GI Txs

Question 1

How do you Tx the following presentations of GERD?
1) Mild
2) Moderate
3) Severe

Answer 1

1) Mild: lifestyle modification
2) Moderate: H2 blockers – cimetidine, ranitidine, famotidine, etc.
3) Severe: PPI - (-prazole’s)

Question 2

How do you Tx Esophageal Neoplasms?

Answer 2

Surgery sometimes with radiation/chemo

Question 3

Mallory-Weiss Tear: Tx?

Answer 3

Usually heals in a few days.PPI or antiemetics may be useful.

Question 4

Esophageal Varices Tx?

Answer 4

-Up to 25% mortality risk with first bleed
-IV vasoconstriction (octreotide) with endoscopic ligation
-Fluid resuscitation
-Patients with cirrhosis should have beta blockers to prevent varices

Question 5

How do you Tx gastritis?

Answer 5

Address underlying cause and control gastric risk factors (NSAIDs, alcohol, etc.)

Question 6

Peptic Ulcer Disease Txs?

Answer 6

1) H. pylori – two common options (there are more…)
-Bismuth, tetracycline, metronidazole, and PPI (2 weeks)
-Clarithromycin, amoxicillin, and PPI (2 weeks)
>Confirm eradication with urea breath test or stool antigen test at least 4 weeks after therapy (and no PPIs for 2 weeks). If positive = EGD with biopsy.
2) Control irritants

Question 7

Zollinger-Ellison Syndrome: Tx?

Answer 7

Control symptoms with PPIwhile preparing for surgical resection of gastrinoma

Question 8

Gastric Adenocarcinoma Tx?

Answer 8

Tumor resectionand chemoor radiation

80% cure rate with early detection. 10% cure rate if there is lymphatic spread.

Question 9

Descr the use of the following for treating constipation:
1) Bulk laxatives
2) Osmotic laxatives

Answer 9

1) Psyllium (Metamucil), methylcellulose (Citrucel), wheat dextrin (Benefiber)
-Absorb water and increase fecal mass
2) Polyethylene glycol (MiraLAX) and others
-Draws water into colon, softening stool. Side effects of bloating, cramping, flatulence.
-Don’t use for opioid induced constipation.

Question 10

Descr the use of the following for treating constipation:
1) Stimulant laxatives
2) Emollient laxatives (“stool softeners”)

Answer 10

1) Bisacodyl (Dulcolax),senna (Ex-Lax)
-Not for long-term use
2) Docusate (Colace)
-Reduces straining by altering surface tension, allowing more water and fat to be mixed in the stool.

Question 11

Bowel Obstruction Tx?

Answer 11

1) Partial and without signs of ischemia = Bowel rest (NPO), nasogastric suctioning, IV fluids
2) Complete or signs of ischemia = Surgery

Question 12

Malabsorption Tx?

Answer 12

Trial can also aid in diagnosis:
-Lactose-free diet or lactase supplementation
-Gluten-free diet for celiac disease
-Pancreatic enzyme replacement for pancreatic insufficiency

Question 13

Celiac Disease Tx?

Answer 13

Gluten-free diet, supplementation for nutrient deficiencies
Steroids for severe refractory cases

Question 14

Crohn’s Disease Tx?

Answer 14

1) Anti-inflammatory / immune suppressing medications. Many options.
-5-aminosalicylic acid agent: mesalamine, sulfasalazine
-Corticosteroids for flare ups
-Immunosuppression: infliximab, azathioprine, methotrexate
2) Surgery is not curative
3) Smoking cessation is especially important

Question 15

Ulcerative Colitis: First, second, and third line Txs?

Answer 15

1st: 5-ASA (mesalamine, sulfasalazine) or steroids
2nd: immunosuppressants (azathioprine, infliximab, adalimumab)
3rd: surgical resection (curative)

Question 16

Irritable Bowel Syndrome Tx?

Answer 16

-High-fiber diet, exercise, and avoidance of triggers
-Supportive care as appropriate fort diarrhea/constipation
-Antispasmodics first-line for IBS pain (dicyclomine, hyoscyamine)
>Tricyclic antidepressants second-line

Question 17

Diverticular Disease Tx when:
1) Outpatient (no high fever, leukocytosis)
2) Inpatient
3) When to do surgery?

Answer 17

1) Oral antibiotics
2) IV antibiotics, IV fluids, IV analgesics, NPO
3) Peritonitis

Question 18

Ischemic Bowel Disease Tx?

Answer 18

AMI and CMI – surgical revascularization

Question 19

Toxic Megacolon Tx?

Answer 19

Initial supportive therapy (ICU: IVF, electrolytes, blood products, bowel rest, abx)
Various surgical options depending on underlying cause

Question 20

Colonic Polyps Tx based on risk?

Answer 20

1) Hyperplastic (lowest risk) = Single: q10y. Multiple: q5y.
2) Tubular polyps (increased risk) = q5y
3) Villous polyps (highest risk) = q3y

Question 21

Colorectal Cancer Tx?

Answer 21

Surgery + (chemo/radiation) depending on location and histology

Question 22

Anal Fissure Tx?

Answer 22

Bulking agents to reduce straining, sitz bath. Stool softeners.
Topical ointment: nitroglycerin, silver nitrate, or gentian violet to promote healing

Question 23

Hemorrhoids Tx based on grade?

Answer 23

-External and grade I or II = high fiber diet, increased fluids, laxatives
-III = add anesthetic/astringent suppository
-IV or refractory = 1st office-based procedures (band ligation, sclerotherapy, excision) 2nd: surgery

Question 24

Appendicitis Tx?

Answer 24

Surgery

Question 25

Acute Pancreatitis Tx?

Answer 25

1) NPO to stop pancreatic secretion 2) IV fluids 3) IV antibiotics; empiric options: Carbapenem antibiotic (-penem’s) OR (FQ, ceftazidime, cefepime) + metronidazole 4) Surgery for gallstones or necrotizing pancreatitis

Question 26

Chronic Pancreatitis Tx?

Answer 26

Some cases can resolve if alcohol is just decreased Low-fat diet Analgesia – NSAIDs + APAP (not opioids since this is chronic)

Question 27

Pancreatic Cancer Tx?

Answer 27

Surgical resection

Question 28

Cholecystitis Tx?

Answer 28

Cholecystectomy

Question 29

Cholangitis Tx?

Answer 29

1) Stabilize with antibiotics until ERCP: FQ, cephalosporin, ampicillin, or (gentamycin and metronidazole) 2) Eventual cholecystectomy

Question 30

Viral Hepatitis Tx?

Answer 30

Fluids. Alcohol and hepatotoxin cessation Acute – supportive treatment. Hep A should wash hands frequently and not share food.

Question 31

1) Hep B Tx? 2) Hep C Tx?

Answer 31

1) Tenofovir is typically preferred 2) Combination of oral therapies depending on specific type. >Should be vaccinated against hepatitis A and B.

Question 32

Cirrhosis Tx?

Answer 32

1) Should be screened q6m for hepatocellular carcinoma >Liver US and alpha-fetoprotein 2) Hepatitis vaccination 3) Ascites warrants diuretic and salt restriction Ultimately: liver transplant for refractory severe disease

Question 33

Hernia Tx?

Answer 33

Surgical