insomnia Flashcards
What is the definition of GastroEsophageal Reflux Disease (GERD)?
Symptoms, or complications resulting from the reflux of gastric contents into the esophagus or beyond, into the oral cavity (including larynx) or lung.
What are the two categories of GERD?
- Symptoms without erosions on endoscopy (nonerosive reflux disease)
- Symptoms with erosions on endoscopy (erosive reflux disease)
What are typical symptoms of GERD?
- Heartburn (pyrosis)
- Regurgitation
- Acidic taste in mouth
What are extraesophageal (atypical) symptoms of GERD?
- Chronic cough
- Asthma-like symptoms
- Recurrent sore throat
- Laryngitis/hoarseness
- Noncardiac chest pain
- Sinusitis/pneumonia/bronchitis/otitis media (less common)
What are alarm symptoms of GERD?
- Dysphagia (difficult swallowing)
- Odynophagia (painful swallowing)
- Bleeding
- Weight loss
- Choking
- Chest pain
- Epigastric mass
What are aggravating factors of GERD?
- Recumbency position (gravity)
- Elevated intra-abdominal pressure
- Reduced gastric motility (e.g., gastroparesis)
- Decreased lower esophageal sphincter (LES) tone (e.g., peppermint, caffeine, nicotine)
- Direct mucosal irritation (e.g., irritating foods, bisphosphonates, NSAIDs)
What are the long-term complications of GERD?
- Esophageal erosion
- Strictures/obstruction
- Barrett esophagus (increased risk of esophageal carcinoma)
- Reduced quality of life (QoL)
What are non-pharmacological interventions for GERD?
- Avoid aggravating foods/beverages
- Reduce fat intake
- Avoid eating 2–3 hours before bedtime
- Remain upright for two hours after meals
- Weight loss if overweight or obese
- Reduce/discontinue nicotine for tobacco users
- Elevate the head of the bed if nocturnal symptoms present
- Avoid tight-fitting clothing
- Avoid medications that may reduce LES pressure or cause irritation
What are the pharmacologic therapies for GERD?
- Antacids (OTC)
- Histamine-2 antagonists (H2As) (OTC/POM)
- Proton pump inhibitors (PPIs) (OTC/POM)
- Promotility agents (OTC/POM)
What is the initial treatment approach for GERD based on severity?
- “Step-down” treatment: Starting with maximal therapy for patients with documented esophageal erosion.
- “Step-up” treatment: Starting with lower-dose OTC products.
What symptoms characterize dyspepsia?
- Epigastric pain/discomfort
- Bloating
- Early satiety
- Symptoms often related to meals and may improve after eating
What are the recommendations for managing dyspepsia?
- Endoscopy for patients at risk for serious outcomes
- Testing and eradicating H. pylori
- Using PPIs, tricyclic antidepressants (if functional), prokinetic agents
- Psychotherapy
What are the defensive forces in the pathophysiology of Peptic Ulcer Diseases (PUDs)?
- Bicarbonate
- Mucus layer
- Mucosal blood flow
- Prostaglandins
- Growth factors
What are the aggressive forces in the pathophysiology of PUDs?
- Helicobacter pylori
- HCl acid
- Pepsins
- NSAIDs
- Ischemia & Hypoxia
- Smoking and alcohol
What are common causes of duodenal and gastric ulcers?
- Duodenal ulcer: H. pylori infection (95%), NSAIDs
- Gastric ulcer: NSAIDs, low-dose aspirin, H. pylori infection
What are the clinical signs and symptoms of a duodenal ulcer?
- Epigastric pain, possibly worse at night
- Pain occurs 1-3 hours after a meal and may be relieved by eating
What are the clinical signs and symptoms of a gastric ulcer?
- Epigastric pain, often made worse by eating
What are the non-invasive tests for H. pylori infection?
- Serologic tests
- Urea breath test (UBT)
- Stool antigen tests
What is the treatment regimen for H. pylori–associated ulcers?
An anti-secretory agent (preferably PPI) + at least two antibiotics for 10-14 days, followed by 2-4 additional weeks of PPI.
What are preventive strategies for NSAID-induced ulcers?
- Test and treat for H. pylori before long-term NSAID therapy
- Determine levels of GI-related risk
- Determine CV risk
What is the medical management of Ulcerative Colitis (UC)?
- Treatment based on disease location and severity
- Mildly active UC: Topical AS for ulcerative proctitis, Oral AS for extensive colitis
- Systemic steroids for nonresponding cases
What are the two forms of Inflammatory Bowel Diseases (IBDs)?
- Ulcerative Colitis (UC)
- Crohn’s disease (CD)
What are common symptoms of IBD?
- Fever
- Abdominal pain
- Diarrhea (may be bloody, watery, or mucopurulent)
- Rectal bleeding
- Weight loss
What is the role of colonoscopy in IBD management?
To confirm the diagnosis and extent of disease.
What tests indicate inflammation in IBD?
- Elevated concentrations of fecal lactoferrin
- Fecal calprotectin
What defines extensive disease in Ulcerative Colitis (UC)?
Proximal to splenic flexure requires systemic/oral therapy
Extensive disease indicates a more severe form of UC that requires more aggressive treatment.
What is the recommended treatment for mildly active UC affecting the rectum and left-sided colitis?
Topical AS for ulcerative proctitis and left-sided colitis, with oral AS being more effective
AS refers to aminosalicylates.
What should be used for induction of remission in mildly active extensive colitis?
Oral AS
AS stands for aminosalicylates, which are anti-inflammatory medications.
What is the treatment for intolerant or nonresponding patients with left-sided UC?
Oral budesonide or systemic steroids
Budesonide is a corticosteroid used to treat UC.
What are the main treatment options for moderately to severely active UC?
Systemic steroids, anti-TNF, or other biologics
Anti-TNF agents include infliximab.
What should be combined with Infliximab for induction of remission in moderately to severely active UC?
Thiopurine therapy
Thiopurines include medications like azathioprine.
If anti-TNF therapy fails in UC treatment, what are the alternatives?
Vedolizumab, Tofacitinib, or Ustekinumab
These are other classes of biologics used in UC.
What is the initial treatment for hospitalized patients with acute severe UC?
Methylprednisolone I.V
This is a corticosteroid administered intravenously.
What should be done if there is no response after 3–5 days of IV treatment for acute severe UC?
Rescue therapy with infliximab or cyclosporine
This is a critical step to manage severe cases.
What is the first-line treatment for induction of remission in mild-active Crohn’s disease?
Oral AS (mesalamine or sulfasalazine)
Mesalamine and sulfasalazine are both aminosalicylates.
What is preferred for terminal ileal or ascending colonic disease in Crohn’s disease?
Oral Budesonide
Budesonide is a corticosteroid effective in localized Crohn’s disease.
What should be administered if a patient with Crohn’s disease is not responding to oral AS?
Oral Metronidazole
This antibiotic is particularly effective for perianal or colonic disease.
What are the preferred therapies for moderate-active Crohn’s disease?
Anti-TNFα agents in combination with thiopurines
Infliximab is an alternative first-line treatment.
What should be administered for severe-active Crohn’s disease?
Intravenous corticosteroids
This is crucial for managing severe symptoms.
What may be needed after 5–7 days in severe-active Crohn’s disease management?
Parenteral nutrition (TPN)
TPN is used when oral intake is not feasible.
What is the role of long-term corticosteroid use in Crohn’s disease maintenance therapy?
No role for long-term use, but oral budesonide may be used for up to 3 months
Long-term steroid use can lead to significant side effects.
What can be used after induction with corticosteroids or infliximab in Crohn’s disease?
Azathioprine/6-MP
Azathioprine is an immunosuppressant.
What therapies may prevent recurrence after surgical resection in Crohn’s disease?
Azathioprine/6-MP or mesalamine
These medications help maintain remission post-surgery.
What antibiotics are used for simple perianal fistulas in Crohn’s disease?
Metronidazole or ciprofloxacin
These antibiotics can help manage infections in fistulas.
What is the recommended management for complex perianal fistulas?
Anti-TNF in combination with surgery
Surgical intervention is often necessary for complex cases.
What adjunctive therapies should be used with caution in active IBD?
Loperamide, antispasmodics, cholestyramine
These can reduce motility and potentially worsen conditions like toxic megacolon.
What is the best treatment regimen for a 35-year-old man with newly diagnosed mildly active UC affecting the descending colon?
Mesalamine enema rectally once daily
This treatment is appropriate for left-sided UC.
What is the best therapeutic choice for a 25-year-old woman with moderately active Crohn disease?
Infliximab intravenously and azathioprine daily
This combination is effective for moderate cases of Crohn’s disease.
