Celiac sprue
Remove gluten from diet (wheat, barley, rye; can still eat corn, rice)
Corticosteroids for refractory disease
Tropical sprue
Folic acid replacement
Tetracycline or sulfa drugs 3-6 months
Gluten removal from diet has no effect
Lactose intolerance
Remove lactose from diet
Adequate diet Ca, protein, fat, vitamins
May use lactase replacement
Whipple disease
TMP-SMX or ceftriaxone for 12 months
Crohn’s
Azathioprine or Mercaptopurine
Anti-TNFa (infliximab, adalimumab)
Steroids and abx for acute exacerbation
Try to avoid surgical resection
UC
Total colectomy is curative
Sulfasalazine (large bowel), 5-ASA/mesalamine (SB)
Supplemental iron
Steroids (acute exacerbations)
IBS
Diarrhea predominant - TCAs/SSRIs, Lotronex (woman), Loperamide PRN
Constipation pred - Fiber building agents, hydration
Reassurance, possible psychosocial therapy
SBO
NPO, hydration
NG decompression
Surgery if refractory, complete obstruction, strangulation
Large bowel obstruction
NPO, hydration
Colonoscopy
Surgery if refractory
Ischemic colitis
IVF, bowel rest
Antibiotics for GI bacteria
Surgical resection of necrotic bowel
Appendicitis
Appendectomy if symptom onset w/i 24-72 hrs
If >5 days: Abx, IVF, bowel rest + interval appendectomy 8 weeks later
Abscess formation w/ appendicitis
Percutaneous drainage
Ileus
Treat underlying cause
NPO
Colonoscopic decompression if no resolution
Volvulus
Self-limited sometimes
Colonoscopic decompression of sigmoid
Surgical repair or resection if cecal volvulus, failed colonoscopic decompression
Diverticulosis
High-fiber diet
Diverticulitis, mild/early
Bowel rest (liquids only) x 3 days Abx (gram neg + anaerobics): fluoro (cipro) + metronidazole OR TMP-SMX + metro OR amoxicillin-clavulanate
Diverticulitis, surgical indications
Any sign of perforation
(including free air under diaphragm on x-ray)
Severe cases
Peritonitis
Hemorrhoids
Warm (sitz) baths
Increase fiber, avoid prolonged straining
Sclerotherapy, ligation, excision if worsening
Anal fissures
Stool softeners + hydration (first line) Topical nitroglycerine (first line) Topical diltiazem, nifedipine, bethanechol (2nd line) Botox injection (2nd/3rd line) Partial sphincterotomy (recurrent)
Anorectal abscesses
Antibiotics
Surgical I&D
Rectal fistula (fistula in ano)
Fistulotomy
Pilonidal disease
Surgical I&D w/ packing
Surgical closure of sinus tracts may prevent recurrence
Carcinoid tumor
Octreotide, IFN-alpha (if refractory) for symptoms
Cyproheptadine, codine, cholestyramine (diarrhea)
Albuterol, theophylline (bronchospasm)
Surgical resection
Vavulvar surgery if needed
Upper GI bleed, stable
PPI IV (in case PUD) Octreotide/somatostatin (splanchnic VC)
FAP
Prophylactic subtotal colectomy <25 yo
Pancreatic pseudocyst
Possibly self-resolving
Treat (drain) if lasting >6 wks, painful, rapidly growing
Exocrine pancreatic cancer
Whipple procedure for non-metastatic cancer limited to head of pancreas
Lesions in body or tail rarely resectable if found early
Adjuvent chemo for resectable cancer
Enzyme replacement therapy
Stenting of ducts, duodenum = palliative
Insulinoma
Octreotide or diazoxide
Surgical resection if you can
Glucagonoma
Octreotide, IFN-a, chemo
Surgical resection if you can
Embolization in metastatic
VIPoma
IVF + electrolyte replacement
Octreotide, corticosteroids, chemo
Surgical resection if you can
Embolization in metastatic
Cholelithiasis
Cholecystectomy for symptomatic patients
Dietary modification, bile salts, shock wave lithotripsy
Cholecystitis
Cholecystectomy (frequently delayed 24-48 hrs for hydration, abx)
Cholangitis
Hydration, IV abx
ERCP/stent to drain bile ducts
Cholecystectomy (delayed)
Gallbladder cancer
Cholecystectomy + LN dissection + partial removal of adjacent hepatic tissue
Adjuvant radiation and chemo
PBC
Ursodeoxycholic acid slows damage, increases survival
Liver transplant may be needed
Treat symptoms as needed
PSC
Ursodeoxycholic acid, MTX, stseroids
Endoscopic stenting, surgical resection
Liver transplant
Gilbert disease
None
Crigler-Najjar syndrome Type I
Phototherapy, plasmapheresis
Liver transplantation
Crigler-Najjar syndrome Type II
Phenobarbital (induces hepatic synthesis of UDP-GT)
Liver transplant alcohol requirement
None for at least 6 months
Varices (hepatic failure)
Prevent w/ BB (propranolol, nadolol)
Rx w/ vasopressin or sclerotherapy
Hepatic encephalopathy
Lactulose
Maybe rifaximin
Budd-Chiari syndrome
Thrombolytics Diuretics AC Angioplasty Shunting
Cirrhosis
Stop alcohol, hepatotoxins
Treat symptoms
Liver transplant if progressive
Ascites
Salt restriction
Diuretics (furosemide + spironolactone together)
Spontaneous bacterial peritonitis
Cefotaxime (or ceftriaxone or other 3rd gen ceph) x 5 d
Albumin (maintains plasma volume, renal fxn)
Portal HTN
Treat symptoms inc dialysis for renal failure
Hepatic shunting (laparotomy/TIPS) (short-term)
Liver transplant usu required in progressive
Wilson disease
Trientine or penicillamine (chelation) Lifelong zinc (maintenance) Restrict dietary copper Supplementary vitamin B6 May need liver transplant
alpha-1-antitrypsin
May need liver or lung transplant
HCC
Surgical resection of small tumors + chemo
Transplant for limited disease
Radiofrequency ablation and chemoembolization if unresectable
Benign liver neoplasms (eg adenoma)
D/C OCP
Serial imaging and aFP (10% malignant transformation)
Resection if >5 cm, growing, etc.
TEF
Surgical repair
Pyloric stenosis
Pyloromyotomy
Necrotizing enterocolitis
TPN
IV broad-spectrum antibiotics
NG decompression
Surgical resection of affected bowel if necrosis
Hirschsprung disease
Colostomy and resection of affected area
Intussusception
Barium enema may reduce defect
Surgery if refractory
Meckel diverticulum
Surgical resection if symptomatic
Glaucoma
Acetazolamide
Mannitol (acute)
Altitude sickness
Acetazolamide
Metabolic alkalosis
Acetazolamide
CHF, diuretics
Loop diuretic + aldosterone antagonist
Thiazide if mild/early
Increased ICP, diuretic
Mannitol
Acute renal failure, diuretic
Mannitol
HTN, diuretic
Thiazide (first line)
Other K sparing (to replace K)
Pulmonary edema, diuretic
Loop
Hypercalcemia, diuretic
Loop
Hypercalciuria, diuretic
Thiazide
Nephrogenic DI
Thiazide
Acne, PCOS; diuretic
Spironolactone
Uric acid kidney stones
Alkalinize urine (K citrate / bicarb)
Dietary treatment kidney stones
Hydration
Normal dietary Ca
Reduce dietary Na, protein, oxalate
Kidney stones that pass (size)
< 4 cm all (8-12 days)
5-7 mm (60%)
8-9 mm (50%)
>10 mm (<25%)
Expectant management kidney stones
Strain urine, 3L fluid daily
Tamsulosin facilitates passage
Pain meds (NSAIDs, Vicodin)
CT repeat in 4 weeks
Hospitalization required for kidney stones
No PO intake b/c nausea Intractable pain Acutely elevated BUN, creatitine Anuria Fever, pyelonephritis, urosepsis
Surgical treatment for kidney stones
If unable to pass stone after 4-6 wks, obstruction, impairment of renal fxn, persistent infection
ESWL if stone in renal pelvis or upper ureter
Ureterorenoscopy w/ possible lithotripsy/stent for ureter stones
Percutaneous nephrostolithotomy for staghorn / >3 cm
Hydronephrosis
Drainage via nephrostomy tube
Treat underlying obstruction (maybe balloon dilation or stent)
ADPKD
Vasopressin antagonists + amiloride (prevent fluid collection in cysts)
Treat UTI and HTN
Drain large cysts for pain control
May need dialysis or transplant
Interstitial nephropathy (AIN)
Stop offending agent
Supportive care until renal recovery
Steroids may help in refractory cases
ARF
Prevent fluid overload Stop drugs causing ATN Dietary protein restriction Steroids Dialysis
CKD
Stop smoking Aggressive BP control (ACE/ARB, BB, loop diuretic, DHP CCP, clonidine, minoxidil) Aggressive DM control (<70 is better) Iron/Epo (Anemia Hgb goal 11-12) Vitamin D Phophate binders ASA 81 daily
RTA Type I
Oral HCO3, K
Diuretics
RTA Type II
Oral HCO3, K
Diuretics
RTA Type IV
Fludrocortisone
K restriction
SIADH
Fluid restriction
Loop diuretics or hypertonic saline if severe (correct Na slowly)
Demeclocycline (last resort)
Hypernatremia
Gradual hydration w/ normal saline (<12 meq/24 hrs)
Too fast = cerebral edema
Hyperkalemia
Calcium gluconate/Cl (treats cardiotoxicity)
NaHCO3 or insulin+glucose or albuterol (shift K)
Sodium polystyrene sulfonate (kayexalate) binds K and removes through GI tract
Furosemide/loop diuretic
Dialysis in severe cases
Hypokalemia
Replace K (oral or IV) (Too fast = arrhythmias)
Hypercalcemia
Hydration Treat underlying disorder Calcitonin and bisphosphonates Steroids decrease intestinal absorption Surgery for hyperPTH or neoplasm
Hypocalcemia
Replace Ca (oral or IV) if needed
Treat underlying disorder
Vitamin D supplementation if needed
UTI
Amoxicillin, TMP-SMX, fluoroquinolones x3-5 days
UTI, pregnant
Amoxicillin, Ampicillin, Cephalosporin
Nitrofurantoin x 7d
Urge incontinence
Anticholinergics (oxybutynin, tolterodine, solifenacin)
Imipramine
Bladder training
Stress incontinence
Conservative therapy (weight loss, Kegel exercises) Surgery (midurethral sling, etc)
Overflow incontinence
Decompress bladder w/ Foley initially
Treat underlying obstruction (surgery), detrusor underactivity (sacral nerve stimulation) as needed
May need intermittent self-catheterization
Bladder cancer
Transurethral cystoscopic resection (superficial)
Partial or total cystectomy (invasive)
Adjuvant intravesical chemo and radiation (try to prevent recurrence), regional radiation and systemic chemo for large/metastatic
Urethritis
One dose IM ceftriaxone +
Doxycycline or Azithromycin x 10 days
Treat sexual partners
Prostatitis
TMP-SMX or fluoro x 4-6 weeks
Treat STD if needed
BPH
Saw palmetto (alternative)
alpha-1-receptor blockers (tamsulosin, selective; terazosin, non-selective, less frequent)
5-alpha-reductase inhibitors (finasteride)
TURP, needle ablation for refractory
Prostate cancer
Radical prostatectomy
Radiation (external beam/brachytherapy)
F/U w/ PSA posttreatment
Antiandrogen esp high-grade/metastatic (luprolide / flutamide)
Older / low life expectancy may not be treated (or active surveillance if caught early)
Epididymitis
< 35: Ceftriaxone + Doxycycline/Azithromycin
> 35 or anal sex: Fluoro or TMP-SMX
Testicular torsion
Manual detorsion
Surgical detorsion + bilateral orchiopexy w/i 6 hrs
Testicular cancer
Eradicate Ball Cancer (etoposide, bleomycin, cisplatin)
Radical orchiectomy
+/- chemo and radiation (seminomas)
+/- retroperitoneal LN dissection, chemo (nonseminomas)
Impotence
Phosphodiesterase-5 inhibitors
Androgen replacement if hypogonadal
Wilm’s tumor
Surgical resection or nephrectomy + chemo
Possible radiation
Urethral displacement (epispadias/hypospadias)
Surgical correction (don’t circumcise before surgery)
Enuresis
Enuresis alarm (most effective long-term)
Behavioral/motivational therapy
Restrict fluids, nighttime chaperone/wakening
Imipramine (up to 6 weeks)
Desmopressin, indomethacin (short term)
Cryptorchidism (undescended testes)
Exogenous hCG (encourage spontaneous descent) Orchiopexy before age 5 (should be brought into scrotum by 6-12 months for +function)
Posterior urethral valves
Cystoscopic transurethral ablation of abnormal tissue
If sick, temporary Foley or urinary diversion (vesicostomy)
