Gastro Conrad Fischer Medquest Pharm Flashcards
42 yr female, HBsAg + > 6mo, HBcAg +
Dx?
Def of Chronic Hep B
1st marker to inc with chronic Hep B? 2nd?
HbsAg
2nd - HbeAg
HBeAg is analogous to what in HIV?
DNA viral load
40 female persistent epigastric pain #1 cause?
non ulcer dyspepsia
gastritis presents with
painless bleeding
Pt has epigastric pain and on PPI and failed? next step?
Biopsy
alarm sx of H. pylori gastritis
weight loss, anemia, dysphagia, guaiac pos stool
What not do serology over biopsy ?
Serology can’t tell you if new/old infection - like FTA for syphillis
Tx for H. pylori - Rx and MoA of them
PPI + 2 Antibiotics +/- Bismuth subsalicylate
Clarithromycin + Amoxicillin
can switch to
Tetracyclin + Metronidazole
List PPI & MoA
Lansoprazole
Ome-
Panto-
Rabe-
Esome-
Irreversibly inhibit H+/K+ ATPase in stomach parietal cells
PPI side effects
acute interstitial nephritis
dec serum Mg/Ca absorption —> bone demineralization and fracture
Ca absorbed better in acidic environment
SE effect of PPI that is also caused by certain antibiotics? Which antibiotic in particular?
Inc risk of C. diff infection - Can be caused by any antibiotic, but Clindamycin in particular
When do you add bismuth?
Add to metro + tetracyclin if 1st round of antibiotic doesn’t work. For the anti inflammatory effect
Unique side effect of bismuth
black colored stool, that isn’t heme or guaiac +
MoA and major side effect of tetracylcin
affects 30S of ribosomes
photosensitivity (and teratogenecity)
Metronidazole - MoA and used for what organisms
(-) nucleic acid synthesis by forming toxic free radical metabolites
used for anerobic infections below diaphram, and protozoal infections
SE of Metronidazole
Disulfiram rxn w/ alcohol, headache, metallic taste, rarely seizures
List H2 blockers
Cimetidine, Ranitidine, Famotidine, Nizatidine
Why do we target histamine in acid reflux?
Histamine stimulates the other 2 stimulations of p+ pumps
1) Ach (+) H/K ATPase
2) Gastrin –> CCK2-R
Ca2+ dependent pathway
56 yr man w. acute variceal hemorrhage from alcoholic cirrhosis
rec IV fluids and rec blood transfusion + FFP
Why not vitamin K?
Rx most likely benefit pt now?
too slow
Octreotide - dec portal pressure bc receptor all through GI tract
& banding
What if Rx fails?
TIPS - Transjugular Intrahepatic Portal Systemic Shunt
Octreotide - other uses? MoA in these cases?
Glucagon/insulinoma
Carcinoid
ZE syndrome
Can dec portal pressure, splanchnic blood flow, (-) PRL, GH, (-) diarrhea in carcinoid
How is propranolol useful in acute variceal bleed?
It isn’t, no effect on acute bleed.
Only time to treat an endo overproduction w/ Rx before surgery?
PRL-oma - use dopamine agonist
48 man with altered mental status 2ndary to hepatic insufficiency
Most effective Tx for Pt 1?
Lactulose - (-) NH4 absorption in GI
Rifamixin - (-) bacteria in bowel
Why not use Neomycin for this pt?
can lead to renal issues
SE of Lactulose use?
Bloating, diarrhea, flatulence
–> hyper Na and HypOkalemia - bc colon used K+ to make feces
Lactulose MoA
non absorbed disaccharide, can’t break down w/o lactase - acidifies bowels, bacteria eat it and release acid, which converts NH3 –> NH4+ , which can’t be absorbed, inc renal excretion bc charged particle
Why does liver issues –> renal issues?
Intravascular volume depleted, low albumin –> HIGH RAAS, kidney v susceptible to toxic injury
Hepatic disease = VC of kidney in Abnormal way - starves them off
Lab changes in hepatorenal disease??
Dec Urine Na < 20 meq/L
Bun/Cr ratio INC - > 20
same lab values as pre renal azotemia
Sx of hepatorenal syndrome?
fluid overload
ascites
edema
low urine Na (like in dehydration)
When kidneys dehydrated, effect?
hold onto vol and Na, BUN Inc bc of Inc ADH leading to inc urea resorption @ collecting duct (urea transporter)
Tx for Hepatorenal syndrome?
replace liver
Midodrine - alpha (+)’r also used for orthostatic hypotension, shunt blood –> kidney
Octreotide
Albumin infusion - intravascular vol dec bc of dec albumin
Penacillamine used for?
chelator for Cu - Wilson’s disease
Other Rx used for Wilson’s disease?
Trientine and Zn
Sx of Wilson’s disease
Liver - hepatitis, liver failure
Brain - dysarthria, dystonia, tremor, Parkinsonism
+ hemolytic disease
+ renal disease
1 test of Wilson’s disease?
Slit lamp test - K-F rings
Most common wrong ans for best test for Wilson’s
Ceruloplasmin levels
Wilson’s disease leads to what renal issue?
Nephrotic syndrome
Penacillamine is also used for?
Hg and Zinc overload
cysteinuria
arsenic poisoning
Cu builds up in thalamus leading to ?
choreoform movements
paranoia
psychosis
not seen in hepatic encephalopathy
54 man alcoholic - n/v, blood from esoph varices
Rx ?
fluid, blood, platelet, FFP
Pt has been given these several times before,
2x treated w/ esoph band ligation
been transfused and has normal PT time
next course of action?
TIPS
How to prevent next episode of variceal bleed
nadalol
propranolol
Tx of acute esoph bleeding?
Octreotide
endoscopic band ligation
What is TIPS?
catheter placed into hepatic v and shunt created thru liver to portal vein,
done in flouroscopy
Pt v distressed by persistent Sx of epigastric and chest pain from GERD
Which Rx relieve heartburn and GERD sx?
1) liquid antiacid + H2B (Cimetidine, Ranitidine)
then
2) PPI
If GERD is severe?
Surgical repair of columnar metaplasia = Fundoplication (suture around LES to tighten it up)
Why do you need to scope surgical GERD pt every 2 years?
0.5 -1 %/yr –> esoph cancer
Why is Cisopride never the ans?
most likely to cause Torsades
T or F GERD is caused by H. Pylori
FALSE. does not cause reflux, a loose LES does.
What can cause a loose LES?
nicotine, chocolate, alcohol, caffeine
When to treat H. pylori?
1/2 of gen pop is H.pylori pos, only treat if have
Gastric PUD
Malt lymphoma
How to treat low grade dysplasia?
high grade dysplasia?
Barrett’s esoph
Low grade - scope in 6 mo
high grade - scrape/cut it out
Barrett’s - scope in 2 mos
38 yr woman w/ dysphagia to solids and liquids
Achalasia
How do diff dx achalasia from Zenker’s , Scleroderma, and esoph cancer?
Zenker’s - bad breath
Scleroderma - puffy, taut skin, no wrinkles
Esoph cancer - > 30, smoker/drinker, solids, then liquids
What is the next test in this pt?
Barium studies
Achalasia also associated with what other dz?
Schatzki ring
Plummer Vinson
Nut cracker esophagus
Diffuse esoph spasm
Tx of Achalasia -
1) Pneumatic dilation - can cause perforation or Surgery (Heller myotomy)
If refused - Botox - wears off after 6 mos
27 healthy GI fellow develops severe bloody diarrhea and abdomen pain over the last day.
10 + BM/ day
pulse 125
temp 103 F
What type of re-hydration should he rec? why?
saline - will stay in vascular space
NOT 5% dextrose in water - that’s like free water - will move EC
Should this pt rec antibiotics,
if so, which one?
mech?
Bc we don’t know what organism is
Flouroquinolonen - treat most common causes
(-) DNA gyrase
Most common micro causes of bloody diarrhea?
- C. jejuni - can also give erythromycin
- Salmonella
To whom can you not give flouroquinolones?
why?
To younger person - affects chondrocytes
leads to tendon rupture
What do you give a younger person if can’t give flouroquinolones?
TMP SMX
eythromycin
