A7. Drugs in gastro-intestinal diseases

Question 1

bristol stool chart?

Answer 1

one note

Question 2

definition of constipation?

Answer 2

Constipation is a disorder where a person passes infrequent stools, has
difficulty passing stools, or experiences sensation of incomplete emptying. (NICE CKS on Constipation)

Question 3

causative factors of constipation?

Answer 3

-social
-Psychological
-Physical
-Organic causes (secondary cause)
-Medications (secondary cause)

Question 4

symptoms of constipation?

Answer 4

abdominal pain, bloating, nausea, straining during bowel movements

Question 5

questions to ask to investigate constipation?

Answer 5

-What is the change in bowel
habit?
-How long?
-Lifestyle?
-Diet?
-Medications?
-Have they tried anything
already?

Question 6

drugs that can cause constipation

Answer 6

one note (especially remember the ones in bold)

Question 7

treatment options for constipation?

Answer 7

-Correct identifiable causes – modifiable vs non-modifiable causes
-Lifestyle advice – dietary: increase fibre and fluid intake, regular
exercise
-For non-modifiable causes laxatives may be a suitable option.

Question 8

what are the different types of laxatives?

Answer 8

-bulk-forming (usually first line)
-osmotic
-stool softeners
-stimulent
-other specialist medications
ONE NOTE

Question 9

Treatment algorithm for constipation?

Answer 9

ONE NOTE

Question 10

How to treat acute/chronic constipation?

Answer 10

-Bulk-forming laxative (adequate fluid intake is important)
-Add or switch to an osmotic laxative
-Add a stimulant laxative
-Advise to gradually reduce and stop laxatives once producing soft, formed stool without straining at least
three times a week.

Question 11

How to treat opioid-induced constipation?

Answer 11

-Avoid bulk-forming laxatives
-Use an osmotic & stimulant laxative
-Other novel agents i.e. PAMORAs e.g. naldemedine, naloxegol (usage not common place yet)

Question 12

How to treat constipation caused by pregnancy?

Answer 12

-Dietary measures, fluids, (8-10 cups/daily) - prevention is
better!
-Bulk-forming, osmotic, glycerol suppositories (stimulants
- but avoid near term)

Question 13

Constipation red flags?

Answer 13

-Persistent unexplained change in bowel
habit
-rectal bleeding
-FHx: colon cancer or IBD
-Palpable mass in the lower right abdomen or pelvis
-Narrowing of stool calibre
-blood in stool
-Severe, persistent constipation -
unresponsive to treatment
-Unexplained weight loss, iron deficiency anaemia, fever, nocturnal symptoms

Question 14

Definition of haemorrhoids?

Answer 14

(also known as piles) are abnormally swollen vascular mucosal cushions in the anal canal (NICE CKS)

Question 15

causes of haemorrhoids?

Answer 15

-Constipation & straining while trying to pass stools
-Ageing (weakening of support structures)
-Raised intra-abdominal pressure – pregnancy, childbirth
-Hereditary factors
-Heavy lifting
-Exercise
-Low fibre diet

Question 16

haemorrhoids management?

Answer 16

-Lifestyle advice - minimise constipation
and straining
-Laxatives (if constipated only)
-Symptomatic relief
(itching/pain/irritation/inflammation) -
simple analgesia &/or topical
haemorrhoidal preparations, calamine,
cocoa butter
-Referral for people who do not
respond to conservative treatment, or
in whom the diagnosis is uncertain

Question 17

Diarrhoea definition

Answer 17

the abnormal passage of loose or liquid stools more than 3 times daily and/or a volume of stool greater than 200 g/day (British Society of Gastroenterology)

Question 18

pharmacists role with diarrhoea?

Answer 18

-Determine frequency and severity of symptoms
-Query underlying cause(s)?
-Medication induced? (C Diff?)
-Stress? Anxiety?
-Infection: fever, contact with another person with diarrhoea, food poisoning?
-Recent travel? (especially to areas with poor hygiene standards)
-Exposure to possible sources of enteric infection?
-Assess for complications of diarrhoea - DEHYDRATION

Question 19

diarrhoea red flags?

Answer 19

-painless, watery, high-volume diarrhoea
-recent hospital or antibiotic treatment
-weight loss
-nocturnal symptoms, disturbing sleep
-persistant vomiting
-blood or mucous in stool
-child who cannot keep fluid down
-Travel history to endemic regions highest risk inAfrica/South Asia

Question 20

drugs that can cause diarrhoea?

Answer 20

one note

Question 21

management of acute diarrrhoea?

Answer 21

-Carry out comprehensive history of episode, then:
-Try to address potential causes -?infection, ?new drugs?
-Advice:
-Try to minimise contact for duration of diarrhoea and for 48 hours after it stops
-Provide advice on hygiene measures
-Explain usually self-limiting
-Hydration
-Oral rehydration solution – Dioralyte
-Dose - according to fluid loss
-Usually 200–400 mL solution after every loose motion
-If cultures confirmed C. difficile infection 1st line oral vancomycin

Question 22

what is overflow diarrhoea?

Answer 22

-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 from the bowel can look like diarrhoea
-Highly prevalent in elderly patients (sometimes children), but anyone
with chronic constipation could suffer
-Shouldn’t be treated with medicines for diarrhoea, as this will cause further blockage

Question 23

Irritable bowel syndrome (IBS) definition?

Answer 23

A chronic, relapsing, and often debilitating disorder of gut-brain interaction

Question 24

Typical clinical features of IBS?

Answer 24

-Abdominal pain/discomfort associated with, or relieved by, defecation
-Change in bowel habit (stool form and/or frequency)
-Abdominal bloating
-Abdominal cramping

Question 25

Describe IBS

Answer 25

-Pathophysiology not understood – biological, psychological & social factors -Can occur anywhere in abdomen -For OTC treatment, need to ensure that patient has been medically diagnosed with IBS

Question 26

Non-pharmacological management of IBS?

Answer 26

-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.

Question 27

Pharmacological management of IBS?

Answer 27

-Dependent on whether more prone to constipation or diarrhoea -Abdominal pain: mebeverine, alverine, or peppermint oil (some preps C/I in peanut allergy) -Next step is a low dose tricyclic antidepressant e.g. amitriptyline 5–10 mg at night (for pain relief) -Selective serotonin reuptake inhibitor -For people with constipation - laxatives (except lactulose – sugar fermented by bacteria and can cause wind, bloating) -For people with diarrhoea - antimotility drug – loperamide

Question 28

red flags of IBS

Answer 28

-Unintentional and unexplained weight loss -Anaemia -Rectal bleeding -Rectal mass -Abdominal mass -A change in bowel habit to looser or more frequent stools, persisting for more than 6 weeks, in a person over 60 years of age -inflammatory markers for inflammatory bowel disease -A family history of bowel or ovarian cancer

Question 29

what is diverticula?

Answer 29

Diverticula are sac-like protrusions of mucosa through the muscular wall of the colon. Formation may be associated with low fibre diet.

Question 30

what is Diverticulosis?

Answer 30

diverticula present without symptoms

Question 31

What is Diverticular disease?

Answer 31

diverticula cause symptoms, e.g. abdo pain but no inflammation or infection

Question 32

What is diverticulitis?

Answer 32

diverticula inflamed and infected

Question 33

non-pharmacological treatment of diverticular disease?

Answer 33

-Increasing fibre in the diet -Increasing fluid intake

Question 34

pharmacological treatment of diverticular disease?

Answer 34

-Analgesia - paracetamol -Bulk forming laxatives -Antibiotics – if diverticulitis -Surgery – only in complicated diverticulitis or immunocompromised patients

Question 35

Describe chron's disease and ulcerative colitis?

Answer 35

-Referred to as Inflammatory Bowel Disease (IBD) -Definition: a chronic, relapsing-remitting, non-infectious inflammatory disease of the GI tract. -Relapsing-remitting means that symptoms can flare up (relapse) and this can be followed by a period with little or no symptoms (remission). -Causes ulceration and bleeding at various places along the GI tract -Crohn’s Disease - anywhere from the mouth to the anus -Ulcerative Colitis (UC) - only affects the colon

Question 36

Describe ulcerative colitis

Answer 36

-Can cause profuse diarrhoea (which can contain mucous and blood) Can lead to: -Anaemia -Dehydration -Poor absorption of certain drugs?

Question 37

Describe GI surgical procedures

Answer 37

-Surgical procedures may affect medicines -Resection of GI tract: Total colectomy, Hemi-colectomy, Anterior resection -May result in the formation of a stoma

Question 38

what are the types of stoma

Answer 38

-colostomy: stoma created in the colon -ileostomy: created in the small intestine ONE NOTE

Question 39

Stoma management and the pharmacist's role?

Answer 39

-Colostomy or ileostomy? - management depends on the location -Review medications: -Long term medicines – especially MR preparations -Medicines may be needed for reducing stoma output -Anti-motility agents (e.g. loperamide) -Anti-secretory agents (e.g. omeprazole) -Co-ordinate with other health care professionals (including dietitians, stoma nurse specialists)

Question 40

types of enteral feeding tubes?

Answer 40

-nasogastric tube (NJ) -Percutaneous gastrostomy (PEG) -Also, may occasionally see an NJ or PEJ, which feed into the jejunum (small intestine)

Question 41

things to confirm as a pharmacist before delivering medications via enteral feeding tubes

Answer 41

-Type, size and position of tube -Licensing of crushing tablets/open capsules, typically this is unlicensed so should use a licensed alternative route where possible -Formulation and drug properties -Modified release preparation? -Interactions with feed? -Is there a risk of blocking the tube?

Question 42

Describe bariatric suregry

Answer 42

-Weight loss surgery for patients who are severely obese -Reduces the size of the stomach -Non-solid diet for 4 weeks post surgery -What medicines would patients need post surgery / lifelong? -Procedures are either restrictive and/or malabsorptive -Will require regular nutritional monitoring -Public health issue – weight management interventions and lifestyle advice