Gastro Flashcards by George Ratcliffe

What is the management plan for acute cholangitis?

1st Line - ABC intensive care approach + IV Abx
- cefuroxime + metronidazole
- Plus biliary decompression non-surgical e.g. ERCP
2nd Line - Biliary decompression surgical + IV Abx
- Choledochotomy

Consider resusitation for some - SEPSIS 6

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What is the management plan for Alcohol withdrawal?

All patients

1st Line - Benzodiazepines (chlordiazepoxide) - reduces symptoms.
- consider Barbiturates if servere/ delirium tremens
Plus pabrinex - prevents progression to Wernicke-Korsakoff
Consider propofol if admitted to ATU and very severe
If pyschotic symptoms e.g. delirium tremens add antipyschotic - haloperidol

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What is the management plan for Alcoholic Hepatitis?

Alcohol abstinence + withdrawal management
- lifestyle management e.g. smoking, weight
Nutrition + vitamin supplementation
- Pabrinex + monitor and correct K+, Mg2+ and glucose
Consider corticosteroids - reduce hepatic encephalopathy
Consider furosemide/spironolactone - ascites
Consider pentoxifylline to reduce risk of hepatorenal syndrome - BMJ
- Priya - Glypressin + N-acetylcystein

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What is the management plan for Anal Fissure?

Acute

1st Line - conservative - Increase fibre + fluid, laxatives
- consider GTN ointment for symptom relief if persistent
- Diltiazem if GTN headaches intolerable

Resistant fissures >8 weeks

1st Line - botulinum toxin injection (no incontinence)
- or surgical sphincterectomy, both have pros
2nd Line - anal advancement flap

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What is the management plan for Appendicitis?

Uncomplicated appendicitis:
- Laparoscopy followed by appendicectomy
- Abx for 24 hours post surgery - cefuroxime/metronidazole
If perforation of appendix
- IV Abx + appendicectomy
If abscess
- 1st Line - IV Abx + CT guided drainage of abscess
- 2nd Line - Appendicectomy if symptomatic 6 weeks later

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What is the management plan for Barrett’s Oesophagus?

Non-dysplastic = PPI (Omeprazole) + surveillance (every 2 yrs)
Low-grade dysplasia
- non-nodular = radiofrequency ablation
- nodular = endoscopic mucosal resection
High-grade dysplasia
- 1st Line = Radiofrequency ablation +/- EMR + Omeprazole
- 2nd Line = Oesophagectomy

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What is the management plan for Cholecystitis?

In mild biliary colic - follow a low fat diet
Any symptomatic gallstones are removed
- Initially remove CBD stones via ERCP
- Then perform elective lap chole once LFT’s stablised
If LFT skewed/inflammation in severe or moderate cases
- perform cholestectostomy if high risk of complications followed by elective cholecystectomy
If indicated in acute setting ideally cholecystectomy is performed <72 hours
Conservative and Medical management
- Supportive -Admission, NBM, IV fluid, Abx + analgesia
  - If infective cause - IV Abx

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What is the management plan for Inguinal Hernias?

Acute - incarcerated or strangulated bowel - Surgery
- If bowel viable - laparoscopic mesh repair
- If bowel gangrenous - bowel resection indicated
- Consider prophylactic Abx
Ongoing
- small asymptomatic - monitor and safety net
- Large asymptomatic
  - if implicated - lap mesh repair + prophylactic Abx

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What is the managament plan for Coeliac disease?

Conservative - strict, life-long gluten free diet + education
Medical - Vit supplementation (Vit D) + nutrients where necessary
- 2nd Line - if unresponsive to diet restriction
  - refer to specialist and treat with prednisolone

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What is the management plan for Crohn’s?

Acute
- 1st Line - Corticosteroids used to induce remission
  - consider ASA-5 (less effective but less SE
- If > 2 events in 12 months add Azathioprine/ mercaptopurine
- If severe, acute events use infliximab
Chronic
- Azathioprine/mercaptopurine to maintain remission
  - Avoid steroids for long-term therapy
- Infliximab is reccomended in refractory Crohn’s or fistulating Crohn’s
Surgery - performed if medication fails, less effective than UC

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What is the management plan for Diverticular Disease?

Asymptomatic - high fibre and fluid diet
Symptomatic Diverticular disease
- Diet modification + oral Abx (cefuroxime and metronidazole)
Uncomplicated Diverticulitis
- 1st Line - Simple analgesia + oral Abx + low-residue diet
- 2nd Line - IV Abx
Symptomatic Diverticulitis
- IV Abx + IV fluid + simple analgesia
- If abscess 1st Line - drainage
- If PR bleed - endoscopic haemostasis/ angiographic embolisation
Surgery - consider in recurrent events or severe complications

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What is the management plan for IBS?

If Constipation predominant:

1st Line - Lifestyle + dietary changes
- - laxatives > lubiprostone if unsucessful
If pain/ bloating - same + antispasmodics (dicycloverine)
- 2nd Line - + CBT/ Hypnotherapy

If Diarrhoeal predominant:

1st Line - Lifestyle + dietary changes
- - antidiarrhoeals
If pain/bloating - same + antispasmodics
- 2nd Line - + TCA/SSRI +/- CBT or Hypnotherapy

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What is the management plan for GORD?

Acute - Standard-dose PPI + Lifestyle changes
- Decrease weight + smoking + fatty meals
- Elevate head when sleeping
Ongoing - 1st Line - continued dose PPI
- 2nd Line - High dose PPI + OGD - referrel
  - if nocturnal consider ranitidine
- 3rd Line - surgery
  - Antireflux surgery - Nissen fundoplication

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What is the management plan for Gastroenteritis?

In all patients

Fluid and electrolyte rehydration + bed rest
- Consider Bismuth to reduce diarrhoea
2nd Line - severe vomiting or diarrhoea consider IV fluid rehydration therapy

If suspected enterotoxigenic

Abx to non-self limiting causes if it will reduce recovery time
If EHEC notify health authorities
Treat botulinum toxin with botulinum antitoxin in ITU
C diff. - Isolate + oral metronidazole (14 days) -> Vancomycin

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What is the management plan for GI perforation?

RESUS - medical emergency
- IV Fluid + electrolytes + IV Abx (cefuroxime + metronidazole)
Surgery - perform peritoneal or pleural lavage
- Large bowel - resection of perforated section using Hartmann’s
- Gastroduodenal - perforation closed via omentum patch
  - Gastric ulcers are biopsied for malignancy
- Oesophageal - Repair of ruptured oesophagus

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What is the management plan for Haemorrhoids?

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All patients - diet + lifestyle modification - Increase fibre + fluid
Grade 1 - consider topical corticosteroids - mild bleeding
Grade 2 - Rubber band ligation/ sclerotherapy or infrared photocoagulation
Grade 3 - Rubber band ligation
Grade 4 or persistent Grade 3 - Surgical Haemorrhoidectomy
- Milligan Morgan or Stapled (better surgical prognosis)

What is the management plan for Cirrhosis?

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1st Line - treat cause and manage complications
- Portal Hypertension - consider Transjugular intrahepatic portosystemic shunt
  - Will increase risk of encephalopathy
- SBP - Abx cefuroxime + metronidazole
- Ascites - Oral spironolactone +/- furosemide
  - Sodium restriction in diet
- Encephalopathy - treat infection if indicated
  - Use lactulose or phosphate enemas
- Support nutrition + NG tube if indicated
- Avoid alcohol, sedation, opiates, NSAIDs + Hepatotoxics
2nd Line - Liver transplant if imminent death of serious liver decomponsation

If due to paracetomol OD - N-acetylcysteine

What is the management plan for Femoral Hernias?

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Surgical is the main management
- Herniotomy - Ligation + excision of sac
- Herniorrhaphy - Repair of femoral defect

What is the management plan for Hiatus Hernia?

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Acute - Symptomatic GORD
- 1st Line - PPI + Lifestyle managememt
  - lose weight, elevate head, avoid large meals + alcohol
Ongoing - maintain PPI
- Surgery performed if - severe complications, unresponsive to HD PPI or prophylactally Rolling Hernia
- Nissen Fundoplication - 360 oesophageal stomach wrap
- Belsey Mark IV - 270 degree wrap

What is the management plan for Intestinal Obstruction?

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General - drip + suck management
- NBM + NG tube w/ gastric aspiration
- IV Fluid + electrolyte replacement
- Analgesia
- Urinary catheter - monitor fluid balance + vitals
Ileus and incomplete SBO should be managed conservatively
Strangulation + LBO require surgery
Acute complete blockage + strangulation - emergency laparotomy

What is the management plan for a Mallory-Weiss Tear?

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80-90% resolve on their own
1st Line - Urgent evaluation + monitoring
- Endoscopy with prophylactic PPI
- Consider anti-emetics
2nd Line - if bleeding doesnt resolve
- Injection sclerotherapy
- Thermocoagulation therapy
3rd Line - in event of severe bleeding event
- Laparoscopic surgery
- Sengsteken-Blakemore tube if Boerhaave’s

What is the management plan for NASH?

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Mainly conservative to control RF
1st Line - increase diet + exercise
- Decrease alcohol consumption as it can excacerbate
- Consider Vit E
- If BMI >40kg/m2 consider bariatric surgery
Manage dyslipidaemia and diabetes medically

What is the management plan for Acute Pancreatitis?

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Assess severity using SIRS>APACHE II

1st Line - Fluid Resus immediately + analgesia (pain ladder)
- consider antiemetic, O2, Ca2+ or Mg2+ therapy
- NG tube - aim to resume regular diet <24hrs
If gallstone cause with BDO or cholangitis - ERCP <72 hours
If gallstone cause without cholangitis - cholecystectomy
- consider prophylactic Abx

If no change seen >5 days perform Contrast Enhanced CT then FNA to check for necrosis/infection

If pancreatic necrosis refer - necresectomy may be necessary

What is the management plan for Chronic Pancreatitis?

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Treat acute episodic pain w/ analgesia (pain ladder)
- In chronic pain - refer to pain specialist
1st Line - alcohol/smoking cessation + lifestyle modification
- Consider analgesia, Creon + PPI
2nd Line - in event of complications
- Pseudocyst - ERCP drainage
- Biliary compression - Stenting + dilation of strictures
- Calcification - Extracorporeal Shock Wave Lithotripsy (ESWL)
Consider resection or prancreatectomy if indicated

What is the management plan for Peptic ulcer disease?

All patients - drug review, stop NSAIDs, aspirin, bisphosphonates * Active bleeding ulcer * 1st Line - endoscopy +/- blood transfusion if severe loss * + IV bolus omeprazole * 2nd Line - surgery or embolisation via laser coagulation/electrocoagulation * H.Pylori - no bleeding * 1st Line - triple (omeprazole + clarithryomicin + amoxicillin * consider alternate regimen if fails * Not H.Pylori associated - no bleeding * 1st line = omeprazole \> ranitidine If recurrent - oral PPI daily or misoprostol if NSAID related

What is the management plan for Perineal Abscesses and Fistulae?

Requires surgical treatment * Abscess - open drainage immediately * Fistulae - Probe inserted to explore + dye into external opening to identify internal opening * Low Fistula - Fistulotomy * High Fistula - Seton performed - suture that allows drainage * Avoid fistulotomy due to incontinence complication

What is the management plan for Peritonitis?

* Localised - depends on the cause: * Appendicitis - surgery * Salpingitis - Abx * Generalised - medical emergency risk of sepsis or death * Resus - IV fluids + IV abx * Catheter, NG tube and central line * Primary - should resolve with Abx * Secondary - laparotomy may be indicated * Spontaneous Bacterial Peritonitis * 1st Line - ciprafloxacin + vancomycin * Or cefuroxime + metronidazole

What is the management plan for Pilonidal sinus?

* Asymptomatic - hair removal + local hygeine * Symptomatic - without abscess * 1st Line - Karydakis surgery under LA * Consider co-amoxiclav before surgery + 5 day course * Symptomatic - without abscess * 1st Line - Surgery and drainage of abscess under LA * Consider co-amoxiclav before surgery + 5 day course + paracetomol * If recurrent - consider more complex exploration surgery under GA

What is the management plan for Ulcerative Colitis?

Acute exacerbations * IV rehydration + prophylactic Abx/DVT * Bowel rest and parenteral nutrition if indicated * 1st Line - topical 5-ASA for 4 weeks * 2nd Line - Oral 5-ASA + 4-8 week corticosteroids * 3rd Line - infliximab - good at inducing remission if severe * If toxic megacolon - consider emergency colectomy Maintaining remission - no steroids * Moderate - Oral or rectal 5-ASA * Severe or 2nd Line moderate - oral Azathioprine/Mercaptopurine * consider Infliximab if unresponsive * Surgery - elective colectomy if unresponsive or frequently relapsing

What is the management plan for Viral Hepatitis A?

* Initially - unvaccinated OR following recent exposure * IM human globullin - recommended for \>40 yrs, shorter effectiveness * Active attenuated HAV - for \<40 yrs, longer effectiveness * Prophylaxis HAV - shown to have some efficacy * Management * 1st Line - Supportive care e.g. bed rest * Symptomatics - antipyretic, anti-emetics * 2nd Line - 1% get Fulminant course of virus * Potentially require liver transplant

What is the management plan for Vitamin Deficiencies?

* Vitamin A * Diet education - chicken, eggs and leafy greens * Vitamin A supplements if indicated * Vitamin B * Pabrinex (Thiamine) - oral initially then IV * Done to present transition to Wernicke-Korsakoff * Ensure thiamine given before glucose in hypoglycaemia * Vitamin C * Diet education - citrus fruits * Absorbic acid \>250mg/24hr orally * Vitamin D * Ergocalciferol + calcium carbonate * Ensure adequate sun/ UV-B exposure * If malabsorbtion - calcitriol e.g. CKD * Vitamin E - supplementation * Vitamin K - supplementation

What is the management plan for Viral Hepatitis B?

* Prevention: blood screening, safe sex, instrument sterilisation * Immunisation - * Passive - IM human immunoglobulin - at risk individuals + neonates w/ mother HbeAg+ * Active - same as above - protects against HDV too * Acute - 1st Line - Support care + antipyretics, anti-emetics * Notifiable disease to report to health authorities * Add antiviral in children or severe cases * 2nd Line - very severe needs assessment for liver transplant * Chronic HBV infection * 1st Line - antiviral therapy - e.g. tenofovir * if HDV co infection - peginterfeon alpha * 2nd Line - decomponsating cirrhosis - liver transplant

What is the management plan for Viral Hepatitis C?

* Prevention: blood screening, safe sex, instrument sterilisation * No vaccination available for Hep C * Acute - monitor for 12 weeks to allow for spontaneous clearance * Support care +antipyretics/ antiemetics + cholecystyramine * Chronic - use antivirals - mainly protease inhibitor +/- ribavirin * Treatment duration 8-16 weeks depending on Genotype and presenting complications * If cirrhosis is present regular liver USS is indicated * Ongoing - referal to specialist to assess liver transplant

What is the management plan for Portal Hypertension?

* Immediate = IV terlipressin + prophylactic Abx * Injection sclerotherapy or band ligation - endoscopy * 2nd Line = Sengstaken–Blakemore tube * TIPPS to prevent further rebleed * Prophylactic BB

Gastro Flashcards

(34 cards)