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MSRA Content > BASIC - GASTROINTESTINAL & HAEMATOLOGY > Flashcards

BASIC - GASTROINTESTINAL & HAEMATOLOGY Flashcards

1
Q

Names of bulk-forming laxatives?

A

Ispaghula husk, methylcellulose, sterculia

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2
Q

Indications of bulk-forming laxatives?

A
  • Constipation (patients who can’t increase dietary fibre)

- Mild chronic diarrhoea

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3
Q

Mechanism of bulk-forming laxatives?

A
  • Hydrophilic substance (polysaccharide or cellulose), not absorbed or broken down in gut
  • Attracts water into stool and increases its mass
  • Increased stool bulk stimulates peristalsis to help relieve constipation
  • Need adequate fluid intake
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4
Q

Side effects of bulk-forming laxatives?

A
  • Mild abdominal distension and flatulence

- Rarely, faecal impaction and GI obstruction

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5
Q

Contraindications of bulk-forming laxatives?

A
  • Colonic Atony
  • Intestinal obstruction
  • Faecal impaction
  • Undiagnosed rectal bleeding
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6
Q

Prescription of bulk-forming laxatives?

A
  • Oral granules, powder to be dissolved in water or tablets (methylcellulose)
  • Dose to be taken with at least 150ml liquid
  • Preferably after meals, morning and evening – e.g. 1 sachet BDS
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7
Q

Names of stimulant laxatives?

A

Senna, Bisacodyl, glycerol suppositories

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8
Q

Indications of stimulant laxatives?

A

Constipation

As suppositories for faecal impaction

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9
Q

Mechanism of stimulant laxatives?

A
  • Stimulant laxatives increase water and electrolyte secretion from the colonic mucosa
  • Increasing volume of colonic content and stimulating peristalsis
  • Direct pro-peristaltic action, although the exact mechanism differs between agents
    o Bacterial metabolism of Senna in intestine produces metabolites that have a direct action on the enteric nervous system, stimulating peristalsis
    o Rectal administration of glycerol suppositories, provokes a similar but more localised effect and can be useful to treat faecal impaction
    o Docusate sodium has both stimulant and faecal softening actions
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10
Q

Side effects of stimulant laxatives?

A
  • Abdominal pain/cramps
  • Diarrhoea
  • Prolonged use
    o Melanosis coli (reversible pigmentation of intestinal wall)
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11
Q

Contraindications of stimulant laxatives?

A
  • Contraindications for Senna
    o Intestinal Obstruction
    o Atony
    o Undiagnosed abdominal pain
  • Contraindications for glycerol suppositories
    o Avoid in haemorrhoids or anal fissures
  • Avoid during pregnancy
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12
Q

Prescription of stimulant laxatives?

A
  • Regular oral administration, usually BDS

- When rectal, PRN or once only

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13
Q

Prescription in palliative care?

A

Prescribe a softener and stimulant (Movicol, co-danthrosate)

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14
Q

Names of osmotic laxatives?

A

Lactulose, Macrogol (Movicol), phosphate enema

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15
Q

Indications of osmotic laxatives?

A

Constipation and faecal impaction – 1st line Movicol in paediatrics
Bowel preparation prior to surgery or endoscopy
Hepatic encephalopathy – lactulose

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16
Q

Mechanism of osmotic laxatives?

A
  • Osmotically active substances (sugars/alcohol) that remain in gut lumen
  • Hold water in stool
  • Maintain volume and stimulate peristalsis
  • Lactulose
    o Reduces ammonia absorption by increasing gut transit rate and acidifying stool
    o Inhibits proliferation of ammonia-producing bacteria
    o Useful in hepatic encephalopathy
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17
Q

Side effects of osmotic laxatives?

A
  • Flatulence
  • Abdominal cramps
  • Nausea
  • Diarrhoea
  • Phosphate enema
    o Local irritation, electrolyte disturbances
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18
Q

Interactions of osmotic laxatives?

A
  • Effects of warfarin may be slightly increased
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19
Q

Contraindications of osmotic laxatives?

A
  • Contraindications
    o Intestinal obstruction (risk of perforation)
    o Severe IBD
    o Toxic Megacolon
  • Contraindications for lactulose
    o Galactosaemia
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20
Q

Caution of phosphate enema?

A

o Heart failure, ascites, electrolyte disturbances

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21
Q

Prescription of osmotic laxatives?

A
  • Orally used prescribed regularly
  • May take a few days for an effect to be seen, as need to pass through GI tract
  • Phosphate enema PRN or once only
  • Taken with or without food
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22
Q

Name of antimotility drugs?

A

Loperamide

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23
Q

Indications of loperamide?

A
  • Symptomatic treatment of diarrhoea
  • Chronic diarrhoea
  • Faecal incontinence
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24
Q

Mechanism of loperamide?

A
  • Opioid similar to pethidine however does not penetrate CNS
  • Agonist of opioid u-receptors in GI tract
  • Reduces peristaltic contractions of gut smooth muscle
  • Transit of bowel contents is slowed and anal sphincter tone is increased
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25
Q

Side effects of loperamide?

A
  • Constipation
  • Abdominal cramping
  • Flatulence
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26
Q

Cautions of loperamide?

A
  • Acute ulcerative colitis – risk of perforation and megacolon
  • C.diff colitis
  • Acute bloody dysentery
  • Children <12 years old
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27
Q

Prescription of loperamide?

A
  • Purchased OTC – 4mg followed by 2mg following each loose stool to maximum of 8mg per day
  • Usually tablets or capsules
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28
Q

Names of antacids?

A

Gaviscon, Peptac

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29
Q

Indications of antacids?

A
  • Mild GORD

- Dyspepsia

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30
Q

Mechanisms of antacids?

A
  • Usually an alginate with one or more antacids (sodium bicarbonate, calcium carbonate, magnesium or aluminium salts)
  • Antacids – buffer stomach acids
  • Alginates – increase viscosity of stomach contents, reducing reflux
  • Form a floating raft, separating gastric contents from GOJ
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31
Q

Side effects of antacids?

A
  • Diarrhoea (magnesium), constipation (aluminium)
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32
Q

Interactions of antacids?

A
  • Divalent cations bind to other drugs and reduce absorption
    o ACEi, cephalosporins, ciprofloxacin, tetracyclines, bisphosphonates, digoxin, levothyroxine, PPIs
  • Increase alkalinity of urine – increase excretion of aspirin and lithium
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33
Q

Contraindications of antacids?

A
  • Caution in fluid overload or hyperkalaemia (sodium or potassium containing preparations)
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34
Q

Prescription of antacids?

A
  • Oral suspensions or chewable tablets

- Take following meals, before bedtime and/or symptomatically

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35
Q

Communications to have in antacids?

A
  • Discuss lifestyle measures to reduce GORD
    o Smaller meals, avoiding food and drink triggers, stop smoking, raising head of bed
  • Leave a gap of >2 hours when taking medications that interact
  • Come back if symptoms of bleeding, vomiting, dysphagia and weight loss
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36
Q

Names of H2RA?

A

Ranitidine

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37
Q

Indications of ranitidine?

A
  • Peptic ulcer disease (2nd line)
  • GORD
  • Dyspepsia
  • Gastric acid reduction in obstetrics
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38
Q

Mechanism of ranitidine?

A
  • H2 receptor antagonists reduce gastric acid secretion
  • Acid usually produced by proton pump of gastric parietal cell
  • Proton pump can be stimulated by other things than histamine so cannot completely suppress gastric acid production
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39
Q

Side effects of ranitidine?

A
  • Diarrhoea, Constipation
  • Headache
  • Dizziness
40
Q

Caution of ranitidine?

A
  • Can mask symptoms of gastric cancer
41
Q

Dose change in renal impairment in ranitidine?

A
  • Reduce dose if eGFR<50 – excreted by kidneys
42
Q

Prescription of ranitidine?

A
  • Can be purchased short-term OTC

- Typical dose 150mg BDS

43
Q

Names of PPIs?

A

Lanzoprazole, Omeprazole, esomeprazole, pantoprazole

44
Q

Indications of PPIs?

A
  • H.pylori eradication
  • Peptic Ulcer
  • GORD
  • Dyspepsia
45
Q

Mechanism of PPIs?

A
  • Irreversibly inhibit H/K/ATPase in gastric parietal cells

- Suppress gastric acid secretion completely

46
Q

Side effects of PPIs?

A
  • GI upset
  • Headache
  • High doses can increase risk of fractures
  • Prolonged – hypomagnesaemia – tetany or ventricular arrhythmias
47
Q

Interactions of PPIs?

A
  • Omeprazole inhibits CYP450 enzymes
48
Q

Caution of PPIs?

A
  • Mask symptoms of gastric cancer
  • Increased risk of fractures – adequate intake of Vit D and Ca
  • Risk of GI infections
49
Q

Max dose in hepatic impairment in PPIs?

A
  • Max dose 20mg
50
Q

Prescription of PPIs?

A
  • Oral usually – best taken in morning
  • 20mg OD omeprazole
  • Lowest dose for shortest period possible
51
Q

Monitoring of PPIs?

A
  • Before – check serum magnesium

- Prolonged use (>1 year) – check serum magnesium

52
Q

Name of antispasmodic?

A

Hyoscine butylbromide (Buscopan)

53
Q

Indications of hyoscine?

A
  • IBS
  • Colicky pain in cancer
  • Palliative care - Reduce copious respiratory secretions (death rattle)
54
Q

Mechanism of hyoscine?

A
  • Competitive inhibitor of Ach
  • Blocks the parasympathetic ‘rest and digest’ effects so:
    o Increase HR and conduction
    o Reduces smooth muscle tone
    o Reduces peristaltic contraction
    o Relax pupillary constrictor and ciliary muscles preventing accommodation
55
Q

Side effects of hyoscine?

A
  • Tachycardia
  • Dry mouth
  • Constipation
  • Urinary retention
  • Blurred vision
56
Q

Caution of hyoscine?

A
  • Angle-closure glaucoma
57
Q

Contraindications of hyoscine?

A
  • GI obstruction
  • Myasthenia gravis
  • Paralytic ileus
  • Prostatic enlargement
  • Urinary retention
  • Arrhythmias
58
Q

Interactions of hyoscine?

A
  • Adverse effects enhanced with other antimuscarinics e.g. TCAs
59
Q

Prescription of hyoscine?

A
  • Buscopan 10mg 8-hourly – available without prescription
60
Q

Names of dopamine receptor antagonists antiemetics?

A

Metoclopramide, domperidone

61
Q

Indications of dopamine receptor antagonists antiemetics?

A
  • Prophylaxis and treatment of nausea and vomiting in reduced gut motility
  • N&V associated with migraine
  • Radiotherapy and chemotherapy induced N&V
  • Prevention of PONV
  • Palliative care – Nausea and vomiting due to gastric stasis and irritation, hiccups
62
Q

Mechanism of dopamine receptor antagonists antiemetics?

A
  • D2 receptor is main receptor in chemoreceptor trigger zone (CTZ)
  • Dopamine promotes relaxation of stomach and LOS and inhibits gastroduodenal coordination
  • Blocking D2 has prokinetic effect
63
Q

Side effects of dopamine receptor antagonists antiemetics?

A
  • Diarrhoea, drowsiness, hypotension, menstrual irregularities
  • Metoclopramide
    o Extrapyramidal syndromes – acute dystonic reaction (facial and skeletal muscle spasms)
    o Galactorrhoea, gynaecomastia
  • Domperidone does not cross BBB
    o Dry mouth
64
Q

Contraindications of dopamine receptor antagonists antiemetics?

A
  • Phaeocytochroma
  • Gastrointestinal obstruction/perforation, 3-4 days after GI surgery
  • Cardiac disease – domperidone
65
Q

Caution of dopamine receptor antagonists antiemetics?

A
  • Young adults
  • Asthma
  • Bradycardia
  • Parkinson’s (Metoclopramide)
66
Q

Dose changes in renal/hepatic impairment of dopamine receptor antagonists antiemetics?

A

Hepatic Impairment

  • Caution in severe
  • Dose reduction of 50% in severe

Renal Impairment
- Avoid in renal impairment

67
Q

Interactions of dopamine receptor antagonists antiemetics?

A
  • Risk of EPSE increased with antipsychotics

- Do not combine with dopaminergic agents for Parkinson’s - antagonise

68
Q

Prescription of metoclopramide?

A

o Short term use – 5 days
o Dose 10mg up to TDS
o Metoclopramide available IV/IM and orally

69
Q

Name of iron supplements?

A

Ferrous Fumarate, Ferrous Sulphate

70
Q

Indications of iron?

A
  • Treatment of iron deficiency anaemia
  • Prophylaxis of iron deficiency anaemia in patients with risk factors:
    o Poor diet, malabsorption, menorrhagia, gastrectomy, haemodialysis
71
Q

Mechanism of iron?

A
  • Replenish iron stores
    o Iron needed for erythropoiesis – synthesise haem component of haemoglobin
  • Iron best absorbed in Fe2+ state – in duodenum and jejunum
  • Absorption increased by stomach acid and ascorbic acid (Vit C)
  • Once in blood, iron bound by transferrin for either bone marrow for erythropoiesis or stored as ferritin in liver, bone marrow, spleen and skeletal muscle
72
Q

Side effects of iron?

A
  • Nausea, epigastric pain
  • Constipation, diarrhoea
  • Bowel motions turn black
  • IV iron – irritation and hypersensitivity reactions
73
Q

Contraindications of iron?

A
  • May exacerbate bowel symptoms in intestinal disease (IBD, diverticular disease, strictures)
74
Q

Interactions of iron?

A
  • Reduce absorption of other drugs
    o Levothyroxine, bisphosphonates
    o Take at least 2 hours before oral iron
75
Q

Prescription of iron?

A
  • Ferrous fumerate – 210mg tablets 1-2 times a day

- Once Fe returned to normal, continue for 3 months to replenish iron stores

76
Q

Communication to patients of iron?

A
  • Taking with food helps reduce GI side effects
  • May turn stools black
  • Iron treatment stopped 7 days before colonoscopy
77
Q

Monitoring of iron?

A
  • FBC until haemoglobin returned to normal

- Should rise by 20g/L per month

78
Q

Name if vitamin B12 supplement?

A

Hydroxocobalamin

79
Q

Indications of hydroxocobalamin?

A
  • Treatment of macrocytic anaemias and subacute combined demyelination of cord in B12 deficiency
  • Pernicious anaemia
80
Q

Mechanism of hydroxocobalamin?

A
  • Addition vitamin B12 replenishes stores
81
Q

Side effects of hydroxocobalamin?

A
  • Diarrhoea, headache, nausea
82
Q

Contraindications of hydroxocobalamin?

A
  • If both Vitamin B12 and folic acid deficiency:

o Replace both simultaneously

83
Q

Prescription of hydroxocobalamin?

A
  • Hydroxocobalamin given by IM injection
    o If prophylaxis of macrocytic anaemia – 1mg every 2-3 months
    o If macrocytic anaemia without neurological complications – 1mg three times a week for 2 weeks and then 1mg every 2-3 months
    o If macrocytic anaemia with neurological involvement – 1mg OD on alternate days until no improvement then 1mg every 2 months
84
Q

Monitoring of hydroxocobalamin?

A
  • FBC before and during treatment
85
Q

Indications of folic acid?

A
  • Folate-deficient megaloblastic anaemia
  • Prevention of neural tube defects
  • Methotrexate treatments
86
Q

Mechanism of folic acid?

A
  • Synthetic form of Vitamin B9 or folate
  • Replaces stores
  • Reduces risk of neural tube defects
87
Q

Side effects of folic acid?

A
  • Abdominal distention
  • Decreased appetite
  • Flatulence
  • Nausea
88
Q

Contraindications of folic acid?

A
  • If both Vitamin B12 and folic acid deficiency:

o Replace both simultaneously

89
Q

Prescription of folic acid?

A
  • Folate-deficiency – 5mg OD for 4 months
  • Prevention of neural tube defects
    o Low risk - 400 micrograms OD, before conception to 12 weeks
    o High risk – 5mg OD, before conception to 12 weeks
    o Sickle Cell – 5mg OD throughout pregnancy
  • Methotrexate treatment – 5mg once weekly to be take on different day to methotrexate dose
90
Q

Monitoring of folic acid?

A
  • FBC before and during treatment
91
Q

Name of vitamin K replacement?

A

Phytomenadione

92
Q

Indications for vitamin K?

A
  • All newborn babies to prevent vitamin K deficiency bleeding
  • Reverse anticoagulant effect of warfarin
93
Q

Mechanism of vitamin K?

A
  • Reverses warfarin by providing fresh supply of Vitamin K for synthesis of Vitamin-K dependent clotting factors (Factor 2, 7, 9, 10)
  • Effect apparent 12-24 hours after administration
94
Q

Cautions of vitamin K?

A
  • Give IV injections very slowly – risk of vascular collapse
95
Q

Interactions of vitamin K?

A
  • May alter warfarin dosing requirements after treatment
96
Q

Prescription of vitamin K?

A
  • Neonates – 1mg IM as single dose at birth
  • To treat high INR – low dose (1mg oral or IV) given
  • Major bleeding – 10mg IV

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