Exam 2 Flashcards
What is upper endoscopy (esophagogastroduodenoscopy) the study of choice for
Evaluating persistent heartburn, dysphagia, odynophagia and structural abnormalities detected on barium esophagography
What is video esophagogography (videofluoorscopy) the study of choice to evaluate
Uses barium; oropharyngeal dysphagia
What is barium esophagography used to evaluate
Esophageal dysphasia *first evaluation is with a Radiographic barium study -> differentiates between mechanical lesions and motility disorders; barium study is more sensitive for detecting subtle esophageal narrowing due to rings, achalasia and proximal esophageal lesions
When do you use esophageal manometry
Establish etiology of dysphagia in patients in whom a mechanical obstruction cannot be found *especially if achalasia is suspected
What are the two systems used for esophageal pH recording
- catheter based: long trans nasal catheter connected to a recording device
- wireless: capsule attached to esophageal mucosa under endoscopic visualization and data transmitted via radiotelemetry to recording device
When do you use pH recording
In patients with atypical reflux symptoms or persistent sx despite PPI
What are some neuro differentials for dysphagia
Brainstem CVA, ALS, MS, pseudobulbar palsy, post polio, guillain barre, Parkinson’s, Huntington, dementia, tardive dyskinesia
What are some metabolic disorders that can cause dysphagia
Thyrotoxicosis, amyloidosis, Cushing, Wilson, med side effects
How does mechanical obstruction present
Solid foods worse than liquids
How does schatzki ring present
Intermittent dysphagia; not progressive
How does peptic stricture present
Chronic heartburn; progressive dysphagia
How does esophageal cancer present
Progressive dysphagia; age over 50
How does eosinophilic esophagitis present
Young adults; small caliber lumen, proximal stricture, corrugated. Rings, or white papules
How do motility disorders present
Solid AND liquids hard to swallow
How does achalasia present
Progressive dysphagia
How does diffuse esophageal spasm present
Intermittent not progressive; may have chest pain
How does scleroderma present
Chronic heartburn, raynaud
What are the sx of oropharyngeal dysphasia vs esophageal dysphasia
Oropharyngeal: localized to neck, nasal regurgitation, aspiration, assoc ENT sx
Esophageal: localized to chest or neck; food impaction
What would you use to dx GERD
PH testing; *if alarm sx -> EGD
How do you treat GERD
If no red flags, acid suppression and lifestyle modifications -> decrease ETOH and caffeine, small low fat meals, bed at an incline, assess psychosocial situation, PPI first line; H pylori eradication if indicated
What are the alarm features for GERD sx.
Weight loss, persistent vomiting, constant or severe pain, dysphagia/odynophagia, hematemesis, melena, anemia
What are the atypical or extraesophageal manifestations of GERD
Asthma, chronic cough, chronic laryngitis (laryngopharyngeal reflux), sore throat, non-cardiac chest pain, sleep disturbances
What is the treatment of extraesophageal reflux manifestations occur for GERD
Twice daily PPI for 2-3 months; improvement of extraesophageal manifestations suggests but does not prove that reflux is cause
What is killians triangle
Where zenker occurs
What are the risk factors for Barrett
Chronic reflux; truncates obesity independent of GERD
Does Barrett product specific sx
No
Do PPIs cause regression of Barrett
No but can reduct risk of cancer
When do you do preventative screening for esophageal adenocarcinoma
Patients with GERD WITH multiple risk factors (hiatal hernia, obesity, white Rae, male, age over 50)
What is the surveillance of those with Barrett
Endoscopy every 3-5 years
What are the sx of peptic stricture
Gradual development of solid food dysphagia over months to years; reduction in heartburn b cause stricture acts as a barrier to reflux
How do you dx peptic stricture
Endoscopy with biopsy is mandatory in all cases
What is the treatment for peptic stricture
Dilation at time of endoscopy; long term therapy with PPI required to decrease risk of stricture recurrence
What are the risks for development of squamous cell carcinoma of the esophagus
Smoking, alcohol, achalasia, Plummer Vinson, tylosis, lye ingestion, hot beverages
What are the most commonly implicated causes of pill induced esophagitis
NSAIDs, potassium chloride, quinidine, zalcitabine, zidovudine, biphsophate meds (*alendronate and risedronate), emperonium bromide, iron, vit C< and *abx
What can you do to prevent pill induced esophagitis
Take pills w/ 4 oz of water and remain upright for 30 min after ingestion; known offending agents should not be given to ppl with esophageal dysmotility, dysphagia or strictures
What are the risk factors for candida esophagitis
Diabetes, systemic corticosteroids, radiation, systemic abx
Which infection of the esophagus can infect normal hosts
HSV
How do you treat CMV esophagitis
Ganciclovir; side effect: neutropenia
How do you treat candida esophagitis
Systemic fluconazole
What should you look at first if someone has just ingested toxins (caustic esophageal injuries)
Circulatory status and assessment of airways and oropharyngeal mucosa (laryngoscopy); chest and ab radiographs to look for pneumonitis or free perforation
What is the treatment for caustic esophageal injury
ICU; initial: supportive with IVF, IV PPI to prevent gastric stress ulceration and analgesics; nasogastric lovage and oral antidotes are dangerous and should NOT*** be given; laryngoscopy should be performed in pts with ARDS to assess need for trach; endoscopy within first 24 hours; if signs of severe injury -> NPO, nasogastric feeding tube, oral feeding after 2-3 days, *no oral corticosteroids or abs; esophageal strictures occur in many with severe injury; warrants endoscopic surveillance 15-20 yrs after incidence for evaluation of SCC
Who is eosinophilic esophagitis more common in
Men
How do you dx eosinophilic esophagitis
Barium swallow: will show multiple concentric rings
- trial of PPI for 2 months to exclude GERD
- endoscopy with esophageal bx required for dx
What does eosinophilic esophagitis look like
White exudates or papules, red furrow,s corrugated concentric rings and strictures
What are the risk factors for esopageal webs
Congenital, Plummer Vinson, eosinophilic esophagitis, graft vs host, pemphigoid, epidermolysis bullosa, pemphigus vulgaris
What is used for dx of esophageal webs and rings
Barium esophagography
What are esophageal rings usually associated with
Hiatal hernia
What is used to dx zenker
Video esophagography
What is kollonychia
Spoon nails
What is feline esophagus a feature of
Eosinophilic esophagitis
What are the risks of bleeding of esophageal varices
Size, presence of red wale markings (dilated longitudinal vessels on variceal surface), severity of liver dz, active alcohol abuse
What is the treatment for esophageal variceal bleeding
Fresh frozen plasma or platelets, vitamin K IV; abx prophylaxis (increased risk of gram neg infection) *fluoroquinolones or 3rd gen cephalosporins preferred; somatostatin and octreotide to reduce portal HTN and lactulose for encephalopathy
What is the goal of beta blocker therapy to prevent variceal bleeding
HR falls by 25% or reaches 55-60 bpm; as long as systolic BP >90 and no side effects
What is balloon tube tamponade
Used for esophageal varices; complications: esoph and oral ulceration, perforation, aspiration and airway obstruction; used for temporizing measure only in patients with bleeding that cannot be controlled until TIPS procedure can be provided
What is TIPS procedure
Transvenous intrahepatic portosystemic shunts; wire passed through jugular v and mesh stent is passed through liver parenchyma creating portosystemic shunt from portal to hepatic v; can control acute hem but has increased risk of encephalopathy; lowers risk of rebleeding but does not decrease mortality *reserved for ppl with 2 or more episodes of bleeding that have failed other therapies
What is required for the dx of achalasia
Barium esophagography followed by EGD to evaluate distal esophagus to exude distal stricture or carcinoma; esophageal manometry confirms dx
What is the tx for achalasia
Botulinum toxin injection, pneumatic dilation, surgery; all rx once daily PPI
What is nutcracker esophagus
Hypertensive peristalsis; LES relaxes normally but elevated pressure at baseline; dysphasia to solid and liquids; intermittent; dx via manometry and video fluoroscopy
What is diffuse esophageal spasm
Uncoordinated esophageal contraction; corkscrew esophagus, rosary bead esophagus on barium x ray; LES is normal; dysphasia to solids and liquids, intermittent; dx via manometry, EGD, barium swallow
How do you confirm esophageal perforation
Contrast swallow usually gastrografin followed by thin barium
How do you treat esophageal perforation
NGT suction, NPO, parenteral abx and surgery
What are the signs of pneumomediastinum
- subcutaneous emphysema in neck or precordial area
- hammans sign: crunching rasping sound heard over precordium mainly during systole and in L lateral decubitus position
- dyspnea * do not measure peak exploratory flow rate because can exacerbate sx -> use pulse oximetry
What are the causes of gastroparesis
DM, postviral, postvagotomy
What are the causes of hemorrhagic gastritis
- aspirin
- stress ulcers
- alcoholic, portal HTN gastropathy
- uncommon causes; ischemia, ingestion of damaging agent, radiation
What are the risk factors for stress gastritis
-mechanical ventilation, coagulopathy, trauma, surgery, burns, shock, sepsis, CNS injury, liver failure, kidney dz, multiorgan failure
What reduces the risk of stress related bleeding
Enteral nutrition
What reduces the incidence of stress ulcer
PPI or H2 blocker
What is the most common clinical manifestation of erosive gastritis
Upper GI bleeding; presents as hematemesis, coffee ground emesis or bloody aspirate in patient receiving nasogastric suction, or melena
How do you dx erosive gastritis
Upper endoscopy -> no significant inflammation on histo
How do you prevent stress ulcers in critically ill patients
Hourly oral administration of liquid antacids, sucralfate or IV PPI
What is Type A gastritis
FUNDIC type; body-predominant and less common form; asymptomatic; common in elderly; AI mech assoc with achlorhydria, pernicious anemia and increased risk of gastric cancer *autoimmune gastritis
What is type B gastritis
Antral type (h pylori); infection early in life or in setting of malnutrition or low gastric acid output is associated with gastritis of entire stomach and increased risk of gastric CA
What part of the stomach does menetrier dz affect
Body
What is anasarca
Generalized edema
What can be used to treat menetrier dz
Cetuximab (ab to EGFR)
What ages are duodenal vs stomach ulcers more prominent
Duodenal: 30-55
Gastric: 55-70
What are descriptions used for epigastric pain caused by PUD
Gnawing, dull, aching, hunger like ; many experience periodicity (periods with no symptoms)
Does nasogastric lavage negative for blood exclude active bleeding from duodenal ulcer
No
Where does h pylori infect to cause duodenal vs gastric ulcers
Duodenal: gastric antrum
Gastric: gastric body (decreases acid)
What do you do after eradicating H pylori
If ulcer is large or complicated, continue tx with PPI q day for 4-6 wks
When do you confirm eradication of h pylori
At least 4 wks after completion of abx thx and 1-2 wks after PPI thx
When are the risk of NSAID complications greater
People over 60, people with previous ulcer, ppl who take NSAIDs + aspirin, corticosteroids, or anticoagulants; within first 3 months of therapy
What are other causes of PUD
Smoking, hypercalcemia, mast oxytocin’s, blood group O (antigens bind h pylori), corticosteroids, alcohol
What is the most sensitive and specific test for h pylori
Stool antigen; urea breath test (false negative with recent therapy)
What do you test for on histo when testing for h pylori
Warthin silver stain or rapid CLO (clofaximine test); false negative with recent PPI, abx, or bismuth compounds
Is serology helpful to show eradication of h pylori
No; shows IgA abs (takes months to go away)
What does leukocytosis suggest in the setting of PUD
Penetration or perforation
Why may the BUN rise in PUD
Absorption of nitrogen from small intestine and presently azotemia
What is the treatment for active GIB
Continuous infusion of PPI IV starting with a bonus; once stable needs EGD
What is dumping syndrome
Rapid gastric emptying, abdominal distress and postprandial vasomotor sx as a result of gastric surgery for PUD
What is bezoar
Small mass of undigested material that accumulates in Gi tract
What ddx should you consider for upper GIB
PUD, erosive gastritis, AV malformation, Mallory Weiss tear, esophageal varices
What ddx should you consider for epigastric pain (dyspepsia)
PUD (severe is uncommon unless perforated), functional dyspepsia (no organic explanation), typical GERD, gastric cancer, food poisoning, viral gastroenteritis, biliary tract dz,
What complications do COX-2 inhibitors cause
CV complications; decreases vascular prostacyclin; Celebrex is equal risk to NSAIDs (usually greater risk)
What are the clinical features of duodenal vs gastric ulcers
Duodenal: pain 1-3 hours after meals; often nocturnal; relieved by food
Gastric: made worse by food (within 30 min of eating); N/anorexia, food aversion, rarely weight loss
What is important in the dx of GASTRIC ulcer
*exclude malignancy
What is the treatment for both duodenal and gastric ulcers
Eradicate h pylor, PPI or H2 blocker for 4-6wks (duodenal) or 6-8 wks (gastric)
What kind of ulcers have a risk factor of smoking
Gastric
What diet factors are risks for gastric adenocarcinoma
Smoked meats and fish, pickled vegetables, nitrosamines, benzpyrene, reduced intake of fruits and veggies
Which blood type is assoc with higher risk of gastric adenocarcinoma
A
When should you consider ZE
When ulcer dz is refractory to therapy, ulcers in weird places, assoc with diarrhea (NG tube can fix this), steatorrhea, weight loss
What is MEN 1
Gastrinoma, hyperparathyroidism (increased calcium) and pituitary neoplasm
What is the confirmatory test for diagnosis of ZE
Gastrin > 1000 ng/L drawn fasting and on acid suppression meds; secretin stimulation test is positive
What is the most sensitive test for detecting primary tumors and Mets of ZE
Radiolabeled octreotide scanning; somatostatin receptor scintigraphy with single photon emission CT allows total body imaging for detection of primary gastrinomas
What should you do in all patients with ZE
Draw: serum PTH, prolactin, LH and FSH, and GH to exclude MEN 1
How do you treat patients with MEN 1
Treat hyperparathryoidism first (may improve hypergastrinemia); for unresectable tumors -> parietal cell vagotomy; chemo
What is the inheritance pattern of MEN 1
AD
What imaging do you do for gastroparesis
Gastric scintigraphy with low fat solid meal; assesses gastric emptying; gastric retention of 60% after 2 hrs or more than 10% after 4 hrs is abnormal
How do you treat gastroparesis
No specific therapy; for acute exacerbation -> NG suction and IV fluid; eat small frequent meals low in fiber, milk, gas forming foods and fat; avoid opioids and anticholinergic; *in DM maintain glucose below 200 mg/dL (can cause gastroparesis even without neuropathy); metoclopramide and erythromycin beneficial (meto -> tardive dyskinesia)
What are the true liver function tests
PT/INR, albumin, cholesterol
What can cause severe (vs mild) elevations of aminotransferases
Acute viral hep, medications, ischemic hep, autoimmune hep, Wilson, acute bile duct obstruction, acute budd chiari syndrome, hepatic artery ligation
What are some nonhepatic causes of aminotransferase elevation
Strenuous exercise, hemolysis, myopathy, thyroid dz, macro-AST
What are nonhepatic sources of AST
Skeletal m, cardiac m, RBCs
What are nonhepatic sources for ALT
Skeletal m, cardiac m, kidneys
What are nonhepatic sources for LDH
Heart, RBC
What are nonhepatic sources for alk phosphatase
Bone, first trimester placenta, kidneys, intestines
What can cause drug induced cholestasis
- non-inflammatory: anabolic steroids, azathiprine, cyclosporine, diclofenac, estrogens, Indinavir, tamoxifen
- inflammatory: amoxicillin-clavulanic acid, azathriprine, azithromycin, celecoxib, cephalosporins, erythromycin, penicillamine
What would be in your ddx for someone who is immunocompromised with acute hep
CMV, EBV, HSV
What is the prodrome of hep A
Anorexia, N/V, malaise, aversion to smoking
What does IgG anti-HAV in absence of IgM anti-HAV indicate
Previous exposure to HAV, non-infectious and immunity
What is the prodrome of Hep B
N/V, anorexia, malaise, aversion to smoking
What can HBV be associated with
Glomerulonephritis, serum sickness, polyarteritis nodosa
Is cholestasis a feature of Hep A or B
A *elevated alk and bilirubin
What do you give to someone who has been exposed to HBV
Hep B immune globulin (hbig) 14 days after exposure plus the vaccine
What is detected during the window period for HBV
Anti-HBc
What is detected during acute infxn of HBV
HBsAg, anti-HBc, HBeAg, HBV DNA
What is detected in someone who was previously infected with HBV
Anti-HBs, Anti-HBc (IgG only)
What indicates a chronic infxn of HBV
HBsAg, anti-HBc (IgM and IgG), HBeAg, HBV DNA
What does someone who is immune to HBV have
Anti-HBs
Besides pregnant women, who has an increased chance of progressing to chronic HEV infection
Transplant patients treated with tacrolimus
What does anti-HCV without HCV RNA indicate
Recovery; rare
What vaccinations should be given to someone with chronic liver dz
HAV and HBV
What are complications of HCV
HCC, cirrhosis, mixed cryoglobulinemia and membranoproliferative glomerulonephritis, lichen planus, AI thyroiditis, lymphocytic sialadenitis, idiopathic pulm fibrosis, sporadic porphyria cutanea , monoclonal gammopathies ; increased risk of non-Hodgkin lymphoma
What does chronic HCV do to cholesterol
Decreases serum level
What is the histo classification of chronic hep
Grade: histo assessment of necrosis and inflammation activity
Stage: level of dz progression; based on degree of fibrosis
What are the extrahepatic manifestations of HBV
Urticaria, arthritis, polyarteritis nodosa vascuitis, polyneuropathy, glomerulonephritis
What are the extrahepatic manifestations of HCV
Mixed cryooblobulinemia, porphyria cutanea tarda, membranoproliferative glommerulonephritis, lymphocytic sialadenitis
What test can ID presence or absence of fibrosis in chronic hep
Serum fibrosure or US elastography
What are idiosyncratic drugs
Variable doses and time of onset for drug induced hep; eg: isoniazid, halothane, phenytoin, methyldopa, carbamazepine, diclofenac, sulfonamides
What do you do for acetominophen OD
Sulfhydryl compounds (N-acetylcysteine) within 8 hrs; measure levels and plot on rumak Matthew chart
What is fulminant hep
Massive hep necrosis with impaired consciousness occurring within 8 wks of onset
What is the treatment for fulminant hep
Supportive: maintain fluid balance, support circulation and resp, control bleeding, restrict protein intake, oral lactulose or neomycin administered; prophylactic abx *one factor that improves survival; liver transplant
What is maddrey’s discriminating function
Calculates PT and serum bilirubin; values >32 poor prognosis for alcoholic liver dz
What is Glasgow alcoholic hep score
Predicts mortality based on age, serum bilirubin, BUN, prothrombin time, and peripheral WBC count; >9 who receive glucocorticoids have higher survival rates
How do you treat alcoholic hepatitis
Low protein diet, daily multivitamin, thiamine, folic acid, zinc, glucose administration increases thiamine requirement and can precipitate korsakoff if thiamine not coadministered, if severe -> corticosteroids; pentoxifylline improves survival (decreases chance of hepatorenal syndrome)
What are ppl with metabolic syndrome at risk fo
CV dz, kidney dz, and colorectal cancer
People with what condition are at increased risk for NAFLD
Psoriasis
What protects against NAFLD
Coffee and physical activity v
What imaging would you do for NAFLD
US, CT or MRI to see microvascular steatosis
People with PBC may have a history of _____-
UTI, smoking, use of hormone replacement therapy, hair dye
What dz are associated with PBC
Sjogren, collagen vascular z, thyroiditis, glomerulonephritis, pernicious anemia, renal tubular acidosis
What is cholestyramine used for
Itching
What abs are present for type I AI hep
Anti smooth muscle and antinuclear
What are the extrahepatic manifestations of autoimmune hep
Rash, arthralgias, keratoconjunctivitis sicca, thyroiditis, hemolytic anemia, nephritis, UC
What is the tx for autoimmune hep
Glucocorticoids, azathioprine, monitor liver functions
What infections are people with hemochromatosis at increased risk for
Vibrio vulnificus, listeria, yersinia and siderophilic organisms
What imaging would you do for hemochromatosis
MRI to assess degree of fibrosis and hepatic iron stores
When would you do a live bx for someone with hemochromatosis
If homozygous; dont do if serum ferritin less than 1000 and ast is Normal
What food should you avoid if you have hemochromatosis
Red meat, alcohol, vitamin C, raw shellfish and supplemental iron
What is the tx for hemochromatosis
Weekly phlebotomy until deplete iron stores, then maintain with phlebotomy every 2-4 months; PPI to reduce iron absorption; chelating agent deferoxamine for pts with anemia or secondary iron overload that cannot tolerate phlebotomies
What is hepatolenticualr degeneration
Wilson
When should you consider Wilson’s
In any child or young adults with hep, splenomegaly with hypersplenism, negative Coombs test for hemolytic anemia, portal HTN and neuro abnormalities
What conditions are associated with Wilson
Renal calculi, aminoaciduria, renal tubular acidosis, hypoparathyroidism, infertility, hemolytic anemia, subcutaneous lipomas
What would you see on imaging for hepatic vein obstruction (budd chiari)
Prominent caudate liver lobe *screening test of choice is contrast enhanced CEUS; can use color or pulsed Doppler US; MRI will show obstructed vessels; direct venom rapid will show cavalry webs and occluded veins (spider web pattern)
What lobes do people with antitrypsin deficiency have emphysema in
Lower lobes (smokers are upper)
What can protect against ischemic hep
Statin
What is the hallmark of ischemic hep
Elevation of aminotransferases often greater than 5000 units/L
What is hepatojugular reflux
When you press on the liver, causes jugular distention; seen in right sided heart failure
What are the causes of noncirrhotic portal HTN
Portal v thrombosis, splenic v obstruction, schisto
How does splenic v obstruction present
Gastric varices without esophageal varices
What imaging should you use for noncirrhotic causes of portal HTN
Color Doppler US and contrast CT
What is the treatment for splenic v thrombosis
Splenectomy
What is charcot’s triad
Fever, RUQ pain, jaundice
What risk is pyogenic liver abscess associated with
GI malignancy
What is the most common cause of hepatic abscess in the US
Ascending cholangitis
What are the most frequently identified organisms causing hepatic abscesses
E. coli, klebsiella pneumoniae, proteus vulgaris, enterobacter aerogenes, strep angiosus (microaerophilic and anaerobic species)
What imaging would you use for a pyogenic liver abscess
- Chest radiograph show elevation of diaphragm if in right lobe
- US, CT, MRI can show intrahepatic lesions
- MRI: characteristic finding is high signal intensity on T2-weighted image
What causes cavernous hemangioma to enlarge
Women taking hormonal therapy
Is focal nodular hyperplasia a true neoplasm
No; proliferation of hepatocytes in response to altered blood flow; stain for glutamine syntahse
What is the difference between focal nodular hyperplasia and hepatocellular adenoma
Hepatocellular adenoma is hypovascular and focal nodular hyperplasia is hypervascular
How can you distinguish focal nodular hyperplasia from hepatocellular adnoma
Arterial phase helical Ct and multiphase dynamic MRI with contrast
What is the treatment for focal nodular hyperplasia
Affected women undergo annual us for 2-3 yrs
What lab findings would you see with cirrhosis
CBC: anemia (microcytic, macrocytic or hemolytic); pancytopenia - Low wbc, platelets and hb
Prolonged Pt
-Chemistry: hyponatremia, hypokalemic alkalosis, glucose disturbances, hypoalbuminemia
Consumption of what reduces the risk of cirrhosis
Coffee and tea
What is cardiac cirrhosis
Caused by constrictive pericarditis or heart failure
What do you order for the child Pugh scoring system
CMP or hepatic function panel (bilirubin, albumin, PT/INR); PE for ascites and encephalopathy
What pressure is increased with portal HTN
Hydrostatic
When do you give beta blockers to patients with varices
Large; small if have variceal red wale marks and advanced cirrhosis (B or C)
Do varices themselves cause any sx
No
If you need to do an emergent endoscopy on someone with active variceal bleeding, what must you also do
Endotracheal intubation
What are Minnesota and sengstaken-blakemore tubes?
Balloon tamponade used for esophageal varices; provides control of hemorrhage
What are complications of balloon tamponade
Esophageal and oral ulceration, perforation, aspiration and airway obstruction
What are the stages of encephalopathy
Mild confusion, drowsiness, stupor and coma
What test is used to detect hepatic encephalopathy
EncephalApp or stroop test
Do serum ammonia levels tell you the progression of encephalopathy
No
What are precipitants of hepatic encephalopathy
Gi bleed, azotemia, consolation, high protein meal, hypokalemic alkalosis, CNS depressants, hypoxia, hypercarbia, sepsis
What is the treatment for hepatic encephalopathy
Lactulose (nonabsorbable disaccharide) results in colonic acidification and diarrhea -> goal to produce 2-3 stools per day; poorly absorbed abx used if cant tolerate lactulose
When should tuberculous peritonitis be considered
In immigrants, immunocompromised, or severely malnourished
What is the test of choice for establishing a dx of ascites
Ab ultrasound
When is abdominal paracentesis performed
All patients with new onset ascites or when patients with known ascites deteriorate clinically to exclude spontaneous bacterial peritonitis
What do you always test ascitic fluid for
Cell count (WBC w/ diff), albumin and total protein, culture and gram stain
What is suggestive of spontaneous bacterial peritonitis
PMN count of greater than 250/mcL (neutrocytic ascites)
What is the best single test for classification of ascites
Serum ascites albumin gradient (SAAG)
- portal HTN (SAAG of 1.1 or more)
- nonportal HTN (SAAG of less than 1.1)
How do you calculate SAAG
Subtracting ascitic fluid albumin from serum albumin
What are optional tests of ascitic fluid
Amylase (pancreatic ascites; perforation of GI tract), bilirubin (perforation of biliary tree), creatinine (leakage of urine), cytology (for carcinomatosis), adenosine delaminates (tuberculous)
What causes of ascites would fall under an SAAG for >1.1
Hepatic congestion (heart failure, tricuspid insufficiency, budd chiari, Veno occlusive dz), liver dz, portal v occlusion, myxedema
What causes of ascites would fall under SAAG <1.1
Hypoalbuminemia (nephrotic syndrome, protein losing enteropathy, severe malnutrition with anasarca), chylous ascites, pancreatic, bile, nephrogenic, urine, ovarian dz, infections, malignant conditions, familial Mediterranean fever, Vasculitis, granulomatous peritonitis, eosinophilic peritonitis
What are the most common pathogens that cause spontaneous bacterial peritonitis
Gram negative (e coli, klebsiella), gram positive bacteria (strep pneumoniae and viridans, enterococcus) ***no anaerobic
What are the sx of spontaneous bacterial peritonitis
Fever and ab pain; can present with change in mental status, worsening of renal fxn
What must you distinguish spontaneous bacterial peritonitis from
Secondary bacterial peritonitis (from other source like appendicitis) **presence of multiple organisms on ascitis fluid gram stain is diagnostic of secondary
How do you prevent spontaneous bacterial peritonitis
Oral once daily norfloxacin, ciprofloxacin or trimethoprim sulfamethoxazole
How do you treat spontaneous bacterial peritonitis
Third gen cephalosporins or combination of beta lactam/beta lactamase agent (ampicillin/sulbactam); DO NOT use aminoglycosides (b/c renal failure); IV albumin to reduce risk of kidney failure
How do you treat secondary bacterial peritonitis
Broad spectrum coverage
How do you treat recurrent spontaneous bacterial peritonitis
Liver transplant
What causes carinomatosis
Adenocarcinoma of the ovary, uterus, pancreas, stomach, colon, lung
Do malignant ascites respond to diuretics
No
What is familial Mediterranean fever
AR; lack protease in serosal fluids; present before age 20; episodic bouts of acute peritontisis associated with serositis of joints and pleura *attacks resolve in 24-48 hrs without treatment; colchicine reduces severity of attacks; main COD -> amyloidosis with renal or hep involvement
What will chest radiograph reveal in half of patients with mesothelioma
Pulmonary asbestosis
What does the ascitic fluid look like in primary mesothelioma
Hemorrhagic; cytology negative; ab CT reveals sheet like masses
How is dx of mesothelioma made
Laparotomy or laparoscopy; prognosis is extremely poor
What is chylous ascites
Accumulation of lipid rich lymph; milky appearance; triglyceride level greater than 1000 mg/dL; usual cause is lymph obstruction or leakage by malignancy (lymphoma)
What does pancreatic ascites look like
High protein level; amylase in excess
What does paracentesis of bile ascites show
Yellow fluid; bilirubin: serum bilirubin > 1
Which vaccine should people with cirrhosis receive
HAV, HBV, pneumococcal, and yearly influenza
Which drugs are contraindicated in people with cirrhosis
NSAIDs, angiotensin-converting enzyme inhibitors, angiotensin II. Antagonists
What do you need to monitor in someone on spironolactone
Hyperkalemia
What is associated with mortality after TIPS
Chronic kidney dz, diastolic cardiac dysfunction, refractory encephalopathy, hyperbilirubinemia
What are the complications of TIPS
Hepatic encephalopathy, infection, shunt stenosis, shunt occlusion
What is the difference between fulminant and subfulminant hepatic failure
Fulminant: encephalopathy and coagulopathy within 8 wks
Sub: later
How is liver transplant prioritization established
MELD score
What do you order for a MELD score
CMP (bilirubin and creatinine) and PT/INR; measures mortality risk in patients with ESLD; *MELD score > 14 required for liver transplant listing
What are clinical predictors of re-bleeding and death in a GI emergency
Age > 60, comborbid illnesses, systoli BP <90, HR >90 and bright red blood in NG aspirate or rectal exam
What are the signs of shock
Hypotension, tachycardia, oliguria (decreased urine output), altered mental status, tachypnea (>24 breaths/min), met acidosis, elevated lactate
How do you stabilize someone in shock
2 large bore (18 gauge or larger) IV lines; give NS or lactated ringers
What does octreotide do
Reduces splanchnic blood flow and portal BP; effective in initial control of bleeding related to portal HTN; administered to all patients with active upper GIB and evidence of over dz or portal HTN
What should be considered if hypotension presents early with ab pain
Ruptured AAA, mesenteric infarction, acute pancreatitis
Where does ulcer penetration occur
Posterior wall -> penetrates into other structures; pain radiates to back and is unresponsive to antacids; treat with PPI and monitored; if no improvement -> surgery
What is gastric outlet obstruction
More commonly caused by gastric neoplasms -> obstructs pylorus; upper endoscopy performed
What should be in your ddx from someone under 50 with lower GIB
Infectious colitis, anorectal dz, IBD; younger than 40 -> neoplasms , crohn, celiac and meckel
What is the most common cause of lower tract bleeding
Diverticulosis; painless
What should be included in your ddx of someone over 50 with lower GIB
Diverticulosis, angiectasias, malignancy, ischemia
Who are angectasias more common in
Over 70 with chronic renal failure
What do maroon stools imply
Lesion in right colon or small intestine
What do black tarry stools suggest
Source proximal to lig of treitz
What does bloody diarrhea with cramping suggest
IBD, infectious colitis or ischemic colitis
What is a therapeutic colonoscopy for lower bleed
Epi injection, cautery, or application of metallic clips or bands
How do you treat hemorrhage from diverticulosis
Self limited
What are the characteristics of acute mesenteric ischemia
Periumbilical pain out of proportion to tenderness; writhing in pain but PE unremarkable; food fear; N/V/distention; ab x-ray shows air fluid levels, thumb-printing (submucosal edema) *CT angiography study of choice; anticoagulation for mesenteric venous thrombosis but not arterial
What does ischemic colitis imaging show
Ab X-ray shows colonic dilation and thumb printing
Sigmoidoscopy shows submucosal hemorrhage, friability, ulceration
What is anoscopic exam used to visualize
Hemorrhoids
What should be performed in ALL patients with hematochezia
Proctosigmoidoscopy or colonoscopy
How do you treat the pain of hemorrhoids
Stool softeners, sitz baths, witch hazel and analgesics
What are characteristics of anal fissures
Due to straining or trauma; tearing pain during defecation followed by throbbing discomfort that can lead to constipation due to fear of recurrent pain; confirmed by looking at anal verge (look like cracks in epithelium); chronic results in fibrosis and development of skin tag
What are treatments for anal fissures
Relaxation of anal canal with nitroglycerin ointment or botulinum toxin; surgical if very severe: internal anal sphincterotomy
How is occult GIB detected
Positive fecal occult blood test, fecal immunochemical test (FIT) or by iron deficiency anemia in absence of visible blood loss
What should patients with iron deficiency anemia be evaluated for
Celiac dz
What is the most useful diagnostic tool for dx of meckel’s
Technetium-99m scan
What are some causes of toxic megacolon
UC, C diff, Ogilvie syndrome
What are the atypical presentations of appendicitis
- retrocecal: less intense and poorly localized pain; Psoas positive
- pelvic: pain in lower ab with urge to urinate or dedicate; ab tenderness absent; obturator sign present
What imaging is used to dx appendicitis
Ultrasound and CT
What is appendectomy before age 21 protective for
UC
How do you treat intestinal obstruction
NG tube decompression and fluid resuscitation; urgent laparotomy for lysis of adhesions must be performed before bowel ischemia develops
What is acute paralytic ileus
Neurogenic failure or loss of peristalsis in intestine in the absence of any mechanical obstruction
How is postoperative ileus reduced
Use of epidural analgesia, avoidance of IV opioids, early ambulation, gum chewing, and initiation of a clear liquid diet
What is ogilvie syndrome
Acute colonic pseudo obstruction; arises in post op state or with severe medical illness; minimal pain and tenderness, severe ab distention; massive dilation of cecum or right colon
What is reynod’s pentad
Charcots triad plus hypotension and confusion -> can result from acute suppurative cholangitis
What do you use to monitor AAA
US
What are risk factors for ectopic pregnancy
PID, infertility, ruptured appendix, prior tubal surgery
Where do most ovarian torsions occur
Right side because increased length of utero-ovarian ligament on the right
What are the risk factors for ovarian torsion
Pregnancy due to enlarged corpus luteum, presence of large ovarian cysts, chemical induction of ovulation, tubal ligation
What is the presentation of ovarian torsion
Unilateral lower ab pain upon exertion
Is the testicle of neonates with prenatal torsion salvageable
No
What imaging is used to dx scrotal torsion
Doppler US
Which ethnicities are IBD more prevalent in
Jewish then non-Jewish whites
What are the extraintestinal manifestations of IBD
Peripheral arthritis, erythema nodosum, aphthous ulcers, pyoderma gangrenosum, conjunctivitis, fatty liver, PSC, thromboembolic events (DVT), nephrolithiasis with irate or calcium oxalate stones
How do you distinguish between UC and infectious enterocolitis
Stool studies and biopsy
Do erythema nodosum and pyoderma gangrenosum occur more commonly with UC or CD
UC
How do you decrease the risk of colon CA with UC
Long term 5 ASA therapy and ingestion of folic acid
Is hypokalemia seen in UC or CD
UC
Would you see hypoalbuminemia in UC or CD
CD
What lab findings would you see in both CD and UC
Anemia, leukocytosis, increased sedimentation rate and CRP level; fecal calprotein levesl increased
What dx studies should b e used for UC
Sigmoidoscopy study of choice; do not do colonoscopy in ppl with bad UC; plan X ray to assess colonic dilation; *lead pipe -. Loss of haustra
What is Prometheus IBD serology 7
Used when cannot decide if UC or CD: includes abs to pANCA, abs to saccharomyes cerevisiae,
How do you dx and treat an abscess caused by crohns
Emergent CT; broad spectrum abx; drainage usually required
How do you treat intestinal obstruction caused by CD
IV fluids with nasogastric suction; placed on low-roughage diet (no raw fruits or veggies, popcorn, nuts)
What is the best noninvasive study for evaluating perianal fistula
Pelvic MRI
What is the treatment for perianal lesions
Oral abx (metronidzole or ciprofloxacin)
What is recommended in patients who have had 100 cm or more of their terminal ileum resected due to crohns
Low fat diet bc fat malabsorption; parenteral vit B 12
When do you give bile salt binding agents (cholestyramine or colesevelam)
Patients with crohns with involvement of terminal ileum -> prevents secretory diarrhea; NOT in patients with extensive ileal dz
How do oxalate kidney stones develop in crohns
Unabsorbed fA bind with calcium, decreasing its absorption and increasing the absorption of oxalate therefore give calcium supplements
What are the adverse effects of glucocorticoids
Mood changes, insomnia, buffalo hump, weight gain (striae), edema, increased glucose, acne and moon fancies
What are the long term side effects of corticosteroids
Osteoporosis, osteonecrosis of femoral head, myopathy, cataracts, calcium and vit D supplementation
What are the side effects of 5-ASA
Acute interstitial nephritis
What is sulfasalazine always administered with
Folate
What should you test for prior to use of TNF abs
Latent tubercuosis with PPD testing and CXR
What do anti-TNF therapies increase the risk for
Non-melanoma skin cA and non-Hodgkin lymphoma
Can the GB be visualized in dubin Johnson syndrome
NO; but can be in rotor
What increases the risk of occurrence of intrahepatic cholestasis of pregnancy
Another pregnancy or use of OCP
What further work up needs to be done if conjugated bilirubin found to be elevated
Viral hep, AMA, ceruloplasmin, ferritin, iron saturation, lipase/amylase
What is the dx test for obstructive jaundice
US; followed by cholangiography
What most commonly occurs persistent mild elevations of ALT and AST
NAFLD
How would biliary dyskinesia present
RUQ pain, normal US, pain longer than 30 min, recurrent sx, not received by BM or antacids; normal liver enzymes, conjugated bilirubin and amylase/lipase; *HIDA scan -> normal (GB visualized within 1 hour)
What is a CCK-HIDA
Tests ejection fraction of GB; less than 35-38% is abnormal -> cholecystectomy
What is protective against gallstones
Low carb diet, physical activity, caffeine in women, high intake of Mg and polyunsaturated fat in men, high fiber diet and statin, ASA and NSAIDs
What are findings of acute cholecystitis on US
GB wall thickening, pericholecystic fluid, and sonographic Murphy sign
What is the procedure of choice for choledocholithiasis
ERCP with sphincterotomy and stone extraction or stent placement
How can you visualize porcelain GB
KUB
When should you do a cholecystectomy in someone with gallstones
Symptomatic, previous complications, underlying condition predisposing to increased risk of complications, pt with gallstones >3 cm
How do you treat acute cholecystitis
NPO, NG suction, IV fluids and electrolytes, analgesia, abx,
What would be the test of choice for ischemic colitis
CT angiography
What do you need to do before an ERCP
Measure INR, pregnancy test, kidney fxn
What needs to be done before a HIDA scan (PIPIDA)
NPO 4-6 hrs before testing; no opiates for 4 half lives of the drug or 6 hrs prior to study, withhold calcium channel blockers, octreotide, progesterone, indomethacin, theophylline, bento, H2 blockers
What is an oral cholecystogram/ography
OCG; contrast tablets swallowed night before exam, X-RAY taken, evaluate GB
What is cholangiography
Uses iodine; percutaneous transheptic
What is the criteria for dx of acute pancreatitis
Two of three: ab pain in epigastric that may radiate to back, threefold or greater elevation in serum lipase and/or amylase, confirmatory findings of acute pancreatitis on cross sectional ab imaging
What are risk factors for acute pancreatitis
Smoking, high dietary glycemic load, ab adiposity, increased age and obesity
What are protective factors against acute pancreatitis
Eating vegetables, use of statins
What is the pain of pancreatitis described as
Boring
What must you rule out if amylase is 3x the upper limit
Salivary gland dz and intestinal perforation
What conditions can also have elevated amylase
High intestinal obstruction, gastroenteritis, mumps, ectopic pregnancy, administration of opioids, after ab surgery
What are associated with an increase in mortality rate of pancreatitis
Hypoalbunemia and elevated serum LDH
What is a sentinel loop
Segment of air filled SI most commonly in LUQ; seen on imagine for pancreatitis
What is the colon cutoff sign
Gas filled segment of transverse colon abruptly ending at the area of pancreatic inflammation (absence of gas distal to splenic flexure caused by colonic spasm rom pancreatic inflammation)
What is used to confirm presence of acute pancreatitis
CT WITHOUT contrast
When is rapid bonus IV contrast enhanced CT used for pancreatitis
Following volume resuscitation after 3 days of severe acute pancreatitis; avoid if serum Cr >1/5
Seeing what on perfusion CT is associate with higher mortality rate of pancreatitis
Fluid collection
What can be used to drain a pseudocyst
Endoscopic ultrasound
What is a complication of ERCP
Pancreatitis
When would you do an ERCP for pancreatitis
Not after first attack unless associated cholangitis, jaundice, or bile duct stone
What is the most important treatment for pancreatitis
Aggressive IV fluid resuscitation
What are the risk factors for 3rd spacing with pancreatitis
Younger age, alcohol etiology, higher hematocrit value, higher serum glucose, systemic inflammatory response syndrome in first 48 hours of hospital admission
If you have hypocalcemia with pancreatitis, what must you give
Calcium gluconate
What does administration of fresh frozen plasma or serum albumin increase the risk of
ARDS
If fluids and RBC replacement doesn’t improve shock in pancreatitis patients, what do you do
Pressers
What are complications of SAP
Necrotizing pancreatitis, multi organ failure, volume depletion, ileus
How do you assess severity of pancreatitis
APACHE II (for all ICU patients), Beside index for severity in acute pancreatitis (BISAP) = BUN >25, impaired mental status, SIRS, age >60, pleural effusion; HAPS (harmless acute pancreatitis score) predicts non-severe course (no ab tenderness, rebound or guarding, normal hematocrit, normal Cr)
What is the ransom criteria pneumonic
GA-LAW; C & HOBBS; stands for: glucose >200, age >55, LDH >350, AST >250, WBC > 16k; calcium <8, hematocrit drop >10%, oxygen <60mmHg, base deficit >4, BUN increase >5, squesteration of fluid >6L
What is the class of pancreatitis using Atlanta criteria
Mild: no organ failure; no local complications
Moderate: transient organ failure <48 hrs; plus or minus local complications
Severe: persistent organ failure >48 hrs
What is autoimmune pancreatitis associated with
Hypergammaglobulinemia (IgG4)
Is there a specific lab test for chronic pancreatitis
No; amylase and lipase often normal
What test would you run on someone with suspected pancreatic steatorrhea
Fecal elastase 1 and small bowel bx
What should be given for pain with chronic pancreatitis
Acetominophen, NSAIDs, tramadol along with tricyclic antidepressants, SSRI and gabapentin or pregabalin (can lower pain med requirement)
Addiction to what is common with chronic pancreatitis
Opioids or narcotics
What is MEN 1
Two or more of the following: parathyroid -> hypercalcemia increased PTH; pancreas (gastrinoma or insulinoma), pituitary
What is men 2A
Thyroid: medullary thyroid CA; elevated calcitonin -> low calcium
Adrenal: pheochromocytoma
Parathyroid: hyeprcalcemia
*can have normal calcium b/c balances out; 5% develop hirschsprung
What is MEN 2B
Marfanoid body habitus, medullary thyroid CA, pheocrhomocytomas, neuromas (on lips, tongue, mouth eyelids)
What is the difference between GER and GERD in a baby
GER: passage of gastric contents into esophagus; happy spitter
GERD: sx or complications as a result of GER; hard to feed, cry a lot, arch and scream, hard to gain weight
When should a child have surgery for GERD
Only if puts nutrition or respiratory status at risk; more common in developmentally delayed children; fundoplication
Where do most cases of intussusception occur
Ileocolic; ileum invaginates into colon at ileocecal valve
What does air enema show with intusseception
Coiled spring appearance
What is the treatment for intusseception
In first 48 hrs -> hydrostatic reduction with contrast enema or pneumatic reduction with air enema *DONT DO EITHER IF PERITONEAL SIGNS
What is the classic metabolic picture of a child with pyloric stenosis
Hypochloremic, hypokalemic, metabolic alkalosis; lose HCl via emesis; kidney holds on to hydrogen at expense of potassium
How do you treat hirschsprung
2 stages: diverting colostomy with bowel that contains ganglion cells; then aganglionic portion removed
What is unconjugated bilirubin usually bound to
Albumin; can be displaced by meds like ceftriaxone
What are examples of non-path causes of neonatal jaundice
Physiologic jaundice, breast milk and breast feeding jaundice
What is the difference between breast feeding and breast milk jaundice
Feeding: function of dehydration and decreased excretion of bilirubin in stool
Milk: deconjugating enzymes
Is conjugated hyperbilirubinemia ever non pathologic
No
What are the path causes off unconjugated hyperbilirubinemia
- increased bilirubin production: erythrocytes enzyme deficiencies, blood group incompatibility, G6PD def
- impaired conjugation
- increased enterohepatic circulation: decreased intake, decreased passage of stool
When should the infant’s cord blood be evaluated
When mom is type O or Rh negative; test for direct ab (Coombs), blood type, and Rh
What are some causes of conjugated hyperbilirubinemia
UTI, biliary atresia/cholestasis, hypothyroidism, galactosemia
What are the phases of acute bilirubin toxicity (with high unconjugated hyperbilirubinemia)
- phase 1: first 1-2 days; poor suck, high pitched cry, stupor, hypotonia, seizures
- phase 2: middle of first week; hypertonic of extensor mm, opisthotonus, retrocollis, fever
- phase 3: after first week; hypertonic
What is BIND
Bilirubin induced neurological dysfunction
How does jaundice progress
Cephalad -> caudad
During what gestational weeks are infants most at risk for developing hyperbilirubinemia
35-36
What labs should you order if the conjugated bilirubin is elevated
Urine culture, blood cultures
How do you treat mild jaundice
No phototherapy; increase frequency of feedings; continue breast feeding but if inadequent give supplemental breast milk or formula
When is exchange transfusion considered
When bili > 25 of sx of encephalopathy
What are the sx of biliary atresia
Cholestatic jaundice, hepatomegaly, acholic stools
What causes idiopathic neonatal hepatitis
Aka giant cell hepatitis; prolonged cholestatis jaundice; liver bx shows disrupted hepatic structure
What is alagille syndrome
Bile duct paucity or arteriohepatic dysplasia; AD; reduction of intrahepatic bile duct
Which crigler najar does bilirubin decrease with phenobarbital
II
What are the different types of stool according to the chart
1: separate hard lumps (hard to pass)
2: sausage shaped but lumpy
3: like a sausage but with cracks
4: soft and smooth sausage
5: soft blobs
6: fluffy mushy
7: pure liquid
What are the reasons to not do a digital rectal exam
The patient has leukopenia
What is melanosis coli
Hyperpigmentation of the colon caused by chronic use of laxatives
What is the definition of acute diarrhea
Less than 2. Wks
What are the most common causes of chronic diarrhea
IBS, meds, lactose intolerance; *presence of nocturnal diarrhea, weight loss, anemia, or positive FOBT warrants further testing
What lab tests should you order for chronic diarrhea
CBC, serum electrolytes, liver fxn, calcium, phosphorous, albumin, TSH, vit A and D, INR, ESR, CRP
What does increased ESR or CRP suggest
IBD
What should you analyze stool for for chronic diarrhea
Electrolytes to calculate osmotic gap (high in osmotic diarrhea or disorder of malabsorption), fat (Sudan stain), leukocytes, calprotectin, lactoferrin (IBD), fecal antigen for giardia and e histolytics, acid fast for cryptosporidium and cyclosporine
When would patients with chronic diarrhea undergo colonoscopy vs endoscopy
Colon: exclude IBD, colonic neoplasia
Endo: small intestine malabsorption disorder (celiac, whipple); in AIDS patients for cryptosporidium and M Avium intracellular
When should neuroendocrine tumors be considered for cause of chronic diarrhea
High volume watery diarrhea that persists during fasting with a normal osmotic gap
What can you test for for a neuroendocrine tumor
VIP (VIPoma), calcitonin, gastrin, urinary 5-hydroxyindoleacetic acid (carcinoid)
What does the hydrogen breath test test for
Carb malabsorption and lactase deficiency
What meds cause microscopic colitis
NSAIDs PPI, ACE inhibitors, SSRI, beta blockers
How do you treat microscopic colitis
Loperamide
What is characteristic of bile salt malabsorption
No weight loss, but deficiencies in ADEK
What are the extrainestinal manifestations of Celiac
Iron deficiency anemia, dermatitis herpetiformis, osteoporosis, depression, fatigue, delayed puberty, amenorrhea, reduced fertility
What is dermatitis herpetiformis
Purification papulovesicles over extensor surfaces of extremities and trunk, scalp and neck
What GI dz can be suggested with elevated alkaline phosphatase but normal GGT
Celiac (malabsorption of calcium)
What would you look for when testing for celiac in someone with IgA def
IgG ab to deamidated gliadin peptides (antiDGP)
When will abs show up when testing for celiac
Only if actually eating gluten
What else are celiac patients also likely to have an intolerance to
Lactose
What are the characteristics of t whipple I
PAS positive, gram positive
What does whipple look like on EM
Trilammellar wall
How do you confirm a dx of bacterial overgrowth
Jejunal aspiration with quantititative bacterial culture
What are causes of bacterial overgrowth
Gastric achlorhydria (PPI therapy), stagnation, motility disorders (DM, vagotomy), gastrocolic or coloenteric fistula
What is short bowel syndrome
Malabsorptive condition caused by removal of small intestine parts; most common causes: crohn, mesenteric infarct, radiation enteritis, volvulus, tumor resection, trauma; depends on length and despite of removal
What is needed to maintain oral nutrition when resecting bowel
At least 200 cm of proximal jejunum
What will be malabsorbed if you remove the duodenum
Folate, iron or calcium; use antidiarrheal agents; octreotide reduces intestinal transit time
What complications SI resection
Gastric hypersecretion; use PPI
What is the most common GI dz in clinical practice
IBS
What is Rome Criteria
Recurrent ab pain or discomfort for at least 3 days per month in last 3 months associated with 2 or more of: improvement with defecation, onset assoc with change in frequency in stool, onset associated with change in appareance of stool
What dietary therapy can help IBS
Low FODMAP diet
What is ogilvie syndrome
Aka acute colonic pseudo-obstruction; spontaneous massive dilation of cecum or right colon w/o mech obstruction; can usually still pass stool; cecal diameter >10-12 risk of colonic perforation
How do you treat ogilvie syndrome
Conservative in patients with smaller than 12 cm dilation, no fever, no leukocytosis; NG and rectal tube placed; ambulated periodically; no oral laxatives *assess cecal size every 12 hours; intervention if *no improvement within 48 hrs, cecal dilation >10 for prolonged period, >12 cm -> neostigmine, colonoscopic decompression
What is the difference between abx assoc diarrhea andd colitis
Diarrhea: occurs during period of abx exposure
Colitis: C diff; TcdA and B toxins *most common after use of ampicillin, clindamycin, 3rd gen cephalosporins, and fluoroquinolones
What should be considered in all hospital patients with unexplained leukocytosis
C diff
What test should you use to test for c diff toxins
PCR - more sensitive than EIA and are able to detect NAP1 hypervirulent strain
What is the presentation of diverticulitis
Constipation -> loose stools because inflammation only allows this to pass
How do you confirm diverticulitis
CT with contrast
What is complicated during an acute attack of diverticulitis
Colonoscopy
What can cause anorectal infections
Gonorhea, syphylis, chlamydia, herpes 2
How do you test for gonorhea
Rectal swabs
What causes condylomata acuminata vs condyloma Lata
Acuminata: HPV
Lata:syphilis
When should you screen for colorectal cancer
45-75
What mutation is common in adenomas vs serrated polyps
Adenomas: APC
Serrated: BRAF activation, MLH-1/MSH-2, or Kras mutation
What is FIT
Fecal immunochemical test - used for colon ca detection
What other kind of cancer are you at risk for with lynch syndrome
Endometrial, ovarian, renal or bladder, Hepatobiliary, gastric, and SI at a young age
What are the extraintestinal manifestations of FAP
Soft tissue tumors of skin, desmoid tumors, osteomas, congenital hypertrophy of the retinal pigment
What other mutation can cause FAP
MuTYH (AR) APC is AD
What should be done to treat ppl with lynch syndrome
Subtotal colectomy with ileorectal anastomoses and surveillance of stump; women undergo pelvic exam, Transvag US, and endometrial sampling (hysterectomy recommended after child bearing years); screening for gastric cA with upper endoscopy beginning at 30
What do you see with cowden syndrome
Hamartomatous polyps and lipomas throughout GI tract, trichilemmomas, and cerebellar lesions
What causes pseudo diarrhea
IBS or proctitis
What is the difference between enterotoxin and entero-adherent pathogens
Entero-adherent: not as much vomiting, but more ab cramping and fever
What food sweetener causes diarrhea
Sorbitol
When do you need to work up acute diarrhea
Dysentery, hypotension, tachycardia, profuse diarrhea (6> per day), fever >101 (38.5), recent abx use, severe ab pain, elderly, immunocompromised, Cr >1.5 times normal, peripheral leukocytes
Which organisms need special cultures
EHEC, vibrio, yersinia, C diff toxin, ova parasites, stool antigen
What organism is found in lunch meat
Listeria
What are the features of staph aureus
Gram positive cocci, clusters, preformed enterotoxins
What are the characteristics of shigella
Gram negative rods; non-motile; enterotoxin shiga toxin; lettuce, raw veggies, fever; fecal leukocytes
What are the characteristics of typhimurium
Gram negative rod; fever; fecal leukocytes; self limited; exposure to reptiles (turtles), ducks and birds *no ab
What are the features of campylobacter
Gram negative spiral shaped rod; fecal leukocytes; self limited; no abx; need campy blood agar to culture; oxidase positive, motile with cork-screw motion
What is vibrio parahemolyticus
Gram negative bacilli; causes seafood associated diarrhea; cytotoxic production; watery or bloody diarrhea
What is vibrio vulnificus
Gram negative; salt water; open would can cause bullous skin lesions; life threatening in immunocompromised especially in cirrhosis and hemochromatosis patients
What is aeromonas hydrophila
Grade negative non spore forming rod shaped faculative anaerobes with flagellum; fresh water; eating fish; necrotizing fasciitis
What is the most common pathogen for travelers diarrhea
ETEC
Does EHEC typically produce a fever
No
What are the characteristics of listeria
Gram positive rod; predilection for pregnant women and hemochromatosis; dx via blood culture
What does rotavirus look like on EM
Wagon wheel appearance
What does adenovirus cause
Fever, chills, myalgia, sore throat, conjunctivitis (most common cause in kids), pharyngitis; prolonged course
What is the most common cause of dysentery in the world
E histolytica
How do you dx E histolytics
Stool ova and parasite or stool antigen; will have fecal leukocytes; treat with metronidazole
Will you see fecal leukocytes with G lamblia
No; check stool for ova parasites and stool antigen
What would you see on micro for cryptosporidium
Acid fast staining, direct fluorescent ab; no fecal leukocytes
Those infected with what are at greater risk for strongyloides stercoralis infection
Human T cell lymphotropic virus
How do you dx strongyloides
Rhabditiform larvae in stool; eosinophils in stool
Where do you get cyclospora cayetanesis
Produce from endemic areas or travel; watery diarrhea; fecal leukocytes negative; resistant to chloride and iodine; dx via oocysts in stool sample
What is cystoisospora belli
Causes acute non bloody watery diarrhea; can last for weeks; severe in immunosuppressed; need repeated stool examinations, if negative do a duodenal biopsy; stain modified acid fast
What can schistoma Mansoni cause
Bloody stools, bladder cancer, liver cysts
What can taenia solium cause
Seizures
In general, when will you see fecal leukocytes
Inflammatory - bloody diarrhea; with the exception of listeria and c diff
When can you use anti motility agents
No fever, no blood; but NOT in EHEC or c diff
What diet should ppl with infectious diarrhea be on
BRAT; bananas, rice, applesauce, toast
What are alcohol gels ineffective against
Norovirus and c diff
What are side effects of bismuth subsalicylate
Darkening of tongue and stools
What can yersiniosis lead to
Autoimmune thyroiditis, pericarditis, and glomerulonephritis
What is the difference in presentation of a pathogen that affects the small vs large bowel
Small: large volume watery stools, ab cramps, weight loss; no WBCs in stool; dehydration
Large:frequent small volume stools; assoc with fever, blood or WBCs in stool
What are the types of antacids and supplements
- low systemic: aluminum, calcium, magnesium
- high systemic: sodium
- supplemental: simethicone
What is the MOA of antacids
Combine with hydrogen ions; increases LES tone; DO NOT reduce acid secretion or production -> rebound acid production possible
Which antacids have a rapid onset
Calcium, magnesium, and sodium
Which antacids have a long duration of action
Calcium and magnesium
Which antacid has the best aid neutralizing capability
Calcium
What is simethicone
Aids in expulsion of gas
What are the side effects of aluminum
Constipation, hypophosphatemia (acute treatment for hyperphosphatemia)
What are the side effects of magnesium
Diarrhea, hypermagnesemia
What are the adverse effects of calcium
Consolation, hypercalcemia (milk alkali syndrome -> nephropathy and metabolic alkalosis), hypophosphatemia, calcium based kidney stones
What are the side effects of sodium anatacids
Gas, hypernatremia, metabolic alkalosis
What are important patient factors to consider when giving antacids
Dosage form, presence of renal or heart dz, electrolyte status, diseases assoc with diarrhea and constipation
When should you take antacids if you are on other medications
1-2 hours before other mediations or 2-4 hours after
What is the surface acting anti ulcer agent
Sucralfate
What is the only histamine blocker that is PO only
Nizatidine
What is the onset of action for H2 blockers
Longer than antacids but shorter than PPI
How long does it take an ulcer to heal on H2 blockers
4-8 wks
What are the more rare side effects of H2 blockers
More likely with long term use; cimetidine: decreases testosterone binding to androgen receptor (gynecomastia in men, galactorrhea in women); neutropenia or thrombocytopenia
What drug interactions exist with H2 blockers
Cimetidine inhibitor of CYP450; ranitidine also weak CYP450 inhibitor
What are the contraindications for H2 blockers
Pregnancy; only if necessary - ranitidine
Which PPIs can only be given PO
Ompeprazole, lansoprazole, deslansoprazole, rabeprazole
What are the side effects of PPI
C diff, kidney dz, bone fractures, MI
What drug interactions exist with PPI
Omeprazole is CYP450 inhibitor
What are the contraindications for PPI
Pregnancy; only if necessary - lansoprazole
What dose sucralfate do
Band aid; can also stimulate prostaglandin and mucus production
What are the side effects of sucralfate
Constipation
What are the contraindications to use of sucralfate
Severe renal failure (contains aluminum)
What is the dosing for sucralfate
4 times a day
What does misoprostol do
Increases mucosal blood flow, stimulates bicarbonate and mucus production; reduces acid output
What is the indication for use of misoprostol
Prevention of NSAID induced ulceration in patients at high risk
What else can misoprostol be used for
With mifepristone for pregnancy termination, alone for cervical ripening, postpartum hemorrhaging
What are the contraindications for misoprostol
Pregnancy, IBD
What do bismuth compounds do
Anti bacterial; OTC for heartburn, indigestion and diarrhea; Rx: in combo with abx for h pylori
What are the adverse effects of bismuth compounds
Consipation, black dark regularly formed stools
What are the contraindications for bismuth compounds
Relative: pt on anti platelets or anticoagulants, severe renal failure
Absolute: allergy, GI bleed
What do you need for treatment of h pylori
At least 2 abx and PPI or H2 blocker
What is the first line therapy for h pylori
10-14 days of a PPI, clarithromycin, and either amoxicillin or metronidazole *all BID
What is the quadruple therapy for h pylori
PPI (BID), metronidazole, tetracycline and bismuth subsalicylate (QID)
What is Prevpac and omeclamox
Both given BID
- prevpac:amoxicillin, clarithromycin, lansoprazole
- Omeclamox: amoxicillin, clarithromycin, omeprazole
What is holiday
QID
Bismuth subsalicylate, metronidazole, tetracycline Plus a PPI
What is pylera
3 capsules QID
Bismuth, metronidazole, tetracycline, PPI
When do you discontinue PPI after eradicatin of h pylori
2-3 wks after
How do you treat someone with h pylori with a penicillin allergy
Metronidazole substitution
How do you treat metronidazole resistant h pylori
Substitute tetracycline; consider quadruple
How do you treat clarithromycin resistant h pylori
Substitute amoxicillin or tetracycline; consider quadruple
How should you treat a pregnant patient with PUD without h pylori
Short course of antacids or sucralfate; moderate: ranitidine; severe: lansoprazole
If someone is at NSAID risk for ulcer what should you do
Change to acetominophen or if NSAID required, COX-2 NSAID and PPI or misoprostol
Which receptors are targeted for anti nausea therapy
5HT3, H1, M1, D2, NK1 (neurokinin)
What do all the serotonin antagonists end in
-setron
Which serotonin antagonist has a SQ injection form
Granisetron
What is alosetron indicated for
IBS-D; PO
What are serotonin antagonists used for
Chemo induced NV, radiation induced, post operative, pregnancy
What is the worst side effect of serotonin antagonists
QT prolongation and torsade’s; dolasetron high risk - no longer used for chemo prophylaxis
Which serotonin receptor antagonists have longer half lives
Palonosetron and granisetron; used for delayed-chemo induced as a single dose
What do the neurokinin antagonists end in
-pitant
When are netupitant and fosnetupitant given
Only in combo with palonosetron; fos is prodrug
Which neurokinin antagonists are PO
Aprepitant, netupitant
What are neurokinin antagonists used for
Chemo induced (most effective with serotonin antagonists combo); prophylaxis of post op *only aprepitant
What are the histamine 1 antagonists
Diphenhydramine, dimenhydrinate, hydroxyzine, promethazine, meclizine, cyclizine
What is doxylamine used for
Used with B6 as inital therapy for NVP
How strong are the antiemetic activity of histamine 1 blockers
Weak; have anticholinergic properties
What is the only indication for meclizine and cylizine
Motion sickness/vertigo
How is hydroxzine administered
IM
What are the D2 antagonists
Phenothiazines: chlorpromazine, perphenazine, prochlorperazine
Which D2 antagonists is PO only
Perphenazine
What is metoclopramide used to treat
Dysmotility; stimulates Ach in gut and increases LES tone
Are dopamine antagonists used for chemo induced vomiting
Yes but in combo with other agents
What are the side effects of dopamine antagonist
Anticholinergic effects, arrhythmia
What is scopolamine
Muscarinic antagonist; patch for 72 hrs; weak antiemetic for motion sickness end of life care;
What are the canniboid agonists
Dronabinol, nabilone
What kind of antiemetic properties do cannabinoids have
Strong; reserved fro treatment of chemo induced *IF treatment resistant; decreases excitation of neurons and minimizes serotonin release; also used for appetite stimulation in anorexic patients
What drug interactions do cannabinoids have
Caution use with other CNS depressants and CV agents and sympathomimetics
What is the high emetogenic regimen for chemo induced nausea
NK receptor antagonist, serotonin antagonist, corticosteroid; give day before for acute and 3 days after for delayed
What is the moderate emetogenic regimen for chemo induced nausea
Serotonin antagonist (palonosetron,granisetron SQ), corticosteroid; give day before and 3 days after; can add NK antagonist or olanzapine or cannabinoid after going up to 3 drug regimen
What is the low emetogenic regimen
One drug of the following: corticosteroid, serotonin antagonist, metoclopramide, prochlorperazine; give day of
What is given for minimal emetogenic regimen
NOTHING
How do you treat breakthrough nausea
One agent from different class to current regimen
What can you use for pregnancy induced nausea
Vit B6 or histamine antagonist with B6 or serotonin antagonist; dopamine antagonist, steroid or different dopamine antagonist
What can be given for motion sickness
Scopolamine, dimenhydrinate, meclizine
Which classes of drugs are used for diarrhea
Prostaglandin inhibitors, opioid agonists, serotonin antagonists, chloride channel inhibitors
What is loperamide
Related to opioids but does not produce opiate like effects; slows motility; side effects: fatigue, urinary retention
What is diphenoxylate
Opiate agonist (C-V); opioid effects seen at high doses; has small quantity of atropine; antipropulsive
What is eluxadoline
Agonist at opioid mu and kappa; anti propulsive; antagonist at delta receptor - decreases secretions; indicated for IBS-D
What are the side effects of eluxadoline (C-IV)
Hepatic/pancreatic toxicity; pancreatitis high risk in patients without a gallbladder
What are the contraindications of eluxadoline
Biliary duct obstruction, sphincter of oddi dysfunction, alcoholism, history of pancreatitis, severe hepatic impairment; *stop therapy if severe constipation lasts 4 or more days
What is alosetron indicated for
Chronic severe IBS-D not responsive to other treatment
What is the major side effect of alosetron
Ischemic colitis; *no refills without follow up exam, physician must enroll in prescribing program, must sign risk-benefit, must sign a statement adhering to therapy plan, self training and testing by physicians to learn to appropriatedly dx IBS required
What are the contraindications of alosetron
History of GI obstruction, perforation, toxic megacolon, diverticulitis, crohns, UC, impaired circulation, severe consipation -> DC immediately
What is crofelemer
Cl channel inhibitor; derived from sap; MOA: blocks CFTR and calcium chloride channels; indicated for non infectious diarrhea in HIV AIDs patients on anti retroviral therapy; side effects: infections of resp/urinary
Which class of drugs is used for ab pain
Antimuscarininc -> hyoscyamine, dicyclomine, clidinium/chlordiazepoxide
Which drug classes are used for constipation
Laxative and cathartic agents, peripheral opioid antagonists, guanylate Cyclase c agonist, selective chloride channel activators
What is linaclotide
Guanylate Cyclase c agonist; increases cGMP; stimulates secretion of chloride/bicarbonate into lumen via CFTR -> increased fluid and accelerated transit; indicated for IBS-C and chronic idiopathic consipation
What is lubiprostone
Prostaglandin derivative; increases intestinal fluid secretion by activated chloride channels; indicated for IBS-C, chronic idiopathic constipation, opioid induced constipation in non-cancer/past cancer adults
What is methylnaltrexone
- relistor: IV/PO, naloxegol: PO, alvimopan PO *Hospital use only
- peripheral mu opioid antagonist; indicated for opioid induced constipation (non-cancer/past cancer); alvimpoan only for accelerating time to GI recovering following bowel resection with anastomoses (prevents post op ileus)
What are the side effects of alvimopan
MI; max 15 doses
What are the classifications of laxatives and cathartic
- stimulants: bisacodyl, castor oil, glycerin, senna, Na picosulfate
- osmotic: lactulose, mag citrate, PEG, sorbitol
- saline’s: mag hydroxide, Na phosphate
- bulk form: dietary fiber, psyllium, methylcellulose, calcium polycarbophil
- stool softeners: docusate, mineral oil
What are the adverse effects of bulk forming agents
Bloating/obstruction (drink fluids - caution in renal failure); lots of drug interactions
What are stool softeners also called
Surfactant and emollient agents
Which stimulant is also osmotic
Sodium picosulfate; also glycerin
What is castor oil hydrolyzed to
Ricinoleic acid
Which laxative has a pretty quick onset of action compared to others
Stimulants
What are the adverse effects of stimulants
Urine discoloration (senna), fluid/electrolyte disturbances with long use
What are the contraindications/cautions of stimulants
GI obstruction, ileus; passed through breast milk
What route can bisacodyl and glycerin be given
PR; faster onset
When is prepopik and large dose PEG used
Pre colonoscopy ONLY
How do saline agents work
They are poorly absorbed so make hyperosmolar solutions and pulls in water; greater volume shortens transit time
What drug interactions/cautions need to be taken with saline agents
Interact with diuretics; cautions: renal dz, CHF/HTN
Besides constipation, what else is lactulose used for
Liver dz (hyperammonia); change in pH traps ammonia in GI
What is the treatment for c diff
Severe: vancomycin
Mild: metronidazole or if oral administration doesn’t work for patient
Recurrent: fidaxomicin; spares anaerobic colonic flora
What are the classes of vancomycin, metronidazole and fidaxomicin
Vancomycin: glycopeptide
Fidaxomicin: macrolide
What do you use to treat h pylori
Bismuth subsalicylate, metronidazole, tetracycline, omeprazole
What is the life cycle of e histolytica
Trophozoite -> binucleated precyst -> tetranucleated cyst
What are the therapeutic goals of treating e histolytica
- eliminate invading trophozoites: metronidazole or tinidazole
- eradicate intestinal carriage of organism - paramomycin or iodoquinol
How do you treat asymptomatic carriage of e histolytica
(Cysts or trophozoites w/o internalized RBC); treat with luminal amebicide agents (paromomycin or iodoquinol)
What is the MOA of iodoquinol
Unknown; most retained in intestine and excreted in feces; adverse effects: diarrhea, nausea, ab pain, HA, rash, itching
What drug class are paromomycin and iodoquinol
Paromomycin: aminoglycoside
Iodoquinol: 8-hydroxyquinolines
What is the first line agent for treatment of giardia
Tinidazole; *metronidazole NOT approved for this indication; can also use nitazoxanide
What is the MOA of nitazoxanide
Inhibits pyruvate ferredoxin oxioreductase; * prodrug -> active is tizaxanide; rapidly absorbed; adverse effects: increased appetite, Flatus, enlarged salivary glands, yellow eyes, dysuria, bright yellow urine
What are the characteristics of cryptosprodium parvum
Oocysts with 4 motile sporozoites; life cycle occurs within intestinal cells
What is the treatment for cryptosporidium parvum
Antidiarrheal agent -> loperamide
Antimicrobial agents: nitazoxanide (preferred), paromomycin
What does cryptosprodium parvum treatment depend on
Immune status
- HIV: antiretroviral therapy with nitazoxanide
- other: reduce immunosuppressant and add nitazoxanide
How do you dx nematodes
Eggs in feces; round worms; immune response is to dead worms and eggs
Are eggs passed in the stool with strongyloides
No; dx with larvae in feces
What are the characteristics of trichuris trichuria
Whip worm; ingestion of eggs -> eggs hatch -> produce more eggs; * no larvae, no transit through intestinal wall, no lung involvement, no eosinophilia, no auto infection; dx: football shaped egg in feces
What is the treatment for nematodes (necator, ancylostoma, strongyloides, ascaris, trichuris, enterobius)
Albendazole, Mebendazole, ivermectin, thiabendazole, Pyrantel pamoate
What is the MOA of albendazole and mebendazole
Inhibits microtubule synthesis, paralyzes worms, worms pass in stool; *prodrug
What is the MOA of thiabendazole
Same as albendzaole; but a lot of side effects: dizziness, anorexia, vomiting, irreversible liver failure and fatal Stevens Johnson syndrome
What is the MOA of ivermectin
Intensifies GABA mediated transmission in peripheral n of nematodes; dont combine with other GABA drugs (benzo, barbiturates, valproic acid)
What is the MOA of pyrantel pamoate
Neuromuscular blocking agent causes release of Ach and inbhition of cholineterase -» paralysis of nematodes; poorly absorbed
Which nematodes does albendazole cover
N Americanus, a duodenale, a lumbricoides, e vermicularis
Alternative therapy for strongyloides and trichuris
What nematodes does mebendazole cover
Ascaris, trichuria, e vermicularis
Alternative for americanus and duodenale
What nematodes does ivermectin cover
Strongyloides*
Alternative for ascaris, second alternative for trichuria, poor against americanus and duodenale
What nematodes does pyrantel pamoate cover
E vermicularis; alternative for americanus and duodenale
What are the types of schistoma and where does each reside
Japonicum and mansoni (intestines); haematobium (bladder)
What are the clinical manifestations of schistoma
Dermatitis, katayma fever, chronic fibrosis
What is the treatment for schistoma
Praziquantel
What is the MOA of praziquantel
Increases permeability of worm cell membranes to calcium -> paralysis and death; excreted by kidneys; side effects: headache, lassitude; low grade fever, itching
What do solium vs saginata attach via
Solium: hooks
Saginata: suckers
What do you use to treat cestodes
Praziquantel, Niclosamide, albendazole
What is the MOA of niclosamide
Not effective against hydatid cyst; inhibition of oxidative phosphorylation or stimulation of ATPase activity; oral administration; use limited by side effects; need long duration of therapy
What drug classes are used to treat UC
5-ASA, Jack stat inhibitors, TNF alpha inhibitors, alpha 4 integrity inhibitors
What drug classes are used to treat crohn dz
IL-12/23 inhibitors, TNF alpha inhibitors, alpha integrity inhibitors
What do all ASA meds have in their names
Sala
What is the MOA Of 5-ASA agents
Reduction in PMN and macrophage recruitment; can also inhibit NFkB pathway
What is sulfasalazine
Sulfapyridine + 5-ASA
What is mesalamine
Single 5-ASA
What is olsalazine
2 molecules of 5-ASA
What is balsalazide
Inert carrier and 5-ASA
What are the diff distributions of ASA tx
Oral: throughout GI tract
Rectal: splenic flexure
Suppositories: reach upper rectum
Which ASA agents have fewer side effects
The ones without sulfa
What are the indications for use of 5ASA
Active and maintenance of mild-moderate UC; except olsalazine only for maintenance and balsalazide only for active dz in males
What is the MOA of TNF alpha inhibitors
Blocks leukocyte migraition to site of inflammation
What are the TNF alpha inhibitors
Adalimumab, infliximab, golimumab, certolizumab (recombinant ab fragment (Fab)); all IgG abs
Which TNF alpha inhibitor is used for UC ONLY
Golimumab
Which TNF alpha inhibitor is used for CD ONLY
Certolizumab
What are the side effects of TNF alpha inhibitors
Infections; need TB testing, liver toxicity, dermatologic, malignancies
What are the indications of TNF alpha inhibitors
Active and maintenance; used only after inadequate response to conventional or immunosuppressant therapy
What are the maintenance doses for each of the TNF alpha inhibitors
- adalimumab: SQ every 2 weeks
- infliximab: IV every 8 weeks
- golimumab: SQ every 4 weeks
- certolizumab: SQ every 4 weeks
What are the alpha 4 integrin inhibitors
Natalizumab and vedolizumab; both IgG
Which alpha 4 integrin inhibitor is only for CD
Natalizumab
What are the side effects of alpha 4 integrin inhibitors (natalizumab)
PML; treatment >2 yrs, prior immunosuppressant treatment, anti-JC virus abs are risk factors
What are the indications for alpha 4 integrin inhibitors
Active and maintenance; used after failed immunosuppressant or TNF alpha inhibitor therapy
What is the maintenance dose for each of the alpha 4 integrin inhibitors
- natalizumab: IV every 4 weeks
- vedolizumab: IV every 8 weeks
What is the IL-12/23 inhibitor
Ustekinumab: IgG ab; also indicated for plaque psoriasis and psoriatic arthritis
What are the side effects of IL-12/23 inhibitors
Infections *TB testing, increased risk of malignancy
What are the indications for IL-12/23 inhibitors
Active and maintenance for CD for patients intolerant to immunosuppressants, steroids, or TNF alpha therapy
What is the dosing for ustekinumab
IV as single infusion and SQ every 8 weeks for maintenance
What is the jak stat inhibitor
Tofacitinib; oral; indicated for psoriatic and RA; side effects: lymphopenia/lymphocytosis, neutropenia, anemia, increased LDL and HDL, increased malignancy
What are the indications for jak stat inhibitors
Active and maintenance of UC *do not use in combo with anything else
What is the dosing for tofacitinib
PO BID
What are the indications for steroids
Acute and or sever UC and CD OR steroid dependent; use lowest dose for shortest amount of time
When are IFN alpha use
Treatment of patients with well compensated liver dz; not long term treatment or planning to be pregnant within next 2-3 yrs
What are the cons of IFN alpha treatment for HBV
Parenteral administration; expensive; side effect: flue like syndrome, dangerous in decompensated cirrhosis
What is the MOA of IFN
Protect nearby healthy cells by allowing them to mount defense; signal macrophage and NK to clear infected cell; act in auto rinse fashion to stimulate lysosome lysis
How does IFN alpha work
Binds to type 1 IFN receptor and activates JAK1 and tyrosine kinase 2 -> phosphorylation of type 1 IFN receptor -> recruitment of STAT1/2 -> transcribe genes
What are the mechanisms of IFN stimulated genes (ISGs)
Inhibit steps of viral replication; ZAP, IFIT, OAS-RNAseL pathway, PKR
What does PEGylated IFN alpha increase levels of during treatment
ALT; but means its working
What toxicities are IFN treatment assoc with
Bone marrow suppression; neurotoxicity (behavioral changes)
What are the characteristics of nucleosides/tides for HBV treatment
HBV DNA RT/DNApol inhibitors; oral*; better tolerated than IFN treatment and higher response; *can be used in patients with decompensated cirrhosis
What is are examples of nucleoside drugs
Lamivudine, telbivudine, entecavine
How can HBV become resistant to nucleoside/tide treatment
Impaired purine/pyramiding kinase activity
What is an example of a nucleotide drug
Tenofovir and adefovir
What is the first line treatment for wild type HBV
Tenofovir (analog of adenosine); used in patients with lamivudine, telbbivudine or entecivir resistance; side effects: proximal renal tubule nephrotoxicity
What is entecavir
Guanosine nucleoside; first line HBV agent; low rate of resistance (except in those who are also resistant to lamivudine); better choice than adefovir or tenofovir in patients with renal insufficiency
Does lamivudine have long term efficacy
No; resistance
What is the treatment for HCV
24-48 wk course of PEGylated IFN plus ribavirin
What is ribavirin
Nucleoside analogs of guanosine; interferes with synthesis of GTP, inhibits capping of viral mRNA, inhibits viral RNA pol; potentiates action of PEGylated IFN; contraindicated in patients with anemia or pregnant*
What is simeprevir
Second gen protease inhibitor; administer in combo with PEG IFN and ribavirin or sofosbuvir +/- ribavirin (chronic genotype 1 infxn)
What are telaprevir and boceprevir
First gen protease inhibitors; administered with PEGylated IFN and ribavirin (chronic genotype 1 infxn); simeprevir has diminished importance of these drugs
What is sofosbuvir
NS5B (RNA dep RNA pol needed for HCV replication) inhibitor; nucleotide analog; use in combo with other antivirals (ledipasvir); used for all genotypes of HCV
What are the NS5A inhibitors
Ledipasvir, elbasvir, velpatasvir; effective for all genotypes; not given as monotherapy b/c resistance; traditionally given with ribavirin and PEg IFN
What is the standard regimen for genotype 1 HCV
Ledipasvir + sofosbuvir
What is the standard treatment for HCV genotype 1,2,3
Velpatasvir + sofosbuvir
Elbasvir + grazoprevir
What abx causes red man syndrome
Vancomycin
What is iodoquinol contraindicated in
Iodine allergies
What are long term side effects of albendazole and mebendazole
Alopecia and GI dz
What are the important characteristics of PEGeylated IFN
Slower clearance, longer 1/2 life, less frequent dose
What is the relationship between IFN and ribavirin
Synergistic
What is the side effect if bisphophatase
Pill esophagitis
