Gastrointestinal Flashcards by Connor Hummel

What are signs/symptoms of liver disease?

-Ascites
-Edema
-Encephalopathy
-Gastroesophageal varices
-Jaundice

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How are Child-Pugh scores for cirrhosis interpreted?

5-6= A = Mild

7-9 = B = Moderate

10-15 = C = Severe

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

Sodium restriction (2000 mg/day)

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What is first-line pharmacologic management of ascites?

Diuretics

Spironolactone 100 mg daily +/- Furosemide 40 mg daily

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When is prophylaxis for SBP indicated?

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

History of SBP

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What antibiotics can be used to SBP prophylaxis?

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

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

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

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What role does rifaximin plan in hepatic encephalopathy?

-Effective add-on to prevent overt hepatic encephalopathy recurrence

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

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What therapies are indicated for primary prophylaxis of esophageal varices?

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

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What therapies are indicated for secondary prophylaxis of esophageal varices?

Variceal ligation + propranolol/nadolol

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How many doses of Hepatitis A vaccine are recommended?

2 (separated by 6-12 months)

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When is Hepatitis A immunoglobulin indicated?

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

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Who should get Hepatitis A vaccine?

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

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What does Hepatitis B surface antigen (HBsAg) indicate?

Individual is infectious; present during acute and chronic infection

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

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

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

-Pegylated interferon
-Entecavir
-TDF
-TAF

*In compensated or decompensated cirrhosis, pegylated interferon NOT preferred

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What monitoring is recommended during pegylated interferon therapy?

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

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What are potential side effects of pegylated interferon therapy?

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

What BBW do the NAs carry?

Lactic acidosis

What is a common side effect with all NAs?

Rebound hepatitis (flare in liver enzymes)

When is Hepatitis C screening indicated?

-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

What is the goal for treatment of chronic Hepatitis C?

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

What are adverse effects of ribavirin?

-Hemolytic anemia (BBW)
-Pregnancy category X

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

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

What are GERD alarm symptoms?

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

What are non-pharmacologic strategies to manage GERD?

-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

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

8-week trial of PPI once daily before a meal

What role do H2 blockers play in GERD management?

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

How should PPIs be administered?

30-60 min before first meal of day EXCEPTION: Dexlansoprazole can be dosed at any time of day

What is recommended when stopping PPIs?

4-6 week taper to prevent rebound hypersecretion

Which patients are usually not appropriate for PPI discontinuation?

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

What are recommended treatment regimens for H pylori?

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

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

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

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

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

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

Naproxen + PPI

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

NSAID + PPI

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

Naproxen + PPI

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

Avoid use of NSAIDs and COX-2 inhibitors

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

COX-2 inhibitor + PPI

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

Phenothiazines (promethazine, prochlorperazine) -Effective in migraine, motion sickness, vertigo, CINV, PONV Serotonin receptor antagonists (ondansetron, granisetron) -Effective in CINV, PONV

What are treatment options for diarrhea?

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

What are non-pharmacologic strategies to manage constipation?

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

What medications are recommended for constipation management?

Stimulant laxatives -Senna -Bisacodyl Osmotic laxatives -PEG