GI Exam 2 (Medications +Tx) Flashcards by Hyuk Lee

IBS Medication

Antispasmodic — Pain/Bloating (2)

(-mine)

Dicyclomine
Hyosycamine

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IBS Medications

Anti-Constipation (IBS-C) — 3

Osmotic Laxatives — First
Lubiprostone — Female 18+
Linaclotide

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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)

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IBS Medication

Psychotropic agents (Pain + Bloating) — Better in IBS-D: Anticholinergic effect)

TCAs (-Triptyline)
Amitriptyline
Nortriptyline

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Antibiotic Associated Colitis

Treatment

General

Admission
Discontinue offending antibiotic agent
Infection control procedures
Correct fluid and electrolyte disturbances

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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

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Antibiotic Associated Colitis

Treatment

Severe

Vancomycin 125 mg PO QID x 10 days

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Antibiotic Associated Colitis

Treatment

Fulminant

Vancomycin 500 mg PO QID
Metronidazole 500 mg IV
Vancomycin PR 500 mg QID

+ Early surgical Consultation

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Antibiotic Associated Colitis

Treatment

Relapse

Repeat course of oral antibiotics
Subsequent relapse require 7 week taper of Vancomycin
Adjuvant Therapy (Probiotics, Fecal Transplantation)

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Toxic Megacolon

Treatment

Reduce Colonic distention to prevent perforation

Correct fluid and electrolyte disturbances

Treat toxemia and precipitating factors

Surgical consultation

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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

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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

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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

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Sigmoid Volvulus

Treatment

Flex sig —> Detorsion

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Crohn

Abscess, obstruction or Fistulas action

General

Surgery

General —> Symptomatic improvement & Control

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Crohn

Symptomatic

Antidiarrheals

Loperamide,
Bile Acid Sequestrant (If significant involvement of terminal ileum

Oral steroid for aphthous ulcer

Triamcinolone (Topical steroid)

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Crohn

Active Disease

Non-Sysmetic Corticosteroids — Mild to Moderate

Budesonide

Systemic Corticosteroids — Severe

Prednisone

Pts who fail oral corticosteroid therapy —> Hospitalization

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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

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Ulcerative Colitis

Main difference from Crohn

5-ASA

Mesalamine
Sulfasalazine (w/ Folic acid)

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Mild-Mod Distal

Rectosigmoid colon

Topical Mesalamine (DOC) — Suppository or enema (PO if can’t tolerate or refuse)

Topical Corticosteroids

Hydrocortisone —> Suppository or enema

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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)

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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

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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

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 ```