Gastrointestinal Flashcards
What are signs/symptoms of liver disease?
-Ascites
-Edema
-Encephalopathy
-Gastroesophageal varices
-Jaundice
How are Child-Pugh scores for cirrhosis interpreted?
5-6= A = Mild
7-9 = B = Moderate
10-15 = C = Severe
What is first-line non-pharmacologic management of ascites?
Sodium restriction (2000 mg/day)
What is first-line pharmacologic management of ascites?
Diuretics
Spironolactone 100 mg daily +/- Furosemide 40 mg daily
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
What antibiotics can be used to SBP prophylaxis?
-Ciprofloxacin 500 mg daily
-Bactrim DS daily
-Rifaximin 400 mg TID or 550 mg BID
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
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
What therapies are indicated for primary prophylaxis of esophageal varices?
-Non-selective beta blockers (propranolol, nadolol, carvedilol)
What therapies are indicated for secondary prophylaxis of esophageal varices?
Variceal ligation + propranolol/nadolol
How many doses of Hepatitis A vaccine are recommended?
2 (separated by 6-12 months)
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
Who should get Hepatitis A vaccine?
-MSM
-International travelers
-Illegal drug users
-Occupational risk
-Homeless individuals
-Chronic liver disease
-HIV
-Children 12-23 mo
What does Hepatitis B surface antigen (HBsAg) indicate?
Individual is infectious; present during acute and chronic infection
What does Hepatitis B surface antibody (Anti-HBs) indicate?
Confers protective immunity; present after recovery from acute infection or after vaccination
What are recommended first-line therapies for chronic Hepatitis B?
-Pegylated interferon
-Entecavir
-TDF
-TAF
*In compensated or decompensated cirrhosis, pegylated interferon NOT preferred
What monitoring is recommended during pegylated interferon therapy?
-CBC w/ differential + hepatic panel every 4 weeks
-TSH and HBV DNA every 12 weeks
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
