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

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Table36.2Ascitesgradingandmanagement
Grade Definition Management
Grade1 Onlydetectableby
ultrasound
Notreatment
Grade2 Moderateasciteson
examination
Noaddedsaltindiet Startspironolactone100mgOD;↑by100mgevery72hourstomax.400mg Ifnotresponding,addfurosemide40mgOD;↑by40mgtomax160mg Aimfor0.5–1kg/dayweightloss Monitorelectrolytes Reducediureticswhenascitesresolved
Grade3 Largeascites+
markedabdominal distension
Large volumeparacentesis: if >5Ldrained/expected, give 100mL20% human albumin solution (HAS) for every 2L drained to prevent post-paracentesis circulatorydysfunction Continuemaximumtolerateddiuretics
Refractory ascites
Doesnotrespond tomaximum diuretics
Mediansurvivalof6months Stopdiureticsunlessurinarysodium>30mmol/day ConsiderreferraltoatertiaryliverunitforTIPSSorlivertransplantation
Spontaneousbacterialperitonitis
Diagnosis:
Asciticneutrophilcount>250/mm
3
PerformdiagnostictapASAPforpatientsadmittedwithascites;delayassociatedwith3×↑in
mortality
Bloodplusasciticfluidcultures Management:
Earlytreatmentwithbroad-spectrumantibioticsasperlocalguidelines
Give1.5g/kg20%humanalbuminsolution(HAS)atdiagnosis(day1)and1g/kgatday3 Repeatdiagnostic paracentesis at 48 hours: look for ↓ in neutrophil countof >25% to indicate effectivetreatment Secondary prophylaxis (e.g. ciprofloxacin 500mg OD) following an episode of spontaneous bacterialperitonitisshouldbeoffered.Obtainlocalmicrobiologyadvice Primary prophylaxis of spontaneous bacterial peritonitis can be considered in specific circumstances.
Acutekidneyinjuryincludinghepatorenalsyndrome
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Diagnosis:
AKIwithreferencetobaselinecreatinine(oftenlowinpatientswithcirrhosisandlowmuscle
bulk)
Hepatorenal syndrome comprises a minority of cases of AKI in cirrhosis and may be
diagnosedintheabsenceofanothercause
Exclude:hypovolaemia,infection,diuretics,nephrotoxicdrugs,parenchymalrenaldiseases Management:
Fluidresuscitationtoachieveeuvolaemia(5%HASorcrystalloid)
Monitorbloodpressure,urineoutput,andfluidbalance
Holddiureticsandanypotentialnephrotoxicmedications
Septicscreenandtreatanyinfection
Considerterlipressinifnoresponsetopreviousmeasures:
Startat1mgQDSandgradually↑ifnoimprovement Givewith100mL20%HASBD
Upto50%ofpatientsdemonstrateagradualimprovement,over1–2weeks.
Hepaticencephalopathy
Diagnosis:
Altered mentalstate ina patientwithliver cirrhosis, with noclear alternative causefound
(diagnosisofexclusion)
Exclude: hypo/hyperglycaemia, alcohol intoxication, drugs, neurological infection, electrolyte disorders, intracranial bleed/stroke/neoplasm, severe systemic medical stress,dementia,psychiatricdisorders Ammonia: highlevels do notconfirmdiagnosis or add prognostic value,butifnormal
makeHEunlikely Identify precipitants including infection; sedative medications; GI bleeding; dehydration/electrolytedisturbance;constipation;worseningunderlyingliverdisease.
Management:
OnlyovertHErequirestreatment(grades2–4,seeFig.36.1) Identify,exclude,andtreatallothercausesforbraindysfunction Lactulose25mLBD—aimfortwoorthreesoftbowelmotions/day,continueafterremission Rifaximin550mgBD—usedforpreventionofHEiffurtherepisodewhileonlactulose.
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Fig.36.1Progressionandclassificationofhepaticencephalopathy.
Monitoringandfollow-up
Patients admitted with hepatic decompensation should be referred to a hepatology/gastroenterologyserviceforspecialistmanagementandfollow-up.
Patients with compensated cirrhosis should be reviewed clinically every 6 months,
including:
USS(screeningforHCC) CalculationofriskstratificationtoolsuchasChild–Pughscore,MELD,orUKELD.
Furtherreading
1.BritishSocietyofGastroenterology.BSG-BASLdecompensatedcirrhosiscarebundle—first24hours. Available at: https://www.bsg.org.uk/clinical-resource/bsg-basl-decompensated-cirrhosis-care-
bundle-first-24-hours/
2. Model for End-Stage Liver Disease (MELD) Score. Calculate score at:
https://www.mdcalc.com/meld-score-model-end-stage-liver-disease-12-older
3.WilkinsonIB,RaineT,WilesK,etal.(2017).Cirrhosis.In:OxfordHandbookofClinicalMedicine, 10th ed (pp. 276–7). Oxford: Oxford University Press. Available at:
https://doi.org/10.1093/med/9780199689903.003.0006
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Part6
Mentalhealth
Bipolardisorder
Depression
Eatingdisorders
Generalizedanxietydisorder
Panicdisorder
Post-traumaticstressdisorder
Psychosisandschizophrenia
Self-harm
Violenceandaggression
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Chapter37
Bipolardisorder
Guideline: NICE CG185 (Bipolar disorder: assessment and management):
https://www.nice.org.uk/guidance/cg185
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
Bipolar disorder is characterized by episodes of mania/hypomania interspersed with episodesofdepression:
Mania:elevatedmood/irritabilitywithseverefunctionalimpairmentfor>7days Hypomania: elevatedmood/irritability with↓/↑functionfor>4days,BUTnot severe enoughto causeamarkedimpairmentinsocialoroccupationalfunctioningandWITHOUTpsychosis.
Diagnosis
History
Include:
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Assessmentofmood Detailedhistoryofcurrentmanic/hypomanic/depressiveepisode:
For mania or hypomania, look for ≥3 of: heightened self-esteem or grandiosity, ↓ needfor sleep, ↑ talkativeness, flight of ideas or racing thoughts, high distractibility, ↑ activity or agitation,↑high-riskbehaviours For depression, look for ≥5 of: depressed mood, lack of interest or pleasure, weight or appetite change, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or guilt, difficulty concentrating or making decisions, recurrent
thoughtsofdeathordying Historyofanypreviousepisodesincludingtriggers,andtreatmentsorinterventionsused Physicalandmentalhealthhistory Medicationhistory(prescriptionandnon-prescription) Historyofsubstanceabuse,smoking,andalcoholconsumption Familyhistory Collateralhistoryifpossible Socialhistoryincludingpsychosocialstressors,e.g.work,relationships Historyofself-neglect,self-harm,orsuicidalthoughts.
Patients should always be asked about potential manic/hypomanic episodes when presentingwithdepression.Iftheydescribeoveractivityordisinhibitedbehaviourlasting >4days,considerreferraltosecondarycare.
Referurgentlyto secondarycare if maniaor severedepressionissuspected,or if the
patientispotentiallyarisktothemselvesortoothers.
DSM-5criteria
1
Bipolar1=mania+depression Bipolar2=hypomania+depression.
Examination
No specific examination is required. However, the examination components required beforespecificmedicationsarestartedarediscussedinTable37.1.
Investigations
No specific investigations are required. However, the investigations which are required beforespecificmedicationsarestartedarediscussedinTable37.1.
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Management
Mostpatientsareinitiallymanagedinsecondarycarebutneedongoingmonitoringinthe community.
Lifestyleandsimpleinterventions
Developacollaborativeriskmanagementplan,including:
Identifyingtriggers
Copingstrategiesandmedicationtitration
Whotocontactinacrisis Ensurepatientswithmaniaorhypomaniacanaccessacalmingenvironment Offerahealthyeatingandphysicalactivityprogramme.
Psychologicalinterventions
Depression
CBT/interpersonal therapy/behavioural couples therapy OR specific evidence-based psychologicaltherapyforbipolardisorder.
Pharmacologicalmanagement
Acutemanagement
Primarycare
Donotroutinelystartmedicationsinprimarycare Somemedicationssuchaslithiumcanberestartedorcommencedunderasharedcareplan.
Secondarycare
Maniaorhypomania
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If taking an antidepressant, consider stopping if it was recently started, the dose was recently adjusted,orthereareprobableissuesofcompliance Start an antipsychotic, e.g. haloperidol, olanzapine, quetiapine, or risperidone, if not already takingmoodstabilizers/antipsychotics.Ifthefirstchoiceisnottolerated,trialasecondchoice Consideraddinglithiumifnotrespondingtotwodifferentantipsychoticsatthemaximumtolerated dose If lithium is not suitable or unsuccessful, consider adding valproate instead (NOT suitable for womenofchildbearingage—see‘Prescribingandmonitoringtips’) If already taking lithium, check levels are within the therapeutic range. If levels are optimal, consideraddinganantipsychotic If already taking valproate/mood stabilizer, consider increasing the dose and adding an antipsychotic Review treatment 4 weeks after symptoms have resolved to decide if long-term treatment is appropriate.Reviewagainat3–6monthsiftreatmentiscontinued.
Prescribingandmonitoringtips
Lithium:
Fluidbalanceisimportantduetolithium’snarrowtherapeuticrange—advisepatienttobe carefulifusualhabitschange(e.g.goingonholiday,exercisingmore)andtoseekmedical attentioniftheyhavediarrhoeaorvomiting Monitorforneurotoxicityateveryappointment:ataxia,cognitiveimpairment,paraesthesia, tremor.Thesecanoccurattherapeuticlevels Many medications interact with lithium. In particular, patients should know to avoid NSAIDswhichcanincreaseserumlithiumconcentrations
Valproate:
Ensurepatientsareawareofthe signs/symptomsofbloodandliverdisorders whichcan developwithvalproateuse Valproate must only be prescribed to women of childbearing age if other options are unsuitable AND they have a pregnancy prevention programme in place (see ‘Further
reading’)
Lamotrigine:
Patients taking lamotrigine should seek urgent medical help if they develop a rash or becomepregnant.
Depression
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Medicationoptions:
FluoxetineplusolanzapineOR
OlanzapinealoneOR
LamotriginealoneOR
Quetiapinealone Ifalreadyonlithiumorvalproate,checklevelsandincreaseifnecessary Iflithium/valproateisatmaximumdoseandcannotbeincreased,addamedication(above).
Chronicmanagement
Bipolardisorderisachronicrelapsing–remittingconditionanditisimportanttofollowupstable patientsevery3–6months Once stable, the need for continued psychologicalinterventions should be discussed as wellas whethermedicationsshouldbereduced,stopped,orcontinuedlong-term Consider:
Whichmedicationsweresuccessfulinanacutesetting
Medicationsideeffects
Potentialbenefitsofstoppingmedication,e.g.safetoconceive
Riskofrelapse Ifstoppingtreatment,stopgradually(overatleast4weeks)andmonitorforrelapsefor2years.
Interactions
Beawarethatmanypsychiatricmedicationsinteractwitheachother,e.g.valproateand lamotrigine—alwayscheckintheBNFbeforeaddinginasecondmedication.
Psychosocialconsiderations
Familyinterventionshouldbeconsideredifappropriate Supportpatientswitheducation,employment,andfinancialissues Supportcarersanddirectthemtoappropriateresources.
Monitoringandfollow-up
Routinereview
Monitorannually:
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Pulse Bloodpressure Weight/BMI Dietandnutritionalstatus Levelofphysicalactivity Bloods:
Glucose
HbA1c
Lipidprofile
LFT
U&E
TFT
Calcium(iftakinglithium).
Drug-specificmonitoring
DrugspecificmonitoringshouldbeperformedasperTable37.1.
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