Gastrointestinal

Question 1

describe peptic ulcer disease

Answer 1

upper gastrointestinal disorders characterized by varying degrees of erosion of the gut wall.
Can be classified as Duodenal or Gastric

Question 2

what is an ulcer

Answer 2

open sore in the lining of the stomach or intestine, much like mouth or skin ulcers.

Question 3

signs and symptoms of peptic ulcer disease

Answer 3

gnawing, burning pain in the upper abdomen
occur several hours after the food leaves the stomach but while acid production is still high.
some experience pain, while others experience intense hunger or bloating.
some have BLACK STOOLS indicating that the ulcer is bleeding (very serious complication of ulcers)

Question 4

diagnosis of a peptic ulcer disease

Answer 4

upper intestinal endoscopy that allows viewing by barium X-ray.
Ulcers are rarely malignant. biopsy specimen can be taken to determine

Question 5

drug treatment for ulcers

Answer 5

antacids
H2 blockers (H2R antagonists)
Proton pump inhibitors
cytoprotective agents
H.Pylori treatment

Question 6

Antacids

Answer 6

neutralize stomach acids
1. Na-bicarbonate (alka-seltzer)
2. Ca-carbonate (Tums)
3. Mg-hydroxide (milk of magnesia)
4. Aluminum hydroxide (amphojel)
5. Combination (Maalox, Mylanta)
A/E - diarrhea or constipation, hypokalemia, hypercalcemia

Question 7

histamine 2 (H2) blockers

Answer 7

block H2 receptors
a. cimetidine (prescription)
b. famotidine
c. nizatidine
d. ranitidine
BCD - all over the counter
A/E - cimetidine, not for older adults - causes dizziness

Question 8

proton pump inhibitors

Answer 8

inhibits acid production parietal cells of stomach
a. OMEprazole
b. LANSOprazole
c. ESOMEprazole
d. RABEprazole
e. PANTOprazole
A/E - nausea, diarrhea, colic belching

Question 9

miscellaneous anti-ulcer drugs

Answer 9

A. Sucralfate - coats ulcer from further acid attack. A/E drowsiness, constipation
B. Bismuth Subsalicylate (pepto-bismal) - coats esophagus and acts as barrier to gastric acids. Tetracycline & Metronidazole (eradicates H.Pylori)
C. Misoprostrol - secretes a gastric mucous barrier which prevent NSAID-induced peptic ulcers. A/E - diarrhea and CAN ABORT A FETUS!!!

Question 10

treatment strategy for the eradication of helocobacter pylori

Answer 10

3-4 drugs for about 2 weeks
1st LINE - PPI, Clarithromycin, and Amoxicillin (penecillin). - Amoxicillin can be replaced with Metronidazole if allergic to penecillin
2nd LINE - PPI, Bismuth, Metronidazole & Tetracycline
3rd LINE - Empiric rescue therapy OR treatment tailored to individual antibiotic sensitivity.

Question 11

What is GERD

Answer 11

Gastroesophageal Reflux disease
A condition in which stomach contents, including acid, back up into the esophagus, causing inflammation and damage to esophagus. Presents as heartburn! broken sphincter!!

Question 12

Symptoms of GERD

Answer 12

COMMON: heartburn, regurgitation, dyspepsia, “sour stomach”
ATYPICAL symptoms - cough, hoarseness, sore throat, shortness of breath
ALARM symptoms - dysphagia, GI bleeding, weight loss, sensation of choking

Question 13

name some foods that worsen GERD

Answer 13

alcohol
carbonated beverages, citrus fruit drinks
chocolate
coffee
peppermint
spicy foods
Tomato products

Question 14

Name some medications that worsen GERD symptoms

Answer 14

Anticholinergics
 Calcium channel blocker's
nicotine
caffeine
NSAIDS
Theophylline

Question 15

GERD drug treatment

Answer 15

stepwise treatment to empirc therapy with acid suppressants
1. Any symptoms - lifestyle modifications. avoid drugs that worsen sypmtoms
2. Empiric therapy for mild/moderate heartburn - antacids for two weeks with or w/o OTC H2RA
3. empiric therapy for typical symptoms of GERD - Standard H2RA dose x 6-12 weeks. moderate/extreme + PPI 4-8 weeks
4. for Pt’s who fail standard treatments above. High dose H2RA x 8-12 weeks or PPI for 8-12 weeks
NOTE: high dose required for BARRETT’S ESOPHAGUS

Question 16

common causes of constipation

Answer 16

not enough fiber in diet
not enough liquids
lack of exercise
IBS
abuse of laxatives
ignoring the urge to have a bowel movement
MEDICATIONS (Narcotics)

Question 17

medications commonly associated with econdary constipation

Answer 17

antacids, anticholinergics, antidepressants, antihistamines
calcium channel blockers, diuretics, Iron
Narcotics, non steroidal anti-inflammatory, opiods

Question 18

categories of anti-constipatory agents

Answer 18

1. Bulk-producing agents (Metamucil)
2. Stool softeners (Docusate)
3. Lubricants or emollients (Mineral Oil)
4. Hydrating Agents (polyethylene glycol, phosphosoda, and Lactulose)
5. Stimulants (Bisacodyl & Sennosides)
6. prostaglandins and prokinetics (Metaclopromide)

Question 19

nausea and vomiting key points

Answer 19

N/V is a biological defense mechanism
effective management is important, especially in cnacer therapy and post operatively.
Multiple causes of central and peripheral neurotransmitter pathways. drugs are effective against N/V of different origins

Question 20

vomiting can be caused by these multiple factors

Answer 20

medical interventions
poison ingestion
gastroenteritis
motion
surgery (post op n/v)
pregnancy
various drugs and radiation
sights, smells, memories

Question 21

antinausea agents category and indication

Answer 21

1. Anticholinergic agents - motion sickness
2. anti-histamine agents - motion sickness, non-producive cough, sedation
3. Neuroleptic agents - phychotic disorders, intracable hiccups
4. Pro-Kinetic agents - delayed gastric emptying, gastroesophageal reflux
5. Serotonin blockers - N/V associated with chemotherapy and post operative N/V
6. Tetrahydrocannabinoids - chemotherapy and anorexia

Question 22

Antihistamines and Anticholinergics mechanism of action and A/E

Answer 22

Dimenhydrinate (gravol), Scopolamine, Meclizine
blocks histamine and acetylcholine receptors in the brain
primarily used for motion sickness
administered orally or as patch behind the ear (scopolamine)
A/E: sedation, dry mouth, confusion, urinary retention

Question 23

Neuroleptic agents

drugs, mechanism and A/E

Answer 23

Prochlorperazine, haloperidol, droperidol
blocks dopamine receptors in the brain and GI tract. mainly used for PONV, chemotherapy
A/E: sedation, movement disorders (stiffness)

Question 24

Prokinetic agents

drugs, mechanism, and A/E

Answer 24

Metoclopramide
blocks dopamine in the trigger chemoreceptor zone which desensitizes the impulse it receives from GI tract
enhances peristalsis

Question 25

Serotonin antagonists | drugs, mechanism, and A/E

Answer 25

Ondansetron, Granisetron, Dolasetron blocks serotonin (5-HT) type 3 receptors. primarily used for chemotherapy and PONV A/E: headaches, diarrhea

Question 26

Cannabinoids | drugs, mechanism, and A/E

Answer 26

Dronabinol, Nabilone similar to marijuana, inhibits brain function, alters mood and perception, which may be beneficial to N/V. primarily used for chemotherapy induced N/V A/E: dissociation, dysphoria

Question 27

corticosteroids for N/V | drugs, mechanism, and A/E

Answer 27

Dexamethasone mechanism not fully understood. primarily used for chemotherapy induced N/V A/E: psychosis, edema, increase risk of infection

Question 28

benzodiazepine for N/V | drugs, mechanism, and A/E

Answer 28

Lorazepam (ativan) mechanism not fully understood. suppresion of anticipatory emesis, retrograde amnesia A/E: sedation

Question 29

what causes diarrhea

Answer 29

1. Bacterial/Viral/Parasitic infection (traveler's diarrhea) 2. reaction to drugs: antibiotics, BP meds, and antacids containing megnesium 3. intestinal diseases. like inflammatory bowel disease or celiac disease 4. functional bowel disorders, such as IBS, in which the intestines do not work normally

Question 30

drug treatment for diarrhea

Answer 30

diphenoxylate. opiod related. high doses = euphoria. used in combination with atropine to discourage abuse. A/E: dry mouth, confusion Loperamide (imodium). non-prescription, opiod related. no potential for abuse as its poorly absorbed

Question 31

travellers diarrhea causes and symptoms

Answer 31

usually caused by infection (E.Coli). 50% of canadians get it when on a two week vacation can cause serious dehydration severe cases require antibiotics: ciprofloxacin / Azithromycin Note: limit the use of antidiarrheas as you want to pass the pathogen out of your body. keeping it in there longer can fester into complications

Question 32

ways to prevent travellers diarrhea

Answer 32

Dukoral vaccine introduces a small dead amount to cholera so the body can make antibodies. Similar toxin as E.Coli so body will defense against it. immunization requires 2 doses - 1 week apart, with last dose taken at least 1 week before travel

Question 33

Inflammatory bowel disease (IBD) desription and two types

Answer 33

idiopathic chronic inflammatory disorders of the GI tract. Etiology unknown - (genetics, environment, autoimmune) 1. Ulcerative Colitis 2. Crohn's disease

Question 34

what is ulcerative colitis

Answer 34

ulcerative process of the rectal mucosa/submucosa which may spread proximally from the rectum in a CONTINUOUS manner to involve part or all of the colon. Mural = just within the colon Symptoms: rectal bleeding

Question 35

what is Crohn's disease

Answer 35

transmural (through the thickness of wall) inflammation involving any part of the intestine, but primarily the distal part of the small intestine and colon symptoms: rectal bleeding (sometimes), rectum and Ileum involved, abdominal mass, perianal disease

Question 36

therapeutic goals for IBD (inflammatory bowel disease

Answer 36

1. resolution of acute exacerbation 2. prevent relapse (induce remission) 3. control intestinal and extra-intestinal complications

Question 37

treatment for IBD

Answer 37

``` mild = antibiotics and aminosalicylates moderate = corticosteroids and immunomodulators severe = biologics, then surgery ```

Question 38

Aminosalicylates | drugs, and mechanism

Answer 38

1. 5-Aminosalicylic acid (5-ASA, mesalamine) - blocks production of prostaglandins and leukotrienes and reduces inflammation 2. Sulfasalazine - delayed absorption by combining with a sulfa compound. causes many A/E (nausea, dyspepsia, headache) 3. Olsalazine - complex that combines 2x 5-ASA which causes fewer side effects All have been RARELY associated with Pacreatitis

Question 39

aminosalicylates A/E's

Answer 39

1. 5-ASA - abdominal pain, cramps, diarrhea, gas, hair loss, headache, dizziness. Pt's with kidney disease should use caution on this drug 2. Sulfasalazine - headache, nausea, loss of appetite, vomiting, rash, fever, DECREASED WBC's and sperm count 3. Olsalazine - diahhrea!, headache, rash, fatigue.

Question 40

Corticosteroids mechanism of action and use

Answer 40

Reduces inflammation and reduces the immune response | Used for acute flare-ups, not for maintenance therapy

Question 41

Oral, Rectal, and IV corticosteroids

Answer 41

Oral - Prednisone Rectal - Hydrocortisone, Budesonide IV - Hydrocortisone, Methylprednisolone A/E: chronic use watch for edema, ulcers, delayed healing

Question 42

when are immunosuppresives used and key points

Answer 42

``` 2nd or 3rd line therapy to avoid colectomy steroid sparing properties -onset can take 6 months -high relapse rate after cessation of treatment ```

Question 43

Immunosuppressive drugs, mechanism of action and A/E

Answer 43

1. Azathioprine - may prevent relapse in Crohn's. A/E:Pacreatitis, arthralgia's (sore joint) 2. Cyclosporine - mechanism unclear. A/E: parathesias (tingling), tremor, hypertension, hyperkalemia. 3. Methotrexate - mechanism unclear but may be beneficial in those with refractory disease. A/E: blood dyscrasias (wacky counts), nausea, hepatotoxicity

Question 44

``` Biologic drugs (anti-tumor necrosis Factor) drugs, mechanism of action, and A/E ```

Answer 44

1. Infliximab 2. Adalimumab Mechansim - antibodies against tumor necrosis factor (TNF) useful in Crohn's disease and Ulcerative Collitis for refractory or steroid dependant disease. decreases inflammatory response A/E: heart failure, infections, Pancytopenia (decreased blood counts), hypotension, hepatotoxicity (failure), seizures, MS, lymphoma.