Dimensions for FB to pass
- once past pylorus, will likely pass, unless
> 2.5 cm wide or
> 6 cm long
Criteria for urgent endoscopy for swallowed FB
- sharp/elongated objects
- toothpicks, aluminum soda can tabs
- perforation usually happens distally (at ileocecum), so remove early
- multiple FB’s
- button batteries
- can manage expectantly if passed esophagus
- repeat film in 24-48h to ensure passed pylorus
- pass completely 48-72h
- immediately if magnet co-ingestion
- coin at level of cricopharyngeus muscle in a child
- complete obstruction with food bolus > 12 h
- FB > 24h
Dose of glucagon for food bolus
- poor data, relaxes LES
- 1-2 mg IV/IM (adults), may repeat x 1 in 20 min
GB and CBD dimensions for pathology on imaging
- GB wall > 3 mm
- GB distension on short axis > 40 mm
- CBD > 5 mm
DDx for decreased LOC in cirrhotic
- GI Bleed (protein absorption)
- ICH (coagulopathy)
- SBP
- Wernicke’s
- hypoglycemia
- high protein meals/change in meds, usual AEIOUTIPS
Direct (conjugated) vs. indirect (unconjugated bili)
An increased total and indirect bilirubin signifies either an overwhelming supply of unconjugated bilirubin to the hepatocytes (e.g., hemolytic anemia) or an injury to the hepatocytes themselves that damages their capacity to conjugate a normal supply of bilirubin (e.g., acute or chronic viral hepatitis). Total and direct bilirubin is increased when there is some obstruction preventing the secretion of the conjugated bilirubin that is produced by normally functioning hepatocytes (e.g., obstructing gallstone, pancreatic mass, or biliary atresia).
Dose of lactulose for hepatic encephalopathy
- prevention
- 30-45 mL PO 3-4x/day, adjust to 3-4 soft BM’s/day
- acute
- 30-45 mL PO Q1h until BM then adjust to 3-4/day
- rectal (acute)
- 300 mL mix with 700 mL water/NS, retain for 30-60 min, repeat Q4-6h
Appendicitis on US
- 6 mm
- non-compressible
Direct vs. indirect inguinal hernias
- direct go directly through defect in transversalis fascia in Hesselbach’s triangle
- inferior epigastric artery/rectus sheath/inguinal ligament
- indirect go through internal to external inguinal ring through patent process vaginalis
Spigelian Hernia
- usually acquired hernia through lateral edge of rectus muscle and arcuate line
- urgent referral, high rate incarceration
Replacement of G/J-tube
see evernote
Grading and Management of Internal Hemorrhoids
- Grade I: luminal bulging above dentate line
- Grade II: Prolapse with straining, self-reduction
- Grade III: Manual reduction
- Grades I-III, reduce, sitz baths, anusol
- Grade IV: thrombosed, irreducible
- surgery to see in ED
Indications/Contraindications for thrombectomy of external hemorrhoids
- if <48h, tense, painful + not pregnant/INR/immunocompromised/child/portal HTN
- may excise
Management of Anal Fissures
- Diltiazem 2% with lidocaine 1.5% BID
- Anusol HC BID
- Sitz Baths
- Refer if not healed by 6 weeks, recurrent, or not in posterior midline
GERD Assessment & Treatment
- endo if:
- PPI x 10y
- Age >45 and symptoms 5 y
- other rx factors
- obese, smoking
- dysphagia/weight loss/vomiting/melena
- treat with PPI, may increase to BID in 4-8 weeks if partial success
- try DC/taper in 8 weeks as 20% may be able to come off
- EGD if not able to control with PPI
When to send for EGD in PUD
endo if
- >50
- vx/bleeding/abdo mass/dysphagia
- fail therapy after H.pylori tx or after PPI DC’ed after 4 wk treatment
SSx Celiac Disease
- failure to thrive
- bloating, diarrhea, cramping
- ADEK deficiency
- LFT elevation
- iron/b12 deficiency anemia
Esophageal FB
Review Evernote
Complications of Bariatric Surgery
see Evernote
