GI

Question 1

Abdominal pain

Answer 1

Ward complain

• Think cholecystits, cholangitis, appendicitiys, pancreatitis, diverticulitis, others
• Characterize onset, character (dull colicky constipation)
• Check vitals, vomiting, BO, flatus, melena

Mx

• NPO
• Obs q1H x4, q4H if stable
• Bld x CBC LRFT bone clotting VBG amylase CRP
• +- Bld x TxS, C/S if fever >38
• CXR, AXR
• Dyspepsia
  &raquo_space;» PO pepcidine 20mg bd/ PO gastreel 1tab tds
• Constipation
  &raquo_space;» laxative
• Colicky: think IO, R/T to BSB if vomiting, NO laxative
  &raquo_space;» PO buscopan 1tab tds prn, IV/IM buscopan 20/30/40mg q6H prn
• RUQ pain: think cholecystitis, cholangitis, Abx if fever
  &raquo_space;» IV zinnacef 750mg q7H + IV flagyl 500mg q8H
• RLQ pain: think appendicitis, TxS
• LLQ pain: non specific, Abx if fever/ WCC
  &raquo_space;» = RUQ pain
• Guarding: U CT abdomen +- TxS, EOT
• Pain control: PO/IV/IM tramadol 50mg q6H prn

Question 2

Ascites

Answer 2

Admission
 - Low salt diet
 - FR 1.2L/day
 - Obs q4H
 - Chart IO
 - BW x1 then alt day
 - Bld x CBC LRFT clotting bone INR RG
 - +- Bld x AFP, CEA, CA125, CA19.9
 - +- Bld  xHBsAg, anti-HCV
 - CXR, AXR
 - ECG
 - Resume usual meds
 - + IV cefotaxime 1g q8H if SBP
 - Plan diagnostic +- therapeutic abdominal tap mane
 >>>> connect to BSB, aim output <=5L per day
 - IV albumin 10g per L

Question 3

Coffee ground vomiting

Answer 3

= UGIB

Question 4

Diarrhea

Answer 4

Ward complain

• IVF if dehydrated
• Bld x RFT
• AXR
• Stool x C/S norovirus CD toxin
• +- PO immodium (loperamide) 2mg q2H prn

Question 5

GE

Answer 5

Admission

• DAT
• +- contact precaution
• Encourage fluid intake
• Obs q4H
• Bld x CBC LRFT bone clotting RG
• Bld x TSH, fT4, VBG
• CXR AXR
• IVF x fluid replacement
• Stool x C/S, norovirus, ova and cyst, CD toxin (recent abx/ hospitalization)
• Resume usual meds
• Chronic: consult GI x colonoscopy

Question 6

GIB

Answer 6

Admission
- NPO
- Chart I/O (foley to BSB if unstable)
- Obs q1H, q4H if stable
- Bld x CBC LRFT bone clotting INR RG TxS
- Bld x AFP, HBsAg, anti-HCV
- CXR, AXR
- ECG
- IVF (resuscitation + maintenance)
&raquo_space;» IV gelofusine/NS 500mL FR (repeat if BP low)
- Transfusion if indicated (Hb<8, transfuse packed cell x2 q4H)
- OGD mane if stable (MO x emergency OGD if unstable e.g. shock/ tachycardia/ profuse bleed)

Question 7

Hemorrhoid

Answer 7

Ward complain

• Anusol ointment LA BD prn
• Faktu 1tab BD/ ointment LA tds
• +- laxative

Question 8

Hepatic encephalopathy

Answer 8

Admission

• DAT/ low protein diet
• Neuro-obs q4H
• Hstix TDS + nocte
• Bld x CBC LRFT bone clotting RG
• Bld x HBsAg, anti-HBs, anti-HCV, anti-HAV IgM, anti-HEV IgM
• Bld x GGT, direct bilirubin, ammonia
• Bld C/S if fever >38
• Urine x multistix
• Sputum x C/S
• ECG + long lead II
• CXR, AXR
• U CTB
• Resume usual meds
• • PO Lactulose 10mL BD to maintain BO x3/D
• • PO fleet enema daily prn

Question 9

Jaundice

Answer 9

Admission

• DAT/ low protein diet
• Obs q4H, neuro-obs (encephalopathy)
• Hstix TDS + nocte
• Bld x CBC LRFT clotting bone RG
• Bld x HBsAg, Anti-HBs, Anti-HCV, HBV DNA (known HBsAg +), Anti-HAV IgM, Anti-HEV IgM, Panadol level
• Bld x GGT, AST, LDH, amylase, direct bilirubin, ammonia
• CXR, AXR
• ECG
• Urine x multistix, toxicology
• +- CTB
• U USG HBP if suspect drainage, fever, abd pain
• Ascites: therapeutic tapping x TCC, C/S
• Resume usual meds
• PO lactulose 10mL BD to maintain BO x3/D (encephalopathy)
• +- PO vitamin K1 (INR >=1.5) 10mg daily
• +- IV albumin 20% 40g (1g/kg) q24H (alb low, hepatorenal syndrome)
• +- Abx if fever
• +- PO entecavir 0.5mg daily
• W/H panadol, TB drugs, steroid

Question 10

Liver failure

Answer 10

Ward complain (deranged LFT)
 - Check encephalopathy, ascites +- pain, HCC, H'stix (hypoglc), INR, RFT (hepatorenal)

• Low protein diet
• Neuro-obs q4H (encephalopathy)
• Hstix TDS + nocte/ q4H
• Bld x HBsAg, anti-HBs, Anti-HCV, HBV DNA (known HBsAg+), Anti-HAV IgM, Anti-HEV IgM, panadol level
• Bld x GGT, AST, LDH, amylase, direct bilirubin
• Bld x ammonia
• Urine toxicology
• +- CTB
• Tapping x TCC, C/S (ascites)
• U USG HBP (drainage), U USG renal (deranged RFT)
• • laxative aim BO x3 per day
    &raquo_space;» Senna, lactulose, colace: regular
    &raquo_space;» Duclolax, fleet enema: prn
• PO VitK1 10mg daily (INR >=1.5)
• +- IV albumin 20% 40g (1g/kg) q35H (alb low, hepatorenal syndrome)
• ABx if fever
• W/H panaodol, TB drugs, steroid
• +- anti-viral (PO entecavir 0.5mg daily)

Question 11

No BO

Answer 11

• RO IO (prev AXR, abd pain, vomiting, flatus)

Mx
 - DAT/ NPO
 - +- blood x VBG amylase CRP
 - +- AXR CXR
 - Laxative
 >>>> PO lactulose 10ml BD prn
 >>>> PO senna 7.5mg/15mg daily prn
 >>>> PO angiolax 10ml BD prn
 >>>> PO colace 100mg tds

> > > > PR ducolax 10mg daily prn
PR fleet enema 1 tube daily prn

Question 12

PR bleeding

Answer 12

Ward complain
Fresh blood: proctoscopy
- Blood stained: observe

• Bld x CBC, LRFT, clotting urgent, TxS
• Adrenaline gauze
• +- IV gelofusine 500mL FR x1
• +- blood transfusion
• +- IV transmin 500mg q8H

Altered blood (LGIB)

• Bld x CBC, LRFT, clotting urgent, TxS
• +- IV gelofusine FR x1
• +- blood transfusion
• +- IV transamin 500mg q8H

Fresh melena (fast UGIB)

• Call MO (U consult surgery)
• NPO
• Bld x CBC, LRFT, clotting urgent, TxS
• CXR, AXR
• +- IV gelofusine 500mL FR x1
• +- blood transfusion
• +- IV transamin 500mg q8H

Old melena (UGIB)

• NPO
• Bld x CBC, LRFT, clotting urgent, TxS
• CXR, AXR
• +- IV gelofusine 500mL FR x1
• +- blood transfusion
• +- IV pantoloc 40mg q24H
• Consult surgery

Question 13

Vomiting

Answer 13

Ward complain

• +-NPO
• Suspect IO: R/T to BSB, aspirate q4H
• IV maxolon 10mg q8H prn (if significant vomiting, after RO IO)
• PO maxolon 10mg tds prn