You ar an HMO and a 35 year old man comes to the hospital for his Endoscopy reports. He has worsening heartburn, occasional water brash and bouts of dry coughing. The endoscopy shows a small sliding hiatus hernia and oesophagitis with moderately severe ulcerations.
- What are the key points of this case?
- What are the critical errors of this case?
Key points:
1. Approach to the patient and ability to convince him for lifestyle changes by explanation and support
- Patient education and counseling about the nature of the disease and future course.
- Correct interpretation of the investigation and implying that the cause of the heartburn is reflux and not hiatus hernia
- Treatment- Start PPI and lifestyle modifications
Critical errors:
1. Failure to commence treatment
You ar an HMO and a 35 year old man comes to the hospital for his Endoscopy reports. He has worsening heartburn, occasional water brash and bouts of dry coughing. The endoscopy shows a small sliding hiatus hernia and oesophagitis with moderately severe ulcerations.
- Explain the condition
Condition: Gastro-oesophageal reflux
Cause: Smoking
Alcohol consumption
Overweight and obesity
Spicy foods
Coffee, chocolates, Red wine
Drugs - NSAIDs and Aspirin
(Hiatus hernia is not the cause of GOR)
(Family history of GOR or Cancer is not the cause of GOR)
Commonality: Very common nowadays
Clinical features: Heartburn which gets worse when lying flat,
Regurgitation of bitter fluid in the mouth
Bouts of dry coughing
Better after having milk or Magnesium Hydroxide
Course: Condition is not serious and is reversible at the moment but Can get worse if left untreated and develop complications
Complications or Red flags:
1. Ulcerations
2. Strictures
3. Rupters
4. Bleeding - Hematemesis, Hematochezia
5. Malignant changes (Barett’s oesophagus)
You ar an HMO and a 35 year old man comes to the hospital for his Endoscopy reports. He has worsening heartburn, occasional water brash and bouts of dry coughing. The endoscopy shows a small sliding hiatus hernia and oesophagitis with moderately severe ulcerations.
- What is the management of this condition?
- Proton pump inhibitors- omeprazole or esomeprazole, taken at night
- Lifestyle modifications:
Stop smoking
Reduce alcohol intake
Physical exercise and lose weight
Only have light evening meals and avoid late bedtime meals
Avoid spicy foods
Avoid red wine, coffee and chocolates - Practise sleeping with your head high by elevating the head of the bed or using several pillows.
- Stopping Aspirin and other NSAIDs.
Suggest Alternative treatments to migraine. - Tell the patient about the red flags
- Arrange future consultations about smoking cessation, alcohol reduction and weight loss issues.
- Repeat endoscopy in the next follow up.
A 30 year old woman has come to the ED due to acute worsening abdominal pain. All clinical signs and symptoms indicate strongly of Acute Appendicitis.
- Explain the Diagnosis to the patient
- Counsel her regarding the need for surgery
- Tell her about the implications of surgery
- Answer her questions.
Condition- Acute Appendicitis (draw diagram and explain in details.
Cause - unknown
Commonality - very common, one in seven individuals in Australia develop this condition, evident on clinical grounds and treated by uncomplicated appendicectomy.
Clinical features- Tummy pain, Fever, nausea/vomiting. Tummy is tender on touch.
Course - in 30% case, it will progress to perforation and peritonitis.
- in the rest, it may resolve after a bouts of acute inflammation.
But as it is very difficult to predict which will perforate and which will not, it is advisable to undergo surgery if clinical diagnosis is confirmed.
Complications (if remained untreated) -
- Appendicular lump
- Appendicular abscess
- Perforation leading to peritonitis
A 30 year old woman has come to the ED due to acute worsening abdominal pain. All clinical signs and symptoms indicate strongly of Acute Appendicitis.
- Tell her about the implications of surgery
- Answer her questions.
Investigations :
1. No investigations needed, diagnosis is based upon strong clinical suspicion
2. USG could be done to rule out Ectopic Pregnancy . WBC could also be done. But none of them is done.
Treatment:
Appendicectomy
Indications - strong clinical suspicion, preferred treatment by doctors, patient’s condition deteriorating and to prevent complications.
Method of surgery- open method or laparoscopy. Both are widely practiced has little difference between the outcome afterwards.
However, for better view of inside the tummy, laparoscopic method is mostly preferred by surgeons.
Which method will be used will be decided by the surgeons and also taken into consideration patient’s requests and requirements.
Complications of surgery-
Anaesthetic, laparoscopic and surgical
During the surgery:
1. Excessive bleeding
2. Injury to surrounding organs, nevers and vessels
After the surgery:
1. Infection and all causes of Postoperative fever
But chances of complications are a minimal. Individually and cumulatively small.
1. Prophylactic antibiotics
2. Compression stocking for thromboembolism
3. Early mobilisation
4. Adequate pain management
Patient will be mobile the day after the procedure.
Normal activity can be resumed one to two weeks after discharge
A middle aged man has come to the ED due to left lower quadrant pain.
What can be the possible causes?
- Diverticulitis
- IBD
- Diverticular abscess
- Ruptured diverticulum leading to peritonitis
- Bowel obstruction
- Colon cancer/mass
- Mesenteric ischemia
- Renal stones
- UTI
- Inguinal hernia
- Abdominal wall pain due to cellulitis, herpes zoster or muscle strain
- Testicular torsion
Females:
12. Ovarian mass
13. Ovarian torsion
14. Salpingitis
15. Ectopic pregnancy
16. PID
17. Tuboovarian abscess
18. Uterine fibroids
19. Endometritis
Causes of Rectal Bleeding
- Diverticular disease
- IBD
- Mesenteric Ischemia
- Ischemic colitis
- Malignancy
- Anal fissures
- Haemorrhoids
- Bleeding disorders
- Blood thinners
- Trauma - accidental and non-accidental
Causes of Anal Discharge
- Anal fistula
- Pilonidal sinus
- Anal incontinence
- Fecal impaction
- Constipation leading to encoperesis
- Cancer of the anal margin
- Solitary rectal ulcer syndrome
- Anal warts
- Genital herpes
- Gonococcla ulcers
A 25 year old man has come to the GP with his colonoscopy photographs. He is having bloody diarrhoea 6-7 times daily for the last 6 months and now wants to know what is causing this.
Explain the diagnosis
Condition: Inflammatory Bowel Disease
- Ulcerative Colitis
- Crohn’s Disease
Cause : Unknown, maybe autoimmue and has a family history positive
Commonality: Very commonly seen nowadays
Clinical features:
1. Recurrent attacks of diarrhoea
2. Blood and mucus in the stool
3. Tummy pain (CD)
4. Fever, malaise and weight loss (CD)
5. Mouth ulcers
6. Low back pain and arthritis
7. Inflammations of the eye
Course: No definite treatment, lifelong management. The attacks of diarrhoea tend to recur every few months to years usually for the rest of the life.
Complications: See differences between UC and CD
Differences between Ulcerative Colitis and Crohn’s Disease
Ulcerative Colitis
1. Ulcerations
2. Involves the large gut mainly (rectum and colon)
3. Bloody Diarrhoea
4. Short history (since it is infective)
5. Long term ulceration is associated with malignant changes in 7-10 years
Crohn’s Disease
1. Inflammation
2. Involves the whole gut (small and large bowels)
3. Mucous diarrhoea
4. Long history of symptoms, around 6 months.
5. Skip lesions, fistulae and bowel obstruction can occur as complications.
A 25 year old man has come to the GP with his colonoscopy photographs. He is having bloody diarrhoea 6-7 times daily for the last 6 months and now wants to know what is causing this.
Explain the management of this condition
IBD management:
1. Treatment of nutritional deficiency and anemia that has been caused due to bloody diarrhoea.
- Drug therapy:
- Sulfasalazine
- Steroids (prednisolone)
- Immunosuppressant drugs - Lifestyle modifications-SNAP
- Stay upto date with your colon cancer screening
- Surgery - Indications:
- severe chronic UC & CD not responsive to medical therapy - Red flags and regular follow up
A 55 year old woman has come to the GP due to tiredness and SOB on exertion.
Blood tests show anemia.
What investigations will you order to determine the type and cause of the anaemia?
Investigations to determine the type of anaemia:
1. Serum iron
2. Serum ferritin
3. TIBC
4. Percentage saturation of Ferritin
- Hb with PBF
- MCV, MCH, MCHC
Investigations to determine the cause of anaemia:
1. Gastroscopy
2. Colonoscopy
3. Barium enema ( if colonoscopy cannot visualise the right side of the colon)
A 55 year old woman has come to the GP due to tiredness and SOB on exertion.
Blood tests show anemia.
What is the management plan for her?
- Exlude the most common causes of IDA in this patient which is Ca Colon and Peptic Ulcer by doing both upper and lower GI endoscopy.
- Start oral iron therapy
-one tablet once daily
- taken with food or milk
Side effects:- constipation
- dark stools
- nausea
- tummy pain
- Start Famotidine for Peptic Ulcer
Causes of IDA in a post menopausal lady.
- Peptic ulcer
- Reflux oesophagitis
- Benign or malignant tumours of the small or large gut
- Dietary causes (if she is a vegetarian)
- Adverse drug reaction by NSAID or Aspirin
- Thalassemia (unlikely)
Management of Hemorrhoids
- Refer the patient to a general surgeon for colonoscopy to rule out any nasty changes.
Rx According to the Grades of Hemorrhoids:
Grade 1&2 :
1. Lifestyle modification- SNAP
2. If constipation present - stool softeners
If not improving :
3. Band ligation
4. Heat coagulation
5. Sclerotherapy
Grade 3&4:
1. Surgery - Hemorrhoidectomy
Management of Diverticulosis
- Refer to the general surgeon for colonoscopy to rule out any nasty changes
- Lifestyle modifications- SNAP
- Painkillers for the tummy pain
Stool softeners for the constipation
Management for Diverticulitis
- Admit the patient to the hospital
- Seen by seniors and specialists
- Open IV access and take blood for investigations: FBE with ESR and CRP
Stool sample for MCS
USG and CT Abdomen
Chest and Abdominal Xray - NPO
- IV saline
- IV painkillers
- IV antibiotics
- Once patient is stable, Colonoscopy to rule out nasty changes
Management of Acute Mesenteric Ischemia
- Admit to the hospital immediately
- Seniors and specialists
- Open IV access and take blood for investigation : FBE
UEC
LFT
Blood grouping and cross matching
Coagulation profile - CT Angiogram
- IV saline, painkillers and Antibiotics
- Surgery to restore the blood supply
A 50 years old man comes with recurring diarrhoea for the last two years.
Tell the possible causes
- IBD
- IBS
- Infections: Infectious diarrhoea
Ischemic colitis
Giardiasis - Diverticular diseases: Diverticulosis
Diverticulitis - Malignancy: Ca colon or rectum
- Others: Thyrotoxicosis
Celiac Disease
Drug induced diarrhoea
