Intestine 2 Flashcards
how do you treat bowel obstruction
Admit to hospital → strict NPO, no narcotics or NSAIDs
Antiemetics – watch for hypokalemia
IV fluids
Correct electrolyte issues (K>4, Mg>2)
Decompress bowel (NG tube with suction)
IV steroids if IBD
Consult surgery
If strangulated hernia or acute abdomen = surgery right away
how do you treat paralytic ileus
Treat underlying cause
– restriction of oral intake w/ slow re-introduction
May require NG suction + IV fluids and electrolytes
Alvimopan – reverses opioid-induced inhibition of intestinal motility, when post-op opioid therapy is indicated
What are IBD medication classes?
5-ASA (sulfasalazine, mesalamine)
corticosteriods (budesonide, prednisone)
immunomodulators - thiopurines, methotrexate, janus kinase inhibitors (-mab), sphingosine 1 phosphate receptor modulators -mod)
biologic therapies - anti-TNF (infliximab, adalimumab, golimumab, certolizumab)
anti-integrins (vedolizumab)
anti-IL 12/23 (ustekinumab)
patients w/ IBD have an increased risk of vaccine-preventable infections so what should you do?
confirm vaccination status
inactivated vaccines - hep a, b, shingles, influenza, dTAP (safely administered with immunosuppression)
pneumococcal vaccine in >65
live virus should never be administered while taking immunosuppressive drugs
surgery indications for crohn’s disease
Poor response to medical therapy
Intraabdominal abscess
Massive bleeding
Internal or perianal fistulas
Intestinal obstruction
admit a crohn’s disease patient if
Intestinal obstruction
Abscess is suspected
Serious infectious complication
Severe diarrhea, dehydration, weight loss, or abdominal pain
Severe or persistent symptoms despite steroids
High fever, persistent vomiting, severe abdominal tenderness
How do you treat a mild/low risk crohn’s disease?
Nutrition
Well balanced diet, smaller, more frequent meals, fluids, avoid fried/greasy foods, trial off dairy
Loperamide for diarrhea PRN up to 4x
Drug therapy based on location of involvement
Terminal ileum or ascending colon disease = extended-release budesonide (steroid)
Left sided or diffuse = oral steroids (prednisone/prednisolone) and taper, sulfasalazine (5-ASA)
how do you treat severe/high risk crohn’s disease?
oral corticosteroid (methylprednisolone/prednisone) w/ tapering + initiation of biologic agent
Early treatment with biologic agents (w or w/o immunomodulators)
anti-TNF = infliximab, adalimumab
+ immunomodulating azathioprine, mercaptopurine, methotrexate
If fail biologics, small molecules (jak inhibitor - upadacitinib)
Nutrition
low-roughage diet, decreased processed foods, TPN, B12, Vitamin D
Symptomatic therapy
Diarrhea = cholestyramine, colestipol, colesevelam
Steatorrhea = low-fat
SIBO = abx
Diarrhea = loperamide, diphenoxylate w/ atropine, tincture of opium (NOT in active severe disease)
How do you treat crohn’s disease if biologic therapies fail?
Failure of biologic therapies = oral small molecules (upadacitinib)
how do you treat mild-mod distal ulcerative colitis?
Topical mesalamine 5-ASA suppository/enema
Oral if not tolerated
No result = combo of topical w/ oral, topical steroid, all three
Maintenance = 5-ASA
How do you treat mild-mod ulcerative colitis?
Combo oral + topical 5-ASA (mesalamine)
+ oral steroid (budesonide or prednisone) if no improvement within 4-8 weeks
If requiring >1 course of steroids every 1-2 years, add thiopurine or biologic agent
How do you treat mod-severe ulcerative colitis?
Oral steroid (prednisone/methylprednisolone) w/ slow tapering followed by oral mesalamine
Biologics or small molecules (infliximab or vedolizumab - older or high risk) with or without immunomodulator recommended when:
Steroids can’t be completely withdrawn
Those who require 2+ steroids every every 1-2 yrs
If don’t respond, IL Antibodies
How do you treat severe + fulminant ulcerative colitis?
NPO x 24-48 hours until improvement (may need TPN)
d/c offending agents
IV fluids, support
IV steroids, enemas → infliximab if no improvement
IV cyclosporine with steroid failure
Surgery
how do you treat toxic megacolon
complete bowel rest (NPO), IV hydration, NG tube, no anti-motility (opioids, anticholinergics), broad spectrum abx if c diff, IV steroids if ulcerative colitis
Infliximab if no steroid response
Surgery if
Clinical deterioration
Failure to improve with medical care after 24-72 hours
Perforation
Uncontrolled hemorrhage
Worsening signs of toxicity and/or dilation
abx associated colitis tx
Contact precautions
Discontinue agent
Fidaxomicin or vancomycin
Fulminant disease = oral vancomycin + IV metronidazole + surgical consult
