Term
| What are hemorrhoids and what causes them? |
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Definition
Increased pressure in veins causes them to bulge and expand
Pregnancy
Obesity
Sitting for long periods |
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Term
| What is the presentation of hemorrhoids? |
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Definition
- Internal - bleed painlessly
- External - anal itching, tender before scab forms |
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Term
| How are hemorrhoids graded? |
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Definition
**Diagnosed by physical exam & anoscopy
Internal hemorrhoid grading:
- 1st degree - bleeding w/ defecation
- 2nd - prolapse w/ defecation that returns spontaneously
- 3rd - prolapse at any time
- 4th - permanantly prolapsed. |
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Term
| How are hemorrhoids treated? |
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Definition
Tx of painful symptoms, try to avoid surgery
- External - anal hygiene and gentleness. Will self resolve
- Internal - surgery only for 4th degree |
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Term
| What are non-pharmacologic options for hemorrhoids? |
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Definition
- Lifestyle - anal health, reduce straining
- Increase fiber and fluids
- For external hemorrhoids: warm baths, sitz bath for hips and butt
- Witch hazel - prep H or Tucks sooths and shrinks tissue.
- Internal: Degree 1-3 use rubber band ligation to cut off blood supply or infrared coagulation (reduced bleeding risk) |
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Term
| What are pharmacologic options for hemorrhoids? |
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Definition
- Local anesthetics - blocks nerve impulses for temporary relief 3-6x daily: the 'caines', pramoxine
- Protectants - emollients form a barrier. AlOH, cocoa butter, glycerin, oils, kaolin/lanolin
- Hydrocortisone - Inhibits prostaglandins
- Flavonoids: inhibit prostaglandins. Diosmin, hidrosmin, hesperidin, rutosides. |
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Term
| What is the difference between nausea and vomiting? |
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Definition
- Nausea - inclination to vomit
- Vomiting - Ejecting of gastric contents, always proceeded by nausea |
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Term
| What are the 5 stages for CINV? |
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Definition
1) Acute - within 24 hours of chemo regimen
2) Delayed - after 24 hours, can last 4-5 days
3) Anticipatory - Before chemo
4) Breathrough - patient does not respond to anti-emetic therapy
5) Refractory - Still nauseous after multiple medications |
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Term
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Definition
Stress, over-eating, travel, hangover
Pregnancy - first 9 weeks
Chemo-induced
Post-op - 25%. Nitric oxide is bad about nausea, propofol is good. |
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Term
| What is the difference between simple and complex symptoms of N/V? |
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Definition
- Simple - will auto resolve
- Complex - will not go away in a few hours, can lead to electrolyte disturbances |
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Term
| What are non-pharmacologic Txs for N/V? |
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Definition
- Diet - light meals, emetrol, ginger and pyridoxine especially in pregnancy, hydration
- Physical - be stable
- Psychiatric - desensitization, distraction |
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Term
| How do antacids work for N/V? |
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Definition
- Neutralize gastric acid for simple N/V
Take episodically when eating too much.
** Mg: diarrhea, Al: constipation |
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Term
| What antihistaminic txs are there for N/V? |
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Definition
H1 antagonists - for motion sickness and PONV
- Cyclizine/Marezine - 50 mg po before departure, repeat q 4-6 h
- Dimenhydrinate/Dramamine - 50-100 mg before departure, repeat q4-6 h
- Diphenhydramine/Benadryl - 25-50 mg PO/IM/IV
- Hydroxyzine/Atarax - off label 25-100 IM q4-6h
- Meclizine/Bonine or antivert
- Scop patch* drug of choice
- Trimethobenzamide/Tigan - 300 mg tid to QID
**anticholinergic side effects |
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Term
| What BZDs are used for N/V? |
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Definition
Bind to BZD receptors to enhance GABA - anticipatory CINV
- Alprazolam/Xanax - 0.5-2 TID on morning of procedure
- Lorazepam/Ativan - 2.5 on night before and morning of |
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Term
| How do butyrophenones work for N/V? |
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Definition
DA2 antagonists for CINV and PONV
- Droperidol/Inapsine - reserved for those who fail alternatives due to QT prolongation
- Haloperidol - long half life, AE: Dementia-related psychosis |
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Term
| How do cannabinoids work for N/V? |
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Definition
Activates cannabinoid receptors for refractory CINV - last line
- Dronabinol/Marinol
- Nabilone/Cesamet - CII |
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Term
| How do H2 antagonists help N/V? |
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Definition
Decrease gastric acid production - used for motion sickness
- Cimetidine/Tagamet
- Famotidine/Pepcid
- Nizatidine/Axid
- Ranitidine/Zantac |
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Term
| How do serotonin receptor antagonists work to treat N/V? |
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Definition
Blocks presynaptic 5-HT3 receptors in the gut wall. STANDARD OF CARE for CINV and PONV
- Dolasetron/Anzemet
- Granisetron - available as a patch
- Ondansetron/Zofran *Drug of choice
- Palonosetron/Aloxi *Drug of choice for DELAYED CINV |
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Term
| What misc agents can be used to treat N/V? |
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Definition
- Dexamethasone - HIGH doses. decrease Pg formation. For delayed CINV and PONV
- Metoclopramide/Reglan - blocks DA2 receptors, for delayed CINV. Black box: tardive dyskinesia. AE: hyperprolactinemia
- Olanzapine/Zyprexa - low dose, blocks DA2 and serotonin. Used for acute and delayed CINV |
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Term
| How are phenothiazines used to treat N/V? |
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Definition
Antagonize D2 receptors with some H1 and M1 effects.
- Chlorpromazine/Thorazine
- Prochlorperazine/Compazine *Drug of choice
- Promethazine/Phenergan - IV irritates blood vessels |
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Term
| How do NK1 antagonists treat N/V? |
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Definition
Inhibits Sub P - for acute and delayed CINV and PONV. Hiccups!
- Aprepitant/Emend or Fosaprepitant |
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