Tx Flashcards
Groin Hernia
ASx- monitor Surgical: - moderate to severe sx - Urgent- incarceration - Emergency- strangulation, bowel obstruction - Laproscopic/open - Mesh: durable and longevity - Aloderm: human cadaver skin; less likely to get infected
Femoral
Surgery
Spigelian hernia
Surgery; very painful and complicated; trapped easily
Richters Hernia
Surgery
Parastomal Surgery
Based on sx
Rectus Abdominus Diastasis
conservative- weight loss, abdominal exercise
surgical- cosmetic/ severe sx
Conservative Tx Hemorrhoids
Dietary- increase water and fiber intake
Toilet habits- avoid lingering
Sitz bath- soaks anus and keeps it clean
Office procedures Hemorrhoids
- banding
- coagulation
- sclerotherapy
Initial Grade 1 or 2 or External
- Dietary therapy
- educate about toilet habits
- oral/ local analgesic
- topical agents to reduce swelling/ treat dermatitis (topical astringent and protectants, topical corticosteriods, topical antiinflammatory agents)
- Decrease sphincter spasms (antispasmotic)
- Venoactive agents to increase venous tone
- Banding
Who gets surgery
- sx despite conservative measures
- grade 4 (+/-) strangulation
- Grade 3 with symptoms
- severe pain with thrombosis
Surgery
- hemorrhoidectomy
- hemorrhoidal artery ligation
- staple hemmorrhoidectomy
Thrombosed Hemorrhoids
Excision and I&D
Rectal Abscess
- I&D
- ABX only if cellulitis
Rectal Fistula
Surgery- eradicate fistula and preserve fecal continence with little rubber tubing tie that they use to tie and pinch off fistula
Anal fistula goals
- relax internal sphincter
- maintain less trauma with stooling
- pain relief
Medical Tx Anal fistual
- cortisone
- topical nitro, diltiazem, bathanechol
- oral: nifedipine, diltiazem
- botulin toxin to paralyze the rectal spasm
Surgical Tx anal fistula
- failure of other tx
- lateral sphincterotomy
- dilatation
constipation
Initial Management
- patient education
- dietary changes: more fiber and water
- bulk- forming laxatives (metamucil, citrucel, fibercon, benefiber)
PRN
- non-bulk forming laxatives (milk of magnesia, miralax, lactulose, senna, biscodyl)
- Enemas- (colace and mineral oil)
Post op give what for constipation
colace and senna
Fecal impact
- Disimpact and colon evacuation: manual fragmentation, mineral oil enemal to soften and lubricate, PEG after evactuate a little
- identify causes
- maintain bowel regimen
Pilonidal Disease
- sitz bath
- I&D if abscess
- surgical excision of sinus tract and cysts
- ABX for cellulitis
- be careful shaving hair in gluteal area
- recurrent
Tx SBO
NPO
IVF
NG tube- decompress intestine
Surgery- done for all the other causes except adhesions and Crohn’s; if adhesion/Crohn give the patient 4 days on other tx before surgery
Tx appendicitis
NPO
IVF
IV ABX- broad spectrum
Surgery- appendectomy
Tx toxic megacolon
Non-operative (first line) - IVF - Correct lab abnormalities - ABX for IBD or infectious (Vanco+Flagy for cdiff) - intravenous corticosteroids (IBD) - NPO - Bowel decompression with NGT Surgery if no improvement - subtotal colectomy with end-ileostomy (50% mortality)
Tx ischemic bowel disorder
- IVF
- Anti-coag (IV heparin)
- IV vasodilator (glucagon systemically or papverine through a catheter)
When does patient need to be in OR ischemic bowel disorder
4-6 hrs
Tx for ischemic bowel disease to infarct
- emergent laporatomy- restoration of interrupted blood flow with arteriotomy/ bypass graft and resection of infarcted bowel
- look again 24-48hrs later to see if alive or dead bowel
- need vasodilators
Tx colonic ischemia
Support -IVF - NPO - Empiric ABX for moderate/severe - NGT - no meds that promote ischemia - optimize cardiac and pulmonary functions Surgery - laparotomy with resection if clinical deterioration despite support - patient will receive colostomy bag
Tx pancreatic cancer
- only curative approach is surgery
- stage 1 to 2b is most likely to be cured by radical resection
- do a whipple if tumor in head of pancreas
- distal pancreatectomy is tumor in body or tail
- chemotherapy
What is a wipple
- resection of head of pancreas
- excise the duodenum and bile duct
- reconstruction with intestine
Protein Energy Malnutrition
• Call your nutrition colleagues ASAP
• Should be followed daily by nutrition consultant
o Help manage dietary requirements
o Correct electrolyte abnormalities
o Replace vitamins and minerals
o Supplements with enteral or parenteral nutrition
Obesity
• Close follow-up is essential • Identify and refer those patients who are motivated to active treatment programs • Programs are multifactorial and emphasize maintenance of weight loss o Dietary instruction and education o Behavior modification o Exercise o Medications o Bariatric surgery
Anorexia
- Goal is restoration of normal body weight and elimination of psychological features
- Inpatient treatment programs are available but may also be necessary in severe cases for management of volume status and electrolytes
- Psychotherapy and medications are available however show little evidence of improvement
- Referral to psychiatrist is essential
Bulimia
- Supportive care to include psychotherapy
- Antidepressants may be helpful
- All patients should be referred to psychiatrist
- Long term psychiatric prognosis is worse with bulimia nervosa than with anorexia nervosa
Iron deficient
• Identify cause of iron deficiency anemia as often this can be a result of occult blood loss
Oral iron
o Ferrous sulfate 325 mg PO one-three times daily
o Continue 3-6 months after restoration of normal labs
Parenteral iron is indicated if:
o Refractory to PO iron
o GI disease
o Hemodialysis
Thiamine deficient
replace thiamine, initially IV followed by PO
B12 deficient
IM or subcutaneous injections of 100 mcg
• Daily for first week
• Weekly for first month
• Monthly for life
Folic acid deficiency
folic acid 1mg PO daily
Vitamin D
o Ergocalciferol (D2) 50,000 units once weekly x8 weeks o Cholecalciferol (D3) 2,000 units daily
HCC
Surgical- Only long term cure
- Resection = tumor <5cm and no/minimal cirrhosis
- Liver transplant – only cure
Medical/palliative – very advanced disease
- Sorafenib (VEGF blocker) slows progression with advanced HCC
Chronic HCV
- Treatment recommended for EVERYONE • - Typically treatment is 12 weeks w/o cirrhosis and 24 weeks w/ cirrhosis
- ledipasvir (90 mg)/sofosbuvir (400 mg) = Harvoni for 12 weeks
Chronic HBV
ETV (Entecavir), Tenofovir
Alcoholic hepatitis
Emergent treatment to improve short term mortality
- Steroids = methyprednisolone 32mg/daily for 1 mo (MELD >18)
- Pentoxiphylline = if steroids contraindicated
General Treatment
- ETOH cessation
- Correct nutritional deficiencies (folate, thiamine, zinc)
- Assist with abstinence (naltrexone, acamprosate, baclofen)
Liver transplant considered only after 6 mo abstinence period from alcohol
Autoimmune hepatitis
o Corticosteroids
o +/- Azathioprine
HCV
8-12 weeks Ledipasvir/sofosbuvir (Harvoni)
HAV
Symptomatic treatment
GI varicies
Emergent Treatment
- 2 large bore IV access/Central access
- pRBC txn hb >7
- NGT w/ lavage (Try to clamp down on bleed; Don’t do unless GI told you to do it)
- Octreotide 50mcg/hr
- Balloon tube tamponade (Minnesota or Blakemore)
- Endoscopy (definitive treatment); Varix ligation (banding), inject, sclerotherapy
- TIPS (transjugular intrahepatic portosystemic shunt)
- Angiotherapy (percutaneous transhepatic embolization)
- Surgical
Prevent rebleed GI varicies
- nadolol titrated to maximal tolerated dose
- Endoscopic: Band ligation
Hepatic encephalopathy
- Lactulose (PO, NGT, rectal and titrate to 3-4 BM’s per day) ; Titrate to number of bowel movements a day
- Antibiotics (xifaxan-nonabsorbable antibiotic which absorbs ammonia)
Ascites
Medical therapy
- Na+ restriction (<1.5g)
- Fluid restriction (<1.5L)
- Diuretics (Second line therapy)- Spironolactone or Furosemide
Surgical
- Large volume paracentesis (5-7L (max 10L))
- TIPS
- liver transplant
UGIB
- Hospitalization
- Two large bore peripheral IV
- Type and cross for blood
- IVF resuscitation and/or blood transfusion and/or clotting factors (500mL or 2L given of IVF); give pRBC is Hgb less than 7; INR>1.5 FFP
- IV PPI BID* (Esomeprazole, pantoprazole)
- IV Octreotide* 50mcg IV bolus -> continuous infusion 50mcg/hr x3-5 days
- Reversal agents for anticoagulant or antiplatelet therapies +/-
- Prokinetic agents (e.g. erythromycin 3mg/kg IV) 30-90 minutes before endoscopic to aid in visualization
- Endoscopy (hemodynamically stable) +/- endoscopic therapy; Injection therapy (epinephrine), thermal coagulation, hemostatic clips, fibrin sealant, band ligation
- Rare intervention: angiography with transarterial embolization, surgical
treatment (vagotomy, pyloroplasty, etc) – typically if failed endoscopy
Endotracheal intubation – massive bleeding
UGIB- ESOPHAGEAL VARICIES
- Prophylactic antibiotics – esophageal varices – broad spectrum
- Intrahepatic portosystemic shunt placement (TIPS)
- Balloon Tamponade – Blakemore tube (requires intubation)
LGIB
- Hospitalization
- Two large bore peripheral IV or a central line
- Type and cross for blood
- IVF resuscitation and/or blood transfusion and/or clotting factors
- Reversal agents for anticoagulant or antiplatelet therapies +/-
- Colonoscopy with therapy
- CT angiography with sclerotherapy
Small bowel Adenocarcinoma
Surgical
small bowel Carcinoid
surgical
small bowel sarcoma
surgical + Imatinib (advanced disease)
small bowel lymphoma
Surgical Excision (Node negative) + Chemotherapy (Node positive)
General diarrhea management
o Fluid replacements- Oral vs IV
o Nutrition repletion- Sugar, salt, water
o Antibiotic therapy- Fluoroquinolones
o Antimotility agents- Loperamide, Pepto-Bismol
o Probiotics
C.diff
o Stop inciting antibiotic
o Contact precautions- soap and water
o Vancomycin or Metronidazole
Campylobacter
supportive in healthy patients- IVF, antiemetics
• Antibiotic therapy for immunocompromised and severe disease
o Fluoroquinolones (Levoflox, Ciproflox), Azith
Salmonella
o IVF replacement
o Electrolyte repletion
o Antibiotic therapy not indicated in healthy patients
o Ciproflox or Levoflox for severe disease, immune compromised patients
Shigella
o Supportive with IVF, electrolyte repletion
o Self limiting lasting average 7 days
o Antibiotic therapy not indicated in healthy patients
• Fluoroquinolone (not Cipro due to resistance), Azith, Bactrim for severe disease and immune compromised
botulism
o Antitoxins
cholera
o aggressive volume repletion- IV or oral fluid and electrolytes
o antibiotics for moderate to severe volume depletion
• macrolides, fluoroquinolones, tetracyclines
Intestinal Entomoeba
o Metronidazole
o Tinidazole
o Ornidazole
cryptosporidium
antiparasitic meds- Nitazoxanide
giardia
Metronidazole, Tinidazole, Nitazoxanide
traveler’s diarrhea
o Flouroquinolones- Ciproflox, Levoflox
IBS
Dietary modification- • Low gas producing foods (beans, onions, celery, bananas, apricots, bagels, pretzels etc.) Etoh, caffeine • Lactose avoidance • Low fodmap diet- fermentable foods (honey, corn syrup, apples, pears, mangoes, cherries etc.) • Gluten avoidance Physical activity Adjunctive pharmacologic therapy: -Patients with IBS-Constipation • PEG (polyethylene glycol) therapy o Lubiprostone o Linaclotide
Mild UC
- Aminosalicylates (5-ASA) drugs- colon version of motrin that only releases in the distal colon
- Mesalazine PR suppository or budesonide rectal foam preferred if mild proctitis
- Rectal and oral 5-ASA i.e po sulfasalazine and PR mesalazine if distal colon inflammation
- After remission long term maintenance with 5-ASA recommended
Mild/moderate UC
- Budesonide orally – targets colon minimal systemic affect
- Prednisone
- Taper over 60 days
Severe UC
- Hospitalization and IV steroids w/ IVF
- Methylprednisolone 60mg/d
- Steroid resistant disease = anti-biologics (when you fail on steroids do an induction therapy with an immunosuppressant)
- TNF-alpha blocker (MC)- infliximab, adalimumab, Golimumab
- VGEF blocker (only use if fail on TNF)- Vedolizumab
- Cyclosporine = last resort
Maintenance UC
- 5-ASA if response to 5-ASA or steroids
- Budesonide
- Immunosuppresants
- Azathioprine or 6-MP
- If inflixamab induction then continue with agent for maintenance or azathioprine (same for Golimumab)
- Probiotics help with maintaining remission
Surgery in UC
colectomy is curative in UC
–Emergency: Life-threatening complications related to fulminant disease such as toxic megacolon unresponsive to medical treatment
–Urgent: Severe disease admitted to hospital and not responding to intensive medical treatment
Diarrhea with CD
- Loperamide
- Terminal ileal disease or resection= bile acid sequestrant
- Short gut = low fat diet
Mild CD
o Colon and small bowel disease = mesalamine
o 5-ASA derivatives, which are mainstay of UC, have shown to be less useful in treatment of CD
Moderate/severe
Steroid therapy
• Short course for severe systemic symptoms and/or refractory to anti-inflammatories
• Treat until remission and then slow taper (60 days)
Immunosuppressants
o Azathioprine (6-MP active metabolite)
o Methotrexate- in adults it can be used for induction and maintenance
TNF – alpha blockers
o Steroid dependent and unable to taper
o Fistula treatment not responding to abx and conventional therapy
o Infliximab, Adalimumab, certolizumab pegol,
o Induction doseage until remission and then maintenance doseage
Anti-integrins
oLose responsiveness to TNF-alpha blockers or don’t respond at all
oVedolizumab
Fistula due to CD
o Antibiotic therapy- metronidazole and ciprofloxacin
o Immunosuppressants and TNF-alpha blockers
o Surgery
Celiac
Diet
o Essential therapy = removal of ALL gluten
o Improvement in 2 weeks on diet
o Often assoc w lactose intolerance either temp or lifelong thus avoid dairy until sx resolution
Supplements
o VitA,B12,D,E
o Initial stages only required usually not long term
Steroids
o Prednisone or budesonide 2 or more wks
• Try and get disease under control
o Unintentional or intentional gluten ingestion may trigger severe diarrhea, hypovolemia, electrolyte imbalance
Lactose intolerance
o Goal of therapy is patient comfort and determining
“threshold” of intake when symptoms occur
o Spread lactose intake throughout the day in quantity <12g (1 cup of milk) and most pts tolerate this w/o lactase
o Lactase enzyme replacement - Lactaid, Lactrase, Dairy Ease
o Calcium supplementation if exclude dairy (prevent osteoporosis)
Cholelithiasis
Asymptomatic (incidental finding) – Expectant management
o Give them signs and symptoms to look out for and to come back if they develop these symptoms
Symptomatic – Prophylactic Cholecystectomy
Cholecystitis
- Admit to the hospital (IVF, pain management, ABX)
- Cholecystectomy- Want to take them out 24hrs from diagnosis
- Pre-op antibiotic prophylaxis towards gram neg rods and anaerobes
- Cipro & Flagy; 3rd Gen Ceph + Flagyl,;Carbapenem; Pip and Tazo
Percutaneous Drainage Indications in cholecystitis:
Pericholecystic abscess, CBD obstruction; significant edema and swelling
Choledocolithiasis Treatment
Removal of the common bile duct stone either endoscopically (ERCP) or surgically.
Acute Cholangitis Treatment
- Admit to the hospital
- Empiric Antibiotic Treatment- Zosyn, Unasyn, Flouroquinolone + Flagyl, Cabapenem
- Establish biliary drainage- ERCP
- Sphincterotomy with stone extraction and/or
- Stent placement if mass or stenosis or significant swelling
PSC
liver transplant
Acute pancreatitis
- Admit to the hospital
• Assess for severity upon diagnosis (next slide)
• Attempt to discover underlying cause
• NPO
• IVF (Lactated Ringer’s or NS)
• Parenteral analgesia
• Parenteral antiemetics
• Repeat labs assessing BUN/Creatinine, HCT q8-12 hours
• Serial exams assess for fluid overload
• Nutrition: Introduction of clear fluids->low fat diet
Chronic pancreatitis
• Low fat diet; refrain from alcohol
• Steatorrhea- FDA-Approved Pancreatic Enzyme
o Decreases diarrhea
o Restores absorption nutrients
• Endoscopic treatment –sphincterotomy, stenting, stone extraction, drainage of pseudocyst
• Whipple, total pancreatectomy or autologous islet cell transplantation
Diverticulitis Medical
Antibiotics – Coverage Enterobacteriaciae & Gram Neg Anaerobe (B.Frag)
o Cipro & Flagyl (IV or PO) (first line)
o Augmentin PO
o Ertapenem (IV)
o Zosyn (IV)
o 2nd or 3rd Cephalosporin plus Flagyl IV
IVF (admitted)
Analgesia & Antiemetics PRN (IV vs PO)
NPO vs Clear Diet vs normal diet
Diverticulitis Surgical
One Stage Procedure
o Colon Resection with primary anastomosis
Two-stage Procedure (two different procedures)
• Colonic Resection with end colostomy (Hartmann’s procedure)
Diverticulosis surgical- who gets it
- Emergent Surgery: free perforation, +/- bowel obstruction
- Urgent Surgery: failure of medical treatment; colonic obstruction; abscess failing non-operative intervention
Diverticular Bleed
Resuscitation if bleeding hasn’t stopped
o Two large bore IV
o IVF NS
o Type and Cross for blood
o Transfuse pRBCS PRN
• Colonoscopy (first step)-Treat active bleeding
• Angiography (2nd step)- Alternative to colonoscopy if bleeding cannot be found
• Surgical Intervention (Segmental Colectomy)- Hemodynamically unstable
Polyps
polypectomy
Lynch
colectomy
FAP
- prophylactic colectomy
- Chemoprophylaxis NSAID and COX2- Celecoxib
colorectal cancer
Surgery – Resection of primary colonic or rectal cancer is the treatment of choice in all stages
Chemotherapy – Stages III&IV Colon cancer
antibodies against the epidural growth factor receptor (EGFR)
Cetuximab and Panitumab
*Used only in Stage IV and always adjunct to traditional chemotherapy
Rectal cancer
Stage I : Excellent prognosis surgery alone
Stage II & Stage III: Chemoradiation + Surgery
Anal cancer
Stage 0-3
- Chemoradiotherapy (Neoadjuvant): 5-FU + Mitomycin + Radiotherapy
- Progression of disease or persisting disease necessitates surgery
Stage 4
- Systemic Chemotherapy: Cisplatin + 5-FU
Active bleed PUD
- IVF, Blood transfusion
- High dose IV PPI (Protonix)bolus and drip
- Endoscopic Intervention
o Epinephrine injection
o Hemoclips
o Thermal coagulation - Surgery
PUD
- Consider PPI – Non H.Pylori and Non-NSAID ulcer
- Advise discontinue of tobacco, minimize alcohol, avoid spicy foods
Gastritis
- H. Pylori – Triple therapy (PPI +Amoxicillin + Clarithromycin)
- D/c offending agent
- Antacids (Alka-Seltzer, Maalox, Mylanta, Rolaids)
- H2RA: cimetidine (Tagamet), famotidine (Pepcid), e.g
- PPI: omeprazole (Prilosec), lansoprazole (Prevacid), pantaprazole (Protonix
GERD
Lifestyle modifications o Lose weight o Avoid exacerbating foods o Avoid large meals o Eat 3 hours before lying down o Elevate head of the bed Meds o Antacids- symptomatic o H2RA- mild o PPI- severe Surgery- Nissen Fundoplication
Isolated Eosinophillia esophagitis
Elimination and elemental diets
PPI
Topical Glucocorticoid- Fluticasone 440-880mcg BID
Esophageal dilatation to tx strictures
Candida esophagitis
fluconazole
pill induced Esophagitis
stop agent
take pill with 8oz water
stay upright for over 30 min after taking pill
eat in 30 min of pill
take antacids, sulcrafate, lidocaine, PPI
Esophageal bleed due to varicies
- 2 large bore IV access/Central access
- pRBC txn (target 25-30)
- Octreotide 50mcg/hr
- Desmopression 1-2 mg q 4 hours
- Endoscopy *- Varix ligation (banding)
- Band ligation*
Last resort
TIPS (transjugular intrahepatic portosystemic shunt)
Angiotherapy
Balloon tube tamponade
Boerhaave syndrome
IVF resuscitation
Broad Spectrum Antibiotics
Prompt Surgical Intervention (mainstay tx)- Left thoracotomy
Mallory weiss tear
Stable patient- healing in 24-48hrs without intervention • IVF PRN • Anti-emetics • Sulcrafate for 1-2wks • PPI for 1-2wks • D/c home
Unstable Patient • H/H q6 o pRBC for hemodynamic support PRN o HCT <30 w/ CAD and symptoms • Correct coagulopathy (warfarin) o Vitamin K/FFP/PCC • EGD • Admit
Zenker Diverticulum
myotomy
Esophageal stricture
Lifestyle Modifications o Weight loss o Avoid exacerbate food and medications o Small meals & eat slowly and deliberately Rx o PPI o Intralesion steroid injection- If PPI and/or dilation fails; Only benign lesion EGD w/ Esophageal dilation*
Dysmotility Disorder
Lifestyle - eat slow, not at bed time CCB/Nitrates Botulism injection into LES Pneumatic dilation Heller Myotomy
Esophageal carcinoma
Surgery- Esophagectomy
- for N2 and greater
Chemo and XRT for everyone else
-5-FU, Cisplatin, Paclitaxel, Anthracyclines
Gastric cancer
Surgery- mainstay tx
- Total gastrectomy
- Esophagogastrectomy- Tumor @ GEJ and Cardia
- Subtotal gastrectomy- Tumors of distal stomach
Adjuvant chemoradiotherapy
o Post-operatively = std of care in US
o 5-FU and Leucovorin
