GI treatments

Question 1

Familial adenomatous polyposis treatment

Answer 1

Prophylactic colectomy

Question 2

Treatment of Juvenile polyps

Answer 2

Polyps in children less than 10 years old

Highly vascular and should be removed

Question 3

Treatment of adenomatous polyps

Answer 3

Removal of polyp

Question 4

Treatment of diverticulosis

Answer 4

High fiber foods
Psyllium if can’t handle bran

If recurrent bleeding perform segmental colectomy

Question 5

Treatment of diverticulitis

Answer 5

Uncomplicated:
Antibiotics-IV 7-10 days
NPO-IV fluids

Symptoms persist for 3-4 days means surgery may be necessary
Recurrent-surgery

Complicated (abscess, colovesical fistula, obstruction, perforation): surgery indicated

Question 6

Acute mesenteric ishemia treatment

Answer 6

Supportive IV fluids and broad spectrum antibiotics
Direct intra-arterial infusion of papaverine relieves occlusion and vasospasm
Direct intra-arterial infusion of thrombolytics and embolectomy if embolism is etiology
Heparin for venous thrombosis
Surgery if signs of peritonitis develop

Question 7

Chronic meseneteric ischemia treatment

Answer 7

surgical revascularization

Question 8

Pseudomembranous colitis treatment

Answer 8

Discontinue offending antibiotic

Metronidiazole-not in infants or pregnancy
oral vanco

Cholestryamine for adjuvant therapy

Toxic megacolon, colonic perforation, anascarca (generalized edema) or electrolyate disturbances may require surgery

Question 9

Sigmoid and cecal volvulus

Answer 9

Sigmoid: decompression via sigmoidoscopy and elective sigmoid colon resection

cecal: emergent surgery

Question 10

Treatment of portal hypertension

Answer 10

Transjugular intrahepatic portal-system shunt (TIPS)

Question 11

Treatment of esophageal varices

Answer 11

Initially: hemodynamic stabilization with fluids

IV ocreotride: splanchnic vasoconstriction and reduces portal pressure
possible IV vasopressin instead of ocreotride

Variceal ligation/banding: initial treatment of choice
Endoscopic sclerotherapy: (higher rates of rebleeding)
Both after emergent upper GI endoscopy

Prophylactic non selective B blocker and IV antibiotics

Question 12

Treatment of ascites

Answer 12

Bed rest, low-sodium diet, and diuretics (furosemide and spironolactone)
Therapeutic paracentesis if tense ascites, SOB, or early satiety
Peritoneovenous shunt or TIPS to reduce portal HTN

Question 13

Treatment of hepatic encephalopathy

Answer 13

lactulose prevents absorption of ammonia
neomycin: decreases ammonia production by intestinal bacteria
Limit protein to 30-40 g/day

Question 14

Management of cirrhosis

Answer 14

Surveillance of LFTs
Compensated (vague symptoms: weakness, anorexia and fatigue)
ultrasound and aFP every 6 months, EDG, varices surveillance endoscopy)

Decompensated (jaundice, pruritus, upper GI bleed)
Variceal hemorrhage: non selective B blocker-repeat EGD yearly
Ascites: dietary Na restriction, Diuretics, parancentesis, abstinence
Encephalpathy: lactulose

Question 15

Treatment of Wilson’s disease

Answer 15

Chelating agents: penicillamine

Zinc: prevents uptake of dietary copper
Can be given prophylactically or pregnant patients

Liver transplantation: if unresponsive to therapy or fulminant liver failure

Question 16

Treatment of hemachromatosis

Answer 16

Repeat phlebotomies

Liver transplantation in advanced cases

Question 17

Treatment of pyogenic liver abscess

Answer 17

Fatal if untreated

IV antibiotics and percutaneous drainage of abscess

Surgical drainage is sometimes necessary

Question 18

Amebic liver abscess treatment

Answer 18

IV metronidazole

Therapeutic aspiration of abscess (image guided percutaneous aspiration) if abscess is large or no response to metro

Question 19

Treatment of budd chiari syndrome

Answer 19

Surgery: balloon angioplasty with stent in IVC
Portocaval shunts

Liver transplantation if cirrhosis is present

Question 20

Treatment of cholelithiasis

Answer 20

No treatment if asymptomatic

Elective cholecystectomy for recurrent bouts of bilary colic

Question 21

Treatment of cholecystitis

Answer 21

Conservative measures of hydration with IV fluids, NPO, IV antibiotics, analgesics, correction of electrolyte abnormalities

Surgery: within first 24-48 hours preferred

Question 22

Treatment of acalculous cholecystitis

Answer 22

Seen in patients with severe iillnesses-trauma, burns, postoperative state, TPN, mechanical ventiation, ischemia, dehydration

Emergent cholecystectomy-if can’t do surgery perform percutaneous drainage with cholecystostomy

Question 23

Treatment of choledocholithiasis

Answer 23

endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction with stent placement
laprascopic choledocholithotomy

Question 24

Treatment of cholangitis

Answer 24

IV antibiotics and IV fluids
Monitor hemodynamics, BP and urine output
Afebrile for 48 hours perform Percutaneous transheptic cholangriography (with catheter drainage) or endoscopic retrograde cholangiopancreatography(with sphinctertomy) for underlying condition
Lapraprotomy (T-tube insertion)
Perform emergently if patient does not respond to antibiotics

Question 25

Treatment of porcelain gallbladder

Answer 25

Prophylactic cholecystectomy (can develop cancer of the gallbladder)

Question 26

Treatment of primary sclerosing cholangitis

Answer 26

Curative: liver transplantation dominant stricture causing cholestasis: ERCP with stent placement for biliary drainage can relieve symptoms Cholestyramine for symptomatic relief (decreases pruritus)

Question 27

Treatment of primary biliary cirrhosis

Answer 27

Symptomatic for pruritus: cholestyramine Osteoprosis: calcium, vit D, bisphosphonates Ursodeoxycholic acid slows progression Liver transplantation is curative

Question 28

Acute appendicitis treatment

Answer 28

Appendectomy within 24 hours

Question 29

Acute pancreatits treatment

Answer 29

NPO IV fluids-correct electrolytes Pain-meperidine or fentanyl 30% of pancreas necrotic=antibiotics 3-4 of ransons criteria should be in ICU

Question 30

Treatment of pancreatic pseudocyst

Answer 30

less than 5 cm=observation | greater than 5 cm=drain percutaneously or surgically

Question 31

Treatment of chronic pancreatitis

Answer 31

``` Nonoperative: Narcotic analgesiics for pain NPO Pancreatic enzymes and H2 blockers Insulin for endocrince insufficiency Alcohol abstinence Frequent, small volume, low fat meals ``` Surgery: pancreatiocjejunostomy-decompresses dilated pancreatic duc Pancreatic resection: distal pancreatectomy, Whipples procedure

Question 32

Upper GI bleed treatment

Answer 32

EGD with coagulation of the bleeding vessel | If bleeding continues repeat endoscopic therapy or proceed with surgical intervention (ligation of vessel)

Question 33

Lower GI bleed treatment

Answer 33

Colonoscopy-polyp excision, infection, laser, cautery Arteriographic vasoconstrictor infusion surgical resection of area-last resort

Question 34

Indications for surgery for GI bleed

Answer 34

Hemodynamically unstable who have not responded to IV fluid, tranfusion, endoscopic intevention, or correction coagulopathies Severe initial bleed or recurrence of bleed after endoscopic treatment Continued bleeding more than 24 hours Visible vessel at base of ulcer ongoing tranfusion requirement (5 units within first 4-6 hours)

Question 35

Achalasia treatment

Answer 35

Chew food to soup like consistency, sleep with trunk elevated, avoid eating before sleeping Anitmuscarinic dicyclomine-unsatisfactory Sublingual nitroglycerin, long acting nitrates, CCBs improve swallowing in early stages of achalasia Injection of botox into LES during endoscopy-must be performed every two years Forceful dilatation-pneumatic balloon most effective (risk of perforation) Heller myotomy: surgical incision of circular muslce layer of LES (patients who do not respond to dilation therapy)

Question 36

Diffuse esophageal spasm treatment

Answer 36

Nitrates and CCBs (decrease amp of contractions) TCAs provide symptomatic relief Possible esphagomyotomy (controversial)

Question 37

esophageal hiatal hernia treatment

Answer 37

Sliding: anatacids, small meals, and elevation of head after meals Nissen fundoplication if there no response to medical therapy or evidence of esophagitis paraesphogeal: elective surgery to avoid complications

Question 38

Mallory weiss tear treatment

Answer 38

Most of the time not necessary Oversewing the tear or angiographic embolization if bleeding continues Acid suppression to promote healing

Question 39

Zenker and epiphrenic diverticular treatment

Answer 39

Zenker: cricopharyngeal myotomy Epiphrenic: esophagomytomy Diverticulectomy is of secondary importance

Question 40

esophageal perforation treatment

Answer 40

Small perforation into lumen and patient stable: IV fluids, NPO, antibiotics, and H2 blockers Patient ill and perforation large (communication with pleural cavity): surgery should be performed within 24 hours of presentation

Question 41

Peptic Ulcer Disease Treatment regimens

Answer 41

Supportive: discontinue aspirin/NSAIDs, restrict alcohol and coffee use, stop smoking, decrease emotional stress, avoid eating before bedtime If positive for H. Pylori: start with triple therapy (amoxicillin, clarithromycin and H2 inhibitor) for 10-14 days and antacids If comes back use quadruple therapy (PPI, bismuth plus amoxicllin and clarithromycin) for one week NSAID induced ulcer: switch to acetiminophen, begin with PPI or misoprostol (reduces risk for ulcer formation) continue for 4 to 8 weeks Treat H. pylori if present H pylori and not NSAID induced treat with H2 blockers or PPIs Surgery: complications of PUD Peforation: Gastric outlet obstruction: GI bleeding

Question 42

GI perforation treatment

Answer 42

Emergency surgery to close peforation and perform definitive ulcer operation (selective vagotomy or truncal vagotomy/pylorplasty) Can progress to sepsis and death if untreated

Question 43

Acute gastritis treatment

Answer 43

Epigastric pain is low and not associated with worrisome findings: treat with empiric therapy with acid suppression. Stop NSAIDs No response after 4 to 8 weeks consider GI endoscopy and ultrasound (rules out gallstones) and test for H. pylori treat findings

Question 44

Treatment of small bowel obstruction

Answer 44

Nonopeative if incomplete and no fever, tachycardia, peritoneal signs or leukocytosis Give IV fluids, potassium, nasogastric tube to empty stomach, antibiotics Surgery if complete obstruction or persistent pain or strangulation suspected (fever, severe/continuous pain, hemataemesis, shock, gas in the bowel wall or portal vein, abdominal free air, peritoneal signs, and acidosis) Perform lysis of adhesion and resection of any necrotic bowel

Question 45

Treatment of paralytic ileus

Answer 45

IV fluids, NPO Electrolyte imbalances (hypokalemia) nasogastric suction if necessary Placement of long tube if necessary but generally do not need surgery

Question 46

Treatment of Crohn's disease

Answer 46

Sulfsalazine: antiinflammatory Metronidazole: if no response to 5-ASA Prednisone: acute exacerbations Azathioprine, 6-mercaptopurine: with steroids if no response to other agents Choelstyramine or colestipol: terminal ileal disease that cannot absorb bile acids NOT antidiarrheals Surgery: reserved for SBO, fistula, disabling disease, perforation or abscesss-segmetnal resection of involved bowel

Question 47

Treatment of ulcerative colitits

Answer 47

Systemic corticosteroids for acute exacerbations Topical application as suppository sulfasalazine maintains remissions Immunosuppressants for refractory disease Surgery: total colectomy-curative indications: debilitating disease, unresponsive to treatment, toxic megacolon, hemorrhage, obstruction, perforation, evidence of colon cancer, failure to thrive in children