Module 1 - GI Disorders Flashcards
1
Q
Symptoms associated with N/V
A
pallor, tachycardia, diaphoresis
2
Q
CTZ
A
Chemoreceptor Trigger Zone
3
Q
NTS
A
Nucleus of the Tractus Solitarius (vomiting center)
4
Q
Which medication should not be used in children and why?
A
promethazine; respiratory depression
5
Q
Serotonin Antagonists at CTZ, NTS, and GI tract
A
- ondansetron
- granisetron
- palonosetron
6
Q
Aloxi (brand)
A
palonosetron (generic)
7
Q
Butyrophenones MOA
A
Dopamine inhibition at CTZ
8
Q
Compazine (brand)
A
prochlorperazine (generic)
9
Q
Maalox, Mylanta
A
Aluminum Hydroxide, Magnesium Hydroxide, Simethicone
antacid
10
Q
Zantac (brand)
A
ranitidine (generic)
11
Q
Phenothiazines MOA
A
Dopamine inhibition at CTZ
12
Q
Drugs with SE of EPS
A
- Phenothiazines (promethazine, eg)
- Butyrophenones (droperidol, eg)
- Benzamides (metoclopramide, eg)
13
Q
hyperemesis gravidarum
A
complication of pregnancy characterized by severe n/v such that weight loss and dehydration occur
14
Q
Assessment of NV
A
- # of episodes
- Onset
- Duration of sx
- Severity of nausea (0-10)
15
Q
Which drug used to tx NV has a BB Warning for the risk of EKG abnormalities (QT prolongation)?
A
droperidol (Inapsine)
16
Q
Which drug is excellent for breakthrough NV?
A
olanzapine
17
Q
List 3 Neurokinin-1 Antagonists
A
- aprepitant (PO)
- fosaprepitant (IV)
- rolapitant (PO)
18
Q
Marinol (brand)
A
dronabinol (generic)
19
Q
Emend (brand)
A
aprepitant (generic)
20
Q
Cesamet (brand)
A
nabilone (generic)
21
Q
Cannabinoids
A
dronabinol (CIII)
nabilone (CII)
22
Q
Which drug class is especially useful for anticipatory NV?
A
Benzodiazepines (lorazepam, alprazolam, eg)
23
Q
Reglan (brand)
A
metoclopramide (generic)
24
Q
metoclopramide dose for NV
A
(pre-tx with Benadryl to prevent EPS), then:
20-50 mg
25
About how long is the onset for an IM dosage form in tx of NV?
~30 minutes
| ODT, IV, PR faster
26
When to apply scopolamine patch? Duration of action?
Appy 6-8 hrs before needed;
| Duration 72 hrs
27
When to take dimenhydrinate or meclizine to tx motion sickness?
30-60 min before needed (PO)
28
Dramamine (brand)
dimenhydrinate (generic)
29
Bonine (brand)
meclizine (generic)
30
PONV treatment of highest risk pts
Always use 2 agents:
1. 5-HT3 antagonist
2. dexamethasone, droperidol, aprepitant, or metoclopramide
31
CINV Acute Emesis (onset, max, resolution)
After chemo administration--
Onset: 1-2 hrs
Max: 5-6 hrs
Resolve: 12-24 hrs
32
CINV Delayed Emesis (onset, max, resolution)
After chemo administration--
Onset: post 24 hrs
Peak: 48-72 hrs
Resolve: gradual over 1-3 days
33
Most difficult type of CINV to tx
Delayed Emesis
34
Highly emetogenic drugs
```
#1. cisplatin
2. cyclophosphamide + doxorubicin
```
35
Prevention of Acute CINV (high emetic risk)
3 drug approach over 2-4 days:
1. 5-HT3 antagonist
2. dexamethasone
3. aprepitant or olanzapine
4. (+/-) lorazepam
36
Prevention of Acute CINV (moderate emetic risk)
1. 5-HT3 antagonist (palonosetron preferred)
| 2. dexamethasone
37
Prevention of Acute CINV (low emetic risk)
*dexamethasone,
| metoclopramide, prochlorperazine, ondansetron, granisetron
38
ROA for Acute vs Breakthrough CINV
Acute: PO whenever possible
Breakthrough: IV/PR often required
39
Tx of Acute Breakthrough CINV
Agent from different drug class
1. prochlorperazine
2. nabilone
3. metoclopramide (+ benadryl)
4. haloperidol
5. olanzapine
40
Acute constipation
Less than 3 BM/week
41
Chronic constipation
Sx > 6 weeks
42
Disease states that slow down GI motility
1. Diabetes
2. Parkinson's
3. CNS/spinal cord injury
43
Constipation referral
Sx > 2 weeks w/o significant relief
44
How much fiber recommended per day?
20-30 g fiber/day
45
Metamucil (brand)
psyllium (generic)
46
Citrucel (brand)
methylcellulose (generic)
47
Fibercon (brand)
calcium polycarbophil (generic)
48
Which bulk laxative produces less gas?
methylcellulose (Citrucel)
| -mix with cold water
49
Which bulk laxative produces less gas?
methylcellulose (Citrucel)
| -mix with cold water
50
Surfactant (stool softner)
docusate (Colace)
51
Saline Laxatives
1. MOM
2. Mg Citrate
3. Fleet's Saline Enema
52
Hyperosmotic Agents
1. Sorbitol
2. Lactulose
3. PEG
4. Glycerin supp.
5. Karo Corn Syrup
53
Stimulant Laxatives
1. Senna
2. Bisacodyl
3. Castor Oil
54
Stimulant Laxative MOA
Locally irritates nerves which stimulates motility
55
Cl- Channel Activator for idiopathic constipation or IBS-C
lubiprostone (Amitiza)
56
Amitiza (brand)
lubiprostone (generic)
57
lubiprostone (Amitiza) dosing
Take with food and water:
24 mcg BID (constipation)
8 mcg BID (IBS-C)
*avoid in pregnancy
58
Guanylate Cyclase Activator for idiopathic constipation or IBS-C
linaclotide (Linzess)
59
Linzess (brand)
linaclotide (generic)
60
linaclotide (Linzess) dosing
Empty stomach, 30 min before breakfast:
145 mcg daily (constipation)
290 mcg daily (IBS-C)
61
Mu opioid receptor antagonists for constipation tx
1. methylnaltrexone (Relistor): 8-12 mg SC QOD
| 2. naloxegol (Movantik): 25 mg PO daily on empty stomach
62
Relistor (brand)
methylnaltrexone (generic)
63
Movantik (brand)
naloxegol (generic)
64
alvimopan (Entereg) indication
tx of post-op ileus (leads to constipation)
| -restricted-access program; high risk pts only
65
GI Prep: tx classes
Hyperosmotics or Saline Laxatives
66
Classifications of diarrhea (acute, persistent, chronic)
Acute: less than 2 weeks
Chronic: greater than 1 month
67
Most common infectious cause of diarrhea in adults?
Rotavirus
68
4 types of diarrhea pathophysiologies?
1. Secretory: ion transport
2. Osmotic: poorly absorbed substances
3. Exudative: IBD
4. Altered Intestinal Transit: decreased exposure time (bowel resection, promotility meds, etc); anything that speeds up intestine
69
Which diarrhea pathophysiologies are characterized by large stool volumes (> 1 L/day)?
Secretory and Exudative
70
Which diarrhea pathophysiology resolves if patient stops eating?
Osmotic
71
Prevention of Traveler's Diarrhea?
Pepto-Bismol 1-4 x daily, prophylactically
72
Antimotility drugs MOA
Activate Mu opioid receptors on bowel smooth muscle to: reduce peristalsis and increase segmentation (mixing)
73
List 4 antimotility agents
1. Loperamide
2. Diphenoxylate
3. Difenoxin
4. Codeine
74
Imodium (brand)
loperamide (generic); OTC
75
Lomotil (brand)
diphenoxylate/atropine (generic); Rx-only
76
Motofen (brand)
difenoxin/atropine (generic); Rx-only
77
loperamide dosing
4mg (2 tabs) initially, then 2mg (1 tab) after each loose stool
Max: 16 mg/day (8 tablets)
78
diphenoxylate/atropine dosing
```
5 mg (2 tabs) 4 x daily
Max: 20 mg/day (8 tablets)
```
79
Absorbents MOA
Use in chronic diarrhea; oral non-absorbed agents absorb excess fluid to help form solid stools
80
List 2 Absorbents used to treat diarrhea
1. polycarbophil (Fibercon)
| 2. psyllium (Metamucil) -- powder formulation absorbs more water than tablet
81
Which antisecretory treatment of diarrhea also has antimicrobial and anti-inflammatory effects?
Bismuth subsalicylate (Pepto-Bismol)
82
Pepto-Bismol dosing
2 tabs or 30 mL every 30-60 min PRN
(up to 8 doses/day)
AVOID in pts who shouldn't take salicylates
83
4 subtypes of IBS
IBS-C, IBS-D, IBS-M, IBS-U
84
Lotronex (brand)
alosetron (generic)
| 5HT-3 antagonist for IBS-D
85
alosetron (Lotronex) classification and dosing
5HT-3 antagonist for IBS-D
Initial: 0.5 mg BID x 4 weeks
*REMS d/t severe constipation in overdose (ischemic colitis)
86
tegaserod (Zelnorm) classification and indication
5HT-4 agonist for IBS-C
| *restricted use only d/t risk of CV disorders
87
Bentyl (brand)
dicyclomine (generic)
| Antispasmotic and anticholinergic for IBS
88
dicyclomine (Bentyl) classification and indication
Antispasmotic and anticholinergic for IBS
| take 30-60 minutes before meals
89
hyoscyamine (Levsin) classificaiton and indication
Anticholinergic for IBS
90
rifaximin (Xifaxan) indication and dosing
IBS with diarrhea
| 550 mg TID x 14 days
91
eluxadoline (Viberzi) classification and indication
Mu-opioid agonist, Delta-opioid antagonist (C-IV)
MOA: slows motility and relieves pain
IBS with diarrhea
92
Pathophysiology of GERD (6 factors)
1. Defective LES pressure
2. Anatomic factors (hiatal hernia, eg)
3. Delayed gastric emptying
4. Esophageal clearance
5. Mucosal resistance
6. Refluxate composition (pH, volume)
93
Causes of defective LES pressure (6 factors)
1. spontaneous LES relaxations
2. increased abdominal pressure
3. atonic LES
4. pregnancy
5. foods
6. medications
94
3 causes of delayed gastric emptying
1. high-fat meals
2. smoking
3. diabetic gastroparesis
95
Atypical GERD sx
(aka extraesophageal sx)
1. chronic cough
2. hoarseness
3. non-allergic asthma
4. dental enamel erosions
96
Alarm GERD sx
1. dysphagia
2. odynophagia
3. bleeding
4. unexplained weight loss
5. continual pain
97
Best diagnostic tool for GERD
PPI trial of 8 weeks
98
Type of cell that produces acid in the stomach?
Parietal cell
99
Indication for antacids as first line tx?
PRN for intermittent GERD sx
| sx LESS THAN twice weekly
100
Only acid suppressing therapy appropriate for erosive GERD?
PPI
| NOT antacids or H2RAs
101
Antacid adverse effects: Mg vs. Al vs. Ca
Magnesium: diarrhea
Aluminum: neurotoxicity, anemia, constipation
Calcium: Milk-Alkali syndrome (HA, nausea, irritability)
102
Antacid DDI causes
1. reduced absorption of other drugs d/t higher pH (digoxin, iron, ketoconazole)
2. chelation and adsorption to some antibiotics
**separate antacids 2 hours before/4 hours after other drugs
103
PPIs with IV formulations
pantoprazole
| esomeprazole
104
PPI capsules you can open and sprinkle in applesauce or down NG tube (4)
1. omeprazole
2. esomeprazole
3. lansoprazole
4. dexlansoprazole
105
PPI with ODT formulation
lansoprazole
106
PPI with instructions NOT to crush
pantoprazole
| rabeprazole
107
In what type of pts would you consider using a H2RA over a PPI?
1. pt with recent antibiotic use d/t increased risk of C diff with PPI
2. pt on HIGH DOSE, IV methotrexate d/t increased risk of toxicity
108
Which PPIs should be avoided d/t inhibition of CYP 2C19?
Omeprazole and Esomeprazole
109
Promotility agent most commonly used in diabetic gastroparesis
metoclopramide (Reglan); increases gastric emptying and LES tone
110
Nexium (brand)
esomeprazole (generic)
111
Dexilant (brand)
dexlansoprazole (generic)
112
Pepcid (brand)
famotidine (generic)
113
Prilosec (brand)
omeprazole (generic)
114
Protonix (brand)
pantoprazole (generic)
115
Prevacid (brand)
lansoprazole (generic)
116
Tagamet (brand)
cimetdine (generic)
117
Axid (brand)
nizatidine (generic)
118
Zantac (brand)
ranitidine (generic)
119
famotidine dosing- GERD and active PUD
OTC: 10 mg BID
GERD: 20 mg BID
PUD: 20 mg BID, or 40 mg at bedtime
120
ranitidine dosing- GERD and active PUD
OTC: 75 mg BID
GERD: 150 mg BID
PUD: 150 mg BID, or 300 mg at bedtime
121
cimetidine dosing- GERD and active PUD
OTC: 200 mg BID
GERD: 400 mg BID
PUD: 400 mg BID, 300 mg QID, or 800 mg HS
122
omeprazole dosing- GERD and active PUD
OTC: 20 mg daily x 14 days Q 4 months
Nonerosive GERD: 20 mg daily
Erosive GERD: 20 mg BID
PUD: 20-40 mg daily/BID
123
pantoprazole dosing- GERD and active PUD
Nonerosive GERD: 40 mg daily
Erosive GERD: 40 mg BID
PUD: 40 mg daily/BID
124
lansoprazole dosing- GERD and active PUD
OTC: 15 mg daily x 14 days Q 4 months
Nonerosive GERD: 15-30 mg daily
Erosive GERD: 30 mg BID
PUD: 15-30 mg daily/BID
125
esomeprazole dosing- GERD and active PUD
OTC: 20 mg daily x 14 days Q 4 months
Nonerosive GERD: 20 mg daily
Erosive GERD: 40 mg daily
PUD: 20-40 mg daily/BID
126
Sucralfate MOA
Mucosal protectant for duodenal ulcer
| MOA: breaks down to insoluble aluminum/sucrose paste and adheres to ulcer to allow protection and healing
127
sucralfate dosing
1 g QID, or 2 g BID
| *administer on empty stomach; separate from other meds 2 hours before or 4 hours after
128
misoprostol MOA
synthetic prostaglandin E1 (replaces PGs inhibited by NSAIDs); mucosal protectant
129
misoprostol adverse effects
TERATOGENIC
| significant GI effects (diarrhea, abdominal pain); use-limiting
130
Treatment of Non-NSAID/H. pylori PUD
H2RA or sucralfate x 6-8 weeks
| PPI x 4 weeks
131
PPI based regimen for H. pylori PUD
1. Clarithromycin 500 mg BID
2. Amoxicillin 1 g BID, or Metronidazole 500 mg BID
3. PPI, BID: Omeprazole 20 mg, Lansoprazole 30 mg, Pantoprazole 40 mg, Esomeprazole 20 mg (or 40 mg daily), or Rabeprazole 20 mg
132
Bismuth based regimen for H. pylori PUD
1. Bismuth
2. Metronidazole
3. Clarithromycin, Amoxicillin, or Tetracycline
4. PPI or H2RA: Omeprazole, Lansoprazole, Pantoprazole, Esomeprazole, Rabeprazole, Cimetidine, Ranitidine, Famotidine, Nizatidine
133
Treatment of NSAID induced PUD
1. if NSAID discontinued: PPI, H2RA, or sucralfate x 6-8 weeks
2. if NSAID continued: PPI x 8-12 week, (or as long as NSAID is required)
134
Antiplatelet induced PUD prophylaxis
1. PPI preferred but if taking clopidogrel, then choose Pantoprazole d/t DDI with esomeprazole and omeprazole
2. Famotidine 20 mg BID
135
pH goal in management of PUD in ED/ICU
Maintain pH > 6
136
4 complications that designate "clinically important bleeding" in SRMB
1. hemodynamic instability
2. decreased Hgb
3. necessity of RBC transfusions*
4. increased ICU length of stay
137
How does SRMD differ from PUD?
- SRMD: multiple, superficial lesions primarily in the stomach with more congestion and bleeding.
- PUD: few, deeper lesions primarily in the duodenum with perforations being more common.
138
4 factors that lead to development of an acute stress ulcer
1. reduced HCO3 secretion
2. reduced mucosal blood flow
3. decreased GI motility
4. acid back diffusion
139
2 major risk factors for development of a stress ulcer
1. Respiratory failure: mechanical ventilation for ≥ 48 hours
2. Coagulopathy: plt count 1.5, or PTT > 2x control value
140
Indication for SRMD prophylaxis (ICU only)
1. Mechanical ventilation ≥ 48 hours
2. Coagulopathy
3. Hx of GI ulcer/bleeding within 1 year of admission and at least 2 of the following 4 factors:
- sepsis, ICU > 1 week, occult bleeding ≥ 6 days, or high-dose corticosteroids
141
Notable ADE of H2RA vs. PPI
H2RA: tachyphylaxis (tolerance)
PPI: risk of Clostridium difficile colitis
142
Neonate
0-28 days
| Term + 28 days (if born premature)
143
Infant
1-12 months
144
Child
1-12 years
145
Adolescent
13-18 years
146
1 oz to mL
1 oz = 30 mL
147
1 tablespoon to mL
1 T. = 15 mL
148
Bedside Schwartz equation
eGFR (mL/min per 1.73 m2) = 0.413 x (ht in cm/SCr)
149
Peds: ranitidine dosing
IV: 1-2 mg/kg Q 8-12 hrs
PO: 2-4 mg/kg BID
150
Peds: famotidine dosing
IV: 0.5 mg/kg 1-2 times daily
PO: 0.5 mg/kg BID
151
Peds: lansoprazole dosing
PO: 1 mg/kg/day
152
Peds: omeprazole dosing
PO: 1 mg/kg/day
153
Encopresis definition
(fecal incontinence)
repeated passage of feces into inappropriate places
-often secondary to soft stool leaking around large mass of stool in rectum
154
What age is bowel continence expected by?
Age 4; otherwise termed delayed bowel training
155
Circular smooth muscles (2) that are part of the physiology for a bowel movement
1. internal anal sphincter
| 2. rectum
156
Skeletal muscles (2) that are part of the physiology for a bowel movement
1. external anal sphincter
| 2. puborectalis muscle
157
Diarrhea definition (#/day)
3 or more loose or liquid stools per day
158
Chronic diarrhea
Lasting 14 or more consecutive days
159
Peds: calculating fluid requirements (per 24 hours)
Up to 10 kg: 100 mL/kg
10-20 kg: 1000 mL + (50 mL/kg x kg over 10)
>20 kg: 1500 mL + (20 mL/kg x kg over 20)
160
Common complication of TPN long term in SBS
Cholestasis: reduction or stoppage of bile flow from the liver to the duodenum
-can lead to liver failure (PNALD)
161
Medication used to prevent or treat PNALD
Ursodiol
| MOA: minor component of bile acid; helps to solubilize cholesterol. PO administration.
162
Cytokines increased in CD vs UC
CD: increased Th1 cytokine activity
UC: increased Th2 cytokine activity
both: TNF-alpha plays key role
163
Two types of IBD
```
Ulcerative colitis (UC)
Crohn's disease (CD)
```
164
Smoking effects in UC vs CD
UC: protective; fewer flare-ups
CD: increased frequency and severity
165
local complications of UC
hemorrhoids, anal fissures, perirectal abcesses
| common during flares
166
severe, life-threatening complication of UC
Toxic megacolon
| -colonic dilation/distention, increased depth of ulceration; s/sx of systemic toxicity
167
difference in complications btwn UC and CD
UC: increased bleeding, carcinoma risk, and rectal involvement
CD: fistulas, strictures, and perianal disease common
168
What markers distinguish IBD from IBS?
fecal calprotectin
fecal lactoferrin
(specific to inflammation in GI tract)
169
What antibodies distinguish UC vs CD?
UC: (+) perinuclear antineutrophil cytoplasmic antibodies (pANCA)
CD: (+) anti-Saccharomyces cervisiae antibodies (ASCA)
170
UC: proctitis
involving the rectal area
171
UC: proctosigmoiditis
involving rectum and sigmoid colon
172
UC: pancolitis
involving majority of colon
173
UC: distal
(left-sided); distal to splenic flexure
| descending colon, sigmoid colon, rectum
174
UC: extensive
extending proximal to splenic flexure
175
UC: mild disease
- less than 4 stools/day (+/- blood)
- no systemic disturbance
- normal ESR
176
UC: moderate disease
- greater than 4 stools/day
| - minimal systemic disturbance
177
UC: severe disease
- greater than 6 stools/day with blood
| - systemic disturbance (fever, tachycardia, anemia, or ESR > 30 mm/h)
178
UC: fulminant disease
1. greater than 10 stools/day with continuous bleeding
2. toxicity (severe systemic disturbance)
3. abdominal tenderness
4. need for transfusion
5. colonic dilation
179
splenic flexure
curvature on the left side of the colon between the transverse colon and descending colon
180
fulminant definition
severe and sudden in onset
181
What is the difference between hematochezia and melena?
hematochezia: gross blood per rectum; indicates lower GI bleeding (sign of CD)
melena: black tarry stools; indicates upper GI bleeding
182
sulfasalazine chemistry and indication
1. sulfapyridine (inactive, associated with ADRs, but prevents systemic absorption in small intestine)
2. + mesalamine (5-ASA, active, anti-inflammatory effects)
Indication: mild IBD
183
Advantages/disadvantages of budesonide
Pros: extensive first pass metabolism so minimal systemic absorption (can take PO for 8 weeks); well tolerated
Cons: CYP3A substrate so DDI with inhibitors increase systemic exposure
184
Mercaptopurine (6-MP) metabolism
AZA (prodrug) > 6-MP > inactive metabolite or active toxic metabolite (TGN)
TMPT: metabolizes 6-MP to inactive metabolite
TGN: accumulation results in bone marrow suppression
185
Azathioprine (AZA) and Mercaptopurine (6-MP) indication
induction and maintenance of remission in UC and CD
- after failure of 5-ASA tx
- slow onset (3-6 months)
- long term tx
186
Cyclosporine indication
induction of remission in refractory IBD
- bridge therapy; not for long term use
- better data in UC
187
Methotrexate indication
induction and maintenance of remission in CD
- add folic acid 1 mg daily to prevent bone marrow suppression
- teratogenic (pregnancy CI)
188
Remicade (brand)
infliximab (generic)
189
Humira (brand)
adalimumab (generic)
190
Simponi (brand)
golimumab (generic)
191
Cimzia (brand)
cerolizumab pegol (generic)
192
TNF-alpha antagonists
induction and maintenance therapy
1. infliximab (Remicade)
2. adalimumab (Humira)
3. golimumab (Simponi)
4. certolizumab pegol (Cimzia)
193
Anti-Adhesion biologics
1. natalizumab (Tysabri)
| 2. vedolizumab (Entyvio)
194
Biologic(s) only used for CD
1. certolizumab pegol
| 2. natalizumab
195
Biologic(s) only used for UC
golimumab (Simponi)
196
Biologics used for CD and UC
1. infliximab (Remicade)
2. adalimumab (Humira)
3. vedolizumab (Entyvio)
197
TNF-alpha antagonists: Class ADRs
- increase risk of serious infections
- injection site reactions
- risk of malignancy/demyelinating disease
- hepatosplenic T-cell lymphoma (HSTCL) risk
- may exacerbate CHF
198
Baseline monitoring for TNF antagonists
PPD, CXR, Hep B/C
-ensure no latent infection that could be reactivated
(live vaccines CI during and 3 months after tx)
199
Biologics administered via IV infusion
1. infliximab (2 hour infusion)
2. natalizumab (1 hour infusion)
3. vedolizumab (30 min infusion)
200
Which biologic is associated with PML?
natalizumab (Tysabri)
| -must test for JC antibody prior to initiation
201
First-line treatment in mild-moderate active UC
if extensive disease: need systemic tx (PO)
-oral sulfasalazine or mesalamine
if distal disease: within reach (topical)
-mesalamine enema or suppository
202
Alternatives for mild-moderate active UC
1. Budesonide CR
2. Prednisone 40-60 mg/day if refractory to ASAs
3. topical corticosteroids for distal disease
4. AZA or 6-MP if refractory to ASAs
203
Moderate-Severe active UC
1. systemic corticosteroids (PO prednisone 40-60 mg daily)
| 2. TNF-alpha inhibitors if unresponsive
204
Severe-Fulminant active UC
1. parenteral corticosteroids (IV: methylprednisolone or hydrocortisone)
2-3. TNF-inhibitor or cyclosporine (similar efficacy)
*transition cyclosporine to 6-MP or AZA for maintenance to
205
Agents that can be used in UC maintenance
1. ASA (mesalamine > sulfasalazine)
2. AZA or 6-MP
3. TNF-alpha antagonist
NOT corticosteroids or cyclosporine
206
Mild-Moderate active CD
1. 5-ASA (minimal efficacy in CD)
2. Budesonide CR (distal/right-sided disease)
3. Antibiotics (perianal disease)
207
Moderate-Severe active CD
1. systemic CS (PO prednisone 40-60 mg/day)
2. MTX
3. TNF-antagonist
*AZA/6-MP not rec for induction tx d/t slow onset (can maintain remission after induction with steroids)
208
Severe-Fulminant active CD
1. parenteral corticosteroids x 3-7 days then PO (methylprednisolone or hydrocortisone)
2. Biologic (infliximab, eg)
3. Cyclosporine (limited data, last resort)
209
Agents used in CD maintenance of remission
1. AZA or 6-MP (first-line)
2. MTX
3. TNF-antagonist or other biologic
(or infliximab + AZA or 6-MP)
210
Pro/Con of combination therapy: TNF antagonist + AZA
Pro: more effective in preventing development of anti-drug antibodies (ADAs)
Con: increase risk of HSTCL
211
What vessels comprise the Hepatic Portal Triad that supplies blood to the liver?
1. Bile duct
2. Hepatic artery
3. Portal vein
212
AST and ALT normal values
```
Aspartate Aminotransferase (AST): 0-50 IU/L
Alanine Aminotransferase (ALT): 5-60 IU/L
```
213
ALP normal value
```
Alkaline Phosphatase (Alk Phos):
35-130 IU/L
```
214
GGT normal value
Gamma Glutamyl Transferase (GGT):
| 0-85 IU/L
215
Bilirubin normal value
Bilirubin: 0-1.4 mg/dl
| Direct/Conjugated Bilirubin: 0-0.3 mg/dl
216
Albumin normal level
Serum albumin: 3.6-5 g/dl
| (LOW in liver disease) - b/c created by liver
217
BUN normal values
Blood Urea Nitrogen (BUN): 10-20 mg/dl
| (LOW in liver disease) - b/c created by liver
218
Components of LFTs
1. albumin
2. bilirubin
3. cholesterol
4. BUN
5. INR
219
Components of LITs
1. AST
2. ALT
3. Alk Phos
4. GGT
220
Modes of transmission for Hep A, B, and C
HepA: fecal-oral
HepB: sexual, parenteral, perinatal
HepC: parenteral
221
Centrilobular Necrosis- definition and drug cause(s)
direct/metabolite-related hepatotoxicity; damage spreads outward from middle of a lobe
-Acetaminophen
222
Nonalcoholic Steatohepatitis (NASH)- definition and drug cause(s)
accumulation of fatty acids in hepatocytes
- Tetracycline
- Valproate
223
Phospholipidosis- definition and drug cause(s)
accumulation of phospholipids in hepatocytes
-Amiodarone
(long half-life)
224
Generalized Hepatocellular Necrosis- definition and drug cause(s)
drug induction of innate immune response (auto-immune type)
| -Isoniazid
225
Toxic Cirrhosis- definition and drug cause(s)
scarring effect of hepatitis (mild, undetected) leads to cirrhosis
- Methotrexate
- Vitamin A
226
Cholestatic Injury- definition and drug cause(s)
accumulation of toxic bile acids in liver
- Chlorpromazine
- Amoxicillin-Clavulanic Acid
- Carbamazepine
227
Liver Vascular Disorder- definition and drug cause(s)
development of large, blood-filled lacunae
- Androgens, Estrogens
- Tamoxifen
- Azathioprine
228
Hepatocellular Injury examples (4)
- damage directly to hepatocytes
1. Centrilobular Necrosis
2. Steatohepatitis
3. Phospholipidosis
4. Generalized Hepatocellular Necrosis
229
Three main histological phases of Alcoholic Liver Disease?
1. Steatosis/fatty liver
2. Acute alcoholic hepatitis
3. Cirrhosis
230
Most common cause of cirrhosis?
Alcoholic Liver Disease
231
Interpreting Maddrey's Score
Acute Alcoholic Hepatitis (AAH) assessment
Score > 32
-poor prognosis
-threshold for starting corticosteroids or pentoxifylline
232
Pentoxifylline indication and MOA
Anti-inflammatory and vasodilator used to treat alcoholic hepatitis
MOA: PDE inhibitor and TNF-alpha modulator
Dose: 400 mg PO TID
233
ETOH Withdrawal treatment
1. fluid resuscitation
2. thiamine 100 mg daily
3. folic acid 1 mg daily
4. multivitamins daily
5. benzodiazepines
234
Complications of Cirrhosis (7)
1. portal HTN
2. varices
3. ascites
4. hepatic encephalopathy (HE)
5. coagulation defects
6. spontaneous bacterial peritonitis (SBP)
7. hepatorenal syndrome (HRS)
235
Immediately life-threatening complications of cirrhosis
1. acute variceal bleeding
| 2. spontaneous bacterial peritonitis (SBP)
236
Risk factors for variceal bleeding
1. poor liver function
2. large varices
3. alcoholic etiology of cirrhosis
4. red wale markings
237
Complications of cirrhosis mainly d/t Portal Hypertension
1. varices/variceal bleeding
2. ascites
3. encephalopathy
238
Complications of cirrhosis mainly d/t Liver Insufficiency
(lack of hepatic enzymes/function)
1. encephalopathy
2. coagulopathies
239
Octreotide MOA and dosing
MOA: selectively vasoconstricts splanchnic vasculature thereby decreasing portal BP
Dosing: 50-100mcg IV load, then 25-50mcg/hr continuous IV infusion x ~5 days
240
splanchnic vasculature defintion
vasculature that flows into hepatic portal vein
| -mesenteric, gastric, splenic, pancreatic veins
241
PPI treatment in variceal bleeding
Esomeprazole or Pantoprazole
dose: 80 mg IV load, then 8 mg/hr continuous infusion
* high dose oral PPI x 4 weeks post-bleed
242
prophylactic antibiotics during acute variceal bleed
-to prevent SBP (serious infection)
Short course (max 7 days):
1. Cephalosporin- ceftriaxone 1g IV q 24 hours
2. Fluoroquinolone- ciprofloxacin 400mg IV BID
243
Comprehensive Treatment for Variceal Bleed
1. volume resuscitation
2. PPI
3. Octreotide IV (~5 days)
4. EVL (banding procedure)
5. 3rd gen. cephalosporin (~7 days)
* secondary prophylaxis: nonselective BB
244
Prevention of variceal bleeding- drug(s) and dosing
Non-selective beta blocker
1. Propanolol 10mg BID or TID
2. Nadolol 20mg daily
- titrate to HR goal: 55-60 bpm
245
most common complication of cirrhosis
ascites
| -fluid accumulation in peritoneal space
246
Serum Ascites Albumin Gradient (SAAG)
-determines cause of ascites
Albumin (serum) - Albumin (ascites) = SAAG
SAAG > 1.1 g/dl = d/t portal HTN
247
Ascites Treatment
1. Spironolactone** 25-50 mg daily
2. Furosemide 20-40mg daily
* *most effective b/c aldosterone antagonist that counteracts RAAS activation that causes ascites
248
Spironolactone : Furosemide ratio
100: 40
- maintain at all times to ensure K+ balance
- max: 400mg/160mg
249
Volume expander needed along with Paracentesis for large volume/refractory Ascites
Albumin infusion: 8g per L of ascitic fluid removed
| if tap >5L
250
SBP mechanism
bacterial translocation through intestines to peritoneal fluid; "spontaneous" infection of ascitic fluid
251
Diagnosis of SBP
PMN > 250 cells/mm3
| PMN = WBC x %neutrophils
252
Treatment of SBP
Choose one for empiric coverage (x 5 days):
1. Ceftriaxone 2g IV q 24 hours
2. Zosyn 3.375g IV q 6 hours
3. Ciprofloxacin
*If SCr >1, BUN >30, or bilirubin >4:
Albumin infusion: 1-1.5 g/kg to prevent HRS
253
Primary/Secondary Prophylaxis of SBP
# Choose one for life (if secondary):
1. Cipro 500-750mg PO daily
2. TMP/SMX 1 DS tab PO daily
3. Norfloxacin 400mg PO BID
254
Asterixis
Hand flapping tremor ("waving goodbye"); symptom of HE
255
Normal ammonia level
normal: less than 35 umol/L
-NOT diagnostic of HE if elevated
AMS + cirrhosis = HE
256
Treatment of HE
1. Lactulose 45 mL/hr until catharsis, then maintenance titrated to 3-4 soft BMs daily
2. Metronidazole 250mg q 6-12 hrs
3. Rifaximin 400mg TID x 5-10 days, then 550mg BID for prevention
4. Flumazenil (no long term benefit)
257
Treatment of HRS
(Discontinue diuretics)
1. albumin + octreotide + midodrine
2. liver transplant
albumin 1g/kg x 1 day, then 20-40g daily
octreotide 100mcg SQ TID
midodrine 5-7.5mg PO TID
258
Pain management in Cirrhosis
1. Acetaminophen
2. Tramadol
3. Fentanyl
4. Hydromorphone
* Avoid NSAIDs
