A7-A8 Drugs in gastro-intestinal diseases Flashcards
1
Q
state what is indicated by the 7 types of stools on the Bristol Stool Chart
A
Type 1 and 2 = constipation
Type 3, 4 and 5 = normal stool
Type 6 and 7 = diarrhoea
2
Q
describe the definition of constipation
A
a disorder where a person passes infrequent stools, has difficulty passing stools or experiences sensation of incomplete emptying
3
Q
compare previous parameters for constipation and the parameters now
A
- previously defined as less than 3 spontaneous bowel movements per week
- now defined as passage of stools less frequently than the person’s normal pattern
4
Q
explain the social causative factors of constipation
A
- diet: low fibre
- lifestyle: lack of exercise
5
Q
explain the psychological causative factors of constipation
A
- access to toilets eg. at schools
- privacy in toilets
- depression / anxiety
- eating disorders
6
Q
explain the physical causative factors of constipation
A
dehydration
7
Q
explain the organic causes causative factors of constipation
A
diseases
- spinal injury
- IBS with constipating element
- Parkinson’s
8
Q
explain the secondary causative factors of constipation
A
organic causes (diseases)
medications
9
Q
symptoms of constipation
A
abdominal pain
bloating
nausea
straining during bowel movements
10
Q
what questions should be asked when investigating constipation?
A
- what is the change in bowel habit? (typical vs now)
- how long? (acute or chronic)
- lifestyle?
- diet?
- medications? (started or stopped any recently)
- have they tried anything already? did it work? what was it?
11
Q
state 3 main drugs that can cause constipation
A
calcium supplements
iron supplements
opioids
12
Q
what are opioids generally co-prescribed with?
A
generally with laxatives as constipation is so common
13
Q
state some other drugs other than the 3 main ones that can cause constipation
A
- aluminium-containing antacids
- antimuscarinics
- antidepressants (mainly tricyclic)
- anti epileptics
- sedating antihistamines
- antispasmodics
- diuretics
- calcium-channel blockers
14
Q
what can constipation cause in respect to new medications?
A
non-compliance
15
Q
describe the treatment options for constipation
A
- correct modifiable causes first
- give lifestyle advice (increase fibre and fluids, regular exercise)
- laxatives may be a suitable option for non-modifiable causes
16
Q
what is generally the first line of laxative treatment for those with constipation? describe this type of laxative and give an example
A
- bulk-forming laxative
- onset of action is quite slow (12-72 hours)
- more gentle and good first option
- eg. Fybogel
17
Q
describe the action of osmotic laxatives and give some examples
A
- pulls water from intestine into poo to make it softer
- Macrogols most common these days (eg. Movicol, Laxido)
- lactulose
- glycerine suppositories (act within 15 minutes)
18
Q
describe the action of stool softeners and give some examples
A
- make it easier to pass motion by softening stool
- OTC: Dulcoease
- sodium decussate (softens stool and stimulates bowel to expel too)
19
Q
describe the action of stimulant laxatives and give some examples. what are stimulant laxatives used in combination with and why?
A
- stimulate movement of gut and increase peristalsis down colon
- stimulates colonic nerves
- used in combination with laxative that’s often stools otherwise it would be like pooing out nuts
examples
- Senna
- bisocodyl
- sodium picosulfate
20
Q
when should stimulant laxatives not be used?
A
in the third trimester of pregnancy as it can put women into labour due to the stimulation of the area
21
Q
state some other specialist medications used for constipation
A
prucalopride
linaclotide
PAMORAs
22
Q
what should be offered as a first line for acute and chronic constipation? what is important with this?
A
bulk-forming laxative (adequate fluid intake is important with this)
23
Q
after trying a bulk-forming laxative as the first line of treatment for constipation, what should be added or switched if stools are hard or soft?
A
- add or switch to osmotic laxative if stools are hard
- add a stimulant laxative if stools are soft but difficult to pass
24
Q
what should be advised to patients who have been using laxatives for a while to treat constipation?
A
- gradually reduce and stop laxatives once producing soft, formed stool without straining at least 3 times a week
- usually stimulant laxatives are stopped first
25
what laxatives should be avoided when treating opioid-induced constipation?
bulk-forming laxatives
26
explain how opioids can cause constipation and why bulk-forming laxatives should be avoided in its treatment
- opioids activate opioid receptors in gut which stops peristalsis
- giving bulk-forming laxative would increase size of faecal blockage and make the gut blockage worse
27
what 2 kinds of laxatives should be used to treat opioid-induced constipation?
osmotic and stimulant
28
what other novel agents can be used to treat opioid-induced constipation?
PAMORAs
eg. naldemedine, naloxegol (usage not common place yet)
29
what advice should be given to those experiencing constipation during pregnancy?
- increase fluids (8-10 cups daily)
- increase fibre intake
30
what laxatives can and should be used to treat constipation in pregnancy? which ones should not be used?
- bulk-forming can be used
- osmotic can be used
- glycerol suppositories (osmotic) can be used
- stimulants should be avoided near term
31
red flags in constipation
- persistent unexplained change in bowel habit
- rectal bleeding
- palpable mass in the lower right abdomen or pelvis
- narrowing of stool diameter
- blood in stools
- severe, persistent constipation that is unresponsive to treatment
- unexplained weight loss
- iron deficiency anaemia
- fever
- nocturnal symptoms
- family history of colon cancer or IBS
32
describe the definition of haemorrhoids
- abnormally swollen vascular mucosal cushions in the anal canal
- affect 13-36% of the general population
- can be painless but can also bleed and cause irritation / itching
33
causes of haemorrhoids
- constipation and straining
- ageing
- raised intra-abdominal pressure
- hereditary factors
- heavy lifting
- exercise
- low fibre diet
34
how does straining cause haemorrhoids?
puts pressure on blood vessels in that area
35
how does ageing cause haemorrhoids?
muscles weaken with age and increase risk of piles
36
what can cause raised intra-abdominal pressure that can then cause haemorrhoids?
pregnancy
childbirth
37
what kind of exercise is common in causing piles?
cyclists
38
what must be minimised if possible when managing haemorrhoids?
constipation and straining
39
when should laxatives be used to treat haemorrhoids and which ones can be used?
- only if caused by constipation
- usually bulk-forming
- stimulants can be used if stools are soft or alongside something else if they are hard
40
describe the symptomatic relief of haemorrhoids
- relief from itching, pain, irritation, inflammation etc.
- simple analgesia and / or topical haemorrhoidal preparations can be bought OTC
- calamine
- cocoa butter
- some preparations that contain stronger steroids are POMs
41
when should people that come into the pharmacy with haemorrhoids be referred to their GP?
- if they don't respond to conservative treatment or if the diagnosis is uncertain
- if someone presents with blood in the stool or on toilet paper, they should be referred unless they explicitly know it is haemorrhoids
42
describe the definition of diarrhoea
- abnormal passage of loose or liquid stools more than 3 times daily and / or a volume of stool greater than 200 g/day
- usually considered type 6 or 7 on Bristol Stool Chart
43
describe acute vs chronic diarrhoea in terms of timescale
- acute: lasts less than 4 weeks
- chronic: last longer than 4 weeks
44
what are the pharmacist's roles when someone comes into the pharmacy presenting with diarrhoea?
- determine frequency and severity of symptoms
- assess for complications of diarrhoea
45
how should pharmacists determine the frequency and severity of diarrhoea symptoms?
- query underlying causes
- medication induced?
- stress? anxiety?
- infection?
- recent travel?
- exposure to possible sources of enteric infection?
46
explain further the symptoms of diarrhoea if caused by infection and how this could happen
- may have fever
- may have been in contact with another person with diarrhoea
- may be due to food poisoning
47
what is a common complication of diarrhoea and what can this cause if not treated?
- dehydration
- can cause acute kidney failure
48
diarrhoea red flags
- painless, watery, high volume diarrhoea
- weight loss
- nocturnal symptoms, disturbing sleep
- persistent vomiting
- blood or mucus in stool
- child who cannot keep fluid down
- travel history to endemic regions (highest risk in Africa / South Asia)
- recent hospital or antibiotic treatment
49
why is it a significant concern if a child that has diarrhoea cannot keep fluid down?
they can dehydrate very quickly du ego their smaller size
50
state drugs that can cause diarrhoea
- allopurinol
- angiotensin-II receptor blockers
- antibiotics
- digoxin
- colchicine
- cytotoxic drugs
- H2-receptor antagonists
- theophylline
- levothyroxine
- magnesium-containing antacids
- metformin
- NSAIDs
- PPIs
- SSRIs
- statins
- high-dose vitamin C
- laxatives!
51
what advice should be given to patients for management of acute diarrhoea?
- try to minimise contact for duration of diarrhoea and for 48 hours after it stops
- provide advice on hygiene (don't share toilets if possible)
- explain it is usually self-limiting
- stay hydrated
52
what is a popular treatment for diarrhoea that is not related to directly stopping the diarrhoea? give an example and describe its dose. can it be used by young children?
- oral rehydration solutions eg. Dioralyte
- usually 200-400 ml solution after every loose motion
- can be used in young children
53
what is the first line of treatment for diarrhoea if a culture confirms C. diff infection?
- oral vancomycin
- antibiotic isn't absorbed by the gut so it remains in the gut lumen and eliminates C. diff from the gut
54
what is overflow diarrhoea?
- severe constipation can cause a blockage in your bowel
- bowel begins to leak out watery stools around the blockage from higher up in the bowel
- the leak can look like diarrhoea
- highly prevalent in elderly patients (sometimes children) but anyone with chronic constipation could suffer
55
what should NOT be used to treat overflow diarrhoea?
- diarrhoea medicines
- this will cause further blockages and worsen condition
56
describe the definition of irritable bowel syndrome
- a chronic, relapsing and often debilitating disorder of gut-brain interaction
- should not be diagnosed by a doctor in one consultation (need to rule other things out first)
57
state some symptoms of IBS
- abdominal pain / discomfort associated with going to the toilet
- change in bowel habit (stool form and / or frequency)
- abdominal bloating
- abdominal cramping
58
where in the abdomen does IBS occur?
can occur anywhere in the abdomen
59
what must be ensured for the OTC treatment of IBS?
- patient must have been medically diagnosed with IBS
- need to rule out there isn't something more serious going on
- lots of IBS symptoms can also be symptoms of GIT related cancers
60
non-pharmacological management of IBS
- increase physical activity
- eat regular meals with a healthy, balanced diet, adjust fibre intake according to symptoms
- drink adequate fluids
- management of stress or anxiety
61
what does the pharmacological management of IBS depend on?
whether the patient is more prone to constipation or diarrhoea
62
pharmacological management of IBS for those with abdominal pain
- initially, mebeverine, alverine or peppermint oil
- next step, lose dose tricyclic antidepressant
- selective serotonin reuptake inhibitor
63
pharmacological management of IBS for those with constipation
- laxatives EXCEPT lactulose
- lactulose is sugar and it is fermented by gut bacteria which can cause wind / bloating
64
pharmacological management of IBS for those with diarrhoea
- anti motility drug
- eg. loperamide
65
IBS red flags
- unintentional and unexplained weight loss
- rectal bleeding
- rectal mass
- a family history of bowel or ovarian cancer
- inflammatory markers for inflammatory bowel disease
- a change in bowel habit to looser or more frequent stools, persisting for more than 6 weeks in a person over 60
- abdominal mass
- anaemia
66
describe the definition of diverticular disease, where in the body and who it is common in and 2 main causes
- diverticula are sac-like protrusions of mucosa through the muscular wall of the colon
- they occur in the sigmoid colon in about 80% of people over the age of 85 (more common in the elderly)
- commonly caused by constipation
- if stool sits in the gut for a prolonged period, bacteria is present for an extended length of time and can cause diverticula
- formation may be associated with a low fibre diet
67
what is diverticulosis?
diverticula present without any symptoms
68
what is diverticular disease?
- diverticula cause symptoms eg. abdominal pain
- no inflammation of infection present
69
what is diverticulitis? state its symptoms, management and what it can lead to
- inflamed and infected diverticula
- usually causes lower abdominal pain, rectal bleeding, fever etc.
- often managed in a hospital setting
- can lead to complicated diverticulitis
70
state 2 examples of symptoms of complicated diverticulitis
perforation of diverticula
abscess
71
non-pharmacological treatment of diverticular disease
- increase fibre in the diet
- increase fluid intake
72
pharmacological treatment of diverticular disease
analgesia
- paracetamol
bulk-forming laxatives
- less likely to have poo hanging around in the system
antibiotics
- if it is diverticulitis
surgery
- only in complicated diverticulitis or immunocompromised patients
73
what is IBD?
- umbrella term for Crohn's disease and ulcerative colitis
- inflammatory bowel diseases
74
describe the definition of IBD
- chronic, relapsing-remitting, non-infectious inflammatory disease of the GIT
- relapsing-remitting means that symptoms can flare up (relapse)
- this can be followed by a period of little or no symptoms (remission)
- causes ulceration and bleeding at various points along the GIT
75
what area does Crohn's disease affect?
anywhere from the mouth (eg. mouth ulcers) to the anus
76
what area does ulcerative colitis affect?
only the colon
77
how are drugs used to treat ulcerative colitis and Crohn's disease?
different drugs are used for the targeting of ulcerative colitis and Crohn's due to the affected areas being different
78
what is pancolitis? what preparations are required to treat it?
- pan colitis means there are ulcers all over the colon
- affects whole colon
- oral therapies required that are modified-release because colon comes after stomach
79
what area of the colon does proctosigmoiditis affect? what preparations are required to treat it?
- affects descending and sigmoid colon, rectum and anal canal
- topical preparations can be used
- enemas and foam enemas are particularly useful (can shoot higher up the colon than suppositories can act)
80
what area of the colon does proctitis affect? what preparations are required to treat it?
- affects rectum and anal canal
- suppositories are usually sufficient to act in this area
81
symptoms of ulcerative colitis
- can cause profuse diarrhoea which can contain mucous and blood
this can lead to:
- anaemia (due to lots of bleeding)
- dehydration (due to going to the toilet lots)
- potentially poor absorption of certain drugs
82
why can ulcerative colitis lead to the poor absorption of certain drugs? due to this, which formulations may be required for treating UC?
due to ulcers in the colon so IV or topical preparations may be required for treating
83
what can GI surgical procedures affect?
medicines
84
state an umbrella term for GI surgeries that can cause differed drug absorption and state the 3 sub surgeries in this category
resection of GIT
- total colectomy
- hemi-colectomy
- anterior resection
85
what may GI surgical procedures result in?
- the formation of a stoma
- can be temporary to rest the gut for a period of time but they are usually irreversible
86
who can have a stoma?
patients of any age can have a stoma
87
what are the 2 types of stoma?
colostomy
- stoma is created in the colon
ileostomy
- created in the small intestine
88
what does the management of patients with a stoma depend on?
the location of the stoma
89
what should be reviewed when patient are given a stoma?
medications
- long term medicines
- medicines may be needed for reducing stoma output
90
which long term medicines in particular need reviewing when a patient gets a stoma? why?
- modified release preparations
- these will be excreted through the stoma exactly as they were ingested as they will not have been broken down (in the case of an ileostomy)
91
state some medicines that may be used to reduce stoma output
anti motility agents
- often at high doses
- eg. loperamide 16mg QDS
anti secretory agents
- eg. omeprazole
92
state 2 types of enteral feeding tubes
- nasogastric tube
- percutaneous gastrostomy tube (PEG)
93
state some things to confirm as a pharmacist regarding medications via enteral feeding tubes
- type, size and position of tube
- licensing of crushing tablets / opening capsules
- formulation and drug properties
- modified release preparation?
- interactions with feed?
- is there a risk of blocking the tube?
94
describe bariatric surgery and its use
- reduces size of stomach (usually to around 30ml)
- used as weight loss surgery for patients who are severely obese
95
describe the diet of patients after having bariatric surgery
non-solid diet for 4 weeks post-surgery
96
what medicines may patients need after having bariatric surgery? what should be considered surrounding other medications? give one example of each question
pain medications
- topical patch may be more convenient
consider could hypotension medications be paused temporarily?
97
what will patients often require from healthcare professionals after bariatric surgery and why?
- will require regular nutritional monitoring
- patients will often also need vitamin replacement
- this is because the procedures are either restrictive and / or malabsorptive
98
state 3 types of bariatric surgery
- adjustable gastric band (lap band)
- vertical sleeve gastrectomy
- roux-en-Y gastric bypass
