GI/GU Case Wrap-up- Jaynstein Flashcards
Case A: Colitis
42 yo man – abd pain and diarrhea after eating red meat 3 days ago. Currently on ABX for cellulitis (Keflex, Bactrim, Clindamycin, Doxycycline)
-etiology? (list potential pathogens)
Salmonella? E. Coli?
doxy- is low risk!!! this abx is NOT known to cause c-diff
ABX’s associated with c-diff:
List HIGH risk Abx
Clindamycin, Cephalosporins, fluoroquinolones, Augmentin
ABX’s associated with c-diff:
List moderate-risk abx
Amox, Macrolides, tetracycline
ABX’s associated with c-diff:
list low-risk abx
Aminoglycosides, metronidazole, vanco , Bactrim
V/S: BP-99/56, HR 124, K += 3.2
Issues?
CT scan shows evidence of colitis.
SHOULD this Pt be admitted?
HypoTN (99/56), Tachy (124) - multiple sxs of dehydration
Leukocytosis, mild hypoK, AKI, ? Mild liver dysfunction
ETOHism
APAP use – getting high, liver dys, ETOH use
YES, admit
Case A: colitis
Plan:
- admit?
- fluids?
- antiemetics?
- Pain meds?
- Abx?
admit, IVF’s – start with 2 L’s and see if he responds hemodynamically
When is enough? VSS & Pt makes urine
Antiemetics: Zofran 4mg IV Q4 hours or Phenergan 6.25mg IV (caution liver, vaso-toxic) Reglan 10mg (caution GI bleed and renal impairment)
- Pain: any are fine–>morphine, dilaudid, fentanyl
- ABX–>Start now, def evidence of bacterial colitis: Cipro–> Change if necessary after culture results
Case A: colitis
patients with AKI (regardless of their underlying, acute medical issues) should be closely monitored–more often in a hospital setting for _______
**fluid replacement
C. diff:
- main symptoms?
- Major risk factors?
- main sx= diarrhea
- Positive stool C diff test
- Previous Abx usage(high risk=clindamycin, penicillins and cephalosporins)
- Advanced age
- Previous hospitalization
- Nursing home resident
C.diff infection= presence of Sx in the form of 3 or more unformed stool over 24 hours for 2 consec. days with positive stools for _________
**pseudomembrane
Sx: Watery diarrhea,
15-30 BMs/day,
Abd pain or cramps,
Fever-low grade,
C. diff tx?
-prevention?
first line tx of C diff= **oral vancomycin (PO) KNOW– 125 mg PO QID x 10 days
- Environmental control and hand hygiene
- Spores can live up to 5 months on a surface
- -Health care worker important vector
Salmonella:
- s/Sx?
- causes/risks?
- tx?
- Gram negative rod: Salmonella enteriditis
- -Carried in GI tract of reptiles, bird, (usually get salmonells from eating **contaminated meat/eggs)
- fever/diarrhea= MC sx
- tx: most cases self-limiting, if uncomplicated- NO abx. If complicated–cipro=TOC, 2nd-bactrim
Shigella:
s/sx?
-causes/risk factors?
- fecal oral spread, **linked to day care centers, changing diapers and poor hand washing.
- sx: diarrhea (bloody, watery, pus, mucus–secretory, fever, N/V, dehydration
Shigella:
tx?
- Rehydration
- 1st line abx: **Ciprofloxacin
- Bactrim or Azithromycin alternate
Campylobacter:
S/Sx?
-causes/risks?
- Sx start 2-5 days after ingestion and last 1 week
- sausages, hard meats, undercooked chicken
- prodrome: fever, HA, myalgia/malaise
- Ascending paralysis= guillian barre –association
Campylobacter:
tx?
- **Ciprofloxacin drug of choice
- Azithromycin alternate
80% of traveler’s diarrhea is caused by _____
(E. coli) Enterotoxigenic-shiga toxin + or - non 0157 strains
–>80% of traveler’s diarrhea
What is the main cause of hemolytic uremia in the US?
E. coli 0157:H7
E. coli 0157:H7 :
- linked to ______
- sx?
Linked to undercooked ground beef, drinking of unpasteurized juices and milk, working with cattle (1% of cattle in US carry)
Sx: bloody diarrhea, severe cramping, nausea/vomiting
E. coli infection:
tx?
- supportive
- abx use is controversial
- 5-20 % mortality
Vibrio cholera:
- etiology?
- incubation?
- cholera, waterborne–> poor water sanitation, eating raw oysters/shellfish
- Incubation: 12-72 hours
Vibrio:
sx?
**rice water stools” and RAPID dehydration,
watery diarrhea, N/V, fever/chills, abd cramping
Vibrio:
abx?
not always recommended, can use doxy or cipro, main tx: push lots of fluids!!!
Giardia:
S/sx?
diarrhea, foul-smelling greasy poop that floats, stomach pain, N, dehydration
Giardia:
-risk factors/exposures?
tx?
- children in daycare, travelers to areas w/ poor sanitation
- tinidazole and nitazoxamide
Case B: GERD
- 68yo F c/o heartburn and regurgitation 5x/week for 5 months
- currently taking OTC Prevacid (PPI) ? (Adequate trial?)
- ETOH: 1-2 glasses most nights
- Mother– gastric cancer
- Current meds: PLAVIX, DILT
- EGD shows: erosive esophagitis, H/ Pylori neg
what DDIs should you be aware of concerning this Pt’s current meds?
-DDIs can occur with Plavix and Diltiazem
plavix + PPI–> combo may decrease clopidogrel active metabolite levels and efficacy
Describe how reflux occurs with GERD
The lower esophageal sphincter (LES) is designed to relax when food passes through the esophagus into the stomach–> **reflux occurs when the LES “tightness” decreases allowing for gastric contents to “reflux” back into the esophagus
-Affects upwards of 7 million American’s
List Causes of lowered LES pressure
- High fat and carbohydrate diet
- ETOH
- Tobacco
- Acidic foods/drinks
- Medications – CCB’s, nitrates–**diltiazem, nitrates ALL relax smooth m
Antacids:
- MOA?
- Onset and duration?
=Increases the pH of the gastric refluxate by neutralizing gastric acid, thereby decreasing its potential to cause damage to the esophageal mucosa. These agents also increase the LES tone through alkalinization of gastric contents.
-Onset 15-30 minutes, duration 1-3 hours
Antacids are 1st line therapy for which group of Pts?
- Pts with mild intermittent Sx of GERD without esophagitis. (TUMs are a great option! they are usually effective, BUT require frequent dosing)
- They may also be used for breakthrough Sx in patients receiving H2-blockers or PPI’s.
Antacids should be AVOIDED with ______
**mg and aluminum containing antacids in CKD, may use calcium-based antacids
GERD meds:
-Sucralfate MOA?
a mucosal coating agent that forms a protective barrier between esophageal tissue and gastric refluxate
–Not FDA approved in tx of GERD – but has been demonstrated to provide some sx relief in these Pts
Sucralfate:
-how should this be prescribed? (dosing)
-which Pts should AVOID this med?
- dosing is 4x a day, this is NOT mono therapy
- Contains aluminum and therefore should be avoided in Pts with CKD
GERD meds:
-H2 antags MOA ?
Acid-suppressive agents that inhibit the action of histamine at the H2 receptor of the parietal cell, decreasing basal acid secretion
T/F: All H2RTs are equally effective and all are available OTC
True
-cimetidine, ranitidine, famotidine
H2 receptor antags:
- symptom relief is experienced in ___% of Pts
- How effective are they in tx of esophagitis? GERD?
- 50-70%
- Not as effective in tx of patients with true esophagitis, but adequate for mild-moderate GERD
- Patients can become tolerant– switching to a different one does not help
H2 receptor antags:
-adverse effects?
serious ADRs very uncommon!
- HA
- Rarely hepatitis
PPIs:
-MOA: irreversibly bind to the ________
-do Pts build a tolerance to PPIs?
H+/K+-ATPase pump of the parietal cell, thereby inhibiting the final step of acid secretion
- ->Tolerance does NOT occur
- ex’s: Omeprazole, pantoprazole, Dexilant, lansoprazole
Which medication is more effective at treating erosion/esophagitis than H2RTs?
PPIs
PPIs are first line for erosive esophagitis and H pylori
PPIs are linked to increased risk of _____
of c-diff, increased fracture risk, vitamin B12 deficiency, CKD, and worsen PNA prognosis
PPIs have many DDIs (CYP2C19) inhibitors:
-list ex’s of meds they interact with
Plavix, diazepam, phenytoin
FDA warning: Caution anticoags/anti-platelets with omeprazole
How often does heartburn occur in pregnancies?
30-50% of pregnancies
Heartburn tx options for pregnant Pts (list ex’s)
- Antacids: BUT NOT those containing sodium-bicarb
- H2RTs are category B
- PPIs are category B with the exception of omeprazole (Prilosec) which is category C
CASE B - GERD: considerations for this Pt–>
- H Pylori neg (if positive = ____ )
- No GIB (if positive = _____ )
- Endoscopy demonstrates grade B esophagitis (any evidence of esophagitis = ____)
- Patient is on Plavix (multiple PPIs contraindicated)
- should ASA be continued?
- PPI
- PPI
- PPI
YES ASA should be cont, but make sure it’s enteric coated
Case C: CKD
38yo AA female with DM-II with progressive kidney disease
- what are some of the goals for this Pt?
- what meds should be modified or d/c in Pts with CKD?
- Halt progression of renal disease
- An ACE-I or ARB should be initiated
- Discontinuation/avoidance of nephrotoxic drugs
Modify or d/c meds that contribute to renal impairment such as:
- Metformin (cant give to Pts with CrCl <30)
- -Vit C and D
- -Cetirizine (Zyrtec)
- -HCTZ
-Improve glycemic control–> Achieve A1C ~7% within 6 months
-Decrease CV risk factors-->HTN Target of <140/90 mm Hg within 2–4 weeks -Hyperlipidemia -Inadequate stain dosing - adjust -Obesity -Smoking