GI Therapeutics Flashcards
Celiac Sprue
Gluten-free diet
Multivit, iron, folate, calcium, vitamin D
Steroids for severely ill
Whipple’s disease
Trimethoprim-sulfamethoxazole BID x 1 yr Parenteral penicillin for ill pts Oral PCN for pts allergic to sulfa Chloramphenicol for failures Supplement folate, B 12, fat soluble vitamins and iron as needed
Achalasia
nitrates, calcium channel blocker
(inconsistent resp.)
Botox (inconsistent resp.)
Disruption of LES
Eosinophillic Esophagitis
dietary modification, topical and oral steroids, dilatation with stricture
Esophageal Spasm
If due to acid→ block acid production
If spontaneous → muscle relaxants
Gastroesophageal Reflux
Lifestlye modifications (↑ head of bed, diet)
Antacids
H2-receptor antagonist
PPI
Metachlopromide
Surgery
How can you decrease adverse events in NSAID users?
PPI and H2 blockers
MOA of PPI
Bind the acid-secreting enzyme H+-K+- ATPase, or “proton pump,” permanently inactivating it
Inhibit >90% of 24 hr acid secretion
H2 blockers MOA
Block, histamine, one of the first stimuli for acid production
Rapid onset <1 hr lasting for 12 hr
Cimetidine (drug-drug interactions), Ranitidine, Nizatidine, and famotidine
Tx for PUD
Pre endoscopy IV PPI
endoscopic hemostasis (cautery, clip or injection)
Followed by feeding and oral PPI for low risk or IV PPI x 72 hr for high risk
Tx for H. Pylori
Abx x 2 wks + PPI
Zollinger-Ellison Sundrome
High dose PPI and removal of tumor
Gastroparesis
Diet
Feeding tube
Anti-emetics
Metoclopramide
Erythromycin
Gastric Pacer
Surgery
When can you use medication to treat obesity?
BMI > 30
BMI > 27 with obesity‐related risk
factors
What medications can you use for tx of obesity?
Orlistat 3x/day w/ meal (inhib fat abs)
Lorcaserin (appetite control)
Qsymia (dec appetite by inc energy used)
Contrave
Liraglutide/Saxenda (stim insulin secretion)
Sibutramine/Meridia (appetite suppressant)
SE Orlistat
diarrhea, gas, and cramping and perhaps reduced absorption of fat‐soluble vitamins
SE Lorcaserin
nausea, dry mouth, dizziness
constipation and fatigue
SE Qsymia
mood changes, fatigue, increased blood pressure, heart rate and insomnia
Preventative tx for travelers diarrhea
Give travelers antimotility agent (Imodium®) and
antibiotics to take on trip
Instruct on when to self-medicate (>24 h)
Bismuth is often sufficient
How do you treat small ileal resection?
<100 cm
> 100 cm
<100 cm Cholestyramine
> 100 cm NO Cholestyramine
How do you treat SB bacterial overgrowth?
Augmentin, Cipro, Metronidazole, Rifaxamin, etc
Tx for esophageal ca
SCC- more sensitive to chemo, chemoXRT and RT
Low stage (Tis & T1) – endoscopic therapy, checmo/surgery if needed
Higher stage (T2 & above) – chemo/XRT then surgery
Gastric ca tx
Low stage (Tis & T1) – endoscopic therapy (EMR/ESD)
Higher stage (T2 & above) – chemo/XRT then surgery (morbid)
SB ca tx
Surgery + chemo mainstay of therapy
CRC tx
Stage 1 and low-risk stage 2: surgical resection is curative and no chemo
All other stages: surgical resection if
possible followed by adjuvant chemo
Anal Fissure tx
High fiber diet (30-50 grams)
Fiber Supplement
Warm Baths
Nitrates (vasodilator allows more
blood to heal)
Cachannel Blockers (relax muscle to let heal)
steroid Creams
Surgical
Botox Sphincterotomy
Anoplasty Advancement Flap
Anal Dilatation
Thrombosed External Hemorrhoid
Excision
will have pain for a few days following excision
Internal hemorrhoids
Bowel regimen: high fiber diet, ↑ fluids, supplemental fiber
Local Destruction: Banding, Heater Probe, Injection
Surgery: Transanal Hemorrhoidal Dearterialization (THD), Conventional Hemorrhoidectomy
Stage I-II can use endoscopic management
Stave III-IV surgical intervention
Perianal abscess
I &D
Abx- immunocomp, diabetics, cellulitis
Seton or fistulotomy palcement
Untreated → necrotizing soft tissue infection
Cholelithiasis
Ursodoxycholic acid- can dissolve small stones but usually doesn’t work
Cholecystectomy- Treatment of choice
Cholecystitis
Cholecystectomy
If too sick to remove—> cholecystitis you
Ascending Cholangitis
ERCP with stone removal/stent, surgery
Primary Sclerosing Cholangitis (PSC)
Underlying disorder
ERCP only for dominant stricture
Admit to hospital and treat with Abx
Cholangiocarcinoma
Surgical resection or liver transplantation
Gallbadder Cancer
cholecystectomy +/- hepatic resection
5 year prognosis – 0-10%
Gastroenteritis
Rehydration
(oral)
Antimotility agents → loperamide (Imodium®)
Zinc & vit A supp (devel world)
Bacillus cereus Food Posioning
Staphylococcal Food Poisoning
Clostridium botulinum Food Posioning
Dilute drink lots of water
Antibiotics will not help because it’s it the bacteria it’s the toxin
Vibrio cholerae
Rehydration: fluid & electrolytes
IV vs. oral (oral rehydration solution – “ORS”)
Antibiotics ↓ duration of illness & shedding of organism
Doxycycline 300 mg single dose (azithromycin 1 gm single dose for pregnant women)
Enterotoxigenic E. coli (ETEC)
Self-limited infection
(sx resolve after 2-4 days)
Antibiotics ± antimotility (loperamide) agents ↓ duration and severity of illness
Fluoroquinonoles (ciprofloxacin 500 mg twice daily X 1- 3 days)
Azithromycin 500 mg daily X 1- 3 days
Rifaximin (non-absorbed antibiotic)
Bismuth subsalicylate
Loperamide (antimotility)
Rotavirus
vaccine to prevent
Giardia duodenalis
Metronidazole 250 mg PO three times daily for 7-10 days or 2 gm PO daily X 3 days (DO NOT DRINK ALC)
Tinidazole 2 gm PO once
Nitazoxanide 500 mg PO q 12 hours with food
X 3 -7 days
Shigellosis
Rehydrate, fluoroquinolones – ciprofloxacin 500 mg twice daily X 3-5 days or 2 gm single dose
Campylobacter
Azithromycin 500 mg once daily X 3-5 days or ciprofloxicin 500 mg q 12 hours X 5-7 days
Resistance to fluoroquinolones in SE Asia
Usually self-limited but 10-20% have symptoms > 7 days
STEC: Shiga toxin producing E. coli
NO Abx or antimotility bc you want the toxin out as fast as it can go- hydrate and keep stable
Nontyphoidal Salmonella (NTS) Enterocolitis
Usually self-limited: diarrhea resolves in 3-7 days
Excrete in feces for 4-5 weeks after resolution of diarrhea
Abx may prolong carriage
but use for those at risk for invasive dz
Ceftriaxone 500 mg q 12 hours X 3-7 days (alt. ceftriaxone, cefotaxine, azithromycin, TMP-SMX)
Amoebiasis
Metronidazole (acts against trophozoites) 750 mg three times daily X 7-10 days
Followed by a “luminal” agent (acts on cysts)
Percutaneous drainage not usually required
Asymptomatic colonization:
Treat with “luminal” agent alone:
Paromomycin Lodoquinol
Clostridium difficile
D/C inciting antibiotic if possible
Metronidazole 500 mg three times daily X 10-14 days for mild to moderate
PO Vancomycin for severe (WBC 20-30,000/mm3) 125-500 mg four times daily X 10-14 days
Typhoid Fever
Fluoroquinolone (ciprofloxicin),
3rd generation cephalosporin (ceftriaxone)
Acute Pancreatitis
IV fluid
Bowel rest
Pain mgmt
Enteral nutrition- try to avoid parenteral
Stop offending agent- drug/alcohol
Cholecystectomy after pancreatitis recovery
Surgical debridement of infected necrosis
Can feed again when pain improves & pt devel appetite (start w/ clear liquids)
Abx if cholangitis or infected necrosis
ERCP if gallstone pancreatits and concurrent cholangitis
Chronic Pancreatitis
Pancreatic enzyme replacement therapy (PERT)
Pain mgmt
Alcohol cessation
Diabetes mgmt
Endoscopic or surgical tx
50% mortality & ↑ risk pancreatic cancer
Hepatitis A
Supportive, dz is self‐limited in the vast majority of cases
Active Immunization >1 yo, travelers, MSM
Passive Immunization- as soon as exposed w/in 2 wks, <1 yo
Hepatitis E
supportive,self‐limited
Immunization trial
Hepatitis B Virus
Tenofovir, Entecavir, or Lamivudine
High risk of HCC (HBeAg+)
Pre (HBsAg) and post (HBIG) exposure immunization
Hepatitis D
Usuallyself‐limiting infections
Hepatitis C
Poor prognosis: alc, HIV coinfection male, older
High HCC risk-hispanics & caucasians 45-60
Hep A pathophys
“Icosahedralshape
Non‐enveloped,single‐strandedRNAvirus”
Hep E pathophys
Non‐enveloped, single‐stranded RNA virus
Hep B pathophys
Envelope proteins
HBsAg (surface)
HBcAg, HBeAg (core)
Gets into nucleus- hard to cure/treat
Hep D pathophys
Dependent on HBV for the production of envelope proteins (‘satellite virus’)
Directlycytopathic
Hep C pathophys
Replication occurs through RNA‐dependant RNA polymerase
Lacks proofreading function → high genetic variability
No complete neutralizing immune response
Diverticulitis
Bowel rest, antibiotics,
Then high-fiber diet.
Surgery for complications (abscess, perforation)
30% pt recurrence and 30% recurrent abd pain
If complicated IR- percutaneous abscess drainage
Surgical resection, debridement, washout
Colonic Ischemia
Mild-Moderate: resuscitation, antibiotics
Severe: laparotomy
Diverticular Hemorrhage
Localize and treat bleeding by colonoscopy or angiography
Cauterize
Acute Mesenteric Ischemia
Surgical Emergency
Irritable Bowel Syndrome
Fiber (30g/day)
Probiotic
Laxatives (PEG3350 nonabsorbed)
Antidiarrheals
Antispasmodics (Hyoscyamine, Dicyclomine)
SSRI, TCA
Rifaximin
