GI treatments Flashcards
Familial adenomatous polyposis treatment
Prophylactic colectomy
Treatment of Juvenile polyps
Polyps in children less than 10 years old
Highly vascular and should be removed
Treatment of adenomatous polyps
Removal of polyp
Treatment of diverticulosis
High fiber foods
Psyllium if can’t handle bran
If recurrent bleeding perform segmental colectomy
Treatment of diverticulitis
Uncomplicated:
Antibiotics-IV 7-10 days
NPO-IV fluids
Symptoms persist for 3-4 days means surgery may be necessary
Recurrent-surgery
Complicated (abscess, colovesical fistula, obstruction, perforation): surgery indicated
Acute mesenteric ishemia treatment
Supportive IV fluids and broad spectrum antibiotics
Direct intra-arterial infusion of papaverine relieves occlusion and vasospasm
Direct intra-arterial infusion of thrombolytics and embolectomy if embolism is etiology
Heparin for venous thrombosis
Surgery if signs of peritonitis develop
Chronic meseneteric ischemia treatment
surgical revascularization
Pseudomembranous colitis treatment
Discontinue offending antibiotic
Metronidiazole-not in infants or pregnancy
oral vanco
Cholestryamine for adjuvant therapy
Toxic megacolon, colonic perforation, anascarca (generalized edema) or electrolyate disturbances may require surgery
Sigmoid and cecal volvulus
Sigmoid: decompression via sigmoidoscopy and elective sigmoid colon resection
cecal: emergent surgery
Treatment of portal hypertension
Transjugular intrahepatic portal-system shunt (TIPS)
Treatment of esophageal varices
Initially: hemodynamic stabilization with fluids
IV ocreotride: splanchnic vasoconstriction and reduces portal pressure
possible IV vasopressin instead of ocreotride
Variceal ligation/banding: initial treatment of choice
Endoscopic sclerotherapy: (higher rates of rebleeding)
Both after emergent upper GI endoscopy
Prophylactic non selective B blocker and IV antibiotics
Treatment of ascites
Bed rest, low-sodium diet, and diuretics (furosemide and spironolactone)
Therapeutic paracentesis if tense ascites, SOB, or early satiety
Peritoneovenous shunt or TIPS to reduce portal HTN
Treatment of hepatic encephalopathy
lactulose prevents absorption of ammonia
neomycin: decreases ammonia production by intestinal bacteria
Limit protein to 30-40 g/day
Management of cirrhosis
Surveillance of LFTs
Compensated (vague symptoms: weakness, anorexia and fatigue)
ultrasound and aFP every 6 months, EDG, varices surveillance endoscopy)
Decompensated (jaundice, pruritus, upper GI bleed)
Variceal hemorrhage: non selective B blocker-repeat EGD yearly
Ascites: dietary Na restriction, Diuretics, parancentesis, abstinence
Encephalpathy: lactulose
Treatment of Wilson’s disease
Chelating agents: penicillamine
Zinc: prevents uptake of dietary copper
Can be given prophylactically or pregnant patients
Liver transplantation: if unresponsive to therapy or fulminant liver failure
Treatment of hemachromatosis
Repeat phlebotomies
Liver transplantation in advanced cases
Treatment of pyogenic liver abscess
Fatal if untreated
IV antibiotics and percutaneous drainage of abscess
Surgical drainage is sometimes necessary
Amebic liver abscess treatment
IV metronidazole
Therapeutic aspiration of abscess (image guided percutaneous aspiration) if abscess is large or no response to metro
Treatment of budd chiari syndrome
Surgery: balloon angioplasty with stent in IVC
Portocaval shunts
Liver transplantation if cirrhosis is present
Treatment of cholelithiasis
No treatment if asymptomatic
Elective cholecystectomy for recurrent bouts of bilary colic
Treatment of cholecystitis
Conservative measures of hydration with IV fluids, NPO, IV antibiotics, analgesics, correction of electrolyte abnormalities
Surgery: within first 24-48 hours preferred
Treatment of acalculous cholecystitis
Seen in patients with severe iillnesses-trauma, burns, postoperative state, TPN, mechanical ventiation, ischemia, dehydration
Emergent cholecystectomy-if can’t do surgery perform percutaneous drainage with cholecystostomy
Treatment of choledocholithiasis
endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction with stent placement
laprascopic choledocholithotomy
Treatment of cholangitis
IV antibiotics and IV fluids
Monitor hemodynamics, BP and urine output
Afebrile for 48 hours perform Percutaneous transheptic cholangriography (with catheter drainage) or endoscopic retrograde cholangiopancreatography(with sphinctertomy) for underlying condition
Lapraprotomy (T-tube insertion)
Perform emergently if patient does not respond to antibiotics
Treatment of porcelain gallbladder
Prophylactic cholecystectomy (can develop cancer of the gallbladder)
Treatment of primary sclerosing cholangitis
Curative: liver transplantation
dominant stricture causing cholestasis: ERCP with stent placement for biliary drainage can relieve symptoms
Cholestyramine for symptomatic relief (decreases pruritus)
Treatment of primary biliary cirrhosis
Symptomatic for pruritus: cholestyramine
Osteoprosis: calcium, vit D, bisphosphonates
Ursodeoxycholic acid slows progression
Liver transplantation is curative
Acute appendicitis treatment
Appendectomy within 24 hours
Acute pancreatits treatment
NPO
IV fluids-correct electrolytes
Pain-meperidine or fentanyl
30% of pancreas necrotic=antibiotics
3-4 of ransons criteria should be in ICU
Treatment of pancreatic pseudocyst
less than 5 cm=observation
greater than 5 cm=drain percutaneously or surgically
Treatment of chronic pancreatitis
Nonoperative: Narcotic analgesiics for pain NPO Pancreatic enzymes and H2 blockers Insulin for endocrince insufficiency Alcohol abstinence Frequent, small volume, low fat meals
Surgery:
pancreatiocjejunostomy-decompresses dilated pancreatic duc
Pancreatic resection: distal pancreatectomy, Whipples procedure
Upper GI bleed treatment
EGD with coagulation of the bleeding vessel
If bleeding continues repeat endoscopic therapy or proceed with surgical intervention (ligation of vessel)
Lower GI bleed treatment
Colonoscopy-polyp excision, infection, laser, cautery
Arteriographic vasoconstrictor infusion
surgical resection of area-last resort
Indications for surgery for GI bleed
Hemodynamically unstable who have not responded to IV fluid, tranfusion, endoscopic intevention, or correction coagulopathies
Severe initial bleed or recurrence of bleed after endoscopic treatment
Continued bleeding more than 24 hours
Visible vessel at base of ulcer
ongoing tranfusion requirement (5 units within first 4-6 hours)
Achalasia treatment
Chew food to soup like consistency, sleep with trunk elevated, avoid eating before sleeping
Anitmuscarinic dicyclomine-unsatisfactory
Sublingual nitroglycerin, long acting nitrates, CCBs improve swallowing in early stages of achalasia
Injection of botox into LES during endoscopy-must be performed every two years
Forceful dilatation-pneumatic balloon most effective (risk of perforation)
Heller myotomy: surgical incision of circular muslce layer of LES (patients who do not respond to dilation therapy)
Diffuse esophageal spasm treatment
Nitrates and CCBs (decrease amp of contractions)
TCAs provide symptomatic relief
Possible esphagomyotomy (controversial)
esophageal hiatal hernia treatment
Sliding: anatacids, small meals, and elevation of head after meals
Nissen fundoplication if there no response to medical therapy or evidence of esophagitis
paraesphogeal: elective surgery to avoid complications
Mallory weiss tear treatment
Most of the time not necessary
Oversewing the tear or angiographic embolization if bleeding continues
Acid suppression to promote healing
Zenker and epiphrenic diverticular treatment
Zenker: cricopharyngeal myotomy
Epiphrenic: esophagomytomy
Diverticulectomy is of secondary importance
esophageal perforation treatment
Small perforation into lumen and patient stable: IV fluids, NPO, antibiotics, and H2 blockers
Patient ill and perforation large (communication with pleural cavity): surgery should be performed within 24 hours of presentation
Peptic Ulcer Disease Treatment regimens
Supportive: discontinue aspirin/NSAIDs, restrict alcohol and coffee use, stop smoking, decrease emotional stress, avoid eating before bedtime
If positive for H. Pylori: start with triple therapy (amoxicillin, clarithromycin and H2 inhibitor) for 10-14 days and antacids
If comes back use quadruple therapy (PPI, bismuth plus amoxicllin and clarithromycin) for one week
NSAID induced ulcer: switch to acetiminophen, begin with PPI or misoprostol (reduces risk for ulcer formation) continue for 4 to 8 weeks Treat H. pylori if present
H pylori and not NSAID induced treat with H2 blockers or PPIs
Surgery: complications of PUD
Peforation:
Gastric outlet obstruction:
GI bleeding
GI perforation treatment
Emergency surgery to close peforation and perform definitive ulcer operation (selective vagotomy or truncal vagotomy/pylorplasty)
Can progress to sepsis and death if untreated
Acute gastritis treatment
Epigastric pain is low and not associated with worrisome findings: treat with empiric therapy with acid suppression.
Stop NSAIDs
No response after 4 to 8 weeks consider GI endoscopy and ultrasound (rules out gallstones) and test for H. pylori
treat findings
Treatment of small bowel obstruction
Nonopeative if incomplete and no fever, tachycardia, peritoneal signs or leukocytosis
Give IV fluids, potassium, nasogastric tube to empty stomach, antibiotics
Surgery if complete obstruction or persistent pain or strangulation suspected (fever, severe/continuous pain, hemataemesis, shock, gas in the bowel wall or portal vein, abdominal free air, peritoneal signs, and acidosis)
Perform lysis of adhesion and resection of any necrotic bowel
Treatment of paralytic ileus
IV fluids, NPO
Electrolyte imbalances (hypokalemia)
nasogastric suction if necessary
Placement of long tube if necessary but generally do not need surgery
Treatment of Crohn’s disease
Sulfsalazine: antiinflammatory
Metronidazole: if no response to 5-ASA
Prednisone: acute exacerbations
Azathioprine, 6-mercaptopurine: with steroids if no response to other agents
Choelstyramine or colestipol: terminal ileal disease that cannot absorb bile acids
NOT antidiarrheals
Surgery: reserved for SBO, fistula, disabling disease, perforation or abscesss-segmetnal resection of involved bowel
Treatment of ulcerative colitits
Systemic corticosteroids for acute exacerbations
Topical application as suppository sulfasalazine maintains remissions
Immunosuppressants for refractory disease
Surgery: total colectomy-curative
indications: debilitating disease, unresponsive to treatment, toxic megacolon, hemorrhage, obstruction, perforation, evidence of colon cancer, failure to thrive in children
