GI pt 3 Flashcards
irritable bowel syndrome
TREATMENT
• REASSURANCE
o Provide support to the patient by explaining that the alterations in visceral motility and sensitivity may be exacerbated by environmental, social, or psychological factors such as foods, medications, hormones, and stress
o Encourage patients to log their symptoms and any associating factors
• DIET CHANGES
o Avoid _____ foods and _____
o Avoidance of FODMAPs helps in some patients – FODMAPs are certain types of carbohydrate foods that are sensitive to people with IBS
o High fiber diet
o Increase _____ intake if constipation is predominant
o R/O lactose intolerance or celiac disease
• PHARMACOLOGIC
o ABDOMINAL PAIN
_____ (anticholinergics) = bentyl (dicyclomine) OR hyoscyamine (levsin)
Side effects: dry mouth, _____, urinary retention remember, anticholinergics dry everything out so don’t give to people with constipation because it’ll make it worse
o DIARRHEA
_____ (Imodium)
Lomotil
Eluxadoline (Viberzi)
o CONSTIPATION
_____ = milk of magnesia OR miralax
IBS agents = _____ (amitiza) OR linaclotide (linzess)
• Amitiza stimulates increased intestinal chloride secretion
o _____ believed to have effects on motility, visceral sensitivity, and central pain perception (anticholinergic side effect)
o _____ for underlying anxiety and depression
o RIFAXIMIN nonabsorbable antibiotic which is thought to suppress bacteria in suspected bacterial overgrowth
o Probiotics may help by altering gut flora
fatty caffeine water Antispasmodics constipation Loperamide Osmotic laxatives lubiprostone TRICYCLIC ANTIDEPRESSANTS SSRIs
crohns disease
SPECIFIC DRUG THERAPY
SUMMARY:
- Initially, start patient on _____ (ex. prednisone) and _____
*give calcium, vitamin ___, and _____ with steroids
- After several months, try to take patient off steroids, but CONTINUE anti-TNF therapy
- If it’s not working (patient is at 80%), add on _____ drugs
INDICATIONS FOR SURGERY
• Over 50% of patients will require at least one surgical procedure
• Main indications are:
o Intractability to medical therapy
o Intra-abdominal _____
o Massive _____
o Symptomatic refractory internal or perianal _____
o Intestinal obstruction
• Patients with chronic obstructive symptoms due to a short segment of ileal stenosis are best treated with resection or stricturoplasty (rather than long term medical therapy)
corticosteroid anti-TNF D bisphosphonate immunomodulating abscess bleeding fistulas
ulcerative colitis
TREATMENT
• TWO MAIN TREATMENT OBJECTIVES:
1. Terminate the acute, symptomatic attack
2. Prevent recurrence of attacks
• DIET (FOR MILD TO MODERATE):
o Regular diet, but limit intake of caffeine and gas producing vegetables
o Fiber supplements decrease diarrhea and rectal symptoms – psyllium, methylcellulose, bran powder
• ANTIDIARRHEAL AGENTS – _____ (IMODIUM), DIPHENOXYLATE WITH ATROPINE (LOMOTIL)
o Should NOT be given in the acute phase of illness, but are safe and helpful in patients with mild chronic symptoms up to four times daily
o Useful at nighttime and when taken prophylactically when bathroom facilities are not readily available
FOR MILD TO MODERATE DISTAL COLITIS
• Patients with disease confined to the RECTUM OR RECTOSIGMOID REGION – generally mild to moderate but distressing symptoms
• TOPICAL AGENTS:
o TOPICAL _____
Hydrocortisone _____ or foam for proctitis (inflammation of lining of rectum)
Hydrocortisone _____ for proctosigmoiditis (form of UC that affects the rectum and sigmoid colon)
o _____ – MESALAMINE DOC, superior to corticosteroids
Suppository at bedtime for proctitis
Enema at bedtime for proctosigmoiditis (for 3-12 weeks with 75% of patients improving)
Patients with early or frequent relapse should be treated with maintenance therapy with mesalamine suppositories or enema nightly or every other night
• FOR PATIENTS WHO DO NOT IMPROVE WITH THE ABOVE TOPICAL THERAPY:
o Combination topical therapy with a 5-ASA suppository or enema at bedtime and a corticosteroid enema or foam in the morning
o Combination of topical agent and oral 5-ASA agent
FOR MILD TO MODERATE COLITIS
• _____ AGENTS – MESALAMINE (ASACOL/PENTASA), BALSALAZIDE (COLAZAL)
o Disease extending above the sigmoid colon is best treated with both an oral and rectal 5-ASA agent (MESALAMINE OR BALSALAZIDE) – results in symptomatic improvement in 50-75% of patients
o Most improve within 3-6 weeks, though some require 2-3 months
o ORAL _____ – has more side effects, but given to patients with significant arthritis (supplement with folic acid)
• _____ – PREDNISONE, METHYLPREDNISOLONE
o Give to those who do not improve with 5-ASA after 2-3 weeks
o Topical therapy with 5-ASA enemas or hydrocortisone foam or enemas may be tried first before steroids – if no improvement in 2 weeks, systemic steroids are indicated
FOR MODERATE TO SEVERE COLITIS
• ORAL _____ – 1st line to induce remission
o Patients should undergo a SLOW taper when disease is under control
• Maintenance therapy is with 5-ASA AGENT (MESALAMINE), sometimes with the addition of an _____ (AZATHIOPRINE OR MERCAPTOPURINE)
• _____ AGENTS – reserved for patients who do not respond to the above therapies
o An immunomodulator is often added to the anti-TNF regimen to help prevent antibodies to the anti-TNF from forming
FOR SEVERE COLITIS
• 10-15% of patients with UC have a more severe course because they may progress to fulminant colitis or toxic megacolon
• Hospitalization is generally required
• GENERAL MEASURES:
o Discontinue all _____ intake for 24-48 hours or until clinical improvement is demonstrated
o _____ for patients with poor nutritional status or if feedings cannot be reinstituted within 7-10 days
o All opioid or anticholinergic agents should be discontinued
o Restore circulating volume with fluids, correct electrolyte abnormalities, and consider transfusion for significant anemia (hematocrit < 25-28%)
o Abdominal exams should be repeated to look for evidence of worsening distension or pain
o Plain ABD radiograph to look for colonic dilation
o Send stools for bacterial culture, c. diff toxin assay, and ova and parasites examination
o Surgical consult
• CORTICOSTEROIDS – IV METHYLPREDNISOLONE OR HYDROCORTISONE
o Hydrocortisone enemas may also be administered twice daily for treatment of urgency or tenesmus
o In patients who have not previously received steroids ACTH (adrenocorticotropic hormone) may be superior to steroids
o Approximately 50-75% of patients achieve remission with systemic steroids within 7-10 days
o With symptomatic improvement oral fluids are reinstituted and if tolerated, IV steroids discontinued and oral started
• ANTI-TNF THERAPY – single infusion of INFLIXIMAB 5 mg/kg has been shown effective in treating severe to fulminant colitis in patients who did not improve within 4-7 days of IV steroids
• CYCLOSPORINE – IV cyclosporine benefits 60-75% of patients with severe colitis who have not improved after 7-10 days of steroids
o May be considered a “bridge” therapy for patients resistant to surgery while mercaptopurine or azathioprine therapy is initiated
o Up to 2/3 of responders may be maintained in remission with combo of oral cyclosporine for 3 months and long term therapy with mercaptopurine or azathioprine
• Subset of patients with severe disease has a more fulminant course with rapid progression of symptoms over 1-2 weeks and signs of severe toxicity – administer broad spectrum abx
If TOXIC MEGACOLON develops (chronic dilation of more than 6 cm):
o In addition to above therapies, nasogastric suction should be initiated
o Patients should be instructed to roll from side to side and onto the abdomen in an effort to decompress the distended colon
o Serial abdominal films to look for worsening dilation or ischemia
o If worsen or fail to improve within 48-72 hours should undergo surgery to prevent perforation
• SURGICAL THERAPY – if they go in and remove the part of the colon that is diseased, it is essentially curative
o Recommended for those who fail to improve after 7-10 days of steroids, infliximab, other immunosuppressants, or cyclosporine therapy unlikely to respond to further medial therapy
o Severe hemorrhage, perforation, and documented carcinoma are absolute indications for surgery
o Also indicated for patients with fulminant colitis or toxic megacolon that does not improve in 48-72 hours, patients with dysplasia on surveillance colonoscopy, and in patients with refractory disease
o Proctocolectomy (surgical removal of the colon and rectum) will need the bag
May have standard ileostomy OR continent ileostomy or internal ileal pouch that is anastomosed to the anal canal
LOPERAMIDE CORTICOSTEROIDS suppository enema 5-ASA 5-ASA SULFASALAZINE CORTICOSTEROIDS CORTICOSTEROIDS IMMUNOMODULATOR ANTI-TNF oral TPN
c diff. colitis
TREATMENT
• Discontinue antibiotics if permissible REMEMBER, CLINDAMYCIN COMMONLY CAUSES C. DIFF
• Initiate therapy with ORAL _____, VANCOMYCIN, OR FIDAXOMICIN
o ORAL METRO USUALLY FIRST LINE
METRONIDAZOLE
diverticulosis
TREATMENT
• DIET:
o Increase dietary _____ through high fiber diet (fruits, vegetables, whole grains) OR fiber supplements (_____, psyllium or methylcellulose)
• LIFESTYLE:
o Promote a generally healthy lifestyle – exercise, avoid red meat, avoid _____
fiber
bran powder
NSAIDs
diverticulitis
TREATMENT
MEDICAL MANAGEMENT – most patients can be treated with abx without surgery; pts should get rapidly better in 2-3 days
• Most managed with conservative measures
• Mild symptoms and no peritoneal signs may be managed initially as outpatients on a clear liquid diet and broad spectrum antibiotics with anaerobic activity: MEMORIZE THESE ABX
o _____
OR
o _____ plus either _____ or _____
o All for 7-10 days or until patient is afebrile for 3-5 days
o Symptomatic improvement usually is seen in 3 days and then diet can be advanced
• Who requires hospitalization?
o Elderly or immunosuppressed
o Patients with increasing pain, fever, or inability to tolerate oral fluids
o Patients with severe diverticulitis (high fevers, leukocytosis or peritoneal signs)
o Complicated disease requires hospitalization – perforation, abscess, obstruction or fistulization
TREATMENT
o NOTHING BY MOUTH – should receive _____ and pain meds
o If ileus present, _____ should be placed
o IV abx that cover anaerobic and gram negative bacteria (ex. cefotxitin, piperacillin-tazobactram, ticarcillin clavulanate – don’t need to know these)
o Symptomatic improvement should be evident within 2-3 days
o IV antibiotics should be continued for 5-7 days before changing to oral antibiotics
o Colonoscopy 6 weeks after acute episode resolved to exclude colon carcinoma or IBD
SURGICAL MANAGEMENT
• Surgical consult and repeat abdominal CT in all patients with severe disease OR those that fail to improve after 72 hours of medical management
• Patients with a localized abscess > or = to __ cm: treated urgently with a percutaneous catheter DRAIN permitting control of infection and resolution of the immediate infection
• Indications for emergent surgical management: free _____ and large (undrainable) _____
• Elective surgery: patients with fistulas or large abscesses
• Colectomy of diseased portion is then completed with anastomosis of remainder
AUGMENTIN METRONIDAZOLE CIPRO TRIMETHOPRIM-SULFAMETHOXAZOLE IV fluids NG tube 4 peritonitis abscesses
colon cancer
TREATMENT
• TOC = _____ – if patient can tolerate anesthesia and has lesions that can be resected, DO SURGERY!
• Do regional lymph node dissection to determine staging (12 nodes)
• ADJUVANT THERAPY FOR COLON CANCER
o STAGE I:
Excellent 5-year survival rate 80-100%
No adjuvant therapy recommended
o STAGE II (node-negative):
5 year survival 50-75%
Benefit from adjuvant therapy has NOT been demonstrated
o STAGE III (node-positive):
5 year survival 30-50%
Post-op _____ reduces mortality by 33% – recommended for all patients
USE COMBO OF _____ (oxaliplatin, 5_FU, leucovorin) don’t have to memorize
Locally advanced cancer may benefit from radiotherapy to reduce risk of local recurrence
o STAGE IV (metastatic disease)
20% have metastatic disease at time of initial dx, another 30% eventually develop it
Long term survival: 5%
Resection of 1-3 liver/lung mets may result in > 5 year survival in 35-55% of cases
_____ first line treatment, plus a biologic agent (bevacizumab)
• FOLLOW-UP POST SURGERY
o Evaluate every 3-6 months for 3-5 years with history, PE, fecal occult blood testing, liver function tests, and CEA levels
o Colonoscopy –
Within 6-12 months post-surgery (look for recurrence)
Then every 3-5 years to look for metachronous (multiple, separate) polyps or cancer
o A change in patient’s clinical picture, abnormal liver function tests, or rising CEA – do CXR and abdominal CT to look for recurrent disease or metastatic disease
SURGERY
chemo
FOLFOX
FOLFOX
