GI PACKET 4 TX Flashcards
HEMORRHOIDS
TREATMENT:
- EARLY DISEASE (stage 1 & 2) – not prolapsed
o Conservative treatment:
increase ___ & ____ intake
avoid straining & limit time spent sitting on toilet
- EDEMATOUS PROLAPSED (stage 4) – painful, itchy, may bleed
o Conservative management PLUS additional medical therapy
OTC topical preps (PREPARATION __, _____, TUCKS)
_______ (often a combo of emollients, anesthetics, vasoconstrictors, astringents, steroids
- for hemorrhoids REFRACTORY TO CONSERVATIVE TX —> ______
o sclerotherapy, photo-ligation, band therapy
o surgical excision = __________
for small subset of patients with chronic, severe bleeding
fluid, fiber H, ANUSOL suppositories surgery hemorrhoidectomy
THROMBOSED EXTERNAL HEMORRHOIDS
TREATMENT: relieved with warm sitz ____, _______, ointments, and possible clot removal
baths, analgesics
ANAL FISSURES
TX: topical _______, topical ____ and ____ cream, botox inj, or sphincterotomy
anesthetics
nitro
Diltiazem
ANAL FISTULA
TREATMENT: surgical incision for fistula (_______)
fistuotomy
PANCREATITIS TREATMENT MILD DISEASE: - “pancreatic rest” o \_\_\_ then advance diet to clear liquids --> soft ---> low fat regular diet o Bed rest & IV fluids o \_\_\_\_\_\_\_ for pain control (morphine = acceptable alternative, preferred in some even though it causes Sphincter of Oddi to spasm) o Ileus --> \_\_\_ tube
SEVERE DISEASE: pt goes into shock with hypotension —> multisystem organ failure
- Large amounts of IV fluids (500-1000 ml/hr for several hours 250-300 ml/hr)
- NPO then advance diet (may need TPN)
- ICU monitoring & correct any coagulaopathies
o If hypocalcemia —> CALCIUM GLUCONATE
o if pancreatic necrosis –> IV ___ (IMIPENEM & possible combo w/ CEFUROXIME)
o if gallstones –> eventual ________ (removal of gallbladder)
o if pancreatic abscess –>percutaneous or surgical drainage
- general surgery consult & infectious disease consult
NPO MERPERIDINE NG abx cholecystectomy
CHRONIC PANCREATITIS
TREATMENT (chronic pain & inflammation)
- Low fat diet
- Avoid _____ (may precipitate attacks)
- Pain control —> avoid _____as addiction is common w/ this disease (bc usually alcoholics)
- Pancreatic enzyme supplements ESP IN PTS W ______
o Lack of lipase –> lack of breakdown of lipids —> fatty stools
- Treat DM or hyperlipidemia
- Monitor for pancreatic cancer due to ↑ risk
alcohol
opioids
steatorrhea
PANCREATIC CANCER
TREATMENT
- Lesions strictly limited to the head of the pancreas —> radical ________ resection (____)
- _____ with radiation
- Resection not feasible —> endoscopic ____ of the bile duct to relieve jaundice
pancreaticduodenal
chemo
stenting
HEP A
TREATMENT
• Generally ______, increase fluids, diet as tolerated.
• Avoid hepatoxic medications
• Prognosis is good, with complete recovery in less than _ months
supportive
3
HEP B
TREATMENT
• Same as for acute hepatitis _
• Encephalopathy or severe coagulopathy indicates acute liver failure and _______ at a liver transplant center is mandatory
• _____ therapy is generally unnecessary in patients with acute hep B but is usually prescribed in cases of fulminant hepatitis as well as in spontaneous reactivation of chronic hepatitis presenting as acute on chronic liver failure
A
hospitilization
antiviral
CHRONIC HEP B
• Patients with active viral replication (HBeAg and HBV DNA in serum and elevated aminotransferase levels)
o ______or _______ (preferred because they are better tolerated and can be taken orally) or with pegylated interferon
o Patients should meet thresholds for treatment
o Goal is aimed at reducing and maintaining the serum ____ level to the lowest possible levels to normalize ALT and have histologic improvement
o Usually ___ months of therapy some require long term therapy (required if they do not seroconvert or relapse).
• Nucleoside and Nucleotide analogs –
PREFFERED FIRST LINE ORAL AGENTS
• Enteavir (Baraclude)
o rarely associated with resistance unless patient is already resistant to ______
o 0.5mg orally for patient not resistant to lamivudine; 1 mg for patients resistant to lamivudine
o Suppression of HBV DNA occurs in nearly all treated patients; histologic improvement observed in 70% of patients
o Reported to cause ______ when used in patients with decompensated cirrhosis
• Tenofovir (Viread)
o 300 mg qd (disoproxil fumarate) or approved in 2016 (alaenamide) 25 mg qd
o Long term use may lead to an elevated serum _______ level and reduced serum phosphate level that is reversible with discontinuation.
• Nucleoside analog
o Lamivudine; (Epivir)
First available;
No longer first line in the US
Rate of resistance reaches 70% by year 5
o Adefovir dipivoxil (Hepsera)
least potent of the oral antiviral agents
Only a small number of patients achieve sustained suppression of HBV replication and long term therapy is often required
Risk for ______ with long term use
o Telbivudine (Tyzeka)
More potent and resistance may develop
Elevated creatine kinase levels are common
• Development of resistance occasionally results in hepatic decompensation
o Most likely to develop to lamivudine
• Sequential addition of a second antiviral gent is usually effective after resistance to the first agent has developed
• Combined use of peginterferon and a nucleoside or nucleotide analog has not been shown to have a substantial advantage over either drug alone
• _______
o Still alternative to the oral agents in selected cases
o 180 mcg subq once weekly for 48 weeks
o Improved biochemical markers and survival in 40% of patients
o Relapses are uncommon in complete responders
o May be considered in order to avoid long term therapy with an oral agent as in young women who may want to become pregnant in the future
o Poor response in co-HIV infected patients
nucleoside nucleotide analag HB DNA 6-12 lamivutidine lactic acidosis creatinine nephrotoxicity peginterferon 2
CHRONIC HEPATITIS D
Treatment
• _______
o may lead to normalization of serum aminotransferase levels, histologic improvement and elimination of HDV RNA in 20-50% of patients
• Relapse may occur and tolerance is poor
peginterferon 2b
HEP C
TREATMENT
• Generally acute Hep C is asymptomatic or mild so requires ______ for symptoms
• Often give _____ (ledipasvir, sofosbuvir) to patients with acute Hep C to prevent chronic hepatitis
no treatment
anti-virals
CHRONIC HEP C
• Previous standard of treatment (these are NOT first line anymore)
• ______ and ____
• Associated with frequent , distressing side effects; discontinuation rates were high as 15-30%
• Caution in those over 65 in whom hemolysis could pose a risk of angina or stroke.
• Contraindicated
o Pregnant and breastfeeding: must practice strict contraception for 6 months ( men and women)
o Decompensated cirrhosis
o Profound cytopenias
o Severe psychiatric disorders
o Autoimmune diseases
o Inability to self-administer or comply with treatment
• ________(DAA) now offer patients a chance for a CURE for their Hep C
• These drugs are well tolerated and have revolutionized the treatment of chronic Hep C
• Very expensive!
• There are a variety of drugs within this “category” that can be used in several different treatment regimens. These regimens involve protocols for virus load monitoring.
• Efficacious but expensive; insurance cover often a barrier
• Additional factor to consider are the presence of cirrhosis or kidney dysfunction piror to treatment and potential drug interactions
• HCV genotype 1 is now easy to cure with oral direct-acting agents and virtually all HCV genotype 2 infection is curable with all oral regimens
• HCV genotype 3 infection especially in association with cirrhosis is the most challenging to treat
• Interferon is rarely required and need for ribavirin is declining
• Screen for HBV or reactivation of HBV or herpes virsus have occurred with direct acting antiviral agents for HCV infection
peginterferon
ribaverin
direct acting antiviral agents
