GI 2 treatments Flashcards by Morgan Evans

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What is the Tx for an anorectal fistula?

Surgery is mainstay (fistulotomy); seton placement in setting of abscess or inflammation

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Perirectal abscess:
1) What is the Tx for all patients?
2) What is a complication of perirectal abscesses?

1) Incision & drainage for ALL abscesses
2) Anorectal fistula

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PUD: For NSAID-induced ulcers, what is a main part of Tx?

D/c offending agent

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PUD Tx: What specific therapy should you use from the H. pylori eradication agents category?

Quadruple therapy: bismuth/TCN/PPI/metronidazole

(highlighted)

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What are the 3 categories of PUD Tx?

Acid anti-secretory agents, mucosal protective agents, & H. pylori eradication agents

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PUD Tx: You should confirm eradication of what 4 weeks after completion of therapy (urea breath test or fecal antigen test)?

H. pylori-associated ulcers

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PUD Tx: For H. pylori Tx, the pt should adhere to strict alcohol avoidance with __________________

metronidazole

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PUD Tx
1) What 2 categories are included in acid-antisecretory agents?
2) List members of each

1) Proton pump inhibitors (PPI), H2-receptor antagonists
2) PPIs: OTC omeprazole, esomeprazole, lansoprazole. Rx dexlansoprazole, pantoprazole, rabeprazole
H2RA: famotidine, nizatidine, cimetidine

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PUD Tx:
1) Give examples of mucosal protective agents
2) Give examples of H. pylori eradication agents

1) Bismuth, sucralfate
2) Quadruple therapy regimen recommended (triple therapy no longer recommended) bismuth/TCN/PPI/metronidazole

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PUD Tx: What do you need to do for H. pylori-associated ulcers?

Treat with appropriate regimen to relieve dyspeptic symptoms, promote healing, and eradicate infection
**Confirm eradication 4 weeks after completion of therapy (urea breath test or fecal antigen test)
Determine need for continued PPI or H2RA (2-4 wks duodenal, 4-6 wks gastric)

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What should you know about treating H. pylori (PUD)?

Macrolide resistance
Strict alcohol avoidance with metronidazole
Initial & salvage treatment tables
Quadruple therapy (individual Rx or PPI + pylera $$$) $1K
Newest regimen - Talicia (omeprazole/amoxicillin/rifabutin) $700

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PUD: How should you Tx NSAID-induced ulcers?

1) D/c offending agent (if possible)
2) Test for H. pylori (not serum) and treat if positive
3) Treat with PPI or H2RA
4) Consider continued daily PPI therapy for prevention in high-risk patients (NSAIDs, antiplatelet therapy)

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PUD: How should you Tx NSAID-induced ulcers?

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How do you Tx gastritis?
What should be discontinued?

1) PPIs (esomeprazole 40 mg PO QD x 2-4 weeks,) sucralfate tabs or susp 1 gm or 1 gm/10 mL PO BID – QID with meals
2) d/c NSAIDs, anticoagulants, alcohol, spicy and greasy foods

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Perirectal abscess:
1) How do you Dx?
2) Tx?

1) CT or MRI helpful (esp in Crohns)
2) Incision & drainage for ALL abscesses, antibiotics for immunocompromised or cellulitis

For all patients with hemorrhoids, what should you recommend for:
1) Dietary & lifestyle modification
2) Medications for symptomatic relief

1) 20-30 g insoluble fiber/day (dietary +/- supplemental), -1.5-2L water/day, avoid straining/lingering, regular exercise (but not heavy weightlifting,) avoid meds causing constipation or diarrhea
2) Topical analgesics & steroids, antispasmodic agents (NTG), Sitz baths

Hemorrhoids:
1) What is the medical Tx?
2) What is the surgical Tx?

1) Grades 1 & 2: Fiber & Sitz baths, rubber band ligation (RBL)
2) Grades 2-4 (failed conservative treatment): surgery
Thrombosed external: excision within 48 hours

Anal fissures:
1) What is the initial Tx?
2) What is the refractory Tx?

1) Fiber supplementation, Sitz baths, topical CCB or NTG
2) Surgery (sphincterotomy)

What is a key part of chronic constipation Tx?

Adequate fluid & fiber intake

What are some dietary and lifestyle measures for chronic constipation Tx?

1) Address adverse psychosocial issues
2) Education: defecatory function & optimal toileting
3) Adequate fluid & fiber intake (trial of fiber supplement)
4) Encourage regular exercise
5) Discontinue constipating medications when possible
+ probiotics (more studies needed)

What are 4 categories of chronic constipation Tx? Give examples of each

1) Osmotic: lactulose, Miralax (PEG), magnesium citrate
2) Stimulant: bisacodyl (Dulcolax), senna
3) Secretagogues: lubiprostone (Amitiza), linaclotide (Linzess), plecanatide (Trulance)
4) Opioid-receptor antagonist: methylnaltrexone (Relistor), naloxegol (Movantik), naldemedine (Symproic)

True or false: Treatment with laxatives can be used intermittently or chronically for chronic constipation

True

Describe how to approach chronic constipation Tx

1) Start with dietary & lifestyle measures
2) Trial of laxatives if no response to dietary & lifestyle changes
a) Start with osmotics (safe in most cases)
b) Trial of stimulants for no response to osmotics
c) Use secretagogues for IBS-C or suboptimal response and/or side effects to less expensive agents
d) Use opioid-receptor antagonists for opioid induced constipation
e) Combination therapy may be needed

How do you Tx fecal impaction?

1) Relieve impaction with enemas (saline, mineral oil, tap-water) or digital disruption 2) Long-term care: maintain soft stools & regular bowel movements

Diverticulosis Tx?

Encourage increased dietary or supplemental fiber, exercise, & avoidance of red meats & NSAIDs

True or false: most diverticulitis pts can be managed without abx

True

Acute diverticulitis Tx: 1) When should you use abx? 2) What are the abx options?

1) Used selectively for uncomplicated disease (immunocompromised, significant comorbid disease, or small pericolonic abscesses < 3-4 cm) 2) Amoxicillin-clavulanate potassium 875/125 mg PO BID x 7-10 days -Metronidazole 500 mg TID + ciprofloxacin 500 mg PO BID or TMP/SMX 160/800 mg PO BID x 7-10 days

What else should you do for pts w acute diverticulitis who you Rx abx to?

Pain control, liquid diet, & reassessment

Describe inpatient mgmt of acute diverticulitis

1) IV antibiotics 2) IV hydration 3) IV pain medications 4) Complete bowel rest or liquid diet

Describe surgical management of acute diverticulitis

1) Surgical consultation & repeat abdominal CT for severe disease or failure to improve after 72 hours of medical management 2) Emergent surgery for generalized peritonitis, large undrainable abscesses, & clinical deterioration despite medical management & percutaneous drainage 3) Percutaneous catheter for drainage of larger abscesses (IR)

Diverticular bleeding: 1) What is the usual volume? Outpatient or inpatient? 2) Do pts usually need intervention?

1) Usually large-volume & usually requires hospitalization 2) Bleeding stops on its own in most cases (~1/3 require intervention) -Need for surgery is rare

Describe diverticular bleeding mgmt

1) Resuscitation 2) Treatment of bleeding site (endoscopic therapy, angiography & embolization, surgery)

List the categories of drugs used to Tx IBDs and give examples

1) Glucocorticoids *short term* (prednisone, budesonide)(topicals for UC mesalamine: suppositories & enemas; glucocorticoids: suppository, foam, enema (hydrocortisone). 2) Oral 5-aminosalicylates (aka, 5-ASA)(sulfasalazine, mesalamine)(topical mesalamine for UC) Immunomodulators (azathioprine, 6-mercaptopurine, methotrexate) 3) Biologic therapies (infliximab, adalimumab, certolizumab pegol, natalizumab, vedolizumab, ustekinumab)