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GPhC Exam '22 > CH1: GASTRO CLINICAL > Flashcards

CH1: GASTRO CLINICAL Flashcards

1
Q

Define Coeliac disease

A
  1. Autoimmune response triggered by gluten
  2. Malabsorption of nutrients
  3. Inflammation of the small intestine
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2
Q

Symptoms of coeliac disease?

A

Acronym - ABCD

Abdominal pain
Bloating
Complications from nutrient malabsorption
Diarrhoea

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3
Q

Patients who are gluten intolerant are at risk of what forms of deficiencies?

A
  1. Low Vitamin D
  2. Low Calcium levels
  3. Low Folate levels
  4. Low Vitamin B12 levels

*The complications of malabsorption of these nutrients = increase risk of bone disease and OSTEOPOROSIS

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4
Q

How is coeliac disease managed? (treatment)

A
  1. Strict glute-free diet
  2. Supplementation
    (Calcium, Vit D & B12 and Folic acid)
  3. Prednisolone (to treat the inflammation of the small intestine if severe or exacerbated)
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5
Q

What are the 2 conditions are patients with Coeliac disease at risk of?

A
  1. Osteoporosis (low Ca2+ and low Vitamin D)
  2. Malabsorption of key nutrients
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6
Q

What is the main difference between ACUTE DIVERTICULITIS and DIVERTICULAR disease?

A

Acute Diverticul(ITIS)- small pouches are inflamed or infected

Diverti(CULAR) disease- small pouches but symptomatic, is more on mild-moderate abdominal pain

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7
Q

How to treat acute diverticulitis (1st line and 2nd line)?

A

1st line- Co-amoxiclav
2nd line - Cefalexin + Metronidazole (if pen allergy)

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8
Q

Management of diverticular disease

A
  1. Bulk forming agent e.g. fybogel
  2. Increase fibre intake
  3. Pain - paracetamol, avoid ibuprofen (increases the risk of diverticular perforation).
  4. Antispasmodic (nausea, abdominal pain, muscle spasms) i.e. mebeverine or albeverine.
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9
Q

Define Inflammatory Bowel Disease (IBD)

A

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)

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10
Q

State the COMMON symptoms of IBD (6)

A
  1. Abdominal pains
  2. Rectal bleeding
  3. Weight loss
  4. Anaemia
  5. Diarrhoea
  6. Fever
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11
Q

Symptoms of Crohn’s disease

A
  1. Abdominal pain
  2. Rectal bleeding
  3. Weight loss
  4. Diarrhoea
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12
Q

Complications associated with Crohn’s disease (5)

A
  1. Colorectal or small bowel cancer
  2. Anaemia and malnutrition
  3. Intestine fistulas
  4. Growth failure and delayed puberty in children
  5. Extra-intestinal manifestation (arthritis, eyes, joints, liver and skin - abnormalities)
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13
Q

State the non-drug treatment for Crohn’s disease (2)

A
  1. Smoking cessation
  2. Nutrition
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14
Q

Identify the 1st line treatment for ACUTE EXACERBATION of Crohn’s disease

A

Glucocorticoid monotherapy
- Prednisolone, methylprednisolone etc

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15
Q

Identify the 2nd line treatment for ACUTE EXACERBATION of Crohn’s disease

A

Budesonide
- if a pt. is contraindicated to 1st line
- if pt. has a distal, ileal, ileocecal or right sided colonic disease

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16
Q

Symptoms of Ulcerative Colitis (3)

A
  1. Bloody Diarrhoea (pus and mucus)
  2. Defecation urgency
  3. Abdominal pain
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17
Q

State what is Proctitis and its treatment regime (1st, 2nd and 3rd line)

A

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

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18
Q

State what is Proctosigmoiditis and its treatment regime (1st, 2nd and 3rd line)

A

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

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19
Q

State what is distal left sided UC and its treatment regime (1st, 2nd and 3rd line)

A

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
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20
Q

State what is Extensive colitis and its treatment regime (1st, 2nd and 3rd line)

A

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.

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21
Q

Medications to avoid for treating diarrhoea associated UC (2)

A
  1. Loperamide
  2. Codeine
    Increases risk of toxin megacolon – can be used under specialist advice!
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22
Q

State the treatment regime (1st, 2nd and 3rd line) of life-threatening ACUTE to SEVERE UC (medical emergency).

A

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

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23
Q

State the maintenance treatment for Proctitis/ Proctosigmoiditis

A

Rectal Aminosalicylates +/- PO Aminosalicylates
*can be given only PO if patient doesn’t want rectal = would be less effective.

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24
Q

State the maintenance treatment for distal left-sided and extensive UC

A

Low dose of oral aminosalicylate

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25
Q

State the maintenance treatment for UC ‘>2 flares in 1 year’.

A

1st line - Oral Azathioprine OR Mercaptopurine (UL)
2nd line - Monoclonal antibiotics (infliximab) if no effects

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26
Q

What is ‘irritable bowel syndrome’ (IBS)?
- symptoms
- triggers

A
  • 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.

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27
Q

What are the non-pharmacological treatment for IBS

A
  • 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
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28
Q

Briefly state the drug treatments for IBS and examples of drugs.

A
  1. 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)
  1. Constipation = laxatives
    Avoid lactulose = which causes bloating (SE of IBS)
    - Linoclotide = unresponsive IBS for 12 months
  2. Diarrhoea = antimotility
    - Loperamide = >12yrs, avoid in CVD pts as it can cause severe QT prolongation in high doses resulting to cardiac arrest
  3. Abdominal discomfort = antidepressants
    - TCAs = amitriptyline (off label) r/v after 4 weeks
    - SSRIs = citalopram or fluoxetine (off-label)
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29
Q

define short bowel syndrome

A
  • 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
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30
Q

State the management of short bowel syndrome

A
  • 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

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31
Q

state the types of formulations that are NOT absorbed in patients with short bowel syndrome.

A

Enteric coating or modified release

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32
Q

state the types of formulations that CAN be absorbed in patients with short bowel syndrome.

A
  • Soluble
  • Uncoated
  • Liquids
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33
Q

Red flags for constipation

A

BAWN

Blood in the stool
Anaemia
Abdominal pain
Weight loss (unexplained)
New onset constipation over 50 y/o

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34
Q

State the non-pharmacological management for constipation

A
  • increase in dietary fibre
  • adequate fluid intake
  • exercise
  • review meds that may cause constipation
    (.e.g. iron preparations, opioids, clozapine and aluminium)
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35
Q

Bulk-forming laxatives (indication, eg, duration of onset)

A

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
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36
Q

Stimulant laxative (indication, eg, duration of onset)

A

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

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37
Q

osmotic laxative (indication, e.g., onset of duration)

A

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

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38
Q

stool softeners (indication, onset, caution)

A
  • 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)
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39
Q

State the ‘short duration’ management of constipation

A

1st line: bulk forming + good hydration
2nd line: osmotic

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40
Q

State the ‘chronic’ management of constipation

A

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

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41
Q

State the ‘fecal impaction’ management of constipation

A

Hard stools:
Macrogol first then stimulant once stool softened
Soft stools:
Stimulant
If persists:
Rectal bisacodyl +/or glycerol

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42
Q

State the ‘opioid induced’ management of constipation

A

Osmotic + stimulant (together)
No response: naloxegol
Avoid bulk forming! -> may cause faecal impaction

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43
Q

State the management of constipation in pregnancy & BF

A

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)

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44
Q

State the management of constipation in children

A

1st line: dietary advice + macrogol (if no faecal impaction)
2nd line: add/ switch stimulant
If stool hard: lactulose or docusate

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45
Q

what are the associated symptoms of diarrhoea?

A
  1. dehydration
  2. cramps
  3. nausea
  4. flatulence
46
Q

what classifies as acute diarrhoea?

A

diarrhoea <14 days

47
Q

what classifies as persistent diarrhoea?

A

diarrhoea 14 - 28 days

48
Q

what classifies as chronic diarrhoea?

A

diarrhoea >28 days

49
Q

Red flag symptoms of diarrhoea

A
  1. unexplained weight loss
  2. Rectal bleeding
  3. Persistent diarrhoea
  4. Recent; travel history, course of abx, PPI
  5. Recent hospital treatment or abx treatment.
50
Q

What is the 1st line treatment for acute diarrhoea?

A

1st line = Oral Replacement Therapy (ORT)
- restore electrolyte/fluid balance

e.g. Dioralyte (3 months+), Racecadotril (3months+)

51
Q

What is the 2nd line treatment for acute diarrhoea for anti-diarrhoeals?

A
  • Loperamide/ codeine
  • over the age of 12 years
52
Q

State the treatment for severe dehydration (and can’t drink)

A
  • hospital
  • IV fluids
53
Q

State the treatment for travellers’ diarrhoea

A
  • Loperamide
  • Rifaximin
54
Q

state the treatment for persistent diarrhoea

A
  • co-phenotrope
    (diphenoxylate (opioid) + atropine (antimuscarinic) )

AND

  • oral rehydration therapy
55
Q

state the treatment for chronic diarrhoea

A

Kaolin - intestinal adsorbent
* can be given alongside morphine (opioid)

56
Q

state the dose recommendation of loperamide & max dose

A

4mg on day 1 THEN
2mg with every loose stool with the max 16mg per day

57
Q

what is the MHRA alert for loperamide?

A

Serious cardiac side effects (QT prolongation, cardiac arrest) with high doses, misuse or abuse

58
Q

contraindication of loperamide

A
  • colitis
  • abdominal distention, where peristalsis is inhibited (e.g. paralytic ileus)
59
Q

Dyspepsia (symptoms, urgent referral symptoms)

A

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)
60
Q

Drug treatment for uninvestigated dyspepsia

A
  • PPI for 4 weeks first
  • If not effective = test for H pylori
  • Treat H pylori if positive
61
Q

Drug treatment for functional dyspepsia

A
  • Test for H pylori and treat if positive
  • Not infected: 4 weeks of PPI/ H2 antagonist
62
Q

H. pylori (causative and diagnosis)

A
  • 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)

63
Q

state the 2 cases where there could be a false positive from the use of the urea C-13 test

A
  1. PPI = stop use 2 weeks before test
  2. ABx = stop use 4 weeks before test
64
Q

state the 1st line treatment for h.pylori for a pt with non-pen allergy

A

(7 days)
PPI + Amoxicillin + (clarithromycin or metronidazole)

65
Q

state the 2nd line treatment for h.pylori for a pt with non-pen allergy

A

(7 days)
PPI + Amoxicillin + (clarithromycin or metronidazole - whichever was not used before)

or

PPI + Amoxicillin + (tetracycline/ levofloxacin - both UL)

66
Q

state the 3rd line treatment for h.pylori for a pt with non-pen allergy

A

(10 days, under specialist)
PPI + Bismuth salicylate + [rifabutin/furazolidone]

67
Q

state the 1st line treatment for h.pylori for a pt with pen allergy

A

(7 days)
PPI + metronidazole + clarithromycin

  • if clarithromycin was used and NOT effective
    PPI + metronidazole + tetracycline (UL) + bismuth salicylate (UL)
68
Q

state the 2nd line treatment for h.pylori for a pt with pen allergy

A

(7 days)
PPI + metronidazole + levofloxacin

OR

PPI + metronidazole + tetracycline + bismuth salicyclates

69
Q

state the 3rd line treatment for h.pylori for a pt with pen allergy

A

(10 days under specialist)

PPI + bismuth salicylates + (rifabutin or Furazolidone) - both UL

70
Q

Gastro-oesophageal reflux disease (GORD); urgent referral symptoms

A
  • 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

71
Q

State the factors that can cause GORD

A

• 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
72
Q

State non-pharmacological advice for GORD

A
  • 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
73
Q

what is the treatment for severe GORD?

A
  • review and discontinue GORD-inducing drugs e.g. AB3 CNNT
  • 8 weeks of PPI -> If this doesn’t work use the H2 antagonist
74
Q

what is the treatment for mild to moderate GORD?

A
  • Antacids/alginate
    AND
    PPI (4-8 weeks), if not tolerated give H2 antagonist
75
Q

Treatment for GORD in pregnancy

A
  • 1st line: Dietary/ lifestyle advice
  • 2nd line: Antacid or an alginate
  • 3rd line: Omeprazole (to control symptoms)
76
Q

State the side effects for Magnesium containing antacids

A

Laxative

77
Q

State the side effects for Aluminium containing antacids

A

Constipating

78
Q

State the side effects for Calcium containing antacids

A

induces rebound acid secretion

79
Q

State the side effects of Simethicone antacids (anti-foaming)

A

relieves flatulence

80
Q

State the side effects of alginate antacids

A
  • increases viscosity of stomach contents
  • Forms viscous gel (raft) that floats on the surface
81
Q

State the interactions of antacids

A

• 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

82
Q

Cholestasis & symptoms

A

• Impaired bile formation or flow
• Symptoms: fatigue, pruritis, dark urine, pale, jaundice

83
Q

Cholestatic pruritus treatment

A
  • Colestyramine: SE= constipation, bleeding, N/V, reduced vitamin ADEK absorption
  • Ursodeoxycholic acid
  • Rifampicin
84
Q

Intrahepatic cholestatic pruritus in pregnancy

A
  • During late pregnancy this can lead to adverse foetal outcomes
  • Treatment of pruritis symptoms: ursodeoxycholic acid
85
Q

Gallstones

A

hard mineral or fatty deposits forming stones in gallbladder bile duct

86
Q

Treatment for asymptomatic gallstones

A

no treatment is needed

87
Q

Treatment for symptomatic gallstones

A

surgery removal

88
Q

Drug treatment for gallstones

A

(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

89
Q

symptoms of anal fissure

A
  • bleeding (bright red)
  • sharp & persistent pain on defacation
  • linear split in the anal mucosa (fissure)
90
Q

Acute management for anal fissure

A

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
91
Q

Chronic management for anal fissure

A
  • 6 weeks or longer -> rectal GTN (SE = Headache)
  • Topical/ oral diltiazem or nifedipine -> lower SE
  • Specialist -> botulinum toxin A
  • Surgery if no drug response
92
Q

Haemorrhoids (what it is, high risk pts, types of piles)

A

• Swelling of vascular mucosal anal cushions
• High risk: pregnancy
• Internal: painless
• External: itchy or painful

93
Q

Treatment management for haemorrhoids

A

• 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

94
Q

Treatment management for haemorrhoids in pregnancy

A
  • bulk-forming laxatives
  • no topical haemorrhoidal preparations – only simple soothing prep if needed
95
Q

Pancreatic insufficiency

A
  • Reduces secretion pancreatic enzymes into duodenum
  • can be due to pancreatitis, CF, pancreatitis tumours, coeliac disease, GI resection
  • may lead to maldigestion and malnutrition
96
Q

Treatment for exocrine pancreatic insufficiency

A

• 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

97
Q

what is a stoma and what are the common forms of stoma?

A

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

98
Q

what types of formulations are not recommended in patients with a stoma?

A
  • EC/ MR preparations = insufficient release
99
Q

name the types of formulations that are advised to be used in patients with a stoma

A
  • uncoated tablets
  • liquids
  • soluble tablets
  • capsules
100
Q

what type of analgesia would you advice to be prescribed in patients with stoma?

A

Paracetamol (soluble, caps or liquid form)

101
Q

what type of analgesia would you AVOID to be prescribed in patients with a stoma?

A
  • Opioids = constipation effect, CI: colostomy
  • Aspirin/ NSAIDs = cx GI bleeding & irritation
102
Q

name the types of antacids that should be AVOIDED to use in patients with a stoma.

A
  • Magnesium salts = laxative effects CI: ileostomy
  • Aluminium salts = constipation effects CI: colostomy
  • Calcium salts = induce gastric acid secretion rebound
103
Q

Counselling pts with stoma care

A

may get increased acid secretion -> give PPI or somatostatin analogues (octreotide)

104
Q

Name the types of symptoms from the use of certain medications can affect stoma care

A
  • diarrhoea
  • constipation
  • GI irritation + bleed
105
Q

Cause of diarrhoea as SE of stoma care

A
  • Sorbitol
  • Magnesium antacids
  • Iron (ileostomy)

Solution: Loperamide and codeine

106
Q

Cause of constipation as SE of stoma care

A
  • opioids
  • calcium antacids
  • iron (colostomy)

Solution: use bulk forming if needed or low dose stimulant if this doesn’t work

107
Q

Cause of GI irritation & bleed as SE of stoma care

A

Aspirin + NSAIDs

108
Q

Use of diuretics or laxatives in pts with stoma care

A
  • 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
109
Q

name the indications of misoprostol

A
  • 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
110
Q

advice of taking misoprostol in pregnancy

A
  • avoid in 1st trimester (1-12 weeks)
  • it can precipitate abortion and cause teratogenicity
111
Q

what are the side effects of misoprostol

A

common - nausea, vomiting and rash

GPhC Exam '22 (16 decks)

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