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81 Cards in this Set
- Front
- Back
Difference between inflammatory and non-inflammatory diarrhea
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1) Inflammatory: mucoid/bloody stools with fecal leukocytes, tenesmus, severe abdominal pain and/or fever
2) Non-inflammatory: watery stools, frequently large volume without and blood/pus. Fever or pain may/not be present |
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Most common cause of acute diarrhea
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Infectious diarrhea
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Subdivisions of infectious diarrhea
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1) Invasive
2) non-invasive |
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Shigella, Salmonella, EIEC and C difficile cause what type of diarrhea?
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invasive
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Viruses, cryptosporidia, giardia, and ETEC cause what type of diarrhea?
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non-invasive
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Ingestion of seafood suggests _____ infection
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vibrio
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Most common cause of traveler's diarrhea
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ETEC
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Responsible for blood diarrhea and hemolytic uremic syndrome
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EHEC
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Giardiasis is treated with __________
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metronidazole
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What is secretory diarrhea?
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Caused by excess secretion of electrolytes and water that typically continues on fasting and causes include enterotoxins (V. cholerae, E Coli, Staph Aureus, B. cereus, Norwalk); Secretory tumors; other factors
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Occurs due to gluten-induced immune mediated process in genetically susceptible hosts
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celiac disease
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Symptoms of celiac disease
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1) Diarrhea, steatorrhea, flatulence, weight loss
2) Diarrhea often episodic, up to 10/day 3) Extra intestinal features - iron deficiency anemia, osteopenia, bleeding tendency, vitamin defi, etc |
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What is tropical sprue?
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Mucosal malabsorption occurring in tropical residence or in soliders deputed in tropical areas. Associated with progrsesive diarrhea, malnutrition, and improvement when tropical residence d/c'd.
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What causes tropical sprue?
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unclear what exactly causes it, but since it's cured with antibiotics, probably a bacteria or parasite.
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In what patients does small bowel intestinal overgrowth occur?
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Patients with multiple ab. surgeries, prolonged narcotic use, or small bowel dysmotility.
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small bowel intestinal overgrowth causes what symptoms?
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diarrhea
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What is short bowel syndrome?
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Condition characterized by diarrhea and malabsorption when >50% of small bowel is either resected or non-functional.
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4 causes of short bowel syndrome
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1) Intestinal gangrene (SMA or SMV thrombosis or CHF)
2) Crohn's disease 3) Strangulated hernia 4) Prolonged intestinal obstruction |
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Treatment of short bowel syndrome
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1) Maintain fluid and electrolyes
2) Total parenteral nutrition, anti-diarrhea meds, IM B12 3) Stimulate intestinal adaptation by low fat diet, medium chain triglycerides, low lactose, vitamins 4) Small intestine transplant if unable to wean off TPN in 1-2 years |
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4 layers of small intestine
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mucosa (or mucous membrane), submucosa, muscularis (or muscularis propria), and adventitia (or serosa)
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To achieve the desired function of digestion & absorption, the mucosa is thrown into folds called _____ that increase the SA by 3 times.
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Plicae
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______ are specialized epithelial cells overlying lymphoid follicles in the small intestine and selectively bind, process, and deliver pathogens directly to lymphocytes, macrophages, or other components of the mucosal lymphoid system.
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M cells
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___________ are the pacemaker cells of the intestine, they regulate intestinal motility.
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Interstitial cells of Cajal
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____ cells contain zinc, antimicrobial peptides, and growth factors and secrete lysoenzymes
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Paneth
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While Fe & Ca are primarily absorbed in duodenum, B12 is primarily absorbed in the ___.
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terminal ileum
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How is B12 absorbed?
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Must bind Intrinsic factor in
The sub-sequent binding and uptake of the IF-B12 complex occurs through a specific receptor-mediated process on the brush border membrane of ileal enterocytes. |
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What produces intrinsic factor?
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parietal cells
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Cause of osmotic diarrhea
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Increased luminal osmolarity leads to water influx into the lumen. Caused by ingestion of poorly absorbable solutes.
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Pseudomembranous Colitis caused by _______-
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C difficile
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Characteristics of malabsorptive diarrhea
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Steatorrhea
Weight loss Nutrient deficiency |
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abetalipoproteinemia: defn
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Bassen-Kornzweig syndrome is a rare disease passed down through families in which a person is unable to fully absorb dietary fats through the intestines.
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intestinal lymphangiectasia: defn
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This disease is characterized by lymphatic vessel dilation,[3] chronic diarrhea and loss of proteins such as serum albumin and globulin. It is considered to be a chronic form of protein-losing enteropathy.
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refers to patients who have normal villus architecture on a gluten-containing diet, but who, at another time, have had or will have villus atrophy that recovered or will recover on a gluten-free diet.
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latent celiac sprue
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What is Whipple's disease?
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rare, systemic infectious disease caused by the bacterium Tropheryma whipplei.
Primarily causes malabsorption but can affect many systems. |
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Cardinal sx of Whipple's disease
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Arthralgias
Weight loss Diarrhea Abdominal pain |
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Late findings/complications of Whipple disease
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Ascites
Massive adenopathy Dementia Pericarditis Endocarditis |
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What is chronic intestinal angina?
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Chronic abdominal pain after eating. Due to atherosclerosis of the SMA.
Can range from mild discomfort to severe ischemic pain. |
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Acute Mesenteric Ischemia (AMI): What is it?
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Acute ischemia insult to small bowel which threatens viability.
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Acute Mesenteric Ischemia (AMI): Causes
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SMA Embolus: 50%
Non-occlusive mesenteric ischemia (NOMI): 25% SMA Thrombosis : 10% Mesenteric Venous Thrombosis : 10% Focal segmental ischemia: 5% |
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Major causes of Acute Mesenteric Ischemia (AMI)
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SMA Embolus
Non-occlusive mesenteric ischemia (NOMI) |
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Risk factors for Acute Mesenteric Ischemia (AMI)
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Patients older than 50 years
Long-standing CHF Cardiac arrhythmias Recent myocardial infarction Hypotension Recent cardiopulmonary resuscitation |
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Acute Mesenteric Ischemia (AMI): Symptoms
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ABDOMINAL PAIN
N/V Diarrhea Constipation Tachycardia |
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Non Occlusive Mesenteric Ischemia (NOMI): Defn
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acute mesenteric circulatory disorder that, in contrast to mesenteric arterial occlusion induced by blockage of blood flow by emboli and thrombi, is not caused by organic occlusion of blood vessels.
This pathology results from reduced intestinal microvascular blood supply associated with an acute inflammatory process, culminating with bowel necrosis. |
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Suspect Non Occlusive Mesenteric Ischemia (NOMI) when?
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Unexplained abdominal distention or GI bleeding
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first sign of intestinal infarction
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distension
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Bacterial concentration in intestine is regulated by
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Normal motor function (MMC)
Gastric acid Immunoglobulins, and possibly bile salts |
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What types of things can cause/predispose to bacterial overgrowth in intestine?
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Anatomical factors: Blind pouches, diverticula
Motility disorders: reduced motility means more time for bacterial to grow. |
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Symptoms of bacterial overgrowth
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Diarrhea or diarrhea & constipation alternating
Weight loss, bloating & flatulence (Steatorrhea, and pain less frequent) |
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What type of anemia can be present in bacterial overgrowth of intestine?
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Macrocytic. This is because the bacteria are competing for B12 and folate.
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How to diagnose bacterial overgrowth?
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Bacterial counts > 10(5) organisms/mL in jejunal aspirate
Hydrogen breath test Schilling test Empiric treatment with oral non-absorbable antibiotics |
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Tx for bacterial overgrowth
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Periodic flushing with Polyethylene glycol
Flagyl / ciprofloxacin / rifaximin Surgical correction |
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What are the two main diseases that are considered Inflammatory Bowel Diseases (IBD?)
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Crohn's disease
Ulcerative colitis |
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What areas of the intestine do
a) Crohn's disease b) Ulcerative colitis affect? |
A) Mouth to anus
B) Generally the colon |
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What layer of the intestine is inflamed in
a) Crohn's disease b) Ulcerative colitis |
A) Transmural inflammation (fistulas and strictures are common)
B) Mucosal inflammation |
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Which of these is there an increased risk of cancer?
a) Crohn's disease b) Ulcerative colitis |
Both
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How are the following affected by smoknig?
a) Crohn's disease b) Ulcerative colitis |
A) Higher risk for smokers
B) lower risk for smokers |
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How are the following managed surgically?
a) Crohn's disease b) Ulcerative colitis |
a) Returns post sx
b) Surgery is curative |
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Symptoms of IBD
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There are remissions and flares.
During flares, there is diarrhea, bleeding, abdominal pain. Anemia and malnutrition are common. |
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Cause of IBD
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Interaction between genes, environment, and the immune response.
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How is IBD different from IBS?
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xcept for certain non-specific symptoms of abdominal discomfort and bowel disturbance, virtually all of the important clinical and laboratory signs of IBD (anemia, malnutrition, bloody stools, tenesmus, fecal WBC, perianal disease, weight loss, fever) are absent in cases of IBS.
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The typical pattern of _________ is chronic inflammation limited to the mucosa of the colon, occurring in a continuous symmetrical distribution from the rectum proximally to all or part of the rest of the large bowel.
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ulcerative colitis
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Crohn's disease most commonly affects which areas?
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Ileocolic (45%)
Small bowel alone (33%) Colon alone (20%) |
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T/F There is NEVER an absence of bleeding in ulcerative colitis
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T. There may be an absence of bleeding in Crohn's disease.
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T/F Fistulization into surrounding tissues and organs occurs only in Crohn’s disease as opposed to ulcerative colitis.
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T
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What are ways to diagnose IBD?
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Colonscopy
Small bowel x rays CT Enterography MR Enterography Goal is to limit radiation |
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What are goals in IBD treatment?
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Accurate and timely diagnosis.
Rapid treatment of exacerbations (avoid therapy-related toxicity) Induction and maintenance of symptoms repression Improve QoL |
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Drug treatment for mild IBD
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Antibiotics, Aminosalicylates
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Drug treatment for moderate IBD
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Prednisone, corticosteroids, budesonide
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drug treatment for severe IBD
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Biologics, surgery
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Crohn's Disease Activity Index: What is it?
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research tool used to quantify the symptoms of patients with Crohn's disease. This is of importance in research studies done on medications used to treat Crohn's disease; most major studies on newer medications use the CDAI in order to define response or remission of disease.
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What are common extra-intestinal and systemic manifestations of Crohn's disease?
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arthritis, iritis, erythema nodosum, fistulae, fever
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How does sulfasalazine work?
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antinflammatory drug that is essentially providing topical relief inside the intestine. It does this via a number of mechanisms such as reducing the synthesis of inflammatory mediators known as eicosanoids and inflammatory cytokines. However, unlike glucocorticoids (another class of drug used in the treatment in inflammatory bowel disease), sulfasalazine has no immunosuppressant action.
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What causes the toxicity of sulfasalazine?
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It is converted to sulfapyridine (toxic) and 5-aminosalicylate (the therapeutic agent).
Newer drugs have sought to deliver 5-aminosalicylate directly to bowel |
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budesonide: MOA
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a rapidly metabolized glucocorticoid steroid
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Biologic therapy includes recombinant peptides or proteins. What is the goal of this treatment in IBD?
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Neutralize pro-inflammatory cytokines
Augment anti-inflammatory cytokines |
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What is infliximab?
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monoclonal antibody against tumour necrosis factor alpha (TNFα). It is used to treat autoimmune diseases.
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Absolute indications for bowel surgery in Crohn's
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Free perforation
Massive hemorrhage Cancer or dysplasia Chronic high grade obstruction |
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Relative indications for bowel surgery in Crohn's
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Intractability
Complex fistulae and abscesses Perianal complciations Growth retardation |
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In Crohn's, patients using what medications had a higher risk of serious infections and mortality?
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Steroids, narcotics (NOT infliximab, 6 mercaptopurine, AZA, MTX)
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T/F Methotrexate and ciprofloxacin should not be used during pregnancy and metronidazole should be avoided in the first trimester.
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T
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What is alendronate?
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used to treat and prevent osteoporosis in IBD
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