Cirrhosis, GERD, PUD

Question 1

What should you give if you perform a paracentesis and pull off more than 5 L?

Answer 1

Give 6-8 g/L of albumin to increase intravascular oncotic pressure.

Question 2

What is the first line treatment for ascites?

Answer 2

Spironolactone +/- furosemide (100:40 ratio) to avoid electrolyte imbalance; Na restriction < 2g/day. Avoid NSAIDs

Question 3

What is the treatment for variceal bleed?

Answer 3

IV octreotide to reduce splanchnic blood flow, endoscopic band ligation as definitive treatment, and antibiotics like ceftriaxone.

Question 4

What is the mechanism of action of octreotide?

Answer 4

Somatostatin analog that decreases splanchnic blood flow and pressure in varices.

Question 5

What are adverse drug reactions (ADRs) for octreotide?

Answer 5

Can affect glucose regulation, pancreatitis, diarrhea.

Question 6

What is the first line treatment for hepatic encephalopathy?

Answer 6

Lactulose.

Question 7

What is the mechanism of action of lactulose?

Answer 7

Acidifies the gut allowing conversion of ammonia to ammonium for elimination.

Question 8

What are instructions for lactulose administration for hepatic encephalopathy?

Answer 8

Titrate to 2-3 soft BMs/day; give every 30 minutes to an hour until a BM is produced.

Question 9

What is the mechanism of action of rifaximin?

Answer 9

Non-absorbable antibiotic that inhibits bacterial RNA synthesis.

Question 10

What are ADRs of rifaximin?

Answer 10

Peripheral edema/ascites, superinfection in gut (C. diff).

Question 11

What is the treatment for hepatorenal syndrome?

Answer 11

Combination of albumin, octreotide, and midodrine to increase MAP by at least 15 mm Hg.

Question 12

What are the treatment options for hepatorenal syndrome type 1?

Answer 12

Albumin + vasoconstrictors (midodrine + octreotide, norepinephrine in ICU).

Question 13

What is the treatment for spontaneous bacterial peritonitis?

Answer 13

Antibiotics (Cefotaxime or ceftriaxone) plus albumin.

Question 14

What is the prophylaxis antibiotic for spontaneous bacterial peritonitis?

Answer 14

Norfloxacin, ciprofloxacin, or Bactrim (daily).

Question 15

What are treatment options for itching related to jaundice?

Answer 15

Antihistamines (diphenhydramine or hydroxyzine), bile acid sequestrants (cholestyramine), tricyclic antidepressants (doxepin).

Question 16

What are non-pharmacist recommendations for GERD?

Answer 16

Weight loss, elevating the head of the bed, staying upright after meals, avoiding large meals and trigger foods.

Question 17

What cells are the site of activation for stomach acid?

Answer 17

Parietal cells.

Question 18

What targets M3 receptors in stomach acid formation?

Answer 18

Acetylcholine.

Question 19

What targets H2 receptors in stomach acid formation?

Answer 19

Histamine; H2 blockers include famotidine.

Question 20

What targets CCK-B receptors in stomach acid formation?

Answer 20

Gastrin.

Question 21

What is the final common pathway for stomach acid secretion?

Answer 21

H⁺/K⁺ ATPase; targeted by PPIs.

Question 22

What are examples of antacids?

Answer 22

Calcium carbonate, aluminum hydroxide, magnesium hydroxide.

Question 23

When are antacids indicated?

Answer 23

For occasional GERD symptoms.

Question 24

What are common side effects of antacids?

Answer 24

Constipation (aluminum), diarrhea (magnesium), electrolyte imbalance.

Question 25

What is the mechanism of action of calcium-containing antacids?

Answer 25

Neutralize gastric acidity, increasing gastric and duodenal pH.

Question 26

What drug interactions do calcium-containing antacids have?

Answer 26

Can decrease absorption of many medications; separate by at least 2 hours.

Question 27

What is the mechanism of action of magnesium and aluminum-containing antacids?

Answer 27

Magnesium hydroxide reacts with hydrochloric acid to form magnesium chloride; aluminum hydroxide neutralizes HCl.

Question 28

What antacids should be avoided in patients with renal failure?

Answer 28

Magnesium and aluminum-containing antacids.

Question 29

What are examples of H2 blockers?

Answer 29

Famotidine.

Question 30

What is the mechanism of action of famotidine?

Answer 30

Inhibits histamine at H2 receptors on parietal cells, decreasing H+ secretion.

Question 31

When is famotidine indicated?

Answer 31

For GERD symptoms <2x/week and allergic reactions.

Question 32

What are side effects of famotidine?

Answer 32

Headache, diarrhea, rare gynecomastia, confusion in elderly, thrombocytopenia.

Question 33

What risk is associated with long-term use of H2 blockers?

Answer 33

B12 deficiency.

Question 34

Which H2 blocker is most offensive for CYP inhibition?

Answer 34

Cimetidine.

Question 35

What are examples of PPIs?

Answer 35

Omeprazole, esomeprazole, pantoprazole.

Question 36

What is the mechanism of action of PPIs?

Answer 36

Irreversibly inhibit H⁺/K⁺ ATPase proton pump in parietal cells.

Question 37

Where are PPIs absorbed and activated?

Answer 37

Absorbed in duodenum, activated by stomach acid. Therefore prodrug

Question 38

Why is it important for patients to take PPIs on an empty stomach?

Answer 38

Food decreases bioavailability by 50%.

Question 39

Which populations have increased bioavailability of PPIs?

Answer 39

Elderly and Asian.

Question 40

How are PPIs metabolized and what do they inhibit?

Answer 40

Metabolized by 2C19 and 3A4; inhibit 2C9 and 2C19.

Question 41

When are PPIs indicated for GERD?

Answer 41

For symptoms >2 weeks.

Question 42

What are adverse drug reactions of PPIs?

Answer 42

Headache, diarrhea, B12 deficiency, hypomagnesemia, increased risk of C. difficile, fractures, pneumonia.

Question 43

What is the mechanism of action of Misoprostol?

Answer 43

PGE1 analog that increases mucus and bicarbonate secretion; used for prevention of steroid and NSAID-induced ulcers.

Question 44

What are adverse drug reactions for Misoprostol?

Answer 44

Diarrhea, abdominal cramping, uterine contractions (pregnancy category X, used for medically induced abortions)

Question 45

What is the mechanism of action of sucralfate?

Answer 45

Forms a viscous barrier at ulcer base by binding with positively charged proteins.

Question 46

What is sucralfate used for?

Answer 46

Duodenal ulcers and mucosal protection.

Question 47

What is needed for sucralfate to be activated? Why’s this important?

Answer 47

Needs acid; do not use with PPIs or H2 blockers.

Question 48

What are adverse drug reactions of sucralfate?

Answer 48

Constipation; could interfere with absorption of other drugs.

Question 49

What is the first-line treatment for H. pylori?

Answer 49

The first-line treatment for H. pylori is Bismuth quadruple therapy, which includes a PPI, Bismuth subsalicylate, Metronidazole, and Tetracycline for 10-14 days.

Question 50

What is the second-line treatment for H. pylori?

Answer 50

The second-line treatment for H. pylori is non-bismuth quadruple therapy, which includes a PPI, Clarithromycin, Amoxicillin, and Metronidazole for 10-14 days.

Question 51

What is the mechanism of action of sodium bicarbonate?

Answer 51

Sodium bicarbonate provides bicarbonate ions that neutralize acid secretions in the GI tract.

Question 52

What are the adverse drug reactions (ADRs) of sodium bicarbonate?

Answer 52

ADRs of sodium bicarbonate include GI issues such as flatulence and bloating, as well as electrolyte disturbances (dose-related). Absorption of other medications can also be affected.

Question 53

What drugs are used to decrease gastric acidity in PUD treatment?

Answer 53

Drugs that decrease gastric acidity include PPIs and H2 receptor blockers (though H2 blockers are not commonly used now). ## Footnote Antacids such as sodium bicarbonate, calcium carbonate, magnesium, and aluminum hydroxide, as well as cytoprotective agents like bismuth subsalicylate, misoprostol, and sucralfate, are also used.

Question 54

Which GERD agent is contraindicated in pregnancy?

Answer 54

Misoprostol is contraindicated in pregnancy.

Question 55

Which GERD drug should be avoided in an elderly woman with a recent history of myocardial infarction who is taking several medications?

Answer 55

Omeprazole should be avoided in this patient.

Question 56

Which drug has been known to cause black staining of the tongue?

Answer 56

Bismuth Subsalicylate has been known to cause black staining of the tongue.