Pharm - biliary tract disease and anorectal disorders

Question 1

What is included in biliary tract disease

Answer 1

gallbladder
bile ducts

Question 2

What is the presentation of acute cholecystitis

Answer 2

1. RUQ pain
2. steady pain that increases in intensity
3. High fat meal is a trigger
4. low grade fever

Question 3

labs assoc with acute cholecystitis

Answer 3

increased bilirubin levels (blood and urine)
US - gallstones in 95% of patients
ERCP - identifies cause/location and extent

Question 4

What is choledocholithiasis

Answer 4

gallstone obstructing the common bile duct

Question 5

What is the treatment for asymptomatic choledocholithiasis?

Answer 5

none

Question 6

What is the symptomatic management of choledocholithiasis?

Answer 6

pain management
-NSAIDs

oral bile acids - dissolution of gallstones

Surgery

Question 7

What nutrition/lifestyle to treat choledocholithiasis

Answer 7

Lower triglycerides

Question 8

What NSAIDs should be used for pain management

Answer 8

Ketorolac (toradol) - injectable NSAID
could also use parenteral morphine or hydromorphone

Question 9

MOA of ketorolac

Answer 9

Inhibits cox 1 and 2 enzymes
-analgesic
-anti-inflammatory
-anti-pyretic

Question 10

Ketorolac info

Answer 10

1. typically IM or IV
2. Do not exceed 5 days of therapy
   -GI bleed
3. Renally dosed

Question 11

Ketorolac BBW

Answer 11

GI risk
CV risk
Renal risk
Bleeding risk
Avoid use with other NSAIDs

Question 12

When to use NSAIDs to treat biliary pain

Answer 12

for patients with contraindications to use of NSAIDs
-more often used with patients with acute cholecystitis

Question 13

What to remember about opioids

Answer 13

Produces generalized CNS depression
Morphine now better than meperidine

Question 14

Opioid warnings/precautions

Answer 14

CNS depression
Constipation

Question 15

Opioid BBW

Answer 15

Addiction/abuse/misuse
Respiratory depression

Question 16

What is a bile acid treatment option

Answer 16

Ursodiol (Actigall)

Question 17

Ursodiol MOA

Answer 17

Decreases cholesterol content of bile associated with gallstones

Question 18

When is ursodiol used for gallstone prevention

Answer 18

used in obese patients during rapid weight loss

Question 19

What monitoring is required with Ursodiol?

Answer 19

1. LFTs monthly x 3 months
2. Abd US every 6-12 months
3. continue therapy for at least 6 months after dissolution of gallstone is noted on US

Question 20

Pt ed with Ursodiol

Answer 20

Take with food

Question 21

Clinical presentation of anal fistula

Answer 21

painful swelling at the anus
pain with defecation

Question 22

Treatment of anal fistula

Answer 22

surgery

Question 23

Clinical presentation of anal fissure

Answer 23

severe, tearing pain with defecation

Question 24

Treatment of anal fissure

Answer 24

avoid straining
increase fluids
fiber to prevent hard BMs
-prunes
-peas
-supplement (Psyllium - metamucil)

Question 25

What is a sitz bath

Answer 25

treat anal fissure -warm bath relaxes anal sphincter and improves blood flow to anal mucosa

Question 26

What is a pharm option to treat anal fissure

Answer 26

topical vasodilatory -nifedipine (reduce pressure) -NTG (increase blood flow); concern of D/D interaction with Phosphodiesterase 5 inhibitors (sildenafil)

Question 27

What is second line anal fissure therapy

Answer 27

botulinum toxin A

Question 28

Protectants for hemorrhoid treatment

Answer 28

internal or external: cocoa butter mineral oil petrolatum ONLY EXTERNAL - glycerin

Question 29

What protectants are only to be used in combination products

Answer 29

internal or external: -calamine -shark liver oil -zinc oxide Applied after each BM Petrolatum may be applied liberally

Question 30

What local anesthetics appropriate for internal hemorrhoids?

Answer 30

no

Question 31

Which local anesthetics can be used up to 6 times daily

Answer 31

benzocaine benzyl alcohol lidocaine tetracaine

Question 32

Which local anesthetics can be used up to 5 times a day

Answer 32

Pramoxine

Question 33

Which local anesthetic can be used up to 3-4 times per day

Answer 33

Dibucaine

Question 34

What is a nonprescription hemorrhoid treatment

Answer 34

Astringents -local and limited protein coagulant effect -relieves irritation and burning Vasoconstrictors -reduce swelling Corticosteroids: -preparation H hydrocortisone 1% cream

Question 35

What are examples of astringents

Answer 35

calamine and zinc oxide (internal or external) witch hazel (external)

Question 36

What is a vasoconstrictor

Answer 36

phenylephrine - avoid in: -HTN -CVD