Gastro - mx use this Flashcards

Question

Cholecystitis management

Answer 1

- NBM - IVF - NSAID Analgesia (diclofenac, indometacin) - Abx IV (ampicillin/ceftriaxone/ertapenem) - Antiemetics - Early laparoscopic cholecystectomy if surgically high risk patient - Pre-cutaneous transhepatic gallbladder drainage

Answer 2

- IV abx - piperacillin/tazobactam or imipenem/cilastatin - IVF - Opioid analgesia (morphine sulphate) - Biliary decompression ERCP (+/- sphincterotomy +/- placement of stent +/- stone extraction) - FIRST LINE Pre-cutaneous trans-hepatic cholangiography - SECOND LINE

Answer 3

- IVF - Blood transfusion if Hb <80g/L Hb <100 g/L + comobidities - Platelet transfusion if Plt <50 - FFP transfusion If prolonged PT/INR - OGD Adrenaline + thermocoagulationb/band ligation Haemoclip +/- adrenaline If bleeding can't be stopped using endoscopic treatments - Angiography with VP injection or embolization

Answer 4

- IVF - IV steroids - NG decompression - Abx (broad spectrum - piperacillin/tazobactam) (If C.difficile suspected/confirmed - vancomycin) - IV ciclopsorin - Total Colectomy with end-ileostomy (if no imporvement with medical treatment after 72h)

Answer 5

- IVF - IV steroids - Abx - Bowel rest - TPN might be required - DVT prophylaxis

Answer 6

``` Mild UC <4 stools per day no more than small amount of blood in stools no anaemia pulse rate <90 no fever N ESR/CRP (<30) ``` oral/rectal 5-ASA derivatives (melsalazine, olsalazine, sulfalazine) +/- rectal steroids (predinisilone, methylpredinisilone) 500 SBAs mentions that you also give oral steroids (gastro Q36)

Answer 7

``` Moderate UC 4-6 stools per day more blood than for mild no anaemia pulse rate <90 no fever N ESR/CRP (<30) ``` oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine) + oral steroids (predinisilone, methylpredinisilone) + immunosuppresants (azathioprine, mercaptupurine, cyclosporin, infliximab) 500 SBAs didnt mention immunosuppresants but mentioned topical steroids (gastro Q36)

Answer 8

``` Severe UC >6 stools per day Visible blood in stools + 1 or more systemic upsets: anaemia pulse rate >90 fever >37.8 ESR >30 ``` oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine) + oral steroids (predinisilone, methylpredinisilone) + immunosuppresants (azathioprine, mercaptupurine, cyclosporin, infliximab) methotrexate if unable to tolerate azathioprine or mercaptopurine ciclosporin -p w severe refractory colitis, rapid onset of action, reduces colectomy rate by 50% 500 SBAs mentions that severe UC is treated w admission for IVF + IV steroids (gastro Q36)

Answer 9

Past: protocolectomy with ileostomy Now: IPAA - ileal-pouch anal anastomosis

Answer 10

- IVF - IV steroids - 5-ASA (mesalazine, sulfalazine, olsalazine) - Analgesia - TPN might be necessary - Monitor markers of disease activity

Answer 11

IV/oral corticosteroids 2nd line Mesalazine (5-ASA), azathioprine/mercaptopurine, infliximab Budesonide less effective than conventional steroids but fewer SE In 1000 SBA's+EMQ they say that to induce remission in Crohn's flare up you use steroids

Answer 12

1st line Budesonide +/or 5-ASA (melsalazine, olsalazine) or oral corticosteroids (prednisolone, 2nd line) 2nd line Immunomodulator therapy (azathioprine, mercaptopurine) + oral corticosteroids Methotrexate second line if unable to tolerate azathioprine or mercaptopurine 3rd line Biological therapies anti-TNFa (infliximab, adalimumab) - used in refractory Crohn's +/- azathioprine +/- oral corticosteroids

Answer 13

1st line - Treatment of underlying liver disease Hep C - oral antivirals [elbasvir + grazoprevir] - Prevention of superimposed hepatic insult No alcohol, hepatotoxic drugs Immunisation against hep A, B, influenza, pneumococci Management of metabolic RF - prevention of osteoporosis - Maintenance of adequate nutrition -Regular exercise to prevent muscle wasting - Monitoring for complications - Na restriction + diuretic therapy for ascites Spironolactone Frusemide - if they dont respond to spirnolocatone 2nd line- Liver transplantation

Answer 14

Treatment of underlying cause Medical treatment – sodium restriction + diuretic therapy • Restricted salt intake <90mmol/day (<5.2 g salt/day) • Spironolactone - increase Na excretion + increase K absorption (with potassium sparring diuretics, sodium reabsorption and potassium excretion are prevented) o Needs monitoring bc of risk of hyperkalaemia • Loop diuretics (e.g. frusemide) – if pt don’t respond to spironolactone o Higher doses cause severe electrolyte disturbance, particularly hyponatraemia Therapeutic paracentesis • Large/refractory ascites • Large-volume paracenteses should be followed by volume expansion using human albumin solution Surgical • TIPS (transjugular intrahepatic portosystemic shunt) – refractory ascites needing frequent paracentesis

Answer 15

corticosteroids - to induce remission in acute UC aminosalicyltes - 5-ASA to induce and maintain remission (1ST LINE) (mild to moderate) Mesalazine - to maintain remission thiopurines (azathioprine, 6-mercaptopurine) - if intolerant to coricosteroids Ciclosporin - severe refractory colitis, rapid onset of action TNFa antibodies (infliximab, adalimumab, golimumab) - severely active UC in adults whose disease has responded inadequately to conventional therapy (moderate to severe UC)

Answer 16

o ICU – mandatory once hepatic encephalopathy is present o Intubation once advanced encephalopathy develops o Neurological status monitoring for advanced encephalopathy – associated with a greater risk of cerebral oedema + intracranial HTN o Monitoring of blood glucose, electrolytes, cultures (high risk of bacterial + fungal infection) o Liver transplantation assessment (all pt should be considered for liver transplantation )

Answer 17

* Acute hepatitis B – entecavir or tenofovir disoproxil (oral nucleoside or nucleotide analogue) * Autoimmune hepatitis - methylprednisolone * Herpes Simplex hepatitis – acyclovir * Budd- Chiari syndrome – anticoagulation (LMWH), TIPS * Wilson’s disease – measures to decrease serum copper (plasmapheresis, continuous veno-venous hemofiltration, album dialysis, plasma exchange, chelation therapy for Wilson’s in the setting of AFP is generally ineffective + may be associated with hypersensitivity)

Answer 18

* To decrease ammonia production – Lactulose (w neomycin) * ICP – Mannitol * Cerebral oedema – therapeutic hypothermia (when medical treatments are not successful) * AKI – haemodialysis, hemofiltration * Treat + prevent abnormal clotting – FFP, platelet concentrates, antifibrinolytic drugs, prothrombin complex concentrates, recombinant activated factor 7 * Paracetamol overdose – acetylcysteine therapy should be administered in all suspected cases, regardless of the dose/timing of paracetamol ingestion * Monitor glucose – IV glucose may be required * Liver transplantation – all patients should be considered

Answer 19

* IVF + correct electrolyte imbalances * NG decompression * Analgesia – morphine sulfate * Anti-emetic – ondansetron (metoclopramide is contraindicated in patients with bowel obstruction as it’s a pro-kinetic) * Correction of underlying cause

Answer 20

* IVF + correct electrolyte imbalances * Emergency laparotomy * Abx – ampicillin + gentamicin or cefoxitin * NG decompression * Analgesia * Correction of underlying cause

Answer 21

• Supportive measures o NBM o O2 o IVF + correct electrolyte imbalances o NG decompression o Abx pre-operatively (broad spectrum: amoxicillin, metronidazole, gentamycin) +/- o Blood transfusion to correct anaemia +/- coagulopathy • Emergency surgery – if suspected/impending perforation, peritonitis, irreducible hernia

Answer 22

* Supportive treatment (no specific anti-viral available) * Post-exposure (<2 weeks) prophylaxis in unvaccinated people - Active/passive immunisation * With worsening jaundice and encephalopathy - liver transplant

Answer 23

* Supportive care – most will achieve seroconversion with appearance of ab to HBsAg in the absence of treatment * Chronic hepatitis B – 1) peginterfeon alpha 2a, 2) tenofovir disoproxil or entecavir * Anti-viral therapy (entecavir, tenofovir disoproxil) – not indicated for acute hepatitis B except in cases of fulminant hepatitis * Liver transplant

Answer 24

* Acute - supportive care * Chronic - Oral direct-acting antiviral therapies – elbasvir (NS5A inhibitors) + grazoprevir (NS3/4 protease inhibitors) ,

Answer 25

* Supportive care * Pegylated interferon alfa * Liver transplantation

Answer 26

Supportive care

Answer 27

- Corticosteroids - if treatment <6m Prednisolone Budesonide if intolerant to prednisolone - Corticosteroids + immunosuppressants - if treatment >6m (immunosuppresants have steroid sparring effects), if pt at high risk of corticosteroid-related SE (post-menopausal women, pt w osteoporosis, DM, glaucoma, cataracts, arterial HTN, major depression, emotional lability) Prednisolone/Budesonide + Azathioprine/mercaptopurine * - Liver transplantion Pt with advanced liver disease who are refractory/intolerant to corticosteroid therapy *methotraxare is 2nd line if unable to tolerate azathioprine/mercaptopurine

Answer 28

Stable patient - CT aortogram Unstable patient - Surgery to rule out ruptured AAA

Answer 29

- IVF - Oxygen - Analgesia - NBM - Abx - NG tube (so that the gastric contents can come up the NG tube rather than then perforated ulcer) - Monitor urine output (may require urinary output) Surgical emergency

Answer 30

- IVF - Analgesia (morphine sulfate, fentanyl) - Oxygen - Anti-emetics (ondansentron) - DVT prophylaxis - Nutritional support (low fat diet, might need an NJ tube) - Tight glucose control (might need to give insulin) - ERCP if severe

Answer 31

No definitive therapy Acute episodic pain - analgesics (paracetamol/ibuprofen + tramadol) Chronic symptoms Lifestyle modifications - decrease smoking + alcohol Dietary modifications (e.g. low fat diet) + enteral feeding Analgesia - Octreotide - SS analogue, may relieve pain Pancreatic enzymes (pancreatin) + PPI (omeprazole) - Acid inhibition increases enzyme activity by decreasing luminal inactivation Glucose control - insulin Pancreatic calcification- curative resection + adjuvant chemo-radiation

Answer 32

Pancreatic endocrine insufficiency (DM) - insulin But be careful - chronic pancreatitis patients are at risk of hypoglycaemia due to impaired hepatic gluconeogenesis and hypoglycaemia Pancreatic exocrine insufficiency (enzymes e.g. lipase, amylase, protease) - pancreatic enzyme supplementation (e.g. pancreatin)

Answer 33

Amyalse Protease Lipase

Answer 34

- IVF - Analgesia - Broad spectrum abx - NG tube - Blood transfusion - Surgery Exploratory laparotomy Correct cause of peritonitis

Answer 35

- Terlipressn ADH agonist, causes splanchnic vasoconstriction and decreases mesenteric blood flow and portal pressure - Prophylactic antibiotics Increased risk of translocation of bacteria from gut into the systemic circulation

Answer 36

``` • Alcohol abstinence + alcohol withdrawal management o Benzodiazepines (oxazepam, diazepam, lorazepam) Long acting (diazepam) – provide greater protection against seizures + delirium Short acting (oxazepam, lorazepam) – safer in older adults + those with hepatic dysfunction ``` • Weight reduction + smoking cessation o Careful with orlistat – might lead to acute liver failure, cholelithiasis, cholestatic hepatitis • Nutritional supplementation + multivitamins o Protein restriction only considered if pt is encephalopathic o Vitamins (B group, thiamine) - should be started parenterally + continued orally o At risk of developing “re-feeding syndrome” --> Monitor for hypokalaemia, hypophosphatemia, hypomagnesaemia • Immunisationon o Influenza + pneumococcal vaccine recommended in patients with chronic ALD o Hep A + Hep B vaccination if Anti-HBs (Hep B surface antibody) + HAIgG are negative • Corticosteroids o Prednisolone o If patients have hepatic encephalopathy • Sodium restriction +/- diuretics o Frusemide + spironolactone o Treatment for ascites • Liver transplant o Second line o For patients with end-stage ALD

Answer 37

With no end-stage liver disease • Lifestyle modification – first line therapy o Weight loss through diet + exercise o Diet should have a high protein: calorie ratio o Exercise with diet increases muscle mass + insulin sensitivity o Abstinence from alcohol + hepatotoxic drugs • Vitamin E (alpha tocopherol) o Vitamin E significantly improves liver function + histological changes in patients with NASH • Gastric bypass with Roux-en-Y o Patients with a BMI >40 kg/m² or o Patients with a BMI >35 kg/m² and at least one or more obesity-related comorbidity With diabetes • Insulin sensitiser o Metformin – does not improve histological scores or fibrosis but leads to weight reduction, reduced HbA1c, reduced plasma glucose With dyslipidaemia • Statins With end-stage liver disease secondary to NASH • Liver transplantation • TIPS

Answer 38

Metronidazole | Can also use vancomycin (2nd line if allergic to metronidazole, if C difficile is resistant to metronidazole)

Answer 39

- low dose oral ASA (e.g. melsalazine) | - oral azathioprine/mercaptopurine if severe

Answer 40

The critical view of safety (CVS) technique is a means of target identification, the targets being the cystic duct and artery This is important to avoid injury to the hepatic artery, hepatic duct or CBD

Answer 41

• Chronic asymptomatic diverticulosis Soluble high fibre diet (20-30g/day) Anti-inflammatories (e.g. Melsalazine) • Acute symptomatic diverticular disease IVF Bowel rest Analgesia (paacetamol, tramadol, morphine sulfate) Dietary modification + fibre supplementation Abx if evidence of infection+/or suspicion of bacterial overgrowth • Surgery Primary anastomosis - One stage resection of affected bowel + anastomosis - Proximal loop ileostomy (diverts contents before they pass via primary anastomosis - protects the primary anastomosis) Hartmann's procedure - if presentation is ACUTE because the bowel needs to rest + inflammation needs to go down before primary anastomosis - Proctosigmoidectomy + Formation of an end colostomy with anorectal stump - Used when primary anastomosis is not possible due to e.g. inflammation o Endoscopic haemostasis/angiographic embolization - In cases of acute rectal bleeding o Oral Abx – bc diverticulitis might be caused by infection, in some patients

Answer 42

• Treatment options o Watchful waiting o Open mesh repair – unilateral primary hernia o Laparoscopic repair – recurrence after open-mesh, bilateral hernias, abx prophyaxis not recommended o Truss Femoral hernias o Elective repair ASAP (high risk of stangulation) o No truss o Reinforce abdominal wall with stitches or use of mesh Inguinal hernias - Reassurance • Direct inguinal hernias o Have a wider neck - less risk of strangulation - can adopt a conservative approach o If patient is obese ask them to lose weight o Ask patient to wear a truss – prevents bowel obstruction !!you should never put a truss over an irreducible hernia!! - Elective surgery • Lichtenstein’s technique o Most commonly performed open mesh repair o Piece of open-weave polypropylene mesh is used to repair + reinforce the abdominal wall • Bilateral hernias o Best repaired laparoscopically (TAPP (transabdominal periperitoneal), TEP (totally extraperitoninal)) • Incarcerated or strangulated hernia o Surgical repair o Prophylactic Abx therapy o In the absence of necrosis or contamination – bowel can be reduced + hernia repaired with a mesh o If gangrenous bowel or contamination – bowel resection required + non-mesh primary tissue repair of hernia (mesh repair avoided as there is risk of mesh infection)

Answer 43

``` Medical mx • IVF + correct electrolyte imbalances • NG decompression • Analgesia – morphine sulfate • Anti-emetic – ondansetron (metoclopramide is contraindicated in patients with bowel obstruction as it’s a pro-kinetic) • NBM • O2 • Correction of underlying cause ``` Surgical - esp if peritonitic • Emergency laparotomy • Abx – ampicillin + gentamicin or cefoxitin * Adhesions – conservative treatment, endoscopy * Sigmoid volvulus – flexible/rigid sigmoidoscopy (1st line), surgery (2nd line) * Caecal volvulus, colorectal malignancy, diverticular disease - surgery * Monitor urine output – oliguria is an important sign of early dehydration

Answer 44

* Thiamine * Vitamin C and other multivitamins (can be given as Pabrinex) • Encephalopathy - oral lactulose or phosphate enemas • Ascites Diuretics (spironolactone with/without furosemide) Therapeutic paracentesis • Hepatorenal syndrome Glypressin and N-acetylcysteine * Monitor and correct K+, Mg2+ and glucose * Ensure adequate urine output

Answer 45

Acute symptomatic GORD • PPIs • Lifestyle modifications – lose weight, elevate the head of the bed, avoid large meals, alcohol, acidic foods Ongoing • Surgical repair +/- anti-reflux procedure o Laparoscopic fundoplication = mobilisation of the distal oesophagus, reduction of the associated hiatus hernia after complete (Nissen’s) or partial (modified) wrapping of the fundus of the stomach around the oesophagus (fundoplication)

Answer 46

* No systemic signs - Bed rest, IVF + electrolyte replacement – no stool culture needed * Systemic signs [>39 or dehydration, visible blood or >2 weeks] – admit + give oral fluids (IV rehydration if severe vomiting) * Abx if severe/if the infective organism has been identified (E.g. ciprofloxacin against – Salmonella, Shigella, Campylobacter) – direct faecal smear then culture ``` invasive diarrhoea (causing bloody diarrhoea and fever) - ciprofloxacin Clarithromycin - traveller's diarrhoea and non-invasive diarrhoeal illnesses when treatment is necessary ```

Answer 47

- Place on a low protein diet | - Lactulose enemas to decrease transit time and decrease GI absorption

Answer 48

- Combination of endoscopic variceal ligation (Band ligation)* + terlipressin** is first line - ABCDE approach - Fluids, regular monitoring - Reduce portal HTN: Terlipressin - OGD * Alternatives include sclerotherapy + balloon therapy * *Alternatives to terlipressin include vasopressin octreotide prophylaxis for the prevention of varicieal bleeidng - propanolol, endoscopic band ligation, TIPPS

Answer 49

Induction - Melsalazine (5-ASA) - IV steroids if severe Maintenance Mild --> oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine) + rectal steroids (predinisilone, methylpredinisilone) Moderate/severe --> oral 5-ASA derivatives (melsalazine, olsalazine, sulfalazine) + oral steroids (predinisilone, methylpredinisilone) + immunosuppresants (azathioprine, mercaptupurine, cyclosporin, infliximab)

Answer 50

Induction of remission - IV steroids Maintenance of remission - Azathioprine, mercaptopurine + oral corticosteroids - Methotrexate second line if unable to tolerate azathioprine or mercaptopurine Biological therapies anti-TNFa (infliximab, adalimumab) - used in refractory Crohn's +/- azathioprine +/- oral corticosteroids

Answer 51

• Conservative – increase fibre to prevent constipation, probiotic, special diet, low caffeine/alcohol/fizzy drinks • Medical o Anti-spasmodics – mebeverin (anti-ach), buscopan o Prokinetic agents – domperidone, metoclopramide o Antidiarrheals – loperamide o Laxatives – lactulose o Low dose TCAs – may decrease visceral awareness – amitriptyline

Answer 52

• Strict, lifelong gluten-free diet • Calcium + vitamin D supplementation +/- iron (ergocalciferol + calcium carbonate +/- ferrous sulfate) o All pt with coeliac disease should take calcium + vitamin D supplements o Iron should only be given to individuals with iron deficiency • Pneumococcal vaccine every 5 years due to hyposplenism

Answer 53

Coeliac crisis – hypovolaemia, severe watery diarrhoea, acidosis, hypocalcaemia, hypoalbuminaemia • Rehydration + correction of electrolyte abnormalities • Corticosteroid (budesonide or prednisolone)

Answer 54

* IVF * Abx * Prompt surgical repair (within 12h)

Answer 55

H2 receptor antagonists suffer from tachyphylaxis - their utility diminishes with time therefore they are often stopped after 2 weeks

Answer 56

Normal diameter of aorta - 2cm <4 cm - annual US 4-5.5cm - US every 3 months >5.5cm - elective intervention 3-4.5 cm – every year 4.5-5.4cm – every 3 months ``` Early intervention rapidly expanding (>1cm/year) tender symptomatic suspected rupture ```

Answer 57

Pulmonary fibrosis – need a baseline CXR Hepatic fibrosis – LFTs monitored weekly, followed by fortnightly, then every 4-6 weeks Neutropenia + myelosuppression – FBC Folate antagonist – contraindicated in pregnancy

Answer 58

Surgical emergency – drip + suck (IVF + NG to decompress) Conservative mx for 48h (in 75% of the cases, adhesions resolve spontaneously) If pt don’t improve/have signs of peritonism/have a palpable mass/have a virgin abdomen - surgery From RevMed

Answer 59

Left colectomy - cancer localised to the descending colon Anterior resection - high lying rectal tumours Abdominoperineal resection - low lying rectal tumours Delorme's procedure - full thickness rectal prolapse Hartmann's procedure - acute perforated diverticulitis Primary anastomosis - sigmoid tumours, when inflammation goes down after Hartmann's procedure as a result of perforated diverticulitis from RevMed 5, 16 p. 129

Answer 60

Left colectomy Removal of 2/3 of the way along the transverse colon up to the start of the sigmoid colon https://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/08/26/10/38/my00141_im00232_c7_left_hemicolectomythu_jpg.jpg Anterior resection Removal of part of the sigmoid colon + the upper 2/3 of the rectum Anal sphincter remains intact + an anastomosis is formed https://www.ccalliance.org/all-in-the-recovery/image-thumb__2459__auto_055d3e6a07d8271f4ca923e2e4c9b72e/Low-anterior-resection-LAR.png Abdominoperineal resection Removal of the distal sigmoid colon, rectum, anus + formation of an end colostomy https://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_and_medical_reference/cancer/abdominoperineal_resection.jpg

Answer 61

``` Clavulanic acid Penicillin Co-amoxiclav Erythromycin Chlorpromazine Oetrogens ```

Answer 62

Normal diameter of aorta - 2cm <4 cm - annual US 4-5.5cm - US every 3 months >5.5cm - elective intervention 3-4.5 cm – every year 4.5-5.4cm – every 3 months ``` Early intervention rapidly expanding (>1cm/year) tender symptomatic suspected rupture ```

Gastro - mx use this Flashcards

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