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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Terlipressin(2mgQDSIV)
Terlipressin is a synthetic analogue ofvasopressin whichreduces portal blood flow and hence varicealpressure Itshouldbestartedassoonaspossibleandcontinuedforupto5days Terlipressinshouldbeusedwithcautioninpatientswithcardiovasculardisease Treatment is often stopped after haemostasis, but this decision should be made by a gastroenterologist. Other vasoactive drugs which are sometimes used by specialists include somatostatinandoctreotide.
Antibiotics(e.g.ceftriaxone1gODIV)
Antibioticsinaccordancewithlocal protocolsshouldbegivenonadmissiontoall chronicliver diseasepatientswithasuspectedUGIB(whethervaricealorduetoanothercause).
Preventionofhepaticencephalopathy
Lactuloseandenemasmaybeusedacutely,andrifaximinlong-term,forthepreventionofhepatic encephalopathy. The dose of lactulose should be titrated to achieve two or three soft bowel movementsperday.
Rebleedingafterendoscopictreatment(requiresseniorreview)
Ifapatientbleedsfollowingmaximalendoscopictherapy,otheroptionsmayberequired.
Foruncontrollednon-varicealhaemorrhage
CTangiogramplusvesselembolization
IfactivebleedingseenonCTandavailablelocally.
Surgery
Ifembolizationnotpossible.
Foruncontrolledvaricealhaemorrhage
Balloontamponade(Sengstaken–Blakemoretube)
Temporarilystopsbleedingin90%ofpatients Onlyusedforshort-termcontrolpriortodefinitivetreatment.Balloonmustbedeflatedwithin24 hoursduetoriskofoesophagealulcerationandrupture ConsiderintubationandventilationpriortoinsertionofaSengstaken–Blakemoretube.
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Transjugularintrahepaticportosystemicshunt(TIPSS)
Considerforvaricealbleedsthatrebleeddespiteendoscopictherapy Aims torelieveportalhypertensionbyusingastenttoshuntbloodfromtheportalcirculationto thehepaticvein,bypassingthecirrhoticliver Contraindications include heart failure, severe pulmonary hypertension, sepsis, and hepatic encephalopathy.
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Fig.27.1FlowchartformanagementofanacuteUGIB.
Considerationsfollowinghaemostasis
Medicationreview
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StopNSAIDs
Continue low-dose aspirin for secondary prevention of vascular events if haemostasis has beenachieved.Failuretorestartaspirinleadstohighercardiovasculareventsandmortality
Restarting other antiplatelet/anticoagulant medication should be discussed between the patient, endoscopist, and other relevant specialities. Do not stop these medications long-term just
becauseofaGIbleed!
Prophylaxisforoesophagealvarices
Primary prophylaxis (varices which have NOT bled): non-cardioselective beta-blockers have beenshowntoreducebleedingandmortality,e.g.carvedilol6.25mgOD Secondary prophylaxis (postvariceal bleed): regular endoscopic band ligation plus non­cardioselectivebeta-blocker.
Furtherreading
1.BlatchfordO,MurrayWR,BlatchfordM(2000).Ariskscoretopredictneedfortreatmentforupper gastrointestinal haemorrhage. Lancet. 356:1318–21. (Calculate score at:
https://www.mdcalc.com/glasgow-blatchford-bleeding-score-gbs#evidence)
2. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, et al. (2011). Meta-analysis: antibiotic prophylaxisforcirrhoticpatientswithuppergastrointestinalbleeding–anupdatedCochranereview. AlimentPharmacolTher.34:509–18.
3. Marks D, Harbord M (2013). Acute upper gastrointestinal bleeding. In: Emergencies in Gastroenterology and Hepatology (pp. 1–20). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199231362.003.0001
1 Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after acute upper gastrointestinal
haemorrhage.Gut.1996;38:316–21.
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Chapter28
Coeliacdisease
Guideline: British Society of Gastroenterology (BSG guidelines on the
diagnosis and management of adult coeliac disease):
https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-the-diagnosis­and-management-of-adult-coeliac-disease/
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Coeliac disease is an autoimmune disorder where an inappropriate, T-cell-mediated immuneresponseagainstglutenleadstomalabsorptionandaninflammatoryresponse.
Diagnosis
History
Thepresentationofcoeliacdiseaseinpartdependsontheageofthepatient.Childrenare morelikelytopresentwithGIsymptomsand/orfailuretothrive.Acommonpresentation inadultsisasymptomaticirondeficiencyanaemia.
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Classicalsymptomsandsignsofmalabsorption:
Diarrhoea Steatorrhoea Weightlossorfailuretothrive Fatigue
Symptomsofspecificnutrientdeficiencies,e.g.fatigueduetoirondeficiencyanaemia Abdominalsymptoms,e.g.nausea,vomiting,bloating,excessiveflatus,pain,andcramping Asymptomaticanddiagnosedthroughscreening,orafteradiagnosisofosteoporosis(seeChapter
24)
Dermatologicalsymptoms,e.g.dermatitisherpetiformis Hyposplenismleadingtoreducedimmunefunction Neurological symptoms, e.g. peripheral neuropathy and paraesthesiae, ataxia, and balance difficulties.
Examination
There are few specific examination signs, so a high index of suspicion is needed. Commonfeaturesinclude:
Aphthousulcers Signsofanaemia,e.g.conjunctivalpallor,angularstomatitis,koilonychia SignsofvitaminB12deficiency,e.g.ataxia,extensorplantars,absentknee/anklereflexes
Poorlyfittingclothesduetoweightloss Abdominaltendernessanddistension Failuretothriveonheight/weightcharts Dermatitisherpetiformis(Fig.28.1):
Cutaneousmanifestationofcoeliacdisease
Extremelyitchybullousrash
Typicallyonbuttocks,scalp,andextensoraspectsofelbowsandknees.
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Fig.28.1Dermatitisherpetiformis.
ReproducedfromBloomSetal(2011)‘OxfordHandbookofGastroenterologyandHepatology2e’ OxfordUniversityPress:Oxford,withpermissionfromOxfordUniversityPress.Seecolourplate1.
Investigations
SeeFig.28.2foranalgorithmforthediagnosisofcoeliacdisease.
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Fig.28.2 Algorithm for the diagnosis ofcoeliac disease inadults. # Villous atrophy is required for a positive biopsy. Other features are supportive but not diagnostic. * 2% of coeliac patients are immunoglobulin(Ig)-Adeficient(10×prevalencegeneralpopulation),thereforeIgAantibodytestingmay leadtofalsenegativesandnotbediagnostic.(SeeTable28.1forabbreviations.)
Bedside
Heightandweightmeasurements.
Bloods
SeeTable28.1forasummary.
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Table28.1Bloodtestsforthediagnosisofcoeliacdisease
Test Rationale
FBC Anaemiaiscommonincoeliacdisease
Ironstudiesandhaematinics Deficienciesiniron,vitaminB12andfolatearecommon,resultinginanaemias
LFT Transaminasesmayberaised
GlucoseandTFT Screeningforothercommonautoimmunediseases
Calcium,vitaminD,andPTH Coeliacpatientsareathighriskofosteoporosis
Antibodytesting:
EMA(endomysialantibodies) IgA-TG2 and IgG-TG2 (tissue transglutaminaseorTTG) IgA-DGP and IgG-DGP (deamidatedgliadinpeptides)
Requiredfordiagnosticpurposes Usingmultipletestsincreasessensitivity,howeveranypositiveantibodyis enoughforthepatienttobereferredforOGDandbiopsy IgG-TG2andIgG-DGPareusefulinIgA-deficientpatientsasalltheother antibodiesareIgAbased
Totalserumimmunoglobulins IfthereisasuspicionofIgAdeficiency
Source:datafromLudvigssonJF,etal(June2014)Diagnosisandmanagementofadultcoeliacdisease: guidelinesfromtheBritishSocietyofGastroenterology.
Other
OGDwithduodenalbiopsy:
Mustbedonewhilethepatientisonagluten-containingdietforadefinitivediagnosis
Apositivebiopsywillshowsignsofcoeliachistology(Box28.1)
Theprevalenceofseronegative coeliacdiseaseis6–22%(butprobablyclosertothelower
end of this range), therefore if the patient is already undergoing OGD to investigate GI
symptoms,duodenalbiopsyshouldbeconsideredevenifserologyisnegative Considerhumanleucocyteantigen(HLA)testing:
CoeliacdiseasehasastrongassociationwithHLA-DQ2.5andHLA-DQ8
HLAtestinghasahighnegativepredictivevalue,butitisnotspecific.Positivegeneticresults
identifythoseatriskofcoeliacdisease,notthosewhohavecoeliacdisease
Itcanbeusedtoexcludecoeliacdiseaseinthosewithequivocalantibodyorhistologyresults,
orinpatientswhoareunabletotolerateagluten-containingdietbeforeOGDandbiopsy
Itcanalsobeusedtoruleoutthediagnosisinfirst-degreerelatives.Thismaybeausefultest
inchildren Considerbonedensityscanning,especiallyifthepatientisathigherriskofosteoporosis(age>55 yearsoradditionalriskfactors).
Box28.1Signsofcoeliachistology
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Villousatrophy Crypthyperplasia Intraepitheliallymphocytosis.
Source:datafromLudvigssonJF,etal(June2014)Diagnosisandmanagementofadultcoeliacdisease: guidelinesfromtheBritishSocietyofGastroenterology.
Management
Patienteducation
Screening:
Strong genetic component: 10% prevalence in first-degree relatives, so consider offering
screening
Thereisinsufficientevidenceforpopulationscreening Directpatientstosupportgroups.
Lifestyleandsimpleinterventions
Muststartagluten-freedietwithappropriatedieteticsupport.
Pharmacologicalmanagement
Mustgivecalciumsupplementationandboneprotectionifappropriate Pneumococcusvaccinationmustbegiven Considerhaemophilus,meningococcus,andinfluenzavaccinations Dapsoneisfirstlinefordermatitisherpetiformis Immunosuppressive agents such as steroid, budesonide, azathioprine, and ciclosporin may be requiredinrefractorydisease.
Psychosocialconsiderations
Livingwithagluten-freediet:
Difficultyinobtaining,increased expenseof,andincreasedtimerequired topreparegluten-
freefood
Impactonsociallifesuchasdifficultyobtaininggluten-freefoodinrestaurants
Impact on travel such as difficulty obtaining or explaining requirementfor gluten-free food
abroad Depressionandfatiguearecommon.
Complications
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