Gastrointestinal

Question 1

What are signs/symptoms of liver disease?

Answer 1

-Ascites
-Edema
-Encephalopathy
-Gastroesophageal varices
-Jaundice

Question 2

How are Child-Pugh scores for cirrhosis interpreted?

Answer 2

5-6= A = Mild

7-9 = B = Moderate

10-15 = C = Severe

Question 3

What is first-line non-pharmacologic management of ascites?

Answer 3

Sodium restriction (2000 mg/day)

Question 4

What is first-line pharmacologic management of ascites?

Answer 4

Diuretics

Spironolactone 100 mg daily +/- Furosemide 40 mg daily

Question 5

When is prophylaxis for SBP indicated?

Answer 5

Cirrhosis and ascites w/ low ascitic protein concentration (< 1.5) AND
-SCr > 1.2
-BUN > 25
-Na < 130

History of SBP

Question 6

What antibiotics can be used to SBP prophylaxis?

Answer 6

-Ciprofloxacin 500 mg daily
-Bactrim DS daily
-Rifaximin 400 mg TID or 550 mg BID

Question 7

What is the first choice for treatment of episodic overt hepatic encephalopathy?

Answer 7

Lactulose
-45 mL every 1-2 hours until at least 2 soft or loose bowel movements/day THEN 15-45 mL every 8-12 hours to achieve 2-3 soft stools/day

Question 8

What role does rifaximin plan in hepatic encephalopathy?

Answer 8

-Effective add-on to prevent overt hepatic encephalopathy recurrence

-Add-on therapy for prevention after the second hepatic encephalopathy episode

Question 9

What therapies are indicated for primary prophylaxis of esophageal varices?

Answer 9

-Non-selective beta blockers (propranolol, nadolol, carvedilol)

Question 10

What therapies are indicated for secondary prophylaxis of esophageal varices?

Answer 10

Variceal ligation + propranolol/nadolol

Question 11

How many doses of Hepatitis A vaccine are recommended?

Answer 11

2 (separated by 6-12 months)

Question 12

When is Hepatitis A immunoglobulin indicated?

Answer 12

High-risk patients traveling to an epidemic HAV area and do not have time to adequately complete vaccine series

Question 13

Who should get Hepatitis A vaccine?

Answer 13

-MSM
-International travelers
-Illegal drug users
-Occupational risk
-Homeless individuals
-Chronic liver disease
-HIV
-Children 12-23 mo

Question 14

What does Hepatitis B surface antigen (HBsAg) indicate?

Answer 14

Individual is infectious; present during acute and chronic infection

Question 15

What does Hepatitis B surface antibody (Anti-HBs) indicate?

Answer 15

Confers protective immunity; present after recovery from acute infection or after vaccination

Question 16

What are recommended first-line therapies for chronic Hepatitis B?

Answer 16

-Pegylated interferon
-Entecavir
-TDF
-TAF

*In compensated or decompensated cirrhosis, pegylated interferon NOT preferred

Question 17

What monitoring is recommended during pegylated interferon therapy?

Answer 17

-CBC w/ differential + hepatic panel every 4 weeks
-TSH and HBV DNA every 12 weeks

Question 18

What are potential side effects of pegylated interferon therapy?

Answer 18

-Bone marrow suppression (neutropenia/thrombocytopenia)
-Headache/flu-like symptoms
-Psychosis/depression
-Thyroid abnormalities
-Neuropathy

Question 19

What BBW do the NAs carry?

Answer 19

Lactic acidosis

Question 20

What is a common side effect with all NAs?

Answer 20

Rebound hepatitis (flare in liver enzymes)

Question 21

When is Hepatitis C screening indicated?

Answer 21

-One-time screening for all patients 18 years +
-Pregnant patients (w/ each pregnancy)
-Annually for MSM w/ HIV, MSM on PrEP, and those who inject drugs

Question 22

What is the goal for treatment of chronic Hepatitis C?

Answer 22

Achieve a sustained virologic response (absence of detectable HVC RNA at least 12 weeks after end of therapy)
-Concentration of 25 or lower

Question 23

What are adverse effects of ribavirin?

Answer 23

-Hemolytic anemia (BBW)
-Pregnancy category X

Question 24

What is an important counseling point for patients taking ledipasvir/sofosbuvir?

Answer 24

Avoid all acid-suppressive medications
-Administer at same time as PPI
-Administer at same time as H2 blocker or spaced 12 hours apart

Question 25

What are GERD alarm symptoms?

Answer 25

-Anemia
-Chest pain
-Choking
-Epigastric mass
-GI bleeding
-Troublesome dysphagia
-Weight loss (unintentional)

Question 26

What are non-pharmacologic strategies to manage GERD?

Answer 26

-Avoid alcoholic beverages, citrus, carbonated beverages, fatty meals
-Avoid consuming food within 2-3 hours before bedtime
-Smoking cessation
-Elevate head of bed by 6-8 in
-Sleep on left side
-Weight loss
-Avoid excessive exercise

Question 27

What is the recommended treatment of classic GERD (heartburn and regurgitation) without alarm symptoms?

Answer 27

8-week trial of PPI once daily before a meal

Question 28

What role do H2 blockers play in GERD management?

Answer 28

-Step-down therapy from a PPI in those w/ uncomplicated GERD
-Addition to PPI for those w/ incomplete symptom response

Question 29

How should PPIs be administered?

Answer 29

30-60 min before first meal of day

EXCEPTION:
Dexlansoprazole can be dosed at any time of day

Question 30

What is recommended when stopping PPIs?

Answer 30

4-6 week taper to prevent rebound hypersecretion

Question 31

Which patients are usually not appropriate for PPI discontinuation?

Answer 31

-Severe erosive esophagitis
-Esophageal ulcer
-Peptic stricture
-Barrett esophagus
-Eosinophilic esophagitis

Question 32

What are recommended treatment regimens for H pylori?

Answer 32

Clarithromycin-based triple therapy
-PPI + clarithromycin (500 mg BID) + amoxicillin (1000 mg BID)
-14 days

Bismuth quadruple therapy
-PPI + bismuth subsalicylate (300 mg QID) + metronidazole (500 mg TID-QID) + tetracycline (500 mg QID)
-10-14 days

Concomitant therapy:
-PPI + clarithromycin (500 mg BID) + amoxicillin (1000 mg BID) + metronidazole (500 mg BID)
-10-14 days

Question 33

Which patients are at moderate GI risk related to NSAID therapy?

Answer 33

At least one of the following:
-Age 65 years +
-High-dose NSAID therapy
-History of uncomplicated ulcer
-Concurrent use of ASA, corticosteroids or anticoagulants

Question 34

Which patients are at high GI risk related to NSAID therapy?

Answer 34

At least two of the following:
-Age 65 years +
-High-dose NSAID therapy
-History of uncomplicated ulcer
-Concurrent use of ASA, corticosteroids or anticoagulants

OR

History of complicated ulcer

Question 35

What is recommended for those w/ low GI risk and high CV risk (on ASA)?

Answer 35

Naproxen + PPI

Question 36

What is recommended for those w/ moderate GI risk and low CV risk?

Answer 36

NSAID + PPI

Question 37

What is recommended for those w/ moderate GI risk and high CV risk (on ASA)?

Answer 37

Naproxen + PPI

Question 38

What is recommended for those w/ high GI risk and high CV risk (on ASA)?

Answer 38

Avoid use of NSAIDs and COX-2 inhibitors

Question 39

What is recommended for those w/ high GI risk and low CV risk?

Answer 39

COX-2 inhibitor + PPI

Question 40

What are first-line medications for management of N/V?

Answer 40

Phenothiazines (promethazine, prochlorperazine)
-Effective in migraine, motion sickness, vertigo, CINV, PONV

Serotonin receptor antagonists (ondansetron, granisetron)
-Effective in CINV, PONV

Question 41

What are treatment options for diarrhea?

Answer 41

-Loperamide
-Diphenoxylate/atropine (can cause sedation, somnolence)
-Bismuth subsalicylate (can cause black stool and tongue discoloration)

Question 42

What are non-pharmacologic strategies to manage constipation?

Answer 42

-Increase hydration
-Increase fiber consumption to 20-30 g/day

Question 43

What medications are recommended for constipation management?

Answer 43

Stimulant laxatives
-Senna
-Bisacodyl

Osmotic laxatives
-PEG