GI
Disclaimer: the clinical information on this site is only meant to serve as a reference. Please consult with your team for individual diagnostic and treatment decisions.
- First line: Zofran (ondansetron), Compazine (prochlorperazine), Phenergan (promethazine, IV no longer available at UPHS)–careful of QTc
- Second line: Reglan (metoclopramide), Tigan (trimethobenzamide), scopolamine patch
- Third line: Ativan (lorazepam), Decadron (dexamethasone), nasogastric tube
- Fast acting: Maalox (aluminum hydroxide-magnesium hydroxide, renal patients will accumulate aluminum and magnesium), Pepcid (famotidine on formulary)
- Slow acting: Prevacid (lansoprazole on formulary)
From: https://accessmedicine.mhmedical.com/content.aspx?sectionid=61696569&bookid=1088
- First line: Senna, Colace (docusate), Miralax (polyethylene glycol), Dulcolax PO (bisacodyl)
- Second line: lactulose, magnesium citrate
- Third line: bisacodyl suppository, tap water enema, mineral oil enema, Fleet enema, manual disimpaction, Golytely (polyethylene glycol x 4 liters)
- First line: Imodium (loperamide), Pepto-Bismol (bismuth subsalicylate)
- Second line: Lomotil (atropine-diphenoxylate, controlled substance)
- Third line: Creon/ZenPep (pancreatic enzymes), Sandostatin (octreotide)
- Suspect if elevated WBC and/or diarrhea once laxatives have stopped or if recent antibiotics
- If test shows C.diff gene positive but toxin negative, they may be colonized. If immunosuppressed and patient has continued diarrhea may choose to treat
- Treatment regimens can include oral vancomycin, fidoxamicin, and IV Flagyl, now less commonly oral Flagyl
- UPHS Antibiotic Stewardship Guidelines for Empiric Treatment/Sensitivities
Small Bowel Obstruction/Adynamic Ileus
- If suspected, consider CT A/P to look for a transition point of a small bowel obstruction that may require surgical intervention
- If small bowel obstruction, avoid laxatives from above, place nasogastric (NG) tube for decompression if symptomatic
- If adynamic ileus, reduce constipating medications and give laxatives
IBD: Crohn’s and Ulcerative Colitis
- Labs to consider: C.diff, stool culture, stool ova/parasites, fecal calprotectin, serum ESR/CRP
- If considering giving biologic agent now or later, check Quantiferon Gold or PPD to rule out TB and check hepatitis serologies
- If the patient has taken Remicade (infliximab), consider checking an infliximab level or infliximab antibody level
- If considering azathioprine, check TPMT enzyme levels
- Will often receive IV steroids until diarrhea/hematochezia improves then convert to oral regimen
- Diet: depending on if needs EGD/ileoscopy/colonoscopy/flexible sigmoidoscopy and symptoms may start with NPO or clear liquids
- Pain regimen: oral or IV Tylenol (acetaminophen), Celebrex (celecoxib)–avoid ibuprofen/naproxen/Toradol (ketorolac), dicyclomine (Bentyl). Use opiates as sparingly as possible
- Option 1: clear liquid diet morning before scope, 4pm start Golytely (polyethylene glycol) 4 liters, midnight stool check and if not clear then order 2 more liters of Golytely then NPO other than bowel prep starting at midnight
- Option 2 (for those sensitive to volume overload or who cannot drink full prep): clear liquid diet morning before scope, Moviprep with 20mg PO Dulcolax (bisacodyl) and 238 grams (14 packets of 17 grams each) of Miralax (polyethylene glycol) dissolved in 64 ounces of liquid
- No red or purple liquids
- If cannot tolerate full prep, may need Dobhoff or nasogastric tube
- Upper versus lower bleed: separated at ligament of Treitz in the mid-duodenum, iron in hemoglobin turns black when it touches gastric acid (oxidation) so darker stool is more likely to have been in the esophagus, stomach, duodenum, or jejunum
- Upper causes: NSAID or alcoholic gastritis, peptic ulcer, varices, AVM/Dieulafoy’s lesion, Mallory Weiss tear, tumor
- Lower causes: diverticulosis, AVM/angiodysplasia, tumor, hemorrhoids, anal fissure, post-polypectomy, colitis (inflammatory or infectious), mesenteric ischemia
- If severe, consider IR embolization or surgical resection in addition to GI scope
GI Bleed: Exsanguination Protocol
- Blood bank: 215-662-3448 / 215-662-3449 at HUP, 215-662-8336 at PPMC
- First round: 10 units RBCs, 6 units FFP, 1 unit platelet of uncrossed blood
- For massive transfusions consider calcium gluconate after the 4th RBC to counteract hypocalcemia due to citrate in packed RBCs and also giving RBC:FFP:platelets in a 4:2:1 ratio (4:1:1 in surgical data) due to dilutional coagulopathy/thrombocytopenia
- Sudden intracellular shifts of potassium, magnesium, and phosphate when glucose is introduced to a patient who has NPO or malnourished for a prolonged period and insulin is secreted and brings these three electrolytes into the cells leading to bloodstream depletion. Phosphate is needed for ATP creation to keep the heart beating so is most focused on. Potassium levels can also be severely low. If started TEN or TPN consider doing so at a slow rate at the beginning and watching for 2-3 days with BID electrolyte panels (with magnesium and phosphate) with aggressive repletions.
- Diagnostic criteria: 2 out of 3 of characteristic epigastric pain which may radiate to the back, lipase elevation, CT A/P with peripancreatic fat stranding
- Treatment: bowel rest with slow advancement (NPO or clears initially), fluids, pain control
- Potential complications: hemorrhagic pancreatitis, necrotizing pancreatitis, pancreatic pseudocyst, pancreatitis-related ARDS (acute respiratory distress syndrome)
- Pseudocyst management: conservative management, IR drainage, GI endoscopic cystogastrostomy (tube through stomach to pseudocyst to allow for drainage)
- Normal to have fevers, indication for antibiotics is necrotizing pancreatitis: prefer carbapenems for better penetration
Cholelithiasis/Choledocholithiasis/Cholecystitis/Cholangitis
- Cholelithiasis: presence of gallstones, may have biliary colic from intermittent blockage
- Choledocholithiasis: gallstone stuck in bile duct (may affect pancreatic duct)
- Cholecystitis: acute inflammation but not infection of gallbladder due to obstructing stone
- Cholangitis: cholecystitis with inflammation to the point of bacterial ascending infection. Charcot’s triad of cholangitis = fever, jaundice, abdominal pain. Reynold’s pentad of cholangitis: fever, jaundice, abdominal pain, hypotension, altered mental status.
- Based on severity may consider conservative management, antibiotics, cholecystectomy, percutaneous cholecystostomy, MRCP/ERCP/sphincterotomy
- ALT or AST rise: hypoperfusion (sepsis, shock, dehydration), congestion (right sided CHF), viral hepatitis, cholecystitis, cholangitis, or pancreatitis, toxin (alcohol, Tylenol, isoniazid, statin), non-alcoholic steatohepatitis, autoimmune hepatitis
- Alkaline phosphate or bilirubin rise: biliary obstruction, primary sclerosing cholangitis, gallbladder/pancreatic cancer, Paget’s disease or bone metastases (alkaline phosphate only), hemolysis or Gilbert’s disease while fasting (bilirubin only)
- Acute liver failure: transaminitis with INR > 1.5 (coagulopathy) and altered mental status (hepatic encephalopathy) without pre-existing cirrhosis (sudden onset)
- Causes: alcohol, viral hepatitis (hepatitis, HIV, EBV, CMV, VZV), NAFLD/NASH (non-alcoholic fatty liver disease, non-alcoholic steatohepatitis), right sided CHF, hemochromatosis, Wilson’s disease
- MELD score: 3 components BIC: bilirubin, INR, creatinine in a formula
- Hepatic encephalopathy: do an infectious workup, free ammonia levels NOT helpful as ammonia crosses through the blood-brain barrier and peripherally appear low, treat with lactulose titrated to 3-4 bowel movements or 500cc of liquid stool per day, can add rifaximin (prior authorization), and sometimes zinc sulfate. May need Dobhoff if patient too encephalopathic to swallow. Test asterixis by having the patient hold their arms out with hands out at a right angle and look for a flapping motion.
- Esophageal varices: careful with Dobhoff and NG tubes if recently banded, once found start on a nonselective beta blocker (nadolol, propranolol, carvedilol). If you have a variceal bleed, empirically start ceftriaxone x 5 days for spontaneous bacterial peritonitis (SBP) prophylaxis.
- Hepatocellular carcinoma (HCC) testing: RUQ ultrasound and AFP serum level every 6 months (mean tumor size doubling time is about 117 days)
- Ascites/anasarca: treat with salt/water restriction, use Lasix (furosemide) and spironolactone at a 4:10 ratio (ex: 40mg Lasix and 100mg spironolactone) to balance potassium, therapeutic paracentesis (give albumin if take out more than 5 liters)
- Spontaneous bacterial peritonitis (SBP): look for ascites PMNs (polymorphonuclear leukocytes which is WBC x % neutrophils/bands) > 250 cells/mm^3 or positive culture (malignant, hemorrhagic, and secondary bacterial peritonitis ascites may also be positive), treat with antibiotics and albumin, if not improving then do a day 3 repeat diagnostic paracentesis to monitor for rising WBC (suggests secondary bacterial peritonitis from bowel perforation). Once you have SBP you need lifelong prophylaxis (often cefpodoxime, ciprofloxacin, norfloxacin, Bactrim)