what are the differentials for diverticulitis
mesenteric ischaemia, diverticulosis, IBS, ovarian cyst/rupture/torsion
what Ix do you want to perform in diverticulitis?
- BEdside - Obs, urine dip and pregnancy test
- Bloods -FBC, UE, LFT, CRP, amylase, INR, clotting screen, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
- CT abdo pelvis - is the imaging of choice
I would also consider doing a PR exam to check for maligancy
what is the management of diverticulitis
- IV fluids, consider catheter and ?NG tube
- Analgesia and antiemetic (NSAIDs and opiates avoided due to risk of perforation)
- sepsis 6 if required
- VTE prophylaxis
- Clear fluids only initially, gradually build up over 2-3 days
- ABx
- Surgical management may be required in severe pts who fail to respond conservatively
WHat investigations should you perform in SBO/LBO?
-Bedside - Obs, fluid balance, PR, pregnancy test
- Bloods -FBC, UE, LFT, CRP, amylase, INR, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
VBG/ABG (lactate is a key marker), bone profile
- erect CXR, then CT abdo pelvis, gastrogafin study may be indicated in SBO
what is the management of SBO
Conservative - Drip and suck - using a wide bore NG tube
Fluid resus
analgesia
VTE prophylaxis
urethral catheter and fluid balance monitoring
- anti emetic
- abx as required
- cardiac monitoring
- correction of electrolytes
Surgical - if obstructing lesions or complications such as evidence of ischaemia or perforation surgery such as resection and primary anastomosis via laparoscopy or laparotomy.
what is the long term management of diverticulitis?
Outpatient colorectal follow-up and colonoscopy
advice high fibre diet - to avoid constipation
elective surgical intervention if recurrent attacks
what is the management of LBO?
if malignant obstruction = surgical options include defuncitoning stoma and resecion with primary anastomosis or stenting
If volvulus = flatus tube decompression
what investigations should you perform in a suspected ectopic
- Bloods -FBC, UE, LFT, CRP, amylase, INR, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
- Serum bHCG + trend, transvaginal USS
what is the management of an ecopic pregnancy
- IV fluids, consider catheter and ?NG tube
- Analgesia and antiemetic
- VTE prophylaxis
- If surgery think NBM, check INR and G&S, stop anticoags/antiplatelets/diabetic medication
- 2 wide - IV bore cannulas
- laproscopic salpingostomy/salpingectomy
- Anti-D prophylaxis
what are the differentials for gastric/peptic ulcer?
- differentials - pancreatitis, cholescystitis
what investigations should you perfrom in gastric/peptic ulcer disease
- Bloods -FBC, UE, LFT, CRP, amylase, INR, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
ECG to rule out cardiac pathology - OGD +- biopsy
what is the initial management of gastric/peptic ulcer disease
- IV fluids, consider catheter and ?NG tube
- Analgesia and antiemetic
- VTE prophylaxis
- If surgery think NBM, check INR and G&S, stop anticoags/antiplatelets/diabetic medication
- PPI
- H.pylori eradication
what are some differentials for renal colic
pyelonephritis, biliary colic
what investigations should you perfrom in renal colic?
- Bloods -FBC, UE, LFT, CRP, amylase, INR, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
- X-ray KUB, CT KUB
what is the management of renal colic
- IV fluids, consider catheter and ?NG tube
- Analgesia and antiemetic
- VTE prophylaxis
- If surgery think NBM, check INR and G&S, stop anticoags/antiplatelets/diabetic medication
- Diclofenac analgesia
- antibiotics if infection
- removal <1 cm - smooth muscle relaxants = tamulosin
- > 1cm uteroscopy or ESWL
- > 2cm - in renal pelvis = percutaneous nephrolithotomy QA
- ureteric stent or nephrostomy if obstruction
what is haematochezia?
passage of fresh red blood in the rectum
what investigations do you perform in an Upper GI bleed
- examine patient - look for signs of common causes - portal hypertension, do PR for melaena
- Bloods - G/S crossmatch, FBC (blood loss), U&Es (increased urea in GI bleeds), LFTs (varices), clotting (coagulopathy common in liver disease), glucose
- Catheterise - monitor UO
- CXR and AXR once stbale
- OGD
- Obs
what is the management of Upper GI bleed
Blatchford score to calculate risk
Rockall score - pre and post endoscopy
Early risk stratification.
Stop any anticoags
All pt should be initially resuscitated
- major haemorrhage protocol, blood transfuse if Hb<7 in variceal bleed or <8 in non-variceal bleeds,
- 2 large bore cannulas IV access
- IV FLUID
- endoscopy within 24 hrs
- Keep pt NBM and correct clotting abnormalities
- Management depends on cause
what is the mangement of variceal bleeding
Pharmacological intervention
- Terlipressin (IV injection)
Analogue of vasopressin (ADH)
Causes splanchnic vasoconstriction
This reduces portal pressures
- Prophylactic antibiotic therapy
Reduces the risk of spontaneous bacterial peritonitis
Endoscopic intervention
- Variceal band ligation (VBL)
Completed acutely. Patients then need to undergo variceal banding programme every 2-4 weeks until varices have gone.
Endoscopic sclerotherapy
Alternative option to VBL that involves injection of a sclerosing agent.
Failed intervention
Patients may re-bleed despite endoscopic therapy. An initial re-attempt of variceal band ligation may be appropriate. If these attempts fail, further options include:
Sengstaken-blakemore tube:
Bridging therapy, at risk of oesophageal necrosis if left > 24 hours.
Oesophageal stent:
Alterantive to Sengstaken-blakemore tube.
Transjugular intrahepatic portosystemic shunt (TIPS) procedure:
Interventional radiological procedure to create a shunt between portal and systemic venous circulation to reduce portal pressure.
A definitive treatment in appropriately selected patients.
what is the management of non-variceal bleeding?
Mechanical (e.g. clips) with adrenaline
Thermal coagulation with adrenaline
Proton pump inhibitor therapy should be reserved for patients with a non-variceal UGIB with evidence of recent haemorrhage during endoscopy.
A repeat endoscopy should be completed in patients who re-bleed, or are suspected to be high-risk of re-bleeding. Unstable patients who re-bleed post-endoscopy should be offered radiological (e.g. embolisation) or surgical intervention.
what investigations should be performed in a ruptured AAA
- Bloods -FBC, UE, LFT, CRP, amylase, INR, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
- bedside USS
- CT angiography
what is the management of AAA
- IV fluids, consider catheter and ?NG tube
- Analgesia and antiemetic
- VTE prophylaxis
- If surgery think NBM, check INR and G&S, stop anticoags/antiplatelets/diabetic medication
- 2 wide bore cannulas
- aim for permissive hypotension
Activate major haemorrhage protocol
- urgent open repair
what investigations do you perform in peritonitis?
- Bloods -FBC, UE, LFT, CRP, amylase, INR, G&S + blood culture if pyrexic, urine dip and culture, bHCG.
- erect CXR
- urgent CT abdo pelvis to identify cause
what is the management of peritonitis?
- IV fluids, consider catheter and ?NG tube
- Analgesia and antiemetic
- VTE prophylaxis
- If surgery think NBM, check INR and G&S, stop anticoags/antiplatelets/diabetic medication
- 2 wide - IV bore cannulas
- Urgent surgical repair
- consider pt comorbidities and chance of survival
