GI: treatments for all DZ Flashcards
Esophageal atresia
surgical repair
infantile hypertrophic pyloric stenosis
surgical pyloromyotomy
infantile GERD
1st
2nd
3rd
1st: mom + baby dietary changes
2nd: H2 blockers and antacids
3nd or mod-severe: PPI
Dysphagia
- eat small meals
- drink fluid with meals
- eat slowly
- sleep with head upright to prevent regurg and aspiration
- tx underlying etiology
Esophageal stricture
- goals of therapy for benign strictures: relief of dysphagia and prevention of stricture recurrence
- esophageal dilation
Gastroparesis
TX
- motility agents
- gastric “pacemaker”
Mallory-Weiss Syndrome
TX:
- not actively bleeding: supportive TX (PPIs, anti-emetics). Most resolve on their own
- Severe bleeding
* thermal coagulation
* hemoclips
* endoscopic band ligation (w or w.o epinephrine)
* balloon tamponade
Boerhaave Syndrome
TX:
- Small and stable: IV fluids, NPO, BS ABX, H2 rec Blockers
- Large or severe: surgical repair
medication/pill induced esophagitis
TX:
- take pills with at least 4 ounce of water
- avoid laying down for 30-60 mins after taking pill
Infectious esophagitis
TX:
- *tx underlying cause**
1. Candida–PO fluconazole
2. CMV–Ganciclovir
3. HSV–Acyclovir
Caustic esophagitis
tx
- supportive–pain meds, fluids
- very very severe– with necrotic tissue +edema present on endoscopy–ICU*****
eosinophilic esophagitis
- Remove foods that cause allg response
- PPIs PRN
- inhaled topical cortcosteroids WITHOUT spacer so it can penetrate
Barretts esophagus
Follow up TXs:
1. Barretts esophagus only (metaplasia): PPIs + rescope every 3-5 yrs
- Low-grade dysplasia: PPIs and rescope every 6-12 MO
- High grade dysplasia: ablation with endoscopy or mucosal resection
Achalasia
TX:
- decrease the LES pressure–botulinum toxin injections, nitrates, surgery is most effective
- Pneumatic dilation of LES
- Esophagomyomectomy (definitive) but LAST resort
- adaptive measures–chewing food fully b4 swallowing etc
Zenker’s diverticulum
TX:
- Observation if small and asympto
- diverticulectomy, cricopharyngeal myotomy
Distal/Diffuse esophageal spasm
TX:
1st line: CCBs, nitrates, Triclylic antidepressants–all anti-spasmatics
2nd line: botulinum toxin injection or pneumatic dilation
3rd: peroral endoscopic myotomy–refractory to meds
Hypercontractile (nutcracker) esophagus
TX:
-need to lower the esophageal pressure with:
CCBs, nitrates, botulinum toxin injection
esophageal web
TX:
- endoscopic dilation of area if symptomatic
- PPI therapy after dilation may decrease risk of recurrence
Shatzki Ring
TX:
- symptomatic: dilation, obliteration with biopsy forceps
- If reflux present– anti-reflux surgery
Squamous Cell Esohpageal CA
Pretreatment and tx
Pre-treatment:
- endoscopic US to look at LNs around eso–STAGING
- Preoperative bronchoscopy–to see if it MET to lungs
TX:
- esophageal resection with chemo
- ADANCED: palliative stentint to improve dysphagia
Adenocarcinoma Esophageal CA
*pre tx and tx
Pre-treatment:
- endoscopic US to look at LNs around eso–STAGING
- Preoperative bronchoscopy–to see if it MET to lungs
TX:
- esophageal resection with chemo
- ADANCED: palliative stentint to improve dysphagia
Esophageal Varies
- acute bleed tx
- prophylaxis
TX:
- FIRST: stabilize patient: 2 large bore IV lines fluids/packed RBCs/FFP***
- *THEN, move onto one of the four mainstay tx options:
- endoscopic ligation intervention–initial tx of choice–
- Pharmacologic:
Octreotide 1st line–MC to use this and endoscopy together
* vasopressin 2nd line - Balloon tamponade: (Temporary) stabilizes bleeding refractory to endoscopic tx
- Surgical decompression: transiugular intrahepatic portosystemic shunt (TIPS)
- refractory to all other tx
- can cause encephalopathy
***also give them ABX to prevent infections
prophylaxis
*nonselective BB (Nadolol or Propranolol)
BeriBeri or Vit B1 deficiency
TX:
- IV thiamine
- PO thiamine
B12 def
TX:
- B12 replacement: PO, SL, Nasal, IM, deep SQ
1. mild-moderate: PO B12
2. Symptomatic anemia and/or neuro findings
a) IM dose weekly until def is corrected.. then monthly
b) PT can switch to a monthly PO dose after s/s resolve
PERNICIOUS ANEMIA PT:
**LIFE LONG IM TX
Vit C def
TX:
- replacment
- general s/s improve in days
- hematologic s/s take weeks
Vit D def
TX
- PO ergocalciferol
- supplementation for dialysis PT is calciferol (active form)
PKU
TX:
- lifetime dietary restriction of PHE
- tyrosine supp
- avoid food high in PHE: milk cheese nuts fish chicken meats eggs legumes aspartame
Acetominophen OD
Antidotes:
- N-acetylcysteine–gluthione substitue
- activated charcoal if drug ingested in last hour
Salicylates OD
- Resusciation–ABCs
- GI decontamination— either gastric lavage or activ charc
- Alkalinization–sodium bicarb
- Glucose helps with CNS s/s
- IV fluids
- Hemodialysis if severe
acute gastritis
TX:
- if HP+: treat with quad therapy (metronidazole, tetracycline, pepto, PPI)
- stop the offending agent(s)
- IV PPIs and H2 blockers as prophylaxis with ICU patients
autoimmune metaplastic atrophic gastritis
Diagnosis:
- Upper endoscopy with biopsy–shows thick, edematous erosions
- HP testing
TX:
- if HP+: treat with quad therapy (metronidazole, tetracycline, pepto, PPI)
- stop the offending agent(s)
- IV PPIs and H2 blockers as prophylaxis with ICU patients
PUD
- +HP infection
- -HP infection
- refractory
Pos HP:
-QUAD tx: Pepto, tetracycline, metronidazole and PPI x14 days
-concomitant tx: clarithromycin, amox, tetracycline
OR
-TRIPLE: Clarithromycin, Amoxicillin and PPI x10-14 days
- Neg HP:
- goal is to suppress acid–PPI, H2 blockers, antacids, pepto, sucralfate
Refractory:
- parietal cell vagotomy
- Bilroth II (
Zollinger-Ellison Syndrome
TX
- Local=tumor ressection
- Mets or unresectable= lifelong high dose PPI
gastric carcinoma
TX
- resection if possible
- Gastrectomy
- Chemo
* poor prognosis since PT usually presents late in the DZ*
carinoid tumors/carcinoid syndrome
TX:
- dep on location
- often surgicla incision
Cholestasis
TX:
- asympto– no tx
- sympto: cholecystectomy if recurrent s/s
Acute Cholecystitis
TX:
- admit and NPO
- IV hydration, pain meds, electrolytes
- IV ABX: Ceftriazone covers gram- & Metronidazole covering anaerobics
- cholecystectomy w/in 72 hours
- recurrance rate with nonsurgical tx is very high– almost 70%—why we counsel PTs to do surgery!
Choledocholithiasis
TX:
*ERCP with stone extraction
Choledocholithiasis
TX:
ERCP with stone extraction** vs choledocholithotomy aka surgery
Cholangitis
Initial Management:
- IV ABX followed by CBD decompression & stone extraction once stable
- ABX= Ampicillin/Sulbactam, Piperacillin/tazobactam, Ceftriaxone + metronidazole, fluroroquinolone + metronidazole, ampicillin + gentamycin
* anything to cover gram neg and anaerobes** - ERCP:
- PTC–drainage with catheter
- open surgical decompression and T-tube insertion for drainage
- Eventually, PT should undergo elective cholycstectomy
Primary Biliary Cholangitis/Cirrhosis (PBC)
TX:
1st line: Ursodeoxycholic acid–can slow progression of the dz by preventing synthesis and absoprtion of cholesterol
2nd. Obeticholid acid
*for pruritis—cholestyramine and UV light
*vit D calcium to prev osteoporosis
Curative—liver transplant
Primary Sclerosing Cholangitis
Management:
- stricture dilation for sympto tx
- cholestyramine for pruritis
- definitive= liver transplant
Nonalcoholic Fatty liver Dz
fix underlying cause
Fulminant Hepatitis
*whats defintive tx ?
Supportive: IV fluids, electrolyte repletion
Mannitol if ICP elevation (elevated ammonia, direct toxin–>edema)
PPI stress ulcer prophylaxis
Platelets, FFP for coagulation factors if bleeding
Definitive=transplant
cirrhosis
TX:
- avoid ETOH and hepatoxic drugs
- weight reduction
- vaccinations for Hep A and B to prevent additional insult
- tx underlying causes when possible
- liver transplant is definitive
hepatic encephalopathy
lactulose ***or rifaximin first lines
second: Neomycin
ascities
sodium restriction
diruetics (spironolactone, furosemide)
paracentesis
Wilson dz
Tx:
- copper chelating agents:
1. Trientine or D-penicillamine with B6
2. zinc supplements help to prevent uptake of dietary copper
3. liver transplant if unresp to therapy or liver failure
Acute Pancreatitis
TX:
- 90% recover in 3-7 days w/o complications + need supportive care only
- ->NPO
- –>IV LR
- –>analgesics
**Advancing diet once pain resolved, clinically improved–>patient directed leads to improved outcomes
Duodenal Atresia
TX:
- decompression of GI tract, electroylte and fluid replacement
- duodenoduodenostomy
volvulus-intial TOC?
TX:
-endoscopic decompression via proctosigmoidoscopy– initial TOC
- rectal tube is left in place to decrease acute reccurence/decr distention
- decompression often followed by elective surgery due to high rate of reccurence
- immediate surgical correction in PTs with +peritonititis +gangrene or endoscopic decompress unsuccessful
Meckel Diverticulum
TX:
-surgical incision is symptomatic
Intussusception
Maagment:
- fluid and electrolyte replacement most imp initial steps
- NG decompression
- Intussusception reduction: pneumati (air) or hydrostatic (saline or gastrografin) decompression
- admitted for observation—10% recurrance in 1st 24 hrs of tx
- Surgical resection if refractory to above
Diarrhea
- fluid repletion mainstay
- ->PO preferred - Diet
-bland low reside diet
“BRAT” Bananas, rice, Applesauce, toast - anti-motility drugs
–>PT <65YO with moderate signs of volume depletion
DO NOT GIVE TO PT WITH INVASIVE DIARRHEA
Norovirus
supportive
Rotavirus
TX:
*oral rehydration mainstay
Staph A.
TX:
*fluid replacement PO preferred
IV if cannot tolerate PO
Bacillus Cereus
TX:
fluid replacement PO pref
IV if cant do PO
Enterotoxigenic E. coli
TX:
- oral rehydration 1st line—usually self limiting
- Loperamide
- Bismuth subsalicylate
Vibrio Cholerae
-tx: mild, severe (1st, 2nd, 3rd), prevention
TX:
- PO rehydration and electrolyte replacement***** usualy self limiting
- If severe
* *1st: Tetracycline
* *2nd: Fluoroquinolones
* *3rd: Azithromycin - prevention: use bottled waters, wash hands, use chemical toilets and cook food well
C diff
TX::
- discontinue offending ABX— INITITAL STEP
- contact precautions + hand hygiene (spores resistant to alcohol based sanitizers)
- PO PO PO PO PO PO PO vancomycin or Fidaxomicin
- recurrance— fecal transplant
Yersinia Enterocolitica
TX:
- fluid and electrolyte replacement 1st line
- severe=fluoroquinolones
Campylobacter Jejuni
TX:
- fluid and elec. repalcemet=mainstay (MC mild and self lim)
- Severe or high risk PT:
* **macrolides=1st line—Azithromycin
Enterohemorrhagic E. coli 0157:H7
TX:
- fluid replacement main stay— supportive measures
- *****AVOID ANTI MOTILITY
- *****AVOID ABX!!!!! —-lysogenic phase: if given ABX… it lyses the cell and these cells ahve the potent toxin in them– can actually directly release the toxin into the BS– making PT more sick
Salmonella Typhi
TX
- oral rehydration + electrolytes– first line
- ABX
* 1st: Fluoroquinoloines (-xacin)
* 2nd: macrolides
3rd: ceftriaxone
Giardia Lamblia
tx
- rehydration mainstay of tx
- Metronidazole DOC
Shigellosis
TX:
- oral rehydration and electrolyte mainstay
- ABX for severe: Ciprofloxacin Or Ceftriaxone (3rd gen cephalosporins)
- if isole is susceptilble— Trimethoprim-sulfamethoxazole or Arithromycin
amebiosis
TX
1) Colitis– metronidazole + intraluminel parasitic (Paromomycin)
2) Liver Abscess: metronidazole + intraluminal antiparasitic + chloroquine
ASYMPO: must be tx alone with intraluminal tx
fecal impaction
Disempaction–colon evacauation–routnie bowel regimen to reduce recurence
- Digital disimpaction followed by warm water enema with mineral oil
2) polyethylene glycol post disimpaction
Anorectcal abscess and fistuals
TX: I/D: mainstay of tx followed by WASH W: warm water cleaning A: analgesics S: sitz bath H: high fiber diet
ABX not usually requried in simple cases
hemorrhohids
Conservative = high fiber diet, increased fluids, warm Sitz baths & topical rectal corticosteroids & analgesics to help pruritis and discomfort or thrombosis.
If refractory to conservative management or debilitating pain or strangulation:
Rubber band ligation is MC; sclerotherapy or infrared coagulation
Excision of thrombosed external hemorrhoids
Hemorrhoidectomy - for stage IV or refractory
diverticulosis
In most cases, the bleeding stops spontaneously
If serious bleeding, resuscitation may be needed
Endoscopic therapy can be utilized to help control bleeding (epinephrine injection, tamponade)
Asymptomatic diverticulosis can be followed - recommend high fiber diet, use bran or psyllium.
diverticulitis
tx:
1) uncomplicated: tx as outpatient– with PO Metronidazole + ciprofloxacin or levofloxacin
- clear diet
2) surgery for complicated:
