Pharm - biliary tract disease and anorectal disorders Flashcards
What is included in biliary tract disease
gallbladder
bile ducts
What is the presentation of acute cholecystitis
- RUQ pain
- steady pain that increases in intensity
- High fat meal is a trigger
- low grade fever
labs assoc with acute cholecystitis
increased bilirubin levels (blood and urine)
US - gallstones in 95% of patients
ERCP - identifies cause/location and extent
What is choledocholithiasis
gallstone obstructing the common bile duct
What is the treatment for asymptomatic choledocholithiasis?
none
What is the symptomatic management of choledocholithiasis?
pain management
-NSAIDs
oral bile acids - dissolution of gallstones
Surgery
What nutrition/lifestyle to treat choledocholithiasis
Lower triglycerides
What NSAIDs should be used for pain management
Ketorolac (toradol) - injectable NSAID
could also use parenteral morphine or hydromorphone
MOA of ketorolac
Inhibits cox 1 and 2 enzymes
-analgesic
-anti-inflammatory
-anti-pyretic
Ketorolac info
- typically IM or IV
- Do not exceed 5 days of therapy
-GI bleed - Renally dosed
Ketorolac BBW
GI risk
CV risk
Renal risk
Bleeding risk
Avoid use with other NSAIDs
When to use NSAIDs to treat biliary pain
for patients with contraindications to use of NSAIDs
-more often used with patients with acute cholecystitis
What to remember about opioids
Produces generalized CNS depression
Morphine now better than meperidine
Opioid warnings/precautions
CNS depression
Constipation
Opioid BBW
Addiction/abuse/misuse
Respiratory depression
What is a bile acid treatment option
Ursodiol (Actigall)
Ursodiol MOA
Decreases cholesterol content of bile associated with gallstones
When is ursodiol used for gallstone prevention
used in obese patients during rapid weight loss
What monitoring is required with Ursodiol?
- LFTs monthly x 3 months
- Abd US every 6-12 months
- continue therapy for at least 6 months after dissolution of gallstone is noted on US
Pt ed with Ursodiol
Take with food
Clinical presentation of anal fistula
painful swelling at the anus
pain with defecation
Treatment of anal fistula
surgery
Clinical presentation of anal fissure
severe, tearing pain with defecation
Treatment of anal fissure
avoid straining
increase fluids
fiber to prevent hard BMs
-prunes
-peas
-supplement (Psyllium - metamucil)
What is a sitz bath
treat anal fissure
-warm bath relaxes anal sphincter and improves blood flow to anal mucosa
What is a pharm option to treat anal fissure
topical vasodilatory
-nifedipine (reduce pressure)
-NTG (increase blood flow); concern of D/D interaction with Phosphodiesterase 5 inhibitors (sildenafil)
What is second line anal fissure therapy
botulinum toxin A
Protectants for hemorrhoid treatment
internal or external:
cocoa butter
mineral oil
petrolatum
ONLY EXTERNAL - glycerin
What protectants are only to be used in combination products
internal or external:
-calamine
-shark liver oil
-zinc oxide
Applied after each BM
Petrolatum may be applied liberally
What local anesthetics appropriate for internal hemorrhoids?
no
Which local anesthetics can be used up to 6 times daily
benzocaine
benzyl alcohol
lidocaine
tetracaine
Which local anesthetics can be used up to 5 times a day
Pramoxine
Which local anesthetic can be used up to 3-4 times per day
Dibucaine
What is a nonprescription hemorrhoid treatment
Astringents
-local and limited protein coagulant effect
-relieves irritation and burning
Vasoconstrictors
-reduce swelling
Corticosteroids:
-preparation H hydrocortisone 1% cream
What are examples of astringents
calamine and zinc oxide (internal or external)
witch hazel (external)
What is a vasoconstrictor
phenylephrine - avoid in:
-HTN
-CVD
