Gastrointestinal Disorders Flashcards
(107 cards)
1
Q
What are some risk factors when chronic NSAID use is present with PUD?
A
- Age ≥ 65
- prev PUD or complication
- high-dose or multiple NSAIDs
- NSAID + low dose ASA
2
Q
What do antacids do?
A
Neutralize gastric acid
3
Q
What are some mngmt options with NSAID use and PUD?
A
- use lowest dose NSAID
- COX-2 selective
- Naproxen
- concurrent PPI or misoprostil use
4
Q
1) What are the serotonin receptor antagonists for N/V?
2) Uses?
3) ADRs?
A
- “-setron”
- dola-, grani-, ondan-, palono-
- acute N/V and chemo-induced N/V
- relatively ↓ complications
- HA and GI effects (constipation and diarrhea)
5
Q
How do prostaglandins (PTG) affect mucosal protection?
A
- ↑ mucus and bicarbonate secretion
- dilation of microcirculatory vessels
6
Q
What is the invasive/active “Gold Std” methods for H. pylori diagnosis?
A
Requires endoscopy
- stained histopathologic specimen
- bacterial culture
- rapid urease tests on mucosal fragments
- detects H. pylori enzyme products
7
Q
What is the MoA of PPIs?
A
- Inhibits proton pump enzyme
- –> profound (~95%)↓ in gastric acid secretion
8
Q
What are the food intake lifestyle modifications for GERD?
A
- avoid anything good
- avoid chocolate, carminatives, and EtOH
- limit caffeine/carbonated beverage intake
- ↑ saliva production (gum or hard candy)
- avoid acidic foods and beverages
- eat smaller meals and low-fat foods
9
Q
What conditions can N/V lead to?
A
- dehydration
- metabolic alkalosis
- loss of e-lytes
- esophageal dmg
10
Q
- When to not use bulk forming laxatives?
- ADRs?
- How to avoid ‘biscuit’ formation?
A
- If large formed stool present –> don’t use
- Flatulence, ABD cramping
- MUST drink sufficient H2O to avoid dehydration
- metamucil biscuit = obstruction
11
Q
What are the ADRs for Calcium Carbonate antacids?
A
- Ca stone formation
- Acid rebound
- Milk-alkali syndrome
- Ca depo in kidneys and other tissues
- Dizziness, dry mouth, HA, and poor appetite
12
Q
What are the activity/behavior lifestyle modifications for GERD?
A
- lose weight
- avoid recumbency for 2-3 hrs s/p eating
- quit smoking
- elevated HOB 6”
- avoid tight clothing
- that you probably shouldnt be wearing anyways
- stop being your daughter’s friend
13
Q
- What are bulk forming laxatives used for?
- MoA?
- Examples?
- Onset?
A
- Prevention of constipation
- Absorb H2O to ↑ bulk –> bowel distention –> initiating and ↑ peristaltic reflex
- psyllium, methylcellulose
- 24 hr to 3 days
14
Q
What are some significant manifestations of H. pylori infections?
A
- PUD (gastric and duodenal ulcers)
- Chronic gastritis
- MALT lyphomas
- Gastric adenocarcinomas —> (higher risk in other countries –> Japan, H. pylori diagnosis = immediate eradication)
15
Q
What is PUD?
A
- Peptic ulcer dz
- refers to ulcers formed in muscular mucosa in wall of GI tract
- usually duodenum or stomach (gastric ulcers)
16
Q
What is the STEP UP therapy regimen?
A
17
Q
What conditions should you be screening for if any red flag Sx are present w/ constipation?
A
- Obstructions
- GI bleeds
- Cancers
18
Q
- When should stimulant laxatives be used?
- ADRs?
- Issues associated w/ stim laxatives?
A
- Typically used at night
- ABD cramping (dose dependent) and diarrhea
- laxative dependency develops, poop neuroses, purgative
19
Q
- What is the noninvasive method for a passive H. pylori diagnosis?
- What do results mean?
A
- antibodies in blood, serum, saliva, urine
- indicates ‘exposure’ not active infection
20
Q
What are the drugs/classes that ↓ LES tone?
A
**All Rx that ↓ gastric emptying** PLUS
- Alpha-blockers, Antihistamines
- Beta-agonists
- Estrogen, EtOH
- Nicotine, Nitrates
- Theophylline
21
Q
- What is considered severe or frequent GERD?
- What is the therapeutic approach?
- About how many relapse s/p d/c?
A
- ≥ 2 episodes/wk
- Standard dose PPI for 8 weeks
- 2/3 of Pts relapse after PPI d/c
22
Q
1) What happens if the volume of an osmotic laxative is ↑?
2) ADRs and other cautions?
A
- ↑ volume of Rx used –> ↑ amount of H2O reserved –> ↑ speed of response
- Diarrhea/cramping, dehydration, e-lyte imbalance
- caution use in renal failure
23
Q
What drugs are used in the Prevpac combo?
A
- clarithromycin + MTZ added seperately
- amoxicillin
- lansoprazole
24
Q
What is the difference btw an antibody and an antigen in terms of detection of an infection?
A
- Antibodies only indicated that one was exposed to the causative agent at one point
- Antigens are components of living cells and indicate the presence of a causative agent
25
What is the onset and duration of antacids?
* Immediate onset
* Duration 20-40 min (fasting), up to 3 hours (after meals)
26
What drugs are used in the Pylera combo?
* bismuth subcitrate + omeprazole is added separately
* metronidazole
* tetracycline
27
1) What are the available cannabinoids for N/V?
2) Uses?
3) ADRs?
1) dronabinol and nabilone
2) mild-mod nausea w/ minimal vomiting - not good for intractable N/V
3) sedation, dizziness, ataxia
28
What are symptoms and/or conditions associated with LPR?
* Wheezing/asthma-like Sx
* Aspiration PNA --\> idiopathic pulm fibrosis
* Chronic coughing or throat clearing
* Hoarseness, laryngitis, sore throat
29
What are the Sx of duodenal ulcers?
* sharp, burning epigastric pain, point tenderness
* ABD pressure, fullness, or hunger
* 1.5 - 3 hr after eating
* Night awakening may occur
* May be relieved by eating
30
1. What is considered mild and intermittent GERD?
2. What interventions are recommended?
1. \< 2 episodes/week
2. STEP UP therapy q 2 wks until Sx control achieved
* Start w/ lifestyle modifications
31
What is ataxia?
loss of full control of bodily movements
* Person looks like they are drunk: \*\*When you're drunk you need "a-taxi-a" to get home\*\*
32
For severe/frequent GERD, what do you do if no Sx for ≥ 3 months?
- Repeat 8 week PPI course
33
What do you do if one PPI doesn't work?
- Failure of one PPI does not indicate other PPI will be ineffective
34
What is Zegerid and when taken?
* chewable PPI combo Rx (omeprazole + NaHCO3)
* only immediate-release oral PPI
* Must be taken on empty stomach
35
What are the Sx of gastric ulcers?
* Pain precipitated or exacerb by food
* diffuse lower ABD pain
36
1. What are PPIs used for in drug therapy
2. What are their advantages?
1. Used for Sx prevention
2. Advantages:
* better Sx relief
* higher and faster healing rates for erosive dz
* no tolerance
37
1. What is simethicone
2. What does it do?
3. What are the systemic side effects?
1. Silicon-based, anti-gas Rx
2. Change surface tension of gas bubbles to ↑ elimination and prevents formation of mucus-surrounded gas pockets
3. Locally acting --\> no systemic side effects
* ok to try almost anytime, if not work then d/c use
38
What 3 factors contribute to mucosa protection?
* mucus secretion
* bicarbonate secretion
* microcirculation
39
1) What are stimulant laxatives used for?
2) MoA?
3) Examples?
4) PO onset, suppository onset?
1. Use for active constipation/impaction
2. ↑ peristalsis by irritating colonic nerves
3. senna, bisacodyl, castor oil
4. PO = 6-12 hours, suppository = 10 mins
40
* What are the noninvasive methods for an active H. pylori diagnosis?
* What does each test look for?
* Stool antigen assay (SAT)
* SAT detects bacterial antigens
* Carbon-13 urea breath test (UBT)
* C-13 UBT detects metabolic products
41
What is approach to selecting ABX thpy if an Active H. pylori infxn is present?
42
What are the ADRs for Aluminum Hydroxide antacids?
* Constipation
* Phosphate depletion
* Osteoporosis (incr Ca excretion and fluoride absorption)
43
What symptom does Aluminum cause?
- Constipation
44
When does tolerance to H2RAs start to set in?
- After 2-6 wks of sustained H2RA use
45
1. What are the definitions of nausea?
* vomiting?
2. What are the causes?
1. nausea = inclination to vomit
* vomiting = ejection or expulsion of stomach contents
2. Too many to list
46
For severe/frequent GERD, what do you do if Sx occur w/in 3 months?
* Get upper endoscopy
* if negative, maintenance PPI at lowest dose to control Sx
47
What are the main causes of PUD?
* H. pylori
* NSAID use
* Physiologic stress-related mucosal dmg (i.e. ICU Pts)
48
1. What are methylnaltrexone (Relistor) and naloxegol (Movantik)?
2. What are they approved for?
3. How are each admin?
1. Mu receptor antagonists that do not cross the BBB
2. Opioid-induced constipation in Pts receiving palliative thpy
3. methylnaltrexone --\> subcut; naloxegol --\> PO oral tabs
49
1. What are the neurokinin antagonists for N/V?
2. Uses?
3. ADRs?
1. aprepitant (Emend), rolapitant (Varubi)
2. chemo-induced and post-surgical N/V
3. Well tolerated but $$$
50
ADRs for Magnesium-based antacids?
* Diarrhea
* Hypokalemia
* Hypermagnesemia (in renal failure)
51
What are the minor defining symptom characteristics of constipation?
* rectal pressure (for most Pt, except Steve d/t ↑ opening area)
* HA r/t ↑ valsalva (pullin' an Elvis)
* ↓ appetite
* ABD pain
52
1. Available IV PPIs
2. Available enteric coated granules
3. Available delayed release tablets
1. Lanso-, esome-, panto-
2. Lanso-, esome-, ome-
3. Panto-, rabe-
53
What unique SE occur with cimetidine?
* menstrual irregularities
* gynecomastia
* erectile dysfunction
54
What drugs are used in the Helidac combo?
* Bismuth subsalicylate + H2RA is added seperately
* metronidazole
* tetracycline
55
1) How are promotility agents used to treat GERD?
1. As adjunct to acid suppression in:
* ↓ esophageal clearance
* LES incompetence
* delayed gastric emptying
56
What are drugs that cause constipation?
* Aluminum-based antiacids
* Anti-Ach (some antihist, antidepress, and antipsycho)
* Iron supplements
* OPIOIDS
57
What are indications for continuous PPI therapy?
* GERD complications (ulcers, strictures)
* erosive esophagitis
* extra-esophageal GERD Sx
* Endoscopic-negative GERD
* Nocturnal sx
* Sx \> 3 times weekly
58
1. What are the corticosteroids for N/V?
2. Uses?
3. ADRs?
1. dexamethasone, methylprednisolone
2. chemo-induced N/V, post-surgical N/V, \*\*preggo-related N/V not controlled by other Rx
3. Most SE avoided b/c only used short-term
59
What impact did serotonin receptor antagonists have on chemo for cancer Pts?
* Caused ↑ remission rates d/t ↑ allowable cancer Rx use b/c of ↓ intractable N/V
60
What is misoprostil?
What does it do?
1. a synthetic PTG E1 analog
2. ↑ mucosal protection - ↓ gastric acid secretions
61
1) What are stool softeners used for?
2) MoA?
3) Examples?
4) Onset?
1) Prevention of constipation and straining
2) Wetting agent used to soften stool mass
3) docusate (calcium, sodium, potassium)
4) 1 to 2 days
62
1. What component in Helidac might lead to an allergic rxn
2. What is an alternative?
1. salicylate allergy
2. Pylera, it contains bismuth subcitrate instead
63
1) What are the red flag symptoms associated with constipation?
* blood in stools
* weight loss
* fever
* anorexia
* N/V
64
What did Warren and Marshall do in 1983?
What did it lead to?
* Performed infamous "petri-dish" experiment and inoculated self w/ H. pylori
* Lead to discover of H. pylori as culprit for PUD and eventual cure for PUD
65
What drug interactions with antacids were mentioned in lecture (drug + rxn)?
1. Tetracycline --\> direct complexation
2. Bisphosphonates --\> reduces absorption
3. Ketoconazole --\> Increased gastric pH decreases absorption
4. Iron (requires acidic pH) --\> ↓ absorption in alkaline pH
66
Complications associated w/ constipation?
1. excessive straining -
* anal fissures
* hemorrhoids
* rectal prolapse ("inney" turns into an "outey")
2. fecal impaction, ostipation, complete bowel obstruction
3. ↑ MvO2
* \*\* d/t vasovagal \*\*MvO2 = myocardial O2 consumption; avg for 300g heart is 30-35 ml/min\*\*
67
* What should you do before you take an antacid liquid?
* How can you minimize bad taste?
* What is most important when taking antacid tablets?
* Shake liquid preps before each dose
* Refrigerate liquids to minimize bad taste
* Chew tablets completely
68
1. Indication for PPI/H2RA combo therapy?
2. When is each Rx admin?
1. For nocturnal acid breakthrough
* d/t histamine release for most
* PPI alone not effective in controlling noc acid breakthrough
2. PPI taken at regular time, give intermittent H2RA to avoid tolerance
69
1) How is mineral oil used as a laxative?
2) MoA?
3) Onset?
1) Mainly used as enema, no longer as PO...b/c it's fucking nasty - Warm enema after digital disimpaction to "ass"ist in emptying of rectum and distal colon in Pts fecal impaction
2) coats feces easing passage of stool and maintaining H2O content
3) 24-48 hours if taken PO
70
What are the major defining symptom characteristics of constipation?
* ↓ frequency
* hard, dry stool
* painful defecation
* ABD distension
* palpable mass (poop tumor)
71
What are the 5 GERD alarm symptoms?
* Hemorrhage
* Unexpected weight loss
* Recurrent vomiting
* Dysphagia
* Chest Pain
72
1) What is lubiprostone do?
2) What is it used for?
1) ↑ intestinal fluid secretion
2) Used for chronic ideopathic constipation and IBS-C
73
What is Gaviscon?
- Al and Mg antacids + alginic acid
74
Disadv of misoprostil?
* severe diarrhea
* not as good as PPIs
* multiple daily doses
* preg category X
* uterine contractions and cervical ripening agent
75
1. What was/is ipecac syrup used for?
* How long until effect achieved?
2. Contraindications
3. Issues with use?
1. Home emergency poison ingestion, 80-90%
* vomit w/in 30 mins 2)
2. Unconscious, depressed gag reflux, and caustic (strong alkaline) substance
3. chronic use --\> cardiotoxicity and muscle dmg
76
1) Examples of osmotic laxatives?
2) MoA?
3) Onset?
1) Hypertonic e-lytes (ex. GoLYTELY), non-absorbable sugars (ex. lactulose), polyethylene glycol
2) ↑ H2O content of bowel --\> stim peristalsis
3) 1-3 hours
77
1. What can the term "constipation" refer to?
2. What is typically normal?
3. What is important to remember about BM frequency?
1. ↓ frequency or difficult fecal evacuation
2. "normal" typically 3/day to 3/week
3. changes from baseline are most important
78
1) What are the promotility agents?
1) Metoclopramide (Reglan) and bethanechol (Urecholine)
79
How does effectiveness differ among H2RAs?
What overall efficacy?
* All H2RAs are equally effective
* 70% ↓ in gastric acid prod across the board
80
What is the main difference btw duodenal ulcers and gastric ulcers in terms of Sx onset?
* In duodenal ulcers, pain occurs 1.5-3 hr AFTER eating
* In gastric ulcers, pain precipitated or exacerb by food
\*\*Pain occurs for both whenever food hits ulcer\*\*
81
1. What are the anti-Ach Rx for N/V?
2. What are they used for?
3. What are the ADRs
1. scopolamine, meclizine, dimenhydrinate
2. simple nausea and motion sickness
3. can't see, can't spit, can't shit, can't pee
82
What information should patients know about antacids and drug interactions (i.e. Pt education)?
* Take 1 to 3 hrs after meals and at bedtime
* Take 1 hr before or 2 hrs after other meds
* No calcium antacids with milk or vitamins
83
1) When do stool softeners work/not work?
2) ADRs?
1) Work only when present @ formation of stool
* not work if stool already formed
2) Diarrhea
84
What are the general uses for laxatives?
* constipation
* prevention of straining (ex. s/p heart surg)
* bowel evacuation
* diag. procedures, parasitic infxnx, drug OD
85
1. What is sucralfate
* what does it do?
2. What is it for?
3. Advantages?
* ADRs?
* Cautions?
4. When to admin?
1. Aluminum-based compound
* binds to exposed epithelial tissue --\> protective barrier to aid healing
2. For treatment of duodenal ulcers
3. ↓ [systemic] b/c only 3-5% absorbed
* constipation is primary ADR
* use cautiously in renal failure
4. admin before meals and at bedtime
86
What are the drugs/classes that ↓ gastric emptying?
* Anti-Ach
* CCBs
* Levodopa
* Loperamide/narcotics/opiates
* TCA
87
What are carminatives and how do they affect the GI tract?
* herbs and spices that act to ↓ GI smooth muscle tone (mints, ginger, cinnamon, etc...)
* ↓ LES pressure --\> ↑ eructation (burping) to prevent gas/flatulence
88
What are the ADRs for Sodium Bicarbonate antacids?
* Systemic alkalosis
* Acid rebound
* Sodium overload
89
1. What are the ADRs for lubricants for constipation?
2. Additional concerns?
1. Can be absorbed --\> inflammatory rxn d/t petroleum rxn (lessened w/ PR admin) and lipid pneumonia
2. Additional Concerns:
* Absorbs fat soluble vitamins
* sphincters don't hold lipids well --\> anal leakage
90
1. What are the dopamine antagonists for N/V
2. Uses?
3. ADRs?
1. promethazine, metoclopramide
2. acute N/V and good general purpose Rx
* really good at making cranky old people sleep
3. EPS, dizziness, confusion
91
Why are Prevpac resistance rates increasing?
Increased H. pylori resistance to clarithromycin
92
Helicobacter pylori:
1. What type of bacteria is it?
2. Where does it reside?
3. How transmitted?
4. Relationship to PUD?
1. An acid-labile, gram-negative rod
2. Btw mucus layer and surface epithelium
3. Fecal-oral and oral-oral transmission
4. Strong assoc w/ PUD
* treatment aimed at elim of H. pylori w/ ABX therapy
93
What is GERD?
What type of condition?
What is it related to?
* Symptoms and/or tissue dmg d/t reflux of gastric contents into the esophagus
* Chronic, relapsing condition
* Related to abnormal anatomy and motor function
94
1. What tests should be used to confirm eradication of H. pylori after 2 weeks s/p treatment?
2. What problem typically occurs?
1. Stool antigen assay (SAT)
2. People self medicate, so antigen testing may give false negative
95
What is an ileus?
Painful obstruction of the ileum or other part of the small intestine
96
What are some PPI potential risks?
* Drug-induced Lupus
* Pneumonia
* Absorption issues
* Fracture risk d/t Ca absorption
* Iron absorption
* Kidney Issues
* Acute interstitial nephritis
* CKD
97
1. What are OTC H2RA used for in GERD drug therapy?
* How many can you take?
* When to take if for PRN?
2. What are Rx H2RA used for in GERD drug therapy?
* Main disadvantage?
1. Treat Sx
* take ≤ 2 times daily
* for food/bev-induced Sx ---\> take 30 mins before consuming causative agent
2. Used for Sx prevention (50-70% of Pt w/ Sx get partial or complete relief)
* tolerance is common
98
1. What benefit does alginic acid provide?
2. What does it have no effect on?
3. What can alginic acid help with?
4. What causes alginic acid efficacy to decrease?
1. Sx relief for some
2. No effect on LES
3. May help w/ acid pocket/postprandial GERD
4. Less effective when lying down
99
Which diagnostic test provides no useful information after a patient has completed eradication therapy for H. pylori?
* Antibody test
* will always show positive result b/c Pt was exposed to H. pylori at one point
100
1. How does Gaviscon work?
2. When does Gaviscon not work?
1. Antacid foam floats on chyme blocking acidic refluxate
2. When patient is lying down
101
* How do antacids impact esophageal healing?
* Can patients switch between antacids? Why/why not?
* do not heal esophagitis, only Sx relief
* products not inter-changable
102
What is the MoA for H2RA?
- Decr histamine (H2) mediated release of acid from gastric parietal cells
103
ADRs of each promotility agent?
* Metoclopramide --\> EPS, tardive dyskinesia
* Bethanechol --\> urinary retention, nausea, flushing, ABD pain
104
What are the two ACG 1st line treatment regiments for H. pylori eradication?
1. Bismuth--based quad thpy x 10-14 d
* PPI + bismuth + MTZ + tetracycline
* H2RA + " + " + "
2. Clarithromycin-based quad thpy x 10-14 d
* PPI + clarithromycin + MTZ + amoxicillin
105
What symptom does Magnesium cause?
- Diarrhea
106
What are the extraesophageal S/Sx of GERD?
* Noncardiac chest pain
* Laryngeal-pharyngeal reflux (LPR)
* Gingivitis, dental erosions and caries
107
1. What is important to know about PPI half life vs duration of action?
2. When should you take PPI?
1. short T 1/2 with long duration of action
2. take 20-30 before first major meal of the day
