 = 3
Others
- Pulse >=100/min = 1
- Presentation with melaena = 1
- Presentation with syncope = 2
- Hepatic disease = 2
- Cardiac failure = 2
Management of an upper GI Bleed
Resuscitation
- ABC, wide-bore intravenous access * 2
- Platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
- fresh frozen plasma to pt w/ fibrinogen level of less than 1 g/litre, or PT/APTT greater than 1.5 times normal
- prothrombin complex concentrate to patients who are taking warfarin and actively bleeding
Endoscopy
- offer immediately after resuscitation in patients with severe bleed
- all patients should have endoscopy within 24 hours
Management of non-variceal bleeding
- NO PPIs before endoscopy to pt with suspected non-variceal upper GI bleeding although PPIs should be given to patients with non-variceal upper GI bleeding and stigmata of recent haemorrhage shown at endoscopy
- if further bleeding then options include repeat endoscopy, interventional radiology and surgery
Management of variceal bleeding
- terlipressin and prophylactic abc should be given to patients at presentation (i.e. before endoscopy)
- band ligation for oesophageal varices and injections of N-butyl-2-cyanoacrylate for pt with gastric varices
- transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures
What is primary sclerosing cholangitis, features, and associations
Biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra hepatic bile ducts.
Associated with UC - 4% with UC have PSC, 80% with PSC have UC
(also crohns and HIV)
Features
- cholestasis - pruritis, jaundice, raised bili and ALP
- RUQ pain
- fatigue
Ix
- MRCP or ERCP
- pANCA might be positive
- (liver biopsy - onion skin)
Crohn’s disease investigations
Bloods - CRP
Colonoscopy. Features suggestive of Crohn’s include deep ulcers and skip lesions
Histology - inflammation in all layers from mucosa to serosa, goblet cells, granulomas
Small bowel enema - high sensitivity and specificity for examination of the terminal ileum - Strictures: 'Kantor's string sign' - proximal bowel dilation - 'rose thorn' ulcers fistulae
Primary biliary cholangitis?
Chronic liver disorder typically seen in middle aged females, thought to be autoimmune. Chronic inflammation can damage interlobular bile ducts cauing progressive cholestasis which may eventually lead to cirrhosis.
Classic presentation - itching in a middle-aged woman Associations - sjogren's - rheum arthritis - systemic sclerosis - thyroid disease
Dx - AMA M2 abs are present in 98% of patients and are highly specific
- smooth muscle antibodies in 30% of patients
- raised serum IgM
Mx - urseodeoxycholic acid
- cholestyramine for pruritis
- fat soluble vitamin supplementation
M rule
- IgM
- anti-mitochondrial antibodies, M2 subtype
- Middle aged females
Crohn’s disease management for inducing remission and mantaining remission?
Stop smoking
Inducing remission
- glucocorticoids (oral, topical or IV) are first line +/- elemental diet
- 5-ASA e.g. mesalazine is second line
- can add azathioprine or mercaptopurine as sadd on but not as monotherapy. or methotrexate alternative to aza
Maintaining remission
- azathioprine/mercaptopurine first line for maintaining remission
- methotrexate second line
- consider 5-ASA if patients has had previous surgery
80% of pts with crohns will end up having surgery
