Small Intestine and Appendix Flashcards
Tx Acute diarrhoea
Oral rehydration therapy is the main treatment as the majority of acute diarrhoea is self-limiting
KCl
NaCl
Dissociate hydrogen citrate with glucose
Often just a solute packet dissolved in water
This + adequate fluid intake tends to be enough
Somtimes loperamide is useful for rapid control of symptoms
Tx confirmed appendicitis
A-E resus
IV Metronidazole/cephalosporin
Laporoscopic appendectomy
Early complications are haematoma/wound infections
Later complications are incisional herniae or small bowel adhesions
complication of perforated appendix
Peritonitis and sepsis
Appendix mass
Inflamed appendix becomes covered in omentum
Appendix abscess
Local/pelvic/subhepatic/subphrenic abscesses develop if the appendix mass fails to resolve
Adhesions
Infertility
Due to tubal obstruction after pelvic infection
complications of bowel obstruction
Bowel wall becomes oedematous and distends
Bacteria proliferate in the obstructed bowel
Bowel distends and blood supply is stretched, eventually leading to ischaemia and strangulation (ischaemia and necrosis)
Eventually bowel perforates
Symptoms develop more gradually in large bowel obstruction as there is more room to expand, even longer if the iliocaecal valve is competent
Tx of small bowel obstruction
A-E resus
NBM + NG decompression of stomach
No strangulation = delay operative procedure for 48 hours
50% of adhesion based SBO resolves with conservative management after 4 days
Strangulation/severe symptoms = theatre management
Antibiotic therapy commenced if there are signs of strangulation
Tx large bowel obstruction
Usually operative – hartmanns procedure
End colostomy with closure of the anorectal stump and resection of the difficult area – usually sigmoid
If it is due to faecal impaction, enemas or manual evacuation will be tried
Tx of coeliacs
Lifelong gluten free diet
Only wheat, barley, rye,
Rice/potatoes/corn/oats are fine
Verify that it is working with endomysial antibody tests
Complication of coeliacs
malnutrition
small bowel lymphoma/adenocarcinoma
what skin rash is associated with coeliacs
dermatitis herpetiformis
Tx chronic pancreatitis
Analgesia (pain management is a vital part of management)
Creon (lipase) and multivite (fat soluble vitamins)
Monitoring of blood sugars
Treatment of alcohol abuse if required
Low fat diet
Partial pancreatectomy/pancreaticojejunostomy may be required if there is unremitting pain, narcotic use or weight loss
Tx of IBS-C
1st line - laxative + lifestyle +antispasmodic if bloating/cramping
ispagula
2nd line for constipation - linaclotide/plecanatide/tenapanor (only if constipation for 12 months and on max dose of initial laxative)
3rd line - SSRI +/- hypnotherapy or CBT
avoid lactulose as it causes
Tx of IBS-D
1st line - loperamide + antispasmodic if painful
2nd line - TCAs +/- hypnotherapy or CBT
Tx of IBS-M
No pain/bloating
Lifestyle/dietary modifications
+/- Laxatives
+/- Loperamide
Pain/bloating 1st line Lifestyle/dietary modifications \+/- Laxatives \+/- Loperamide Antispasmodic
2nd line
Lifestyle/dietary modifications
TCA or SSRI
CBT/hypnotherapy
Tx acute crohns
Mild attack – but systemically well
Oral prenisolone
Tapered steroids and clinic review
Severe attack –symptoms + systemic upset
Admit if: raised temp/pulse/ESR/CRP/low albumin
IV steroids – hydrocortisone 100mg/6hrs
NBM + parenteral nutrition or elemental diet
High level monitoring is required
2nd line pharmacological
Thiopurines
Azathioprine
6-mercaptopurine
Before prescribing the TMPT gene needs to be tested for as a deficiency of the gene can cause severe acute myelosuppression when thiopurines are given
3rd line
Biological agents - Infliximab
On improvement transfer to oral prednisolone as per mild attack
If unable to control surgical advice should be given
Antibiotics are considered if there are septic signs
Tx maintenance of Crohns
Thiopurines first line
Azathioprine/6-mercaptopurine
Methotrexate second line
When thiopurines are contraindicted (TMPT)
Thiopurines unsuccessful
if methotrexate has been used previously successfully
Oral metronidazole is useful for anal disease
Tx acute UC
Mild/moderate (less than 6 motions per day, systemically well)
Proctitis/proctosigmoiditis
Topical aminosalicylate (e.g. mesalazine)
+/- oral mesalazine
more extensive disease
Loading dose oral mesalazine
+/- oral beclometosone
Topical mesalazine
2nd line
If these aren’t effective after 4 weeks add oral prednisolone
3rd line
Tacrolimus after 2-4 weeks of inadequate control
4th line
Biological agents
Considered by a specialist
Tx acute fulminating severe UC
MDT management
Start with IV corticosteroids
Assess the patient with regard to surgical intervention
SC heparin
Avoid any antimotility drugs – including opioids
2nd line
IV ciclosporin
Escalate to this if there is 72 hours of no improvement/worsening on oral corticosteroids
3rd line
Biological agents
Considered by specialist
indications of surgery in UC
> 8 motions a day
Pyrexia
Tachycardia
Colonic dilatation
low albumin
Anaemia
CRP >45
complications of IBD
Bowel perforation
Lower GI haemorrhgae
Toxic dilatation (more common in UC)
Colonic carcinoma - Risk is raised in crohns but barely raised in UC
pancolitis = These patients require 2 yearly colonoscopies
Crohns specific complications Small bowel obstruction Fistulae (10%) Abscess formation B12/folate/iron deficiencies Terminal ileum is where B12 is absorbed
UC maintenance
5- ASA derivatives
Sulfasalazine
Mesalazine
Oral thiopurines are second line
Maintenance is lifelong
