GI pt 2 Flashcards
acute upper GI bleed
EVALUATION AND TREATMENT
- UGI bleeding is _____ in the majority of cases
o Even high-risk patients are more likely to die from underlying cause rather than “bleeding out”
- MUST identify those patients who are in need of emergent therapies (ex. bleeding varices)
- ABCs!
- Hematocrit may take 24-72 hours to equilibrate with the extravascular fluid so NOT a reliable indicator of the severity of acute bleeding
- Assess the patient’s _____ status FR
o In hemodynamically stable patients aggressive _____ management or _____ replacement can be delayed until further evaluation is completed
o Elevated _____ (>100) and low SBP suggest a more significant hemorrhage
o In patients with hemodynamic compromise more urgent situation!
Start _____, type and screen for blood product replacement, stat _____ (CBC, electrolytes, PT/PTT/INR, LFTs, BUN/Cr)
Prep for upper _____
- UGI bleed endoscopy – early therapeutic endoscopy
o Varices band ligation or sclerotherapy
o Non-variceal etiologies sclerotherapy, electrocoagulation, heater probes, and lasers
- _____ or longer acting derivative _____ – used for both varices and PUD either before endoscopy or when it is unsuccessful, contraindicated, or unavailable
- 5 variables that are independent predictors of adverse outcomes in upper GI bleeding
o Initial hematocrit < 30%
o Initial systolic BP < 100mgHg
o Red blood in the nasogastric lavage
o History of cirrhosis or ascites on examination
o History of vomiting red blood
self-limited hemodynamic fluid blood product HR IV fluids labs endoscopy Somatostatin octreotide
acute lower GI bleed
TREATMENT
• Triage similarly to UGI bleed
• Discontinue _____ and _____
antiplatelet
anticoagulants
PUD
TREATMENT - \_\_\_\_\_ agents o TOC = \_\_\_\_\_ o 2nd LINE = H2 blockers - Mucosal agents – \_\_\_\_\_, misoprostol, antacids - Eradication of H. pylori if present o H. PYLORI ERADICATION CALLS FOR “QUADRUPLE THERAPY” – TREAT PATIENTS WITH 14 DAYS OF 1. \_\_\_\_\_ BID 2. \_\_\_\_\_ QID 3. \_\_\_\_\_ QID 4. \_\_\_\_\_ TID - Stop NSAIDs & STOP smoking - Ulcers refractory to treatment (very rare) may require surgery
Acid-antisecretory PPIs bismuth sucralfate PPI bismuth subsalicylate tetracycline metronidazole
gastric cancers/tumors
ZOLLINGER-ELLISON (ZE) SYNDROME(GASTRINOMA)
TREATMENT
- Cure can only be achieved if gastrinoma(s) can be _____ prior to metastatic spread
- In patients with metastatic liver disease, treatment is focused on controlling acid hypersecretion with _____ (these patients will be on massive doses of PPIs)
- PPIs end in -prazole (ex. omeprazole, esomeprazole)
resected
PPIs
gastric cancer (gastric adenocarcinoma)
TREATMENT
- Curative _____ & post-op _____ or chemoradiation
- Palliative Modalities: resection, surgical diversion, laser or stent therapy, radiation therapy, chemotherapy
surgical resection
chemotherapy
celiac disease
TREATMENT: remove all _____ from diet (all wheat, rye, barley)
- Need to work with dietician b/c many products (including meds) have gluten
- Most people with celiac disease are also lactose intolerant
- Short term dietary supplements needed (___, ___, ___, ___)
- **if disease is not responding to gluten free diet (but they have good compliance as seen by IgA) poor prognosis
- Consider the development of T Cell lymphoma in patients who have appeared to relapse (weight loss, abdominal pain, malabsorption)
gluten
A, B12, D, E
whipples disease
TREATMENT: goal = prevent progression to _____ symptoms (b/c they can be permanent)
- ABX therapy shows dramatic improvement in several weeks w/ complete clinical response in 1-3 months
o _____ aka _____ double strength = first line (need meds that cross the BBB)
o Untreated = fatal
- discontinuation of tx relapse in 1/3 (follow closely for signs of relapse) treat for 1 year
- After TX, repeat _____ at 6 & 12 months for histology to follow healing process
neuro
TMP-SX
BACTRIM
duodenal biopsies
SIBO (small intestinal bacterial overgrowth)
TREATMENT: treat underlying cause
- diet of high _____, low _____ and low _____ may reduce s/s
- 1-2 weeks of broad spectrum abx (_____ 500 mg)
o _____ for 7-10 days is better but more expensive
- If symptoms recur use cyclic tx
- If motility disorder use agents to ↑ motility
o Prokinetic agents = metoclopramide (REGLAN)
o _____ (SandoSTATIN) - also used for portal HTN (not FDA approved for use for SIBO but works)
- ***avoid continuous ABX to prevent resistance, d/c narcotics, minimize PPI use
fats carbs fiber CIPRO RIFAMPIN Octreotide
lactase deficiency
TREATMENT achieve pt _____
- Patients need to find out how much they can tolerate before they get s/s
o High lactose foods = milk, ice cream, cottage cheese, unpasteurized yogurt (bacteria produces lactase, but it’s well tolerated)
o Milk can be pre-treated with lactase 70-100% lactase free
- Limit lactose to < 12 g day (equivalent to 1 cup of milk)
- OTC lactase enzyme replacement = _____ (caplets that can be taken with milk products)
comfort
LACTAID
ileus
TREATMENT: tx medical or surgical condition that caused the problem
- restrict _____ intake and slowly enhance diet as bowel function returns
- severe, prolonged ileus __ suction, _____ & electrolytes
oral
NG
parenteral fluids
bowel obstruction
TREATMENT:
non-surgical tx will result in complete resolution in 75% of partial obstructions and 16-36% of complete obstructions
***any pt with suspected bowel osntruction admitted to hospital
- aggressive _____ resuscitation (IV fluid and electrolyte replacement, ___)
- bowel decompression (usually w/ _____) to manage nausea and emesis
- Broad spectrum abx (covering gram – and anaerobes) _____
- Surgical consult (if complicated go to OR for abdominal exploration)
early surgical evaluation for strangulation/ischemia “never let the sun set on a bowel obstruction”
o Patients for immediate surgery:
Free air on plain xrays or CT indicating bowel perforation
Signs of ischemia
Complete or closed loop obstruction
fluid
NPO
NG tube
2nd gen cephalosporin
OGILVIE SYNDROME
TREATMENT: address underlying condition (get the colon working again)
- NC or _____ tube for decompression
- Increase pt mobility to promote colonic movement
- Avoid opioids and anticholinergics
- Can use _____ but avoid oral laxatives (can increase perforation)
- Patients who fail conservative management can be treated more aggressively
o _____ injection and colonic decompression via colonscopy
rectal
enemas
Neostigmine
appendicitis
TREATMENT = surgical _____ (laparoscopic approach if early & uncomplicated)
need pre-op _____ prophylaxis to cover gram – and anaerobic bacteria
appendectomy
abx
hernias
TX OF HERNIAS = _____ hernia repairs (place a _____ patch over the hole/weak spot)
laparoscopic
mesh
