[أبـ البراء ـو]

السلام عليكم
نبدأ بإذن الله سلسة حالات الأستقبال وكيفية التعامل معاها
وسأنقل لكم المتبع لدينا فى أستقبال الباطنة بمستشفيات جامعة عين شمس
والأدوية المتاحة
سأكتبها على فترات
الرجاء التركيز ستسفاد كثيرا
هذه خبرة مخالطتى لمدرسين مساعدين ونصائحهم فى الأستقبال
والله الموفق
نبدأ بأكثر الحالات شائعة فى الأستقبال

Haematemsis & melena.

1st aid measures :-

1-Vital data : pulse .. ... Bl.pr.

2-Canula & give : ((haematemsis cocktail )) ...............> Dicynon"hemostatic" , Konakion "vit.k ", Cyclokabron " antifibrinolytic" ,and Zantac
" H2 blocker"

3-Ryle ---------------à Never before canula
*Values : -Ensure no bleeding
-To wash by cold water with or without adrenaline to cause
local VC.

*Continue wash till it become clear to prepare pt. For endoscopy .
N.B.: Pt. Fit for endoscope means :-
- Ryle wash becomes clear .
- Pt. is not shocked.
- Pt is not in encephalopathy.

4- 3 blood samples ((obtained from the canula before giving cocktail ))
- One for CBC -----à baseline Hbe
-----àPlat. ((decrease in HCV +ve pt. ))
- One for ****bolic profile ----àRoutine ..
- One for blood preparation.

5- ECG ....to exclude ISHD.

** If bleeding severe or pt not fit for endoscope or not available
endoscope
** We may use Sangstakin ---àinflate gastric ballon with 250-300 cc saline
** sangstakin should not be left more than 48 hours to prevent necrosis .





** Also in case of severe bleeding we can give :-
-Somatostatin:- [Octeriotide = antigrowth hormone] 25-50 ug\h..."one
ampoule contain 100 ug"
- 400 saline or Ringer أميول واحد على مدى 4 ساعات +
Value : VC.
- Glypressin "One ampoule contain 1mg "
2 أميول الآن ثم 1 واحد أميول كل 6 ساعات

$$. Take care :
It cause coronary VC, so give nitroderm patches if blood
pr. Allows.
Glypressin is # in IHD, old age…..
Blood is given if pt. chocked.
Plasma is given if pt INR >1.5
Plat. Is given if pt plat. >50,000
Till blood --àgive Colloid which last in intravascular space more than crystalloids. E.g. : Dextran,haemgel….
If Colloid not available -----à give crystalloids E.g.: Saline, Ringer.



II- History taking :
History of :- chronic liver dis., Gu or Du, Drug Intake : aspirin, NSAID, anticoagulant.

III-Examination : HSM , ascites , flapping tremors….

IV:-Upper GIT endoscope àshould be done when Pt. becomes fit for it .
Value : 1- Diagnostic for cause of bleeding
2- Therapeutic ( as mentioned before).

TTT of bleeding Oesophageal varices:

I ) 1st aid measures .
II) Injection sclerotherapy.
III) Anticoma…to avoid encephalopathy..
*Enema \4 h.
* protein restriction 20gm\d.
* Lactulose 30 cm\3 times\d àstopped if diarrhea
*Eradicate bact. Flora :
- Flagyl 250 mg (1*3*7)esp with renal impairment
- Neomycin 500 mg (2*4*5) #with renal impairment.
Side effect : ototoxicity so not given >5days

IV)Guard against SBP by Noroxin (Norfloxacin ) 1*2 .
V) Give (Dicynon ,konakion, Cyclocapron, Zantac) à 2 amp\8h.{ Zantac is # with thrombocytopenia.)

.If bleeding persist we give :-
Sandostatin, Glypressin

After bleeding stopped :
1- follow up GI for injection
.( ميعاد المنظار والحقن )
2Drug to decrease portal hypertensionàIndral 10mg à1*4
(If Indral can't be given as in case of DM\BAor PVD or CHF)
Give Effox 40 mg à1*2
3- Vit. K (1*3)
4- Liver support Eg: Legalon 1*3
5- Diuretics àdepend on pt is compensated or not à i.e. pt has
ascites.

TTT OF PU

a)1st aid measures
b)Upper GIT endoscopy for D.D.-à if active bleeding à injection with adrenaline
c) Losec ( Omeprazole) vial + 200 cc Ringer over 2 hours.
d) If anteral gastritis or Duà Tripple therapy to eradicate h.pylori
It includes :- PPI e.g. : Gastrazole 1*2*15 days
- Clarithromycin 2*2*15 days
- Amoxicilin 2*2*15 days.

Discharge Pt. when :-
Melena stopped
Hb = 8 or more.
Avoid spicy food , smoking , NSAID

NB: If pt. with PU with severe haematemsisà consult à Surgery.

Indication of admission of pt:
Haematemsis, melena
Tense ascitis
SBP
Hepatic encephalopathy
Recommended pt

القادم تكمله للدرس لم أرد أكتب الكثير حتى لا يمل أحد المرة القادمة
متابعة للجوانب الأخرى المصاحبة غالبا لل
Haematemsis & melena
EX
Tense ascitis ( TTT)
Tapping
SBP ( spontinous bacterial peritonitis ):
Hepatic encephalopathy


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