GI Drugs and Conditions Flashcards
Cimetidine
“tidines” H2 blockers on parietal cells.
Reversible blockers, need to take every 12 hours.
Contraindicated in preggers and breast feeding
Cimetidine (only, not other H2’s) blocks P450–LOTS OF DRUG INTERACTIONS and antiandrogenic effects. Can cross BBB.
Omeprazole
-prazoles. Inhibit H/K ATPase of parietal cells.
Take every 24 hours. ** Prodrugs–require protonation for activation.**
Increased risk of C. Dif infection (decreased instestinal pH), pneumonia.
Increased Hip fractures from less Mg2+ with chronic use.
H. Pylori Treatments (2)
Triple Therapy:
1) PPI, 2) Amoxicillin 3) Clarithromycin or Metronidazole (“P.A.C.”)
Quadruple therapy (now recommended):
1) PPI, 2) Amox, 3) Clarithromycin, 4) Metronidazole (“P.A.C.M.”)
Antacids (what antibiotic can you not take in combo with)
All cause hypokalemia. Can be combine with alginic (alginate) acid: reacts with esophageal bases to foam=good for GERD
Alu-minum Hydroxide (“minimum amount of feces”): Constipatino, and hypophsophatemia, prox muscle weakeness and seizures
Calcium Carb: hypercalcemia, chelates other drugs: eg TETRACYCLINE
Mg Hydroxide: Diarrhea (Mg: must go to the bathroom), hyporeflexia, hypotension, cardiac arrest.
Sucralfate/Bismuth
Binds to ulcer base: physical barrier and allows bicarb to reestablish pH gradient.
Sucralfate: Requires acidic conditions (thus don’t take with PPI/H2s/Antacids). Good for DUODENAL ulcers
Bismuth subsalicylate (pepto bismol): T**URN STOOL BLACK. **Binds ulcers, direct antimicrobial activity against H. pylori and binds enterotoxins (CAN be combined wih tetracycline or metranidazole to increase H pylori killing)
Misoprostol
PGE1 analog used to _prevent NSAID induced ulcers***_
Mucosal protective (stimulated mucosal prolif and bicarb production), also has antacid properties
Dose dependent diarrhea.
NOT FOR PREGGERS
Metoclopramide
DA antagonist; Prokinetic agent (DM, post surg, illeus)
Antiemetic, Raises LES tone=Tx for GERD, accelerates GI emptying
SEs: Extrapyramidal symptoms (Parkinsonian Tremor, Tardive dyskinesia), anxiety, depression, drowsiness.
“MeTO makes you GO” prokinetic agent
Lubiprostone
PGE1: Used for Chronic Idiopathic Constipation
Turns on type 2 chloride channels causing fluid secretion
“Lubs the colon with salt solution; PG=prostone=pushes
Laxativies:
Bulk Forming
Stool softeners
Osmotic
Stimulant
Bulk Forming: Fiber, psyllium, methylcellulose
Stool softeners: Allows for water and lipids to get into feces
Osmotic: MgOH (milk of mag), sorbitol, lactulose (removes ammonia in liver disease via NH4+ fecal excretion), PEG.
—Osmotics for colon prep (rapid evac): MgCitrate with NaPO4
Stimulant: of enteric nerves—Bisacodyl (Dulcolax), aloe vera, senna (ex-lax), cascara sagrade
Antidiarrheals (2)
Lotamil=Atropine+Diphenoxylate (opiate agonist): addicition possible (given with atropine to prevent addicts from using it as injection). Need Rx
Loperamide (immodium): inhibits ACh release via opiod recetpor; NO potential for addiction/tolerance; doesn’t cross BBB
Sulfasalazine (what does this help prevent and mechanism?)
Sulfapyridiine (antibacterial) and 5-aminosalicylic acid (anti-inflammatory).
Activated by colonic bacteria. Tx for UC and CD.
Helps prevent cancer: Aspirin inhibits COX which is part of the adenoma-carincoma sequence (APC–>Kras–>P53 + Cox=Colon Cancer)
Tox: Malaise, nausea, sulfonamide allergy, reversible oligospermia
Budesonide
Controlled release oral glucocorticoid
Can give prednisone or prednisolone instead.
Antimetabolites for UC/CD
Azathioprine or 6-mercaptopurine (“azathioPURINE because its a 6mp precursor”)
Methotrexate (leucorvorin can rescue….)
Anti-tumor necrosis factors
Infliximab, Adalimumab, certolizumab—all anti-TNF alphas
SEs: opportunistic infections from suppresion of helper t-cell response (anti-TNF secreted by Macros to turn on T-cells)
CHECK FOR TB (PPD) before intiation as TNFalpha (along with IFN-G) to fight/prevent recurrence of Tb
Anti-integrin
Natalizumab (anti-alpha 4 integrin)
preventing leukocyte extravastion
Ses: reactivation of latent human polyoma virus
Tx: for CD and MS
Ondansetron
“setrons” 5-ht3 antagonist.
“won’t throw up drinking too much citrone”
“Don’t get sick at party, keep ON DANcing with ondansetron”
Decreases vagal stim. powerful centrally acting antiemetic.
Used for postop vomiting and in patients undergoing cancer chemo
SEs: headache/constipation
Best combo is with corticosteroid or NK1 receptor antagonist
Aprepitant
Fosaprepitant
“prepitants” used as antiemetics
Aprepitant (oral): “ape-ite”
Fosaprepitant (IV)
Diphenhydramine
H1 blockers: Benadryl. Anti-emetics
Others: Dimenhydrinate, Meclizine
Octreotide
Somatostatin analog
Used for Acromegaly, ACUTE VARICEAL BLEEDS, VIPoma, and carcinoid tumors
Causes of Acute Pancreatitis
GET SMASHED
Gallstones, Ethanol, Trauma
Steroids, Mumps, Autoimmune, Scorpion Stings, Hypercalcemia/HyperTRIglyceridemia, ERCP, Drugs
(hypertriglyceridemia, NOT hypercholesterolemia)
Sofosbuvir
Nucleotide Analog for HCV
Telaprevir, Bocceprevir, Simeprevir
Protease Inhibitors for HCV
Ribavirin
Ribose Nucleoside Analog for HCV
“ribavirin removes RNA”
Treatment for HBV?
HBV histologically vs HCV?
Interferons and Nucleoside Analogs:
(Adefovir, dipivoxil, entecavir, lamivudine, telbiviudine,)
(Tenoavir, disoproxil fumarate)
HBV=ballooning degeneration and hyperproduction of HBsAG
HCV: inflammatory infiltrate
Japenese man with blood type A most likley to develop?
Intestinal type Gastric carcinoma:
Risk Factos: Blood Type A, and Smoked foods (high in nitrosamines)
Presentations of Gastric Carcinoma
Acanthosis nigricans, Virchows Node, Leser-Trelat Sign (lots of severae keratosises on dermis), Early satiety
NETs:
1) Gastrinoma
2) VIPoma
3) Glucagonoma
4) Somatostatinoma
- Ulcers, unrelenting diarrhea (associated with MEN1)
- Diarrhea, Met Acidosis, HypoK
- Necrolytic Migratory Erythema (Rash in groin)
- Gallbladder issues (cuz Somatostatin knocks down CCK)
Rupture of ulcer in antrum of stomach causing severe bleeding…what artery?
In the proximal duodenum? What else can be damaged here leading to?
Tumor in the third portion of the duodenum most likely vessel to invade?
LEFT GASTRIC
Gastroduodenal; can rupture into pancreas causing pancreatitis
SMA
During appendectomy what is most likley to get knicked due to its close proximity?
Right Ureter is very close to cecum
Diseases above and below pectinate line (2 each)?
Blood supply above and below/
Above: Adenocarcinoma and Internal Hemorrhoids; Superior Rectal Artery (
Below: Squamous Cell Carcinoma and External Hemorrhoids
APC vs HNPCC
HNPCC: Mismatch repair predisposing for Colorectal, ovarian and endometrial cancer
APC: controls WNT protein which regulates cell proliferation. ACP also controls processes that regulate cell attachment to tissue and if it move into/away from tissue
Conjugated bilirubinemia with polymers of epinephrine metabolites in liver?
Dubin Johnson Syndrome
Dark black liver is though to be due to these polymers of epinphrine in hepatocytes.
Prolonged Hypotension at risk for what GI condition (2, but prolly more)
1) Mesenteric ischemia particularly at splenic flexure
2) Inflamated and enlarged gallbladder (stasis, and ischmia causes necrosis and inflammation)
HAV and HEV enveloped?
NO, don’t get this wrong again.
Ventral pancreas and dorsal emborylogically produce?
Ventral: Main Panc duct (initially attached to common bile duct). Most of unciate process. “Ventral is smaller so it contributes by forming main duct”
Dorsal: Most of head, Body, tail. ACESSORY DUCT
Increased Estrogen puts woman at risk for what GI condition?
Gall bladder stasis=increased risk for cholelithiasis
Where does the SMA touch on the GI tract?
Transverse Portion of the duodenum. The duodenal jejunal flexure is later.
Duodenal Atresia associated with (what other things associated with this)? Presentation?
Down’s syndrome (Hirschrpungs, Annular pancreas, Celiacs)
Billious vomiting
Gut rotation is around what artery?
When?
SMA
6th week = herniation
10th = returns to abdominal cavity and rotates around SMA in the process
Tracheoesophageal Fistula presentation
Non-billeous vomit with aspiration of stomach contents
DD btwn presentations of Congential Pyloric Stenosis and Duodenal atresia?
Congential Pyloric stenosis billeous vomiting occurs several weeks after birth (need time for pylorus to hypertrophy; might also have a palpable mass)
Duodenal atresia (down’s): billeous vomiting withing 48 hours of birth
Portal Triad? What’s in it and their relative locations. What ligament is it in?
Bile duct (lateral to) Hepatic Artery. Portal vein is posterior to both.
Hepatoduodenal Ligament
Stomach Collaterals (3 big ones, 1 minor):
1) Celiac to SMA via?
2) SMA to IMA via?
3) IMA to Interal Iliac?
4) Internal thoracic/mammary to External Iliac
1) Celiac Trunk to SMA via: Superior pancreaticoduodenal to Inferior pancreaticoduodenal
2) Middle colic to Left colic (splenic flexure)
3) Superior rectal to Middle/inferior rectal
4) Supeiror epigastric to inferior epigastric
Hepatic Architecture Zones?
Zone 1: Increased O2, affected first by toxins (eg coccaine) and viral hep (makes sense since its carried via blood).
Zone 2: Intermediate
Zone 3: Least O2 tension thus affected first by ischemia (remember liver has dual blood supply, so fairly resistant), Cyp450s******, Most sensative to METABOLIC toxins, Locaiton of alcoholic hepatisis*****
Mu agonists effect on billiary tree?
Agonists can cause sphincter muscle contraction leading to/worsening billiary colic
Inguinal Hernia above or below inguinal ligament?
Above. Femoral is below.
CMV vs HSV esophagitis?
HSV Punched out ulcers.
CMV Linear ulcers
Adenocarcinoma vs squamous cell carcinoma of esophagus?
Adenocarcinoma=lower 1/3, usually GERD/Barrett related.
Squamous Cell: Upper 2/3s usually smoking/ETOH related
Chronic Gastritis types? Locations?
Type A: Fundus/Body, Autoimmune destruction of parietal cells
Type B: Antrum; H Pylori, most common, MALT lymphoma and Gastric adenocarcinoma associated dt chronic inflammation
Menetrier disease?
Hypoproteinemic hypertrophic gastrophthy; Gastric Hypertrophy (increased mucus cells) with protein loss.
Brain looking gastric rugae. Precancerous; increase
Stomach can types? Diffrences? Risk Factors?
Intestinal (most common): H pylori, smoked foods, tobacco/ETOH, chronic gastritis. Associated with Blood type A. “Ulcer with RAISED margins”
Diffuse: Signet ring cells (no h pylori association), stomach wall is grossly thickened/leathery (Linitis plastic)
Celiacs:
HLA?
Antibodies?
Histology?
Associated skin condition?
Associated with what Immunodeficiency?
HLA: DQ2/DQ8 (DQ makes you poo)
Antibodies: Anti-tissue transglutaminase and anti-endomysial
Histology: VILLOUS ATROPHY/BLUNT WITH CRYPT HYPERLASIA CONTAINING INCREASED INTRAEPITHELIAL LYMPHOCYTES
Associated skin condition: Dermatitis herpetiformis.
Associated with what Immunodeficiency: Increased prevelance of celiacs with IgA deficiency**** (Increased t-cell lymphoma too)
Abetalipoproteinemia dt def of what?
MTP (microsomal transfer protein) effectively preventing B48 and B100 from attaching to chylomicrons/VLDLs
Immuneresponse in Crohns vs UC?
Crohns: Granulomas thus TH1 (IFN-gamma) with Macros (secreting IL-12/2)
UC: TH2 Response (cuz there are autoimmune antibodies associated p-ANCA)
Zenker diverticulum is caused usually by? Where?
Cricopharyngeal muscle dysfunction (poor relaxation) causing pharyngoesophageal false diverticulum between thyropharyngeal and cricopharygneal portions.
Adult presents with currant jelly stool, what is the dx and what do you need to be concerned about (2 things)?
Intussusception
Bowel Ischemia, and possible colon cancer
(tumor is usually what stool “drags” on to telescope the intestine)
Sawtooth on biopsy is pathognumonic for?
Hyperplastic Polyps
Worst colonic polyp to have? What can they cause?
Sessile villous polyp
Sessile=sppreading along side of colon
Villous=villianous
Larger villous adenomas can cause bleeding and MUCINOUS diarrhea***** (signet ring cancer does not cause this type of diarrhea despiting having mucin in thier cell bodies)
Most common locations of colorrectal cancer?
Rectosigmoid colon > Ascending > Descending
Molecular pathogenesis of CRC?
Sporadic Pathway (15%): Microsatellite instability pathway (can be associated with HNPCC)
Chromosome Instability pathway (“adenocarcinoma sequence) (85%): APC–KRAS–p53/DCC/Cox
“KRAS=KOLON RAS”
Arsenic and Vinyl chloride put pnts at risk for what GI disease?
Hepatic Angiosarcoma
Nutmeg condition is the term used with what pathophysiology. Conditions causing it and conditions causing those conditions?
Fluid congestion, increased back pressure.
Budd Chiari (caused by PCV, Preggers, HCC, Hypercoag states, OCPs, Lupus Anticoagulant)
Right Sided HF (Left Sided HF, Pulm HTN)
PAS positive staining liver?
What other effects systemically?
What other thing are PAS positive?
Alpha 1 antitrypsin.
Panacinar emphysema
PAS+: 1) Macrophages (Whipple’s), Candida (in lungs), Glycogen (in Ewing’s Sarcoma)
Tx for Crigler Najjar Type II?
Another feature of this drug?
Phenobarbitol (up regulated UDP-gluc transferase)
Phenobarb is CYP inducer. Also binds inside the GABA channel increasing duration of opening.
Youth with issues keeping balance, and has a lot of issues forgetting/not making sense. Disease?
Other findings?
Tx?
Inheritance pattern? Chromo?
Wilson’s (LOW CEROPLASMIN). Defect is in ATP7B: hepatocyte copper transporting ATPase dumping into bile
Ataxia, Dementia, Dyskenisia, Hemolytic anemiat, Asterixis, Corneal Depostis (Kayser fleischer ring)
Penicillamine (“PENNIes are made of copper”) or Trientine.
Auto Rec, Chromo 13
Bronze Diabetes?
Other components to presentation.
Blood labs?
Gene?
Hemochromatosis.
Cirrhosis, skin pigmentation, CHF, tsticular atrophy, HCC
Increased Ferritin, Decreased TIBC, increased Iron (“iron overloaded state”)
HFE (C282Y or H63D) gene; associated with HLA-A3
Primary Billiary Cirrhosis histology?
Primary Sclerosing Cholangitis?
PBC: LYMPHOCYTIC infiltrate causing destruction of intralobular bile ducts and granulomas
PSC: ONION RING FIBROSIS of BOTH intra and extrahepatic bile ducts
Gallstone risk factors?
4F’s
Female, Fat, Forties, Fertile (Preggers)
Prolonged Total parenteral nutrition puts patient at risk for?
Gallstones from lack of enteral stimulation (thus more billiary stasis)
Pain presentations in Pancreatitis vs Biliary Colic?
Epigastric pain radiating to back (both sides)
Biliary colic=RUQ pain radiating to R scapula only
History of DVTs in different locations?
Trousseau syndrome in Pancreatic Adenocarcinoma.
Magnesium should be thought of as a?
Smooth muscle relaxer.
Signet ring cells in(2)?
Gastric Adenocarcinoma
and Lobular Carcinoma in situ (of breast)
Serotonin’s affect on GI? (antagonists?)
Increases gut motility=diarrhea (why in serotonin syndrome you get the shits)
Antagonism: Constipation and ANTI-EMETIC (“-setrons”)
Congential Pyloric Stensosi Presentation/Associations?
Age 2-6 weeks old
Male > Female (usually first born male)
Nonbillious projectile vomitting
Dehydration with potnetial hypokalemic, hypochloremic met alk
Palpable olive like buldge on abdominal exam
One word to associated with Reye syndrome?
Caused by?
Only time to give it?
HEPATOENCEPHALOPATHY
Aspirin in sick kid. From decreased mitochondrial beta oxidation via reversible inhibition
Kawasaki’s disease
40 yo female with pruritus but no jaundice.
Primary Biliary Cirrhosis
Locations of absorption in intestine for different vit/minerals
“Dude, I just fucked in butt vit condom”
Duodenum=Iron
Jejunum=Folate
Illeum=B12, Vit C
Tropical sprue associated with travel to where? What deficiency?
Carribean. Folate and B12 def (megaloblastic anemia)
Responds to antibiotics (cause is unknown)
Thin older lady presenting with new DM2, what are you thinking?
Pancreatic Carcinoma.
Kayser Fleischer ring seen in (2)
Wilson’s disease and in PBC
Morphine does what 2 things in GI system?
Constipatory and causes sphinctor of Oddi contraction—worsening pain in Acute cholecystitis (use Meperdine)
Site of fat absorption of post cholecystecomy?
Jejunum. Digestion in duodenum.
Hep A histology?
Ballooning and degeneration of hepatocytes
Esophageal varices are result of anastomaosis between?
Caput medusa?
Left Gastric vein with esophageal vein
Paraumbilical Veins with Super/Infeiror Epigastric Veins
Metoclopromide MOA? Effects?
Major SE?
For Diabetic Illeus; promotes gastric emptying.
D2R agonist which acts also as antiemetic and prevents regurgitation via increasing LES tone.
Risk for Agranulocytosis
