CH1: GASTRO CLINICAL Flashcards
Define Coeliac disease
- Autoimmune response triggered by gluten
- Malabsorption of nutrients
- Inflammation of the small intestine
Symptoms of coeliac disease?
Acronym - ABCD
Abdominal pain
Bloating
Complications from nutrient malabsorption
Diarrhoea
Patients who are gluten intolerant are at risk of what forms of deficiencies?
- Low Vitamin D
- Low Calcium levels
- Low Folate levels
- Low Vitamin B12 levels
*The complications of malabsorption of these nutrients = increase risk of bone disease and OSTEOPOROSIS
How is coeliac disease managed? (treatment)
- Strict glute-free diet
- Supplementation
(Calcium, Vit D & B12 and Folic acid) - Prednisolone (to treat the inflammation of the small intestine if severe or exacerbated)
What are the 2 conditions are patients with Coeliac disease at risk of?
- Osteoporosis (low Ca2+ and low Vitamin D)
- Malabsorption of key nutrients
What is the main difference between ACUTE DIVERTICULITIS and DIVERTICULAR disease?
Acute Diverticul(ITIS)- small pouches are inflamed or infected
Diverti(CULAR) disease- small pouches but symptomatic, is more on mild-moderate abdominal pain
How to treat acute diverticulitis (1st line and 2nd line)?
1st line- Co-amoxiclav
2nd line - Cefalexin + Metronidazole (if pen allergy)
Management of diverticular disease
- Bulk forming agent e.g. fybogel
- Increase fibre intake
- Pain - paracetamol, avoid ibuprofen (increases the risk of diverticular perforation).
- Antispasmodic (nausea, abdominal pain, muscle spasms) i.e. mebeverine or albeverine.
Define Inflammatory Bowel Disease (IBD)
Umbrella term that describes 2 conditions;
1. Crohn’s disease (affecting the any part of the GIT- mouth to rectum)
2. Ulcerative colitis (only affecting the large intestine and rectum)
State the COMMON symptoms of IBD (6)
- Abdominal pains
- Rectal bleeding
- Weight loss
- Anaemia
- Diarrhoea
- Fever
Symptoms of Crohn’s disease
- Abdominal pain
- Rectal bleeding
- Weight loss
- Diarrhoea
Complications associated with Crohn’s disease (5)
- Colorectal or small bowel cancer
- Anaemia and malnutrition
- Intestine fistulas
- Growth failure and delayed puberty in children
- Extra-intestinal manifestation (arthritis, eyes, joints, liver and skin - abnormalities)
State the non-drug treatment for Crohn’s disease (2)
- Smoking cessation
- Nutrition
Identify the 1st line treatment for ACUTE EXACERBATION of Crohn’s disease
Glucocorticoid monotherapy
- Prednisolone, methylprednisolone etc
Identify the 2nd line treatment for ACUTE EXACERBATION of Crohn’s disease
Budesonide
- if a pt. is contraindicated to 1st line
- if pt. has a distal, ileal, ileocecal or right sided colonic disease
Symptoms of Ulcerative Colitis (3)
- Bloody Diarrhoea (pus and mucus)
- Defecation urgency
- Abdominal pain
State what is Proctitis and its treatment regime (1st, 2nd and 3rd line)
Inflammation of the lining of the rectum to the anus.
1st line- TOPICAL Aminosalicylates
2nd line - PO Aminosalicylates
3rd line - TOP/PO Corticosteroids for 4- 8 weeks if aminosalicylates are CI
State what is Proctosigmoiditis and its treatment regime (1st, 2nd and 3rd line)
Inflammation affecting the sigmoid colon and rectum.
1st line - TOP Aminosalicylates
2nd line - PO Aminosalicylates OR
PO Aminosalicylates + TOP corticosteroids for 4-8 weeks
3rd line - PO Aminosalicylates AND PO corticosteroids for 4 to 8 weeks
State what is distal left sided UC and its treatment regime (1st, 2nd and 3rd line)
Inflammation that begins at the rectum up to the left colon (affecting the sigmoid colon and descending colon)
1st line- TOP Aminosalicylates
2nd line - High dose PO Aminosalicylates OR
High dose PO Aminosalicylates + TOP corticosteroids 4-8 weeks
3rd line - PO Aminosalicylates + PO corticosteroids for 4-8 weeks
- Rectal preparations are more effectives i.e. suppositories, foam and enemas. PO & TOP are less effective but still work- depending on patient preferences
State what is Extensive colitis and its treatment regime (1st, 2nd and 3rd line)
Inflammation affecting the entire colon.
1st line- TOP Aminosalicylates & HIGH dose of PO Aminosalicylates
** if no remission after 4 weeks, stop TOP aminosalicylates
2nd line - PO high dose aminosalicylates + PO corticosteriods for 4-8 weeks
3rd line - If aminosalicylates is CI - PO Corticosteriods for 4 to 8 weeks can be used.
Medications to avoid for treating diarrhoea associated UC (2)
- Loperamide
- Codeine
Increases risk of toxin megacolon – can be used under specialist advice!
State the treatment regime (1st, 2nd and 3rd line) of life-threatening ACUTE to SEVERE UC (medical emergency).
1st line = IV corticosteroids (hydrocortisone or methylprednisolone) whilst assessing the need for surgery
2nd line= IV Ciclosporins, if corticosteroids are CI
If no symptomatic improvements within 72 hours
3rd line = IV Ciclosporins + IV corticosteroids
4th line = Infliximab, if ciclosporins are CI OR Surgery
State the maintenance treatment for Proctitis/ Proctosigmoiditis
Rectal Aminosalicylates +/- PO Aminosalicylates
*can be given only PO if patient doesn’t want rectal = would be less effective.
State the maintenance treatment for distal left-sided and extensive UC
Low dose of oral aminosalicylate
State the maintenance treatment for UC ‘>2 flares in 1 year’.
1st line - Oral Azathioprine OR Mercaptopurine (UL)
2nd line - Monoclonal antibiotics (infliximab) if no effects
What is ‘irritable bowel syndrome’ (IBS)?
- symptoms
- triggers
- common chronic relapsing and often life-long.
- common in women and people aged 2-30
Symptoms: AB pain, diarrhoea, constipation, urgency, incomplete defecation, passing mucus and bloating.
Exacerbated by: coffee, alcohol, milk, fried foods and stress.
What are the non-pharmacological treatment for IBS
- Increase physical activity
- eat regular meals
- reduce insoluble fibre (e.g. bran)
- reduce caffeine, alcohol and fizzy drinks
- drink at least 8 cups of water daily
Briefly state the drug treatments for IBS and examples of drugs.
- GI spasms = antimuscarinics, antispasmodics
CI in pts with paralytic ileus
- antimuscarinics = hyoscine butyl bromide, propantheline bromide, dicycloverine < CI: Cardiac diseases>
- antispasmodics = alverine, mebeverine, peppermint oil (cx- heartburn & GI irritation, safe in pregnancy)
- Constipation = laxatives
Avoid lactulose = which causes bloating (SE of IBS)
- Linoclotide = unresponsive IBS for 12 months - Diarrhoea = antimotility
- Loperamide = >12yrs, avoid in CVD pts as it can cause severe QT prolongation in high doses resulting to cardiac arrest - Abdominal discomfort = antidepressants
- TCAs = amitriptyline (off label) r/v after 4 weeks
- SSRIs = citalopram or fluoxetine (off-label)
define short bowel syndrome
- pt has a shortened bowel due to a large surgical resection (with or without stoma formation)
- which will affect the pts ability to absorb essential nutrients
- may repair absorption of other drugs
State the management of short bowel syndrome
- ensure adequate absorption of nutrients and fluids
- replace nutritional deficiencies < Vit A, B12, D, E, K, Magnesium, Selenium, Zinc and essential fatty acids
To treat diarrhoea = for inadequate digestion
1st line: Loperamide (exert antidiarrhoeal actions, reduce intestinal motility, not sedative and no addictive potential)
2nd line: Codeine
state the types of formulations that are NOT absorbed in patients with short bowel syndrome.
Enteric coating or modified release
state the types of formulations that CAN be absorbed in patients with short bowel syndrome.
- Soluble
- Uncoated
- Liquids
Red flags for constipation
BAWN
Blood in the stool
Anaemia
Abdominal pain
Weight loss (unexplained)
New onset constipation over 50 y/o
State the non-pharmacological management for constipation
- increase in dietary fibre
- adequate fluid intake
- exercise
- review meds that may cause constipation
(.e.g. iron preparations, opioids, clozapine and aluminium)
Bulk-forming laxatives (indication, eg, duration of onset)
IND: small hard stools
- increases the faecal mass
- stimulates peristalsis
- must take enough water for it to work and to prevent GI blockage
- takes 2-3 days to work
Stimulant laxative (indication, eg, duration of onset)
E.g. Glycerol and docusate are also stool softeners
- MOA: stimulates colonic nerves -> peristalsis
- Onset = takes 6-12 hours to work
- Avoid = intestinal obstruction
Co-danthromer and Co-danthrusate are cardiogenic – very strong
- only used in terminal illness
- causes red urine
osmotic laxative (indication, e.g., onset of duration)
E.g. lactulose, macrogols (movicol)
- MOA: increases the amount of fluid in the large bowel -> peristalsis
- takes 2-3 days to work
- also have faecal softening properties
stool softeners (indication, onset, caution)
- MOA: increases water penetration into the stool
- quickest laxative: docusate enema takes 5-20 minutes
- liquid paraffin: avoided due to anal seepage, granulomatous disease of GIT, lipid pneumonia on aspiration
(caution: to use due to its side effects)
State the ‘short duration’ management of constipation
1st line: bulk forming + good hydration
2nd line: osmotic
State the ‘chronic’ management of constipation
1st line: bulk forming + good hydration
2nd line/ no change: add/ change to macrogol (or lactulose 2nd line)
No change after 6 months: prucalopride (women only)
Withdraw lactulose slowly when the patient improves
State the ‘fecal impaction’ management of constipation
Hard stools:
Macrogol first then stimulant once stool softened
Soft stools:
Stimulant
If persists:
Rectal bisacodyl +/or glycerol
State the ‘opioid induced’ management of constipation
Osmotic + stimulant (together)
No response: naloxegol
Avoid bulk forming! -> may cause faecal impaction
State the management of constipation in pregnancy & BF
Dietary/ lifestyle first -> fibre supplements such as bran/ wheat
1st line: bulk forming
2nd line: lactulose
3rd line: Bisacodyl or senna (avoid senna near term)
State the management of constipation in children
1st line: dietary advice + macrogol (if no faecal impaction)
2nd line: add/ switch stimulant
If stool hard: lactulose or docusate
what are the associated symptoms of diarrhoea?
- dehydration
- cramps
- nausea
- flatulence
what classifies as acute diarrhoea?
diarrhoea <14 days
what classifies as persistent diarrhoea?
diarrhoea 14 - 28 days
what classifies as chronic diarrhoea?
diarrhoea >28 days
Red flag symptoms of diarrhoea
- unexplained weight loss
- Rectal bleeding
- Persistent diarrhoea
- Recent; travel history, course of abx, PPI
- Recent hospital treatment or abx treatment.
What is the 1st line treatment for acute diarrhoea?
1st line = Oral Replacement Therapy (ORT)
- restore electrolyte/fluid balance
e.g. Dioralyte (3 months+), Racecadotril (3months+)
What is the 2nd line treatment for acute diarrhoea for anti-diarrhoeals?
- Loperamide/ codeine
- over the age of 12 years
State the treatment for severe dehydration (and can’t drink)
- hospital
- IV fluids
State the treatment for travellers’ diarrhoea
- Loperamide
- Rifaximin
state the treatment for persistent diarrhoea
- co-phenotrope
(diphenoxylate (opioid) + atropine (antimuscarinic) )
AND
- oral rehydration therapy
state the treatment for chronic diarrhoea
Kaolin - intestinal adsorbent
* can be given alongside morphine (opioid)
state the dose recommendation of loperamide & max dose
4mg on day 1 THEN
2mg with every loose stool with the max 16mg per day
what is the MHRA alert for loperamide?
Serious cardiac side effects (QT prolongation, cardiac arrest) with high doses, misuse or abuse
contraindication of loperamide
- colitis
- abdominal distention, where peristalsis is inhibited (e.g. paralytic ileus)
Dyspepsia (symptoms, urgent referral symptoms)
Also known as indigestion, is discomfort/pain that occurs in the upper abdomen often after drinking/eating.
- Symptoms: upper abdominal pain, heartburn, gastric reflux, bloating, N/V
- Urgent referral symptoms (ALARM)
A naemia - due to GI bleeding
L oss of weight - potential sign of malignancy
A norexia
R ecent/new onset dyspepsia - 55+ years unresponsive to treatment
M alaenia - blood in stools, dyshphagia, haematemesis (“coffee grounds” in vomit)
Drug treatment for uninvestigated dyspepsia
- PPI for 4 weeks first
- If not effective = test for H pylori
- Treat H pylori if positive
Drug treatment for functional dyspepsia
- Test for H pylori and treat if positive
- Not infected: 4 weeks of PPI/ H2 antagonist
H. pylori (causative and diagnosis)
- most common cause of peptic ulcers, bacterial infection that grows in the digestive tract and tends to attack the stomach lining.
Diagnosis
* Urea (13C) breath test or stool helicobacter antigen test (SAT)
state the 2 cases where there could be a false positive from the use of the urea C-13 test
- PPI = stop use 2 weeks before test
- ABx = stop use 4 weeks before test
state the 1st line treatment for h.pylori for a pt with non-pen allergy
(7 days)
PPI + Amoxicillin + (clarithromycin or metronidazole)
state the 2nd line treatment for h.pylori for a pt with non-pen allergy
(7 days)
PPI + Amoxicillin + (clarithromycin or metronidazole - whichever was not used before)
or
PPI + Amoxicillin + (tetracycline/ levofloxacin - both UL)
state the 3rd line treatment for h.pylori for a pt with non-pen allergy
(10 days, under specialist)
PPI + Bismuth salicylate + [rifabutin/furazolidone]
state the 1st line treatment for h.pylori for a pt with pen allergy
(7 days)
PPI + metronidazole + clarithromycin
- if clarithromycin was used and NOT effective
PPI + metronidazole + tetracycline (UL) + bismuth salicylate (UL)
state the 2nd line treatment for h.pylori for a pt with pen allergy
(7 days)
PPI + metronidazole + levofloxacin
OR
PPI + metronidazole + tetracycline + bismuth salicyclates
state the 3rd line treatment for h.pylori for a pt with pen allergy
(10 days under specialist)
PPI + bismuth salicylates + (rifabutin or Furazolidone) - both UL
Gastro-oesophageal reflux disease (GORD); urgent referral symptoms
- occurs when the stomach acid leaks from the stomach and moves up into the oesophagus.
Urgent referral symptoms (GAUD)
• GI bleed
• Age 55 +
• Unexplained weight loss
• Dysphagia
State the factors that can cause GORD
• Consuming fatty foods, pregnancy, hiatus hernia, FH, stress, obesity, smoking, alcohol, drugs (AB3 CNNT)
- Alpha/ beta blockers, anticholinergics, benzodiazepines, bisphosphonates, corticosteroids, NSAIDs, TCAs, nitrates
- Loosens up the sphincter making acid reflux easier
State non-pharmacological advice for GORD
- Healthy eating
- weight loss
- avoid trigger foods
- eating smaller meals
- eat evening meal 3-4 hours before bed
- raise head of bed
- smoking cessation
- reduce alcohol
what is the treatment for severe GORD?
- review and discontinue GORD-inducing drugs e.g. AB3 CNNT
- 8 weeks of PPI -> If this doesn’t work use the H2 antagonist
what is the treatment for mild to moderate GORD?
- Antacids/alginate
AND
PPI (4-8 weeks), if not tolerated give H2 antagonist
Treatment for GORD in pregnancy
- 1st line: Dietary/ lifestyle advice
- 2nd line: Antacid or an alginate
- 3rd line: Omeprazole (to control symptoms)
State the side effects for Magnesium containing antacids
Laxative
State the side effects for Aluminium containing antacids
Constipating
State the side effects for Calcium containing antacids
induces rebound acid secretion
State the side effects of Simethicone antacids (anti-foaming)
relieves flatulence
State the side effects of alginate antacids
- increases viscosity of stomach contents
- Forms viscous gel (raft) that floats on the surface
State the interactions of antacids
• Increases stomach pH (more alkali)
- Enteric-coated capsules broken down in the stomach rather than the intestines
- Antacids should not be taken with other drugs due to impaired absorption
- Bisphosphonates, tetracyclines, ciprofloxacin
• Sodium content
- Check sodium content of antacid
- Should not be taken with lithium/ in hypertension/ heart/ liver/ renal failure
- Low sodium antacid: co-magaldrox/ mucogel/ malox
Cholestasis & symptoms
• Impaired bile formation or flow
• Symptoms: fatigue, pruritis, dark urine, pale, jaundice
Cholestatic pruritus treatment
- Colestyramine: SE= constipation, bleeding, N/V, reduced vitamin ADEK absorption
- Ursodeoxycholic acid
- Rifampicin
Intrahepatic cholestatic pruritus in pregnancy
- During late pregnancy this can lead to adverse foetal outcomes
- Treatment of pruritis symptoms: ursodeoxycholic acid
Gallstones
hard mineral or fatty deposits forming stones in gallbladder bile duct
Treatment for asymptomatic gallstones
no treatment is needed
Treatment for symptomatic gallstones
surgery removal
Drug treatment for gallstones
(only for mild to moderate pain e.g., while waiting for surgery)
- Analgesia for pain: paracetamol or NSAID
- Severe pain: IM diclofenac or IM opioid if diclofenac not suitable
symptoms of anal fissure
- bleeding (bright red)
- sharp & persistent pain on defacation
- linear split in the anal mucosa (fissure)
Acute management for anal fissure
Present for less than 6 weeks
- Bulk-forming or osmotic laxatives
- Short-term topical with local anaesthetics (lidocaine) or analgesic (paracetamol/ibuprofen)-> but avoid in pregnancy
Chronic management for anal fissure
- 6 weeks or longer -> rectal GTN (SE = Headache)
- Topical/ oral diltiazem or nifedipine -> lower SE
- Specialist -> botulinum toxin A
- Surgery if no drug response
Haemorrhoids (what it is, high risk pts, types of piles)
• Swelling of vascular mucosal anal cushions
• High risk: pregnancy
• Internal: painless
• External: itchy or painful
Treatment management for haemorrhoids
• To loosen stools with increase fibre intake +/- bulk-forming laxatives
• Pain: paracetamol
- avoid opioids as this causes constipation (will worsen)
- avoid NSAIDs as this will exacerbate rectal bleeding
•Pain/ itching: topical preparations
- anaesthetics e.g., lidocaine – use for a few days
- corticosteroids – use no longer than 7 days due to SE
- lubricant
- antiseptics
Treatment management for haemorrhoids in pregnancy
- bulk-forming laxatives
- no topical haemorrhoidal preparations – only simple soothing prep if needed
Pancreatic insufficiency
- Reduces secretion pancreatic enzymes into duodenum
- can be due to pancreatitis, CF, pancreatitis tumours, coeliac disease, GI resection
- may lead to maldigestion and malnutrition
Treatment for exocrine pancreatic insufficiency
• Pancreatic enzyme replacement = PANCREATIN (Creon)
- contains lipase, amylase, and protease which digests food for absorption
- take with meals and snacks – prevents the early breakdown
• Patients with CF = fibrosing colonopathy at high dose pancreatin
- CF patients should not exceed 10000 units/kg/ day of lipase
- Report any new abdominal symptoms
• Levels of fat-soluble vitamins and micronutrients should be monitored
- Give supplements when needed
what is a stoma and what are the common forms of stoma?
Artificial opening on the abdomen to divert flow of faeces of urine into external pouch located outside of the body
common forms: colostomy and ileostomy
what types of formulations are not recommended in patients with a stoma?
- EC/ MR preparations = insufficient release
name the types of formulations that are advised to be used in patients with a stoma
- uncoated tablets
- liquids
- soluble tablets
- capsules
what type of analgesia would you advice to be prescribed in patients with stoma?
Paracetamol (soluble, caps or liquid form)
what type of analgesia would you AVOID to be prescribed in patients with a stoma?
- Opioids = constipation effect, CI: colostomy
- Aspirin/ NSAIDs = cx GI bleeding & irritation
name the types of antacids that should be AVOIDED to use in patients with a stoma.
- Magnesium salts = laxative effects CI: ileostomy
- Aluminium salts = constipation effects CI: colostomy
- Calcium salts = induce gastric acid secretion rebound
Counselling pts with stoma care
may get increased acid secretion -> give PPI or somatostatin analogues (octreotide)
Name the types of symptoms from the use of certain medications can affect stoma care
- diarrhoea
- constipation
- GI irritation + bleed
Cause of diarrhoea as SE of stoma care
- Sorbitol
- Magnesium antacids
- Iron (ileostomy)
Solution: Loperamide and codeine
Cause of constipation as SE of stoma care
- opioids
- calcium antacids
- iron (colostomy)
Solution: use bulk forming if needed or low dose stimulant if this doesn’t work
Cause of GI irritation & bleed as SE of stoma care
Aspirin + NSAIDs
Use of diuretics or laxatives in pts with stoma care
- May cause dehydration which may cause hypokalaemia
- Switch to potassium-sparing diuretic (amiloride, spironolactone)
- May need potassium supplements
- Use liquid form potassium (better than MR forms)
- Fluid and Na depletion may occur which can cause hypokalaemia and increase the risk of digoxin toxicity
name the indications of misoprostol
- is a synthetic prostaglandin analogue and a potent uterine stimulant
- Used for benign gastric ulcers, prophylaxis of NSAIDs-associated ulceration and termination of pregnancy following mifepristone
advice of taking misoprostol in pregnancy
- avoid in 1st trimester (1-12 weeks)
- it can precipitate abortion and cause teratogenicity
what are the side effects of misoprostol
common - nausea, vomiting and rash
