GI Summy 2

food-drug interactions

• warfarin can interact with proteins/high k value in formula

  • monitor inr and consider dose adjustment

• phenytoin absorption reduces greatly

  • hold feeds +- 2 hours

• fluoroquinolones can bind to divalent cations in formula

  • hold feeds +- 2 hours

• fluoroquinolones get absorbed in duodenum

  • admin iv, dont give through tube in pts that terminate in jejunum

macro and micronutrients composition of total enteral nutrition

• macronutrients

  • dextrose 3.4 kcal/g

  • amino acids 4 kcal/g

  • lipids

    • emulsion 10 kcal/g

    • dietary 9 kcal/g

• micronutrients

  • electrolytes

  • vitamins

  • trace minerals

diagnostic for gerd

if there are any alarm sx or age >60, go straight to endoscopy

• we are concerned about more malignant underlying causes

if no alarm sx or age <60, can start with an h.pylori test

• → treatment! be my tummy protector, or ppi trial if no improvement

• → ppi trial

typical gerd sx

heartburn, dysphagia

try qd ppi trial for 8 weeks

extra-esophageal sx

hoarseness, chronic cough, asthma

try bid ppi trial for 12 weeks

atypical sx

chest pain, dyspepsia, nausea, bloating, belching

just scope em

mild, infrequent gerd tx

antacids, h2ras

mild-moderate gerd tx

otc ppi for two weeks

severe gerd or erosive esophagitis

rx ppi for 8 weeks

nsaid induced pud

treat duo ulcers for 4 weeks, gastric for 8

• can do with ppi, h2ra, or sucralfate

h pylori testing

invasive aka endoscopic tests

• can get biopsy sample to do histology, culture, etc

non invasive aka non endoscopic

• ab testing → does not tell you if the infection is active or in the past

• urea breath test

• fecal antigen test

dyspepsia alarm symptoms

• dysphagia

• odynophagia

• upper gi bleed → blood in vomit or stool

• unexplained weight loss

when to refer to pcp for gerd

after two weeks

otc ppis

omeprazole, esomeprazole, lansoprazole

rx ppis

pantoprazole, rabeprazole, dexlansoprazole

portal triad

• proper hepatic artery

• hepatic portal vein

  • splenic vein

  • sup mes

  • inf mes

• common bile duct

sketch path of biliary tree

• cystic duct brings bile from gallbladder

• the l/r hepatic ducts drain bile from the liver

  • form the common hepatic duct

• common hepatic duct and cystic duct join to form common bile duct

• when the main pancreatic duct joins it, forms hepatopancreatic ampulla

  • contains pancreatic juices and bile

• terminates into major duodenal papilla

gallstone in cystic duct

still able to secrete bile

no jaundice

gallstone in common bile duct

block all sources of bile and most likely cause jaundice

gallstone in hepatopancreatic ampulla

pancreatitis plus blockage of bile and jaundice

phases of acid secretion

basal

cephalic

gastric

• food in stomach is sensed by mechanoreceptors → activate vagus

• protein broken down into aa’s by pepsin are sensed by gastrin cells that sample lumen

  • releases gastrin

intestine

pancreatic exocrine secretions

• carbs broken down by alpha-amylase

• fats broken down by lipases

• proteins broken down by proteases, like pepsin

• nucleic acids broken down by nucleases

macronutrient maldigestion

• can lead to fatty diarrhea

  • get those orange rings due to water insoluble vitamins like vitamin a

• pancreatic exocrine insufficiency → not enough enzymes for digestion of smth

• bile salt deficiency

• inactivation of pancreatic lipases

• inherited enzyme deficiency

macronutrient malabsorption

• small bowel mucosal disease

• structural abnormality → eg damage to villi preventing absorption

• rapid transit → moves through the gi tract too fast to get reabsorbed

general liver function

• synthetic function

• clearance and protection

• storage of vitamins and iron

• exocrine function

• metabolic function

hepatocellular injury abs

lfts → enzymes leaking from cells

cholestatic liver injury

interruption of normal bile secretion or drainage

• can be a mechanical obstruction like a gallstone or tumor

• look for increase alkaline phosphatase, bilirubin (gets excreted into bile)

synthetic capacity labs

• PT/INR, probs best markers of liver function

• albumin

acute liver injury

• coagulopathy → increased risk of bleed, bruising, increased INR and PT

  • production of vit k dependent coag factors decreases

• encephalopathy

  • cant process blood and remove toxins like ammonia

• no pre-exiting liver dx

portal htn

• loss of sinusoidal caps due to fibrosis

  • they try to defend themselves via endothelina but that increases R and engorges the vessels

• pressure gradient greatly increases and prevents blood flow through liver

hepato-renal syndrome

• kidney injury secondary to liver disease

• drop in ecv due to vasodilation causese drop in blood flow to other organs such as kidneys to protect liver and brain

  • renal artery vasocontriction

spontaneous bacterial peritonitis

• infection in peritoneal space in pts with ascites

• watch for wbc count

hrs-aki

• an aki in the context of advanced liver dx

  • increase in scr >0.3 mg/dl over 48 hr or increase more than 50% over 1 week

• gotta meet a shit ton of criteria, like a diagnosis of exclusion

  • cirrhosis with ascites

  • aki diagnosis

  • no improvement in scr with volume challenge, gotta make sure the pts not hypovolemic

  • lack of shock

  • no nephrotoxin

  • no structural kidney dx

glp-1 agonists

slows gastric emptying and decreases food intake to increase satiety

Semaglutide

12.4% tbwl reater than placebo at one year

Liraglutide

5.6% tbwl greater than placebo at one year

Tirzepatide

17.8% tbwl reater than placebo at 72 weeks

Sympathomimetics

stimulate anorexic signaling and suppress appetite

Phentermine

• short term use 3 months only

• 4.4% tbwl greater than placebo

Phentermine/Topiramate

• topiramate suppresses appetite and enhances satiety

• 8.6-9.4% tbwl greater than placebo at one year

Buproprion/Naltrexone

• dopa/ne reuptake inhibitor and opioid antagonist

• regulates appetite and reward system

• 4.22-5.2% tbwl greater than placebo at one year

Orlistat

• reduces absorption of dietary fat by inhibiting lipases

• take before fat containing meals

• 4% tbwl greater than placebo at one year

post-bariatric surgery

• monitor more often

• try liquid over solid

• crushable ir crushes er

• consider non-po routes if possible

vitamin a

• teratogenic at high doses

• decreases bone mineral density

vitamin e

increased mortality from hemorrhagic stroke