1 GI Flashcards
What is the cause of coeliac disease?
Adverse reaction to gluten
(= a protein found in
WHEAT, BARLEY & RYE)
What is coeliac disease ?
Autoimmune condition associated with chronic inflammation of the small intestine (unable to absorb nutrients)
Gluten (= protein in barley, wheat and rye)
Coeliac disease symptoms?
Abdominal pain
Diarrhoea
Bloating
Risk of malnutrition CA & vitamin D
Coeliac disease Tx
There is no treatment
Life long gluten-free diet
Mineral and supplements given only by specialist NEVER SELF MEDICATE!!!!
Prednisolone as initial treatment management while awaiting specialist advice
Assess for risk OSTEOPOROSIS
Ulcerative colitis, where does it start and where does it end?
Colon only
Crohns disease, start and end
From mouth to anus
Antacids ok to give in hypertension
Aka low NA+ preps
Maalox
Altacite plus
Mucogel
co-magaldrox
Proprantheline (tx ibs)
CI
Pregnancy Down syndrome Hypertension Heart failure Age under 12 and over 65
Drugs causing BEZOAR formation
Sucralfate suspension
aluminum hydroxide gel
enteric-coated aspirin
guar gum
cholestyramine
enteral feeding formulas
psyllium preparations
nifedipine XL
meprobamate
IBS
which 3 conditions
Short bowel syndrome
Constipation
Diarrhoea
IBD
which conditions
Crohn’s disease
Ulcerative colitis
When are
Methylnatrexone or naloxegol prescribed in constipation
Opioid induced constipation
last option
Specialist
When are
Co-danthramer (red urine)
And
Co-danthrusate
Prescribed in constipation and for who?
opioid constipation usually
In palliative care only as they are carcinogenic
Examples of
Bulk forming laxatives
When will they start working
Sterculia
Ispaghula husk (allergy-check)
Methylcellulose
24-72 hrs
Example of an
Osmotic laxative
How long till they start workingqq
Magnesium hydroxide
Lactose
Macrogol (laxido,cosmocol,movicol)
48-72 hrs
Examples of
Stimulating laxatives
How long till they start working
Bisacodyl Co-danthramer Senna (yellow urine) Glycerin suppository (also softener) Sodium picosuffate Docusate sodium
6-12 hrs
Examples of
Stool Softeners + SE
Liquid paraffin (not recommended)
Methyl cellulose
SE:
Malabsorption of fat soluble vits A,D,E,K
Anal seepage
Lipid pneumonia
—————
Other class laxatives can also be softeners:
Docusate, glycerin suppository
When is
Prucalopride - lubiprostone
Serotonin receptor agonist- Chlorine channel antagonist
Given in constipation
When 2 different class laxatives (Stimulating + osmotic) are given at highest recommended, tolerated dose for 6 months
Constipation tx
Opioid induced
Which laxative to avoid?
- Two different class laxatives (stimulant + Osmotic)
- In palliative pts: co-danthramer/ co-danthrusate
- Specialist: methyl naltrexone or naloxgel
Avoid bulk forming laxative in opioid constipation
Constipation in child tx
- Macrogel +diet + exercise
- Add stimulant
- Add lactose or stool softener
Constipation in pregnancy and breastfeeding Tx
- Bulk forming (if fibre supplement fail)
- Osmotic (lactose)
- Senna / bisacodyl (POM)
- Docusate sodium or glycerin suppository
Note: senna CI near term, unstable pregnancy
Pregnancy and senna
CI
near term
Unstable pregnancy
(POM)
Isphagula husk (bulk forming laxative)
Allergy causing
Give 3 examples
Rhinitis
Bronchospasm
Anaphylactic shock
CI
omeprazole
Most effective acid secretion PPI
Best taken in morning hour before breakfast
CI in
Esomeprazole / omeprazole ❌clopidogrel
Gastric cancer (can mask!)
Lactulose CI in:
MR-EC preparations (⬇️ stool ph)
IBS
Mesalazine
Sulfasalazine SE
headache Nausea Watery diarrhoea Indigestion Skin rash - itch Fever Metallic taste Yellow body fluids Discoloured contact lens( harmless)
Corticosteroids SE
Diabetes Hypertension Fluid retention Upset stomach Weight gain Immunosuppressant Osteoporosis
CI kidney + liver problems
Monoclonal antibody
(Adalinmumab, inflicimab)
SE
Allergy Flu symptoms Fever Chills N+V Fatigue Diarrhoea Muscle ache Hypotension (low BP)
loperamide CI
Under 12 Pregnancy Active UC!!!!! Severe pain Bloody diarrhoea Liver failure Water retention Conditions with low gut mobility Antibiotics related colitis (clindamycin) 16mg max daily!
Tamsulosin otc age:
45-75 yr
GTN ointment SE
Headache
Pancreatin inactivated by
Heat
Gastric acid
Iron SE
Loose stool
Dark stool
Sore skin
H.pylori fist time eradication duration
How effective %?
1 week
More than 90% effective
> 90%
Anti-muscarinics indicated in (treat)
CI?
Asthma/COPD
Motion sickness
Dysmenorrhea
Arrhythmias
CI in ulcerative colitis
Lactulose CI
IBS
MR /EC
Mesalazine
What’s CI in Crohn’s disease
Loperamide
Codeine
MAB infliximab is as effective as ….
in Crohn’s disease
If IV corticosteroids CI in pts
Ciclosporin
Monoclonal antibodies
To check for what infection before starting?
Tuberculosis TB
Take sexual contraception until 18weeks AFER treatment with MAB
Before taking
aminosalicylates:
Such as:
Balsalazide (Colazal, Giazo)
Mesalamine (Apriso, Asacol, Delzicol, Lialda, Pentasa)
Olsalazine (Dipentum)
Sulfasalazine (Azulfidine, Sulfazine
As for allergy to….?
Aspirin
What is external manifestation in IBS
Pain in joints, eyes , skin, osteoporosis and arthritis
antimuscarinic drugs
Examples
Antipsychotics (clozapine, quetiapine) Atropine. Benztropine. Biperiden. Chlorpheniramine. Certain SSRIs (Paroxetine)
But used as antispasmodic
Dicyclomine
propantheline
Hyocine
Antimuscarinics
MOA
SE
reduce colonic motility by inhibiting parasympathetic stimulation of the myenteric and submucosal neural plexuses. They also inhibit gastric emptying.
SE:
Dry mouth with difficulty swallowing and thirst.
dilation of the pupils with difficulty accommodating and sensitivity to light - i.e. blurred vision.
increased intraocular pressure.
hot and flushed skin.
dry skin
CANT: SEE,SPIT,PEE,POOP
What is ulcerative colitis
UC occurs when the lining of your large intestine (also called the colon), rectum, or both becomes inflamed.
Diverticulitis tx
Bowel rest Only if: Infection present Or Immunosuppressed
Antibiotics
IV- gram negative or aerobic
Diverticula disease tx
High fibre diet
Bulk forming laxatives—>methycellulose
Ulcerative colitis
(Proctitis/ proctigmoiditis)
(Inflam rectal/ rectal+colon)
CI
1. aminosalicylates
Balsalazine
Olsalazine
Mesalazine
Sulfalazine
ALTERNATIVELY: ORAL Prednisolone or rectal corticosteroids
- ADD
oral prednisone (after 4 weeks with aminosalicylate)
ADD
Tacrolimus if no response after 2-4 weeks
CI: loperamide and codeine
Ulcerative colitis
Extensive (high up in colon)
Left sided colitis (down the colon)
ORAL
- High dose aminosalicylates PLUS rectal
Or oral beclometase
Alternative: oral prednisone alone
- ADD
oral prednisone (after 4 weeks with aminosalicylate)
ADD
Tacrolimus if no response after 2-4 weeks
CI: loperamide and codeine
Ulcerative colitis tx
SEVERE
Oral prednisone
Alternatively: Monoclonal antibodies (MAB)
adalimumab Infliximab No improvement?
1. Stat hospital MEDICAL EMERGENCY IV Corticosteroids ( + assess need for surgery)
Alternatively: IV Ciclosporin OR surgery
If IV ciclosporin CI give: infliximab
- If no improvement within 72hrs of hospital admission
IV Ciclosporin PLUS IV corticosteroids OR Surgery
Ulcerative colitis
Maintaining remission Tx
Proctitis/ proctsigmoiditis
And
Extensive colitis / left sided colitis
Reals AS alone (more effective than with oral)
Low dose oral AS
Azathioprine / mercaptopurine
But : if 2+ flare ups in 12months required IV corticosteroids
After one severe flare up
Remission not maintained after oral AS
—-> continue MAB if effective/Tolerated in acute flare up
Crohn’s disease
1+ acute flare up in 12 months or first presentation:
- CORTICOSTEROIDS
Prednisolone
Methyl Prednisolone
IV hydrocortisone
Alternatively in patients with: right sided colonic disease: budesonide or AS
2+ acute flare ups in 12 months (maintaining remission of CD)
Azathioprine or mercaptopurine
Alternatively: methotrexate
Alternatively: MAB
After surgery:
Azathioprine OR mercaptopurine OR AS
Short bowel disease
MR/EC suitable?
Deficiency of what vits?
Not suitable
Vits: A, E, D, K; zinc, selenium, magnesium, essential fatty acids
Diarrhoea
What is it and red flags
Increased frequency or volume or both
Acute 14 days or less
Chronic 14+
Red flag: weight loss, rectal bleeds, travel, antibiotics, recent hospital visit
Diarrhoea
Causing bacteria
Food poisoning:
Salmonella
Campylobacter
E-coli
Loperamide SE
Qt prolonged Cardiac arrest Dizziness, Headache, Doesn’t cross BBB
Dyspepsia
Symptoms
Upper abdominal pain Fullness Early satiety Bloating Belching Nausea
Dyspepsia
Immediate referral:
A L A R M
Aneamia
Loss of weight
Anorexia
Recently changed, unexplainable dyspepsia in 55+, not responding to tx
Melena (blood in stool)
In-Investigated dyspepsia tx
- Antacid
- PPI for 4wks
- H.pylori test if no improvement
Investigated dyspepsia
Tx
- H.pylori test if Positive (eradication therapy)
2. PPI or H2 antagonist for 4wks (if test negative)
Aluminium and magnesium salts are
Long or short acting
Long
Calcium containing antacids
Can cause:
Constipation
Rebound acid secretion
hypocalcemia
Alkalosis
Milk alkali syndrome (Hugh blood ca)
Milk alkali syndrome symptoms
high urine output. headache and confusion. fatigue. nausea. pain in your abdomen
Antacids
How should they be taken
2 hours before and after medicines
Especially:
Tetracyclines
Quinolones
Bisphosphates
PPI
Examples
Esomeprazole Lansoprazole (30-60mints before food) Omeprazole ✅ pregnancy Pantoprazole Rabepazole
“Best in morning, swallow whole, don’t chew or crush”
“2hrs before or after food”
PPI
SE
Can mask gastric cancer Increased risk fractures (osteoporosis) Increased GI infections c.difficile Abdominal pain, nausea, constipation Subacute cle 1 year after taking PPI Low mg 3mths-1yr PPI + digoxin = toxicity
Take Ca + Vit D
Or bisphosphate
Omeprazole and methotrexate
Toxic
Omeprazole decrease methotrexate clearance
Ppl treatment (duration)
Shortest duration and lowest dose
PPI withdraw
Resolves by it self usually
If not give steroids
Suralfate
Tx for benign ulcers/stress ulcers
1 house before food
& enteral feeds
H2 Antagonist
Examples
SE
ALWAYS rule out malignancy
ESP in pts 55+
Cimetidine
Ranitidine
Famotidine
Nizatidine
SE: Headaches Rashes Dizziness Diarrhoea Confusion + psychological reactions Depression Hallucinations in elderly + very ill
Hyoscine butylbromide injection
Nausea in palliative care
CI
Tachycardia
Cardiac disease
Hypotension
Anaphylaxis
CAN CAUSE DEATH
Misoprostol
(Rxed in elderly for ulcers that can’t leave NSAIDS)
Postagladin
Tetrogenic in pregnancy
Avoid MG in antacid
NSAIDs treating ulcers tx
- Withdrawal NSAIDs if possible
2. PPIs or H2A or misoprostol
NSAIDs risk factors
Age 65+
History of peptic ulcers
Other GI complications
Co-morbidities:
Diabetes
Cardiovascular disease
Hepatic/renal impairment
Taking other meds:
Bisphosphate
Corticosteroids
SSRI’s
NSAIDs
If pts have 3+ risk factors
Continue PPI (after healing) Or H2A or misoprostol
ADD cox2 selective NSAIDs
GORD
Gastro oesophageal reflux disease
Heart burn and bring up acid
GORD tx
Mild
Severe
Pregnancy
Children
Mild:
Antacids + alginates
PPI - H2A
Severe
PPI for 4-6wks
Maintain remission with low PPI/H2A
Pregnancy
Antacids or alginate
Omeprazole
Children
Resolves after 12-18 months
Thicker feeds or alginates
Food allergies
Symptoms
Tx
Symptoms:
Vomiting, rashes, anaphylactic shock, colic, diarrhoea
Causes:
Egg, fish,milk,nuts
Tx:
Sodium cromogilcate
Chlorphenamine
Adrenaline (epipen)
Pancreatin
Causes
How to take
Cystic fibrosis
Chronic pancreatitis
Zollinger-Ellison syndrome
Coeliac disease
How to take:
Distribute food intake increase frequency and decrease quality
Avoid: difficulty to digest food: lentils,beans,avoid reduced fat foods
Starch, fat, protein
Take with food
If mixed with food or drink have it within 1 hr
ME/EC = increase pancreatin doses
Pancreatin
SE
Increased or decreased Uric acid
(Severe joint pain, AKI)
NV, abdominal pain, skin around mouth irritation/buccal mucosa (perioral skin)
Pancreatin
Fibrossing colonopathy in cystic fibrosis
With increased doses of pancreatin
At risk male, severe CF, laxative use
Nutrizym 22
Pancrease HL contra indicated in kids 15 and under
Pts stat report SE abdominal pain
Stoma
MR/EC Not suitable
Avoid sorbitol (laxatives)
(Take K+ supplement (liquid = better) (digoxin?)
Split daily doses
Avoid laxatives
Can have bulk forming
Increased doses codeine /loperamide can be used
