Diarrhea/Constipation/IBS/IBD Flashcards
CMV Diarrhea - DOC
Ganciclovir
Diarrhea common on cruise ships…spreads fast!
Norwalk
Treatment: supportive
Diarrhea most common in children
Rotovirus
Test: Rotazyme
Treatment: fluids +/- nitazoxanide
Diarrhea - Food poisoning with preformed toxin associated with reheated fried rice
Bacillus cereus
Treatment: supportive
Diarrhea - Gram - rod, fecal-oral transmission by contaminated water or unpasteurized milk. Also associated with Guillan-Barre.
campylobacter jejuni
Treatment: azithromycin
Diarrhea - Gram + rod from kids eating spores from honey –> paralysis and constipation
Clostridium botulinum
Treatment: trivalent antitoxin
Diarrhea - gram+ rod, nosocomial or antibiotic associated
Clostridium difficile
Treatment: metronidazole, vancomycin
Diarrhea - from uncooked beef, causes hemolytic uremic syndrome
E.Coli
Treatment: no abx, supportive
Diarrhea - acid fast rods usually seen in HIV + with CD5 < 50
Mycobacterium Avium Complex (MAC)
Diarrhea - gram - comma shaped rods, produces enterotoxin that increases cAMP in intestines. From contaminated water and seafood.
Vibrio cholorae
Treatment: fluid, glucose + Na (gatorade), doxy or FQ
Diarrhea - gram - coccobacillus causes enterocolitis in kids, also causes granulomatous microabcesses that can simulate acute appendicitis
Yersinia enterocolitica
Treatment: Bactrim
Diarrhea - associated with daycare, hikers, anal-oral in MSM
Giardia lamblia
Get stool antigen
Treatment: tinidazole or nitazoxanide
Most common helminth in US. Deposits eggs outside anus (itching).
Enterobius vermicularis
Treatment: albendazole or mebendazole
Antisecretory, anti-inflammatory, antibacterial agent for diarrhea
Pepto-Bismol
Pepto-Bismol ADE
binds to tetracycline
black tongue and dark stools
Pepto-Bismol cautions
contains salicylate (ASA) toxicity in large doses and increased bleeding risk
What are the anti motility agents?
OTC Loperamide (Imodium) Rx Diphenoxylate/Atropine (Lomotil)
*Lomotil cautions
weak opioid and has addiction potential (controlled substance)
Botanical rx from the red sap of the Croton lechleri plant in S.America approved for diarrhea in HIV+ patients
Crofelemer (Fulyzaq)
125mg BID po
Prophylaxis for traveler’s diarrhea
Doxycycline 100mg QD
Bactrim BID
Ciprofloxacin 500 mg QD
*Constipation - bulk forming agents
psyllium, bran
swell in water and increase bulk
12-24 hours
*1st line because low SE’s
Constipation - stool softeners
docusate
facilitates mixing of water and fatty materials in gut and create wetting effect
1-3 days
Constipation - osmotic agents
sorbitol, lactulose, sucralose
makes stool softer and bulkier
Constipation - stimulant laxative
bisacodyl (dulcolax)
Senna (Senokot)
take at bedtime for stool in am
Constipation - saline laxatives
magnesium, citrate, phosphate
osmotic effect that increases intraluminal volume –> stimulates peristalsis
*also used for bowel cleansing
Constipation - hyperosmotic laxative
glycerin (acute constipation) lavage solutions (bowel prep) GoLYTELY
Chronic idiopathic constipation and IBS-C in women - Drug
Lubiprostone (Amitiza)
Cl Channel Activator
increases intestinal fluid secretion –> motility
Preg C
Foundation of treatment for constipation
- identify and correct underlying problem
2. dietary fiber or bulk forming laxatives
Acute constipation - treatment
enemas or glycerin suppository
if ineffective, osmotic agents or stimulant laxatives
What other condition/disorder can impact IBS?
Depression and psychological disorders
Who does IBS typically effect?
Healthy women, 30-50 yrs old
*General approach to treatment - IBS-C
Fiber
Osmotic laxatives
Cl Channel Activators (Lubiprostone)
*General approach to treatment - IBS-D
Antidiarrheals
Cholestyramine
5-HT3 antagonists (Alosetron-restricted)
*General approach to treatment - IBS-Pain/Gas/Bloating
anticholinergics (Dicyclomine)
SSRI
psychological treatment
Which fiber products are used in the treatment of IBS-C?
psyllium (Fiberall, Metamucil) or Polycarbophil (Fiber Con)
Fiber products - ADE
cramping, diarrhea
Which osmotic laxatives are used to treat IBS-C?
Milk of Mag and Sorbitol
Milk of Magnesium - ADE
hypermagnesemia, diarrhea, cramps
Milk of Magnesium - DDI
Tetracycline and FQs (because of the Mg)
*Which Cl Channel Activator is used to treat IBS-C?
Lubiprostone (Amitiza)
*Lubiprostone - Preg Cat?
C (may cause increased pregnancy loss)
do pregnancy test before/during and use effective contraception
Which two antidiarrheals are used to treat IBS-D?
Immodium and Lomotil
*Which antidiarrheal is better for use during pregnancy and breastfeeding?
Immodium (B/L2)
Lomotil is C/L3
Which 5-HT3 antagonist can be used to treat IBS-C?
Alosetron (Lotronex)
*Restricted access
Why is Alosetron restricted?
can cause ischemic colitis
Which anticholinergic can be used to treat IBS with pain/gas/bloating?
Dicyclomine (Bentyl)
Why is Bentyl not the BEST option for IBS with pain/gas/bloating?
QID
L4 (suppresses lactation)
tachycardia
What are the preferred SSRIs to treat IBS with pain/gas/bloating?
Citalopram (Celexa) and Escitalopram (Lexapro)
Which SSRI has the most GI side effects?
Sertraline (Zoloft)
SSRI - ADE
headache, diarrhea, drowsiness, sexual dysfunction
Which 2 SSRIs are well known inhibitors of CY2D6?
Fluoxetine (Prozac) and Paroxetine (Paxil)
Why are citalopram (Celexa) and escitalopram (Lexapro) not used during breastfeeding?
may cause infant somnolence
What disorder? chronic inflammation of colon, bloody diarrhea, abdominal pain, no skip lesions and higher risk for toxic megacolon and colon cancer.
Ulcerative colitis
What disorder? chronic inflammatory disease anywhere from mouth to anus, skip lesions fistulas and non-bloody diarrhea
Crohn’s disease
*IBD - mild vs mod vs severe
Mild - < 4 stools/day +/- blood
Mod - > 4 stools/day +/- blood
Severe - >6 stools day +/- blood
Fulminant > 10 stools day +continuous blood, abd distension
*Why to you give abx for crohn’s disease treatment?
treating fistulas
What is the preferred abx for crohn’s?
metronidazole
What is the preferred 5-ASA for IBD?
mesalamine
Routes - mesalamine
lots! po, suppository, rectal suspension, retention enema
Which corticosteroid is preferred for IBD?
Controlled release budesonide (Entocort EC)
Why are steroids typically given IV during severe IBD?
because npo…resting the gut
Corticosteroids - ADE
secondary adrenal insufficiency (HPA suppression) osteoporosis PUD impaired wound healing worsening or cause DM
*UC - General Treatment (Mild/Mod)
5-ASA like Mesalamine (oral +/- enema) or steroid like Budenosine or Infliximab
*UC - General Treatment (Severe)
TNF-alpha antagonists + oral therapies or IV steroids x 3-5 days or IV Cyclosporine
*UC - General Maintenance
5-ASA like mesalamine (oral +/- enema)
NOT steroids
*CD - General Treatment (Mild)
Budesonide or mesalamine +/- metronidazole
*CD - General Treatment (Mod)
same as mild
+/- steroids, azathioprine, MTX, TNF-alpha antagonists
*CD - General Treatment (Severe)
Steroids x 7-28 days +/- metronidazole +/- steroids, azathioprine, MTX or TNF-alpha antagonists
*CD - General Maintenance
(budesonide or mesalamine) or azathioprine or TNF-alpha antagonists
NOT steroids
*Lubiprostone - MOA
local chloride channel activator that enhances a chloride-rich intestinal fluid secretion without altering Na and K concentrations in the serum
*Adalimumab (Humira) and InfliXimab (Remicade)- class?
TNF alpha antagonist
*TNF alpha antagonist - MOA
breakdown granulomas leading to the dissemination of TB being confined
*Methotrexate - MOA
inhibits dihydrofolic acid reductase –> interferes with DNA synthesis, repair and cellular regulation
