GI Exam 2 (Medications +Tx) Flashcards
IBS Medication
Antispasmodic — Pain/Bloating (2)
(-mine)
Dicyclomine
Hyosycamine
IBS Medications
Anti-Constipation (IBS-C) — 3
Osmotic Laxatives — First
Lubiprostone — Female 18+
Linaclotide
IBS Medication
Antidiarrheals (IBS-D)
Loperamide — First
Bile Salt Sequestrants — Fail
Loperamide
SSRA
- Alosetron (Fail ALL other therapy — Female ONLY)
- Ondansetron (Off-label use)
Non-absorbable antibiotics
-Rifaximin (Significant bloating)
IBS Medication
Psychotropic agents (Pain + Bloating) — Better in IBS-D: Anticholinergic effect)
TCAs (-Triptyline)
Amitriptyline
Nortriptyline
Antibiotic Associated Colitis
Treatment
General
Admission
Discontinue offending antibiotic agent
Infection control procedures
Correct fluid and electrolyte disturbances
Antibiotic Associated Colitis
Treatment
Mild/Moderate
Metronidazole 500mg PO TID x 10 days (First line)
Can’t take Metro or therapy failure after 5-7 days —> Vancomycin
Vancomycin 125 mg PO QID x 10 days
Antibiotic Associated Colitis
Treatment
Severe
Vancomycin 125 mg PO QID x 10 days
Antibiotic Associated Colitis
Treatment
Fulminant
Vancomycin 500 mg PO QID
Metronidazole 500 mg IV
Vancomycin PR 500 mg QID
+ Early surgical Consultation
Antibiotic Associated Colitis
Treatment
Relapse
Repeat course of oral antibiotics
Subsequent relapse require 7 week taper of Vancomycin
Adjuvant Therapy (Probiotics, Fecal Transplantation)
Toxic Megacolon
Treatment
Reduce Colonic distention to prevent perforation
Correct fluid and electrolyte disturbances
Treat toxemia and precipitating factors
Surgical consultation
Diverticular Bleeding
Treatment
Pt w/ active bleeding
Pts w/o active bleeding
w/ active bleeding
Resuscitation and stabilization
Endoscopy (EGD)
W/O active bleeding
Refer —> Scope
Diverticulitis
Treatment
Mild
Conservative Measures
Outpatient
Oral broad-spectrum antibiotics (7-10days)
1: Metronidazole 500mg + Ciprofloxacin 500mg
2: Metronidazole 500mg + TMP-SMX-DS (If pt cannot take Ciprofloxacin)
3: Amoxicillin-Clavulanate (Augmentin
NOT recommended unless pt cannot take both of Ciprofloxacin and TMP-SMX DS
Clear liquid diet
Diverticulitis
Treatment
Severe
Inpatient
NPO
IV Broad-spectrum antibiotics
**Continued until inflammation is stabilized —> Transition to PO abx
IV fluid and electrolyte replacement
IV pain management
**Surgical consultation as indicated
Sigmoid Volvulus
Treatment
Flex sig —> Detorsion
Crohn
Abscess, obstruction or Fistulas action
General
Surgery
General —> Symptomatic improvement & Control
Crohn
Symptomatic
Antidiarrheals
Loperamide,
Bile Acid Sequestrant (If significant involvement of terminal ileum
Oral steroid for aphthous ulcer
Triamcinolone (Topical steroid)
Crohn
Active Disease
Non-Sysmetic Corticosteroids — Mild to Moderate
Budesonide
Systemic Corticosteroids — Severe
Prednisone
Pts who fail oral corticosteroid therapy —> Hospitalization
Crohn
Maintenance
Absence of maintenance therapy —> Symptom relapse in 80% of pts within 1 yr
Immunomodulators
Azathioprine
6-Mercaptopurine
Methotrexate
TNF Agents
Infliximab
Adalimumab
Certolizumab
Ulcerative Colitis
Main difference from Crohn
5-ASA
Mesalamine
Sulfasalazine (w/ Folic acid)
UC
Mild-Mod Distal
Rectosigmoid colon
Topical Mesalamine (DOC) — Suppository or enema (PO if can’t tolerate or refuse)
Topical Corticosteroids
Hydrocortisone —> Suppository or enema
UC
Refractory DIstal
Frequent relapse —> Maintenance
Oral + Topical 5-ASA
+ Oral Prednisone if symptoms still persist
Maintenance
Nightly (every other night) of topical 5-ASA
(PO = Less effective)
UC
Mild-Mod EXTENSIVE
Extending proximal to the sigmoid
Oral 5-ASA
Mesalamine
Sulfasalazine (+Folic Acid)
NO improvement in 4 wks —> Oral Corticosteroids added to 5-ASAs
Prednisone OR Methylprednisolone
UC
Refractory Extensive
Immunomodulators
Anti-TNF Agents (Pick one) — (-mab)
Infliximab
Adalimumab
Golimumab
Anti-integrin therapy
(Moderate to severe UC who fail all other therapies)
Vedolizumab
UC
Severe or Fulminant (Pan Colitis)
Inpatient care
Surgical consultation early
NPO
Parenteral fluid/electrolyte replacement
IV corticosteroids
Maintenance therapy
Oral Mesalamine or Sulfasalazine (+Folic Acid) — Daily
Mercaptopurine OR Azathioprine (=2 relapses/yr)
Microscopic Colitis
Discontinue offending medications if possible
Symptomatic care
Antidiarrheals
If diarrhea persists —> Budesonide x 4 wks
IBS
Treatment
Reassurance and Education
Psychosomatic vicious cycle
Anxiety over symptoms —> worsening symptoms
IBS
Adjunctive Pharmacologic Therapy
Antispasmodic (Pain/bloating)
Dicyclomine
Hyosycamine
(-mine)
IBS
Adjunctive Pharmacologic Therapy
Anti-Constipation (IBS-C)
Osmotic laxatives — First
Lubiprostone — Female >18
Linaclotide
IBS
Adjunctive Pharmacologic Therapy
Antidiarrheals (IBS-D)
Loperamide — First
Bile salt sequestrants — Fail Loperamide
SSRA (-setron)
Alosetron — Fail all other therapy (Female ONLY)
Ondansetron
Non-absorbable antibiotics
Rifaximin — significant bloating
IBS
Adjunctive Pharmacologic Therapy
Psychotropic agents (pain + bloating)
TCAs (-Triptyline)
Ami
Nor
Jaundice
Treatment aimed at underlying etiology
After initial lab testing, Referred for further testing and evaluation
Acute Liver Faliure
Admission for inpatient management
IV fluid and electrolye replacement
Dietary monitoring
Gastroprotective measures (Prevention of stress Gastropathy) -IV PPI or H2
Other treatments as indicated based on etiology
Hepatitis A
Bed rest if needed
Symptomatic care
Antiemetic, Antidiarrheals, Fluids regular meals
Avoid strenuous exercise or work
NO ETOH or HEPATOTOXIC MEDS
Hep B
Supportive
Encephalopathy or Coagulopathy — Severe disease
Inpatient management
Antiviral Therapy
Hep C
Re-check HCV RNA (PCR) @ 12 wks after exposure or after diagnosis
Peginterferon for 12-24 wks
Chronic Viral Hepatitis
HCV
Harvoni
NAFLD (NAFL or NASH)
Lifestyle changes
Diet, exercise, weight loss
Vitamin E
Insulin sensitizing agents — Metformin
Alcoholic Steatohepatitis
R/O other causes for acute hepatitis
US & Biopsy
Admit to GI
Alcohol abstinence Prevention and Tx of alcohol withdrawal Fluid management Nutritional support Infection surveillance Prophylaxis against gastric mucosal bleeding — IV PPI
Cirrhosis
Inpatient
Abstinence from ETOH
Dietary Consultation
Immunizations — HAV, HBV, Flu shot
Liver transplant — Ultimately
Ascites
TIPS
Spontaneous Bacterial Peritonitis
ADMIT
Ceftriaxone (IV)
Prophylaxis
Ciprofloxacin (Once Daily) OR TMP-SMX DS
Hepatorenal Syndrome
Improving liver function
If can’t improve liver function in the short term —> Admit to ICU
Hepatic Encephalopathy
Admission
Lactulose — Ammonia reducer
Toxic Liver Injury
Discontinue offending agent
Primary Biliary Cirrhosis
R/O Other etiologies of biliary tract obstruction — FIRST
Ursodeoxycholic acid
Bile salt sequestrants (Chole, Cole) — Pruritist
Hemochromatosis
Deferoxamine
Phlebotomy
Wilson
Chelation of Copper
Budd-Chiari Syndrome
Directed at underlying cause and complications — Ascites
Admit any pt w/ suspected hepatic vein obstruction
Cholelithiasis
NONE — Asymptomatic
NSAIDs — Intermittent, mild biliary colic
Cholecystectomy — Continued pain or frequent Cholecystitis
Acute Cholecystitis
Admission for supportive care
Cholecystectomy — timing dependent on presentation and severity
Choledocholithiasis
Endoscopic stone removal — even in ASYMPTOMATIC
Cholecystectomy — Prevent recurrence or complication
Acute Cholangitis
Admission
ERCP — biliary drainage and removal of obstruction
Surgery — if ERCP fails or is unavailable
Cholecystectomy — once infection is cleared
Acute Pancreatitis
General measures
ERCP for gallstone pancreatitis within 24 hrs of admission
If alcohol abuse —> NO ERCP
Acute Pancreatitis
MIld
Admission
NPO
Bed Rest
IV Fluid and E
Morphine!!! — Pain control
Acute Pancreatitis
SEVERE
ICU
Early surgical consultation
IV F and E// Monitoring of Hemodynamics status
Antibiotics
Chronic Pancreatitis
Referral to GI/Pancreatology NO ETOH Low fat diet Non-opioid pain control Pancreatic enzyme supplementation
