Gastrointestinal Disorders Flashcards
Nonpharmacologic interventions are aimed at
decreasing the incidence of acid reflux and enhancing
esophageal clearance in patients with gastroesophageal reflux disease (GERD). Which strategy would be most effective?
A. Refraining from food consumption 1 hour before
going to bed.
B. Eating peppermint after meals.
C. Wearing tight-fitting clothes.
D. Discontinuing smoking.
Lifestyle modifications are aimed at lessening the incidence of acid reflux and enhancing esophageal acid clearance. Modifications include dietary modifications, smoking cessation, avoidance of tight-fitting clothes, avoidance of medications that act on the lower esophageal sphincter, elevation of the head of the bed while sleeping, weight loss, and chewing gum to promote salivation. Answer A is incorrect; avoiding food consumption within 1 hour of bedtime is insufficient – the patient should avoid food consumption within 2–3 hours of going to bed. Answer B is incorrect; eating peppermints after meals is not a recommended lifestyle modification; mint can loosen the lower esophageal sphincter. Answer C is incorrect; the recommendation is NOT to wear tight-fitting clothes. Answer D is correct; smoking cessation is a recommended lifestyle modification.
Correct Answer: D
A 67-year-old woman with rheumatoid arthritis takes
naproxen 500 mg by mouth daily, metoprolol 25 mg by mouth twice daily, aspirin 81 mg by mouth once daily, and alendronate 70 mcg by mouth weekly. Which is the best gastroprotective therapy to recommend?
A. Lansoprazole 30 mg daily.
B. Esomeprazole 40 mg twice daily.
C. Misoprostol 200 mcg twice daily.
D. No gastroprotective therapy necessary.
Preventive therapy should be selected according to a combined assessment of GI and CV risk. To calculate the GI risk, risk factors should be assessed and tabulated (e.g., no risk factors: low risk; one or two risk factors: moderate risk; three or more risk factors or having a previous ulcer complication or concomitant use of corticosteroids or anticoagulants: high risk). This patient has two GI risk factors (e.g., age older than 65 and aspirin therapy); she thus has moderate GI risk. Cardiovascular risk is defined as either low or high. This patient has high CV risk because she takes
low-dose aspirin. Preventive therapy should be selected for someone with moderate GI/high CV risk. Therapy options include naproxen plus a PPI (or misoprostol). Answer A is correct; PPI is a recommended therapy. Answer B is incorrect; standard-dose PPI is recommended therapy, which is
once daily, not twice daily. Answer D is incorrect; from the GI and CV risk assessment, gastroprotective therapy is recommended. Answer C is incorrect; although misoprostol is approved for moderate GI/high CV risk, the dose indicated is low, which may reduce misoprostol adverse events. In addition, misoprostol is not dosed often enough. The recommended dose is 800 mcg four times daily
Correct Answer: A
Which best describes the patient who would most
require counseling on the importance of using two
forms of contraception during hepatitis C virus (HCV)
treatment and for 6 months after completing treatment?
A. 29-year-old woman receiving elbasvir/grazoprevir
plus ribavirin.
B. 47-year-old woman receiving glecaprevir/
pibrentasvir.
C. 53-year-old woman receiving sofosbuvir/
velpatasvir.
D. 36-year-old woman receiving ledipasvir/
sofosbuvir.
Answer A is correct. Ribavirin is category X and must not
be taken during pregnancy or within 6 months of the patient or the patient’s partner becoming pregnant. Answers B–D do not include ribavirin in the regimen, so teratogenicity is not a concern.
Correct Answer: A
A 52-year old woman with liver cirrhosis of unknown
cause presents to the emergency department today
with increased confusion, change in sleep patterns,
and decreased ability to function at work. Her head
computed tomography (CT) findings and vital signs
are normal. Liver function test results are consistent
with cirrhosis. Which therapy is best to recommend
for her hepatic encephalopathy (HE)?
A. Rifaximin.
B. Lactulose.
C. Flumazenil.
D. Protein restriction.
Hepatic encephalopathy is a diagnosis of exclusion. On
diagnosis, treatment of HE should be initiated. Lactulose is standard-of-care therapy according to the practice guidelines; lactulose should be initiated at 45 mL/hour until evacuation occurs and then tapered to achieve 2 or 3 stools daily. Answer A is incorrect; rifaximin is approved pharmacotherapy for reducing the risk of OHE but is not first-line therapy and is commonly reserved for patients whose condition does not respond to, or patients who are intolerant of, lactulose. Answer B is correct; lactulose is first-line therapy according to the guidelines. Answer C is incorrect; drugs affecting neurotransmission (e.g., flumazenil and bromocriptine) are not recommended by the guidelines. Use of these agents should be reserved for those with conditions unresponsive or refractory to other therapies. Answer D is incorrect; protein restriction is no longer a standard therapy. Although protein restriction is sometimes used during acute episodes, long-term use should be avoided.
Correct Answer: B
A 57-year-old white man with alcoholic liver disease
(Child-Turcotte-Pugh [CTP] class B) received initial
therapy with propranolol 10 mg by mouth twice daily
after a screening endoscopy 1 month ago. In the clinic
today, he appears to be tolerating the propranolol dose and reports no signs of lightheadedness, fatigue, or shortness of breath. His vital signs from today and
his visit 1 month ago are summarized in the following
table. Which drug is best for this patient?
Temperature: (F):
1 Month Ago: 98.8 Today: 98.7
Blood Pressure, mm Hg:
1 Month Ago: 130/90 Today: 130/83
Respiratory Rate, Breaths/min.
1 Month Ago: 16 Today: 15
Heart Rate, beats/min.
1 Month Ago: 89 Today: 81
A. Change propranolol to nadolol 20 mg by mouth
daily.
B. Add isosorbide mononitrate 10 mg by mouth twice
daily.
C. Continue current therapy and reevaluate in 4
weeks.
D. Increase propranolol to 20 mg by mouth twice
daily.
Individuals with large varices and cirrhosis should receive primary prophylaxis against variceal bleeding with nonselective β-blockers as first-line therapy. The guidelines call for titrating the β-blocker to the maximal dose tolerated. A goal heart rate of 55–60 beats/minute is reasonable if the patient’s blood pressure allows it. Answer A is incorrect; according to the case, the patient seems to be tolerating propranolol; thus, changing from one nonselective β-blocker to another is not the best option. Answer B is incorrect; adding a long-acting nitrate would likely reduce portal pressure, but studies have been inconclusive, with some studies suggesting increased mortality. Thus, this is not a recommended therapy for primary prophylaxis. Answer C is incorrect; 1 month of therapy without meeting the targets shows that an intervention is necessary; thus, making no changes is incorrect. Answer D is correct; increasing the propranolol dose for someone who is tolerating the drug but not yet taking the maximal tolerated dose is the best option. Continued follow-up and evaluation of the need for additional dose adjustments according to heart
rate and blood pressure are necessary.
Correct Answer: D
A patient with chronic hepatitis B virus (HBV) infection has taken lamivudine 100 mg by mouth daily for
18 months. His HBV DNA became undetectable after
2 months of therapy and remained so until 6 weeks
ago. Laboratory data from 6 weeks ago are as follows:
aspartate aminotransferase (AST) 197 IU/mL, alanine
aminotransferase (ALT) 227 IU/mL, total bilirubin 2.7
mg/dL (indirect 1.9 mg/dL, direct 0.8 mg/dL), serum creatinine (SCr) 1.1 mg/dL, and HBV DNA 47,600
IU/mL. His HBV DNA value from 1 week ago was
51,200 IU/mL. Which is the best course of action?
A. Add entecavir.
B. Add adefovir.
C. Discontinue lamivudine and add entecavir.
D. Discontinue lamivudine and add tenofovir.
Patients develop virologic breakthrough while receiving NA therapy because of medication nonadherence or the development of antiviral resistance. The guideline recommendation for patients developing breakthrough is counseling regarding medication adherence and confirmation of breakthrough by retesting HBV DNA in 1–3
months. This case provides no information regarding the patient’s medication adherence but does provide two different HBV DNA concentrations that are 5 weeks apart and detectable; thus, from the information given, the patient has developed virologic breakthrough while adherent to lamivudine therapy. To manage breakthrough, the guidelines recommend either changing the NA agent (preferred) or adding another, different NA to the current therapy.
Specific management varies depending on the current NA therapy (Table 15). Answers A and B are incorrect; adding entecavir or adefovir to lamivudine is not recommended by the guidelines. Changing to entecavir monotherapy is not recommended by the guidelines, making Answer C incorrect. Answer D is correct because lamivudine resistance can be managed by changing to tenofovir.
Correct Answer: D
Which best describes the correct population and
methodology recommended for serologic testing for
immunity after administration of the HBV vaccine?
A. Patients with chronic liver disease: Test for anti–
hepatitis B surface antibody (anti-HBs); test 1–2
months after the last dose of the vaccine series.
B. Patients with chronic liver disease: Test for anti–
hepatitis B early antigen (anti-HBe); test 3–4
months after the last dose of the vaccine series.
C. Health care workers: Test for anti-HBs; test 1–2
months after the last dose of the vaccine series.
D. Health care workers: Test for anti-HBe; test 3–4
months after the last dose of the vaccine series.
Serologic testing for immunity is recommended only for
those whose subsequent clinical treatment relies on knowing their status (e.g., health care workers, public safety workers) because of their high risk of continued exposure. The guidelines recommend testing for anti-HBs concentrations 1–2 months after the last dose of the vaccine series, making Answer C correct. Individuals with antiHBs concentrations of 10 IU/L or greater are considered immune. Answer A is incorrect; although the serologic test (anti-HBs) and the time point (1–2 months after completing the vaccine series) are correct, the patient population with chronic liver disease is not. Answer B is incorrect; the serologic marker (anti-HBe) and the time point (3–4 months after completing the vaccine series) are incorrect. In addition, patients with chronic liver disease are not
included in the recommendations with respect to serologic testing for immunity. Answer D is incorrect; health care workers should be tested; however, testing for anti-HBe is incorrect, as is the time point of 3–4 months.
Correct Answer: C
You are contacted by one of the new gastrointestinal
(GI) medical fellows regarding the use of infliximab
for a patient with a history of Crohn disease (CD),
HBV, GERD, and arthritis. The patient takes mesalamine (Pentasa) 1 g by mouth four times daily,
azathioprine 100 mg by mouth once daily, esomeprazole 40 mg by mouth once daily, entecavir 0.5 mg by mouth once daily, and acetaminophen 325 mg by mouth twice daily. Which is the best first recommendation to provide the GI fellow regarding infliximab therapy for this patient?
A. Premedicate with an antihistamine, acetaminophen, and corticosteroids before the first dose.
B. Obtain additional information regarding this
patient’s use of entecavir and HBV history before
prescribing therapy.
C. Assess cardiac function by obtaining an echocardiogram before administration.
D. Order a tuberculosis (TB) test to rule out TB; then
administer infliximab.
The GI fellow remembered correctly that infliximab
prescribing has special precautions. According to the prescribing information, therapy is contraindicated in patients with active infection, latent TB (untreated), heart failure (New York Heart Association class III or IV), recent malignancies, optic neuritis, or a preexisting demyelinating disorder. In addition, because predisposition to infection may occur with all the anti-TNFα agents, the risk-benefit of use should be evaluated in those with chronic infections.
Before initiating therapy, patients should be screened for TB, HBV, and HCV, and patients should be educated to avoid live vaccines during therapy. Answer B is the best recommendation because, according to this patient’s medication list, the patient takes entecavir, which suggests the patient has a chronic infectious disease (e.g., HBV). Additional information (e.g., the status of the patient’s chronic infectious disease, whether the disease is active
[HBV RNA concentration]) must be obtained to determine whether infliximab therapy is indicated for this patient, making Answer B correct. Although premedicating with an antihistamine, acetaminophen, and/or a corticosteroid is recommended when administering infliximab, this is not the best answer. First, it should be determined whether therapy is even indicated for this patient; thus, Answer B is better than Answer A. Infliximab therapy is associated
with exacerbating underlying heart failure and is contraindicated in a subpopulation of individuals with heart failure (class III and IV). However, according to the information in the case, this patient does not have heart failure, so an echocardiogram is not recommended (Answer C is incorrect). Because of infliximab’s action on TNF, latent infections such as TB can become reactivated during therapy. Therefore, a TB test before initiation is recommended; however, this is not the best choice because it should first be determined whether therapy is even indicated for this
patient; hence, Answer D is incorrect.
Correct Answer: B
When treating ascites and liver disease what is the ratio for spironolactone and furosemide combination
Spironolactone: furosemide, 100:40mg
Can titrate up
Treat abdominal and peripheral edema (target 0.5kg per day wt loss)
Titrate up every 3-4 days to maximum 400mg/160mg
Considering spontaneous bacterial peritonitis (SBP)
List risk factors/ indications for primary prevention
Ascitic fluid protein concentration <1.5
With
SCr >= 1.2
bun >= 25
Na <= 130
Cirrhotic patient with CTP score>= 9 points with bilirubin >= 3
Variceal bleed
Spontaneous bacterial peritonitis mgt is in hospital with broad spectrum abx and albumin. Any patient with a history of SBP should receive secondary prevention describe three antibiotics you can give
Ciprofloxacin 500 mg
Trimethoprim sulfamethoxazole DS daily
Rifaximin 400 mg (2x200mg tablet) TID or 550 mg BID
Regarding the pharmacologic therapy for hepatic encephalopathy what is the first line and add on treatment for overt HE
Lactulose
Rifaximin as add on
Alternative neomycin, metronidazole
What is the dose of lactulose and rifaximin for hepatic encephalopathy prevention
Lactulose 15-45 ml every 8-12 hours to achieve two to three stools per day
Rifaximin 550mg BID as add on
Not recommend post TIPS
Discontinuing prevention if HE is well controlled or liver function or nutritional status has improved
When prophylaxising for variceal bleed name two non-selective beta blockers and doses
Goal doses
Propranolol 20 mg twice a day
Nadolol 40 mg daily (nadolol needs renal dosing)
When recommending non-selective beta blockers what are the most common adverse drug reactions
Fatigue
lightheadedness
shortness of breath
bradycardia
sexual dysfunction
