Chapter 1: Gastro-intestinal system Flashcards
1
Q
What are the monitoring and reporting requirements for Aminosalicylates
A
Monitoring: Renal function before starting, 3 months later and then annually Reporting: (All) Blood dyscrasia- sore throat, fever, rash, ulcers, bleeding Mesalazine: switching brands- advise to report any changes in symptoms
Sulfasalazine: colours body fluids orange/yellow
2
Q
Why is liquid paraffin no longer recommended
A
Due to anal irritation and seepage of paraffin after prolonged use
3
Q
What is Sucralfate used for and what is its caution
A
Benigh gastruc ulcers, Chronic Gastritis
Caution: BEZOAR formation- stone like mass found in GI system especially in critically ill patients in intensive care or with enteral feeds
4
Q
What is Pancreatin and what are the appropriate counselling points
A
Creon - mixtures of enzymes used to aid digestion
- Patients should adequate hydration at high doses
- Capsules should be swallowed whole and not chewed
5
Q
Which antacids can cause contipation and which can cause diarrhoea
A
Magnesium containing = laxative effects (diarrhoea)
Aluminium & Calcium containing= constipation effects
6
Q
Which GI conditions are the following drugs used for
Hyoscine butylbromide
Alverine Citrate
Mebeverine
A
(All) Gastro-intestinal smooth muscle spasms
Hyoscine: IBS, Acute spasms
Mebeverine: IBS
7
Q
Which electrolytes are affected by PPIs
A
Hyponatreamia
Long term use: Hypomagnesaemia (more common after 1 year but sometimes after 3 months)
8
Q
What are some side effects of Loperamide and what is the MHRA alert
A
Flatulence, GI disorders, Nausea, Headache, Dizziness, Dry mouth
MHRA alert: Serious cardiovascular events (e.g. QT prolongation, TDP, cardiac arrest) with large overdose, naloxone can be given as an antidote
9
Q
Name the bulk forming laxatives and some of their side effects
A
Ispahula husk, Methylcellulose and Sterculia
Flatulence, Abdominal distension (bloating), GI disorders
Take with atleast 150ml of water
Do not use for opioid induced constipation as can precipitate intestinal obstrution
10
Q
Name the Stimulant laxatives and some of their side effects
A
Bisacodyl, Co-danthramer (palliative care only) Docusate (stool softening properties), Glycerol, Senna and sodium picosulfate
S/E: GI discomfort and Cramps
Co-danthramer and senna colours the urin red
11
Q
Name the osmotic laxatives and some of their side effects
A
Lactulose, Macrogol, Magnesium hydroxide
S/Es: Nausea, vomitting, cramps, bloating, flatulence
12
Q
What do the words “low Na+” on antacid preparations indicate?
A
Sodium content of less than 1mmol per tablet or 10ml dose. This is written on for people with hypertension
13
Q
When would you advise patients to take antacids
A
Space doses out from other drugs (2 hour gap)
Alginates create a raft so should be taken after food (if taken before food, the food will penetrate the raft as they enter the stomach)
14
Q
When should PPIs be taken?
A
At least 30 mins before food for optimal absorption
15
Q
What drug, used for GI ulcers, should be avoided in all trimesters of pregnancy and in women of a child bearing age unless absolutely necessary?
A
Misoprostol
Used in GI for NSAID induced ulcers
Teratogenic - also used for termination of pregnancy
16
Q
Safest PPI in pregnant women?
A
Omeprazole
17
Q
Diarrhoea advice in a pregnant woman?
A
Avoid loperamide.
Lifestule advise best: Maintain adequate hydration
refer if present for more than 48 hours or more than 6 loose stools in 24 hours
18
Q
Safest laxative in pregnant women?
A
If dietary and lifestyle advice fails you can use bulk forming (first line).
an osmotic (lactulose) can be used. Bisacodyl and senna should only be used if a stimulant effecct is necessary but their use near term should be avoided.
Docusate and glyercol suppositiories can be used.
19
Q
How do you treat haemorrhoids in pregnant woman
A
No topical haemorrhoidal preparations are licensed for use during pregnancy. If required a simple, soothing product should be used.
Local anaesthetics and steroids should be avoided.
20
Q
Which antiemetic drug can be purchased over the counter?
A
Prochlorperazine: Buccastem (for migraines)
Motion sickness
Hyoscine: Kwells (10+), Kwells Kids (4+), Joy Rides (3+), scopoderm patches (10+)
Cinnarizine: Sturgeron (5+)
Promethazine: Phenergan (2+)
21
Q
What laxative and what anti-emetic are recommended for use in terminally ill patients?
A
Laxative: co-danthromer/ co-danthrusate (can colour urine red) It is locally irritant- avoid contact with skin
Anti-emetic: Ondansetron, Haloperidol- these are good for opioid induce N&V (Haloperidol also used first line for delirium in palliative care- this is very common)
22
Q
Which laxative should be used where there is faecal impaction?
A
Osmotic laxatives
23
Q
What is the MHRA saftey alert with PPIs
A
Subacute cutaneous lupus erythematosus (SCLE)
development of lesions with associated athralgia
24
Q
When is metoclopromide contraindicated for treating sickness?
A
3 - 4 days after Gastrointestinal surgery
GI heamorrhage
GI obstruction
Under 18 years due to neurological effects
Epilepsy
Parkinsons
25
Which laxatives are used in opioid induced constipation/ immobility
Osmotic or Stimulant
do not use bulk forming
26
What is Colestipol?
When should other medications be taken in relation to this drug?
A bile acid sequestrant used to lower cholesterol (LDL specifically)
Take other medication 1 hour before or 4 hours after this medication as it can effect absorption
can affect the absorption of Vitamins A D E K and Folic acid
27
Which of the following is not a typical symptom of IBS?
A. Abdominal pain
B. Bloating
C. Constipation
D. Diarrhoa
E. Emesis (vomiting)
Emesis (vomiting)
28
Why can Crohns disease cause secondary osteoporosis?
Reduced absorption of dietary vitamins and minerals.
29
What is fistulating Crohn's disease?
When there is the formation of a fistula between the intestine and adjacent structures, such as the perianal skin, bladder, and vagina. It occurs in about 1/4 patients, mostly when the disease involves the ileocolonic area.
30
What common harmful lifestyle factor can make Crohn's worse?
Smoking
31
In the treatment of acute Crohn's, what is used to induce remission in patients with a first presentation or a single inflammatory exacerbation of Crohn's in a 12-month period?
A corticosteroid (either prednisolone, methylprednisolone or intravenous hydrocortisone).
32
Acute Crohns: In patients with distal ileal, ileocaecal or right-sided colonic disease, in whom a conventional corticosteroid is unsuitable or contra-indicated, what can be considered and why?
Budesonide can be considered, it is less effective but may cause fewer side-effects than other corticosteroids as the systemic exposure is limited.
Aminosalicylates (sulfasalazine and mesalazine) are an alternative option. But less effective.
33
When would add-on treatment be used in Acute Crohn's?
If there are two or more inflammatory exacerbations in a 12-month period, or if the corticosteroid dose cannot be reduced.
34
Acute Crohn's: What can be added to a corticosteroid or budesonide to induce remission?
Azathioprine or mercaptopurine can be added. Azathioprine or mercaptopurine [unlicensed indications] can be added to a corticosteroid or budesonide to induce remission. In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, methotrexate can be added to a corticosteroid.
35
Acute Crohn's: Add-on treatment: In patients who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity is deficient, what can be added to a corticosteroid?
Methotrexate
36
Under specialist supervision, monoclonal antibody therapies with what are options for the treatment of severe, active Crohn's disease, following inadequate response to conventional therapy?
Adalimumab, Infliximab
37
How does adalimumab work?
anti TNF
38
How does infliximab work?
Anti TNF
39
What BMI is required for treatment with orlistat
30 kg/m2 or more
OR
28 kg/m2 or more in the presence of other risk factors such as type 2 diabetes, hypertension or hypercholesterolaemia
40
The absorption of which vitamins is impaired during treatment with orlistat
A D E K
&
Folic acid
41
In the maintenance of remission in Crohn's, which drugs used as unlicensed monotherapy can maintain remission
Azathioprine and mercaptopurine
42
What are the symptoms of Crohn's relapse?
Weight loss, abdominal pain, diarrhoea and general ill-health.
43
Methotrexate should only be used in patients to maintain remission if what?
if they are intolerant of or not suitable for azathioprine or mercaptopurine treatment.
44
What drugs should not be used for the maintenance of remission in Crohn's?
Corticosteroids or budenoside.
use to induce remission only
45
What drug is licensed for the relief of diarrhoea associated with Crohn's disease?
Colestyramine
loperamide and codeine can also be used.
46
Are patients with coeliac disease recommended to self medicate with OTC vitamin and mineral supplements?
No
should be refered so their requirements can be assessed. OTC strengths may not be enough
47
What are coeliac patients at increased risk of?
Malabsorption
Vitamin and mineral deficiency - can increase the risk of osteoporosis
48
What is diverticular disease?
Diverticula (sac-like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain in the absence of inflammation or infection. Can cause large rectal bleeds
49
What is the treatment for diverticular disease
high fibre diet or bulking forming laxatives for constipation symptoms
Paracetamol for pain and antispasmodics
50
What is not recommended in uncomplicated diverticular disease?
Antibiotics unless the patient presents with signs of infection/immunocompromised
the use of NSAIDS or opioids is not recommended in uncomplicated diverticular disease
51
What is the treatment for complicated diverticular disease?
Hospital admission required - IV antibacterials covering gram negative and anaerobes & Bowel rest
52
True or false:
There is insufficient evidence to justify the role of fibre, rifaximin, antispasmodics, mesalazine, and probiotics in the prevention or treatment of diverticulitis.
TRUE
53
What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?
Avoids the sulfonamide-related side effects of sulfasalazine
(sulphonamides are CYP inhibitors)
54
Sulfasalazine is a combination of what two compounds?
5-ASA and sulfapyridine
Sulfapyridine acts only as a carrier to the colonic site of action but still causes side effects
55
What compound is mesalazine?
5-ASA
56
Balsalazide is a pro drug of what?
5-ASA
57
What are extraintestinal manifestations?
When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis
58
In a patient with a first presentation or single inflammatory Crohn's exacerbation in a 12 month period, what drug is used?
If this is not suitable, or if the patient has right-sided colonic disease, what could be used? When would these not be appropriate and why?
1. Corticosteroid - prednisolone, methylprednisolone or IV hydrocortisone
2. Budesonide or aminosalicylates. Not appropriate if severe presentation as they are less effective (even though they have fewer side effects)
59
When would you add in additional treatment (on top of steroid monotherapy) in a Crohn's disease exacerbation?
What would you add?
2 or more inflammatory exacerbations in 12 months, or if the steroid dose cannot be reduced
Azathioprine or mercaptopurine
60
Is mercaptopurine licensed in severe UC or CD?
No
61
What can be added to a steroid to induce remission in a Crohn's patient?
If these are not suitable, what could be used?
1. Azathioprine, Mercaptopurine (unlicensed)
2. Methotrexate
62
What test do you need to do before starting someone on azathioprine or mercaptopurine?
TPMT levels. If activity is deficient, it may not be suitable
FBC weekly for 4 week, then every 3 months
Patients should be advised to monitor for signs of bone marrow suppresion
63
What monoclonal antibodies are licensed for Crohn's?
Adalimumab
Infliximab - can also be used for active fistulating CD
64
Should steroids be used for the maintenance of remission for Crohn's?
No- only to induce remission
65
What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn's?
Metronidazole and ciprofloxacin (unlicensed)
66
If metronidazole is given for fistulating Crohn's, how long for and what are the associated risks?
1 month (no longer than 3) due to risk of peripheral neuropathy
67
What is used to control the inflammation in fistulating Crohn's disease (and continued for maintenance)? How long should they be on this for?
Azathioprine or mercaptopurine (unlicensed) or infliximab
68
Can you use loperamide and codeine phosphate in acute UC?
No- contraindicated as it increases the risk of toxic megacolon
69
What type of laxative may be useful for proximal faecal loading in proctitis?
Macrogol
70
What is first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of proctitis and proctosigmoiditis?
What would be second line?
1. Rectal aminosalicylates. Oral prednisolone should be considered for the treatment of patients with subacute proctitis or proctosigmoiditis.
2. Rectal corticosteroid or oral prednisolone
71
Which aminosalicylates have rectal preparations?
Mesalazine and sulfasalazine
72
What is first line treatment for patients with acute exacerbation mild-moderate left-sided or extensive UC?
High induction dose of an oral aminosalicylate, with addition of a rectal aminosalicylate or oral beclometasone dipropionate if necessary.
Oral prednisolone alone is recommended for patients who cannot tolerate or who decline aminosalicylates, in whom aminosalicylates are contra-indicated or in patients with subacute left-sided or extensive ulcerative colitis.
73
In patients being treated with aminosalicylates for UC, when would you add in oral prednisolone?
No improvements within 4 weeks of initial therapy. If patient is on beclometasone, discontinue this
74
Why does oral budesonide have fewer systemic side effects than corticosteroids?
It exerts its action locally in the colon
75
True or false: Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable
TRUE
76
Are corticosteroids suitable for maintenance treatment of UC?
No because of their side effects
77
What should be given in severe acute UC?
IV corticosteroids
IV ciclosporin is an alternative (unlicensed)
78
What monoclonal antibodies are used for acute UC?
Adalimumab, golimumab, infliximab, vedolizumab
79
What can be used to maintain remission after an acute exacerbation of proctitis/proctosigmoiditis?
Rectal aminosalicylate can be started alone or in combination with oral aminisalicylate
80
What can be used to maintain remission after an acute exacerbation of left-sided or extensive UC?
Low dose oral aminosalicylate
Oral azathioprine or mercaptopurine [unlicensed indications] can be considered to maintain remission, if there has been two or more inflammatory exacerbations in a 12-month period that required treatment with systemic corticosteroids, or if remission is not maintained by aminosalicylates, or following a single acute severe episode.
81
True or false: When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.
TRUE
82
What are the red flag side effects of aminosalicylates?
Agranulocytosis, Bone marrow suppression, Neutropenia, Cardiac inflammation, nephrotoxicity
83
What are the monitoring requirements for aminosalicylates?
Renal function should be monitored before starting treatment, at 3 months, and then annually Patients should report any unexplained bleeding/bruising/fever/malaise during treatment
FBC - drug should be stopped immediately if any indication of blood dyscrasia (disease/disorder of the blood)
84
Within what time period during starting sulfasalazine treatment do haematological abnormalities often occur?
Within the first 3-6 months of starting treatment Discontinue if these occur
85
What should patients on sulfasalazine be aware of if they wear contact lenses?
May stain the lenses yellow/orange
86
What should a patient be screened for if starting vedolizumab?
TB Contraindicated in those with TB
87
What is alverine citrate used for?
GI spasms Dysmenorrhoea
88
Why would lactulose not be suitable in a patient with IBS?
Causes bloating
89
In IBS patients who have had constipation the last 12 months but have not responded to laxatives, what can be used?
Linaclotide
90
What is 1st line for diarrhoea in IBS?
Loperamide
91
What is co-phenotrope used for and what is a main side effect of it?
Decreases faecal output
Opioid that crosses BBB
92
Patients on colestyramine long term may need supplements of vitamins A, D, K, and folic acid. Why?
Can intefere with absorption of fat soluble vitamins
93
What is the advice around taking colestyramine with other drugs?
Manufacturer advises take other drugs at least 1 hour before, or 4–6 hours after, colestyramine.
94
What role does teduglutide have in short bowel syndrome?
Teduglutide is an analogue of human glucagon-like peptide-2 (GLP-2), which preserves mucosal integrity by promoting growth and repair of the intestine.
95
In patients with short bowel syndrome/stoma, what kinds of preparations would be unsuitable and why? (hint- types of release)
Enteric-coated and modified-release preparations are unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy, as there may not be sufficient release of the active ingredient.
for patients with a stoma, use loperamide melts rather than capsules
96
Bran is a type of what laxative?
Bulk forming
97
Isphaghula husk is a type of what laxative?
Bulk forming
98
Methylcellulose is a type of what laxative?
Bulk forming (also acts as a faecal softener)
99
Sterculia is a type of what laxative?
Bulk forming
100
What is onset of action for bulk forming laxatives?
Within 72 hours
101
Bisacodyl is what type of laxative?
Stimulant
102
Sodium picosulfate is what type of laxative?
Stimulant
103
Senna is what type of laxative?
Stimulant
104
Docusate sodium is what type of laxative?
Stimulant laxative and faecal softener
105
What is co-danthramer and co-danthrusate used for and what patient group is it limited to? Why?
Constipation in palliative care only (carcinogenic)
106
Arachis oil enema would be contraindicated in patients with what allergy?
Peanuts
107
What are the warnings associated with liquid paraffin as a lubricant?
Anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.Should not be taken immediately before going to bed
108
Lactulose is what type of laxative?
Osmotic
109
Macrogol is what type of laxative?
Osmotic
110
What is lubiprostone used for?
Licensed for the treatment of chronic idiopathic constipation in adults whose condition has not responded adequately to lifestyle changes
111
What is prucalopride used for?
It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
112
What is 1st line for short duration constipation where dietary measures have not helped?If stools are soft but difficult to pass, what would be more appropriate?
1. Bulk forming 2. Stimulant laxative
113
1. In patients with opioid induced consitipation, what would be appropriate?
2. If these do not work, what can then be used?
1. Osmotic laxative and stimulant laxative
Docusate sodium can be used to soften the stools
2. Naloxegol, Methylnaltrexone bromide
114
What type of laxative should be avoided in opioid induced constipation?
Bulk forming
115
What is 1st line for constipation in pregnancy after dietary measures?
Bulk forming laxativeOr lactuloseDocusate sodium and glycerol suppositories can also be used
116
True or false: Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause side-effects
TRUE
117
What is 1st choice for constipation in breast feeding after dietary requirements?
Bulk forming laxative
Lactulose or macrogol can be used if stools remain hard
118
1. What is 1st line for constipation in children after dietary measures?
2. If response is inadequate, what can be tried?
3. If stools remain hard, what can be used?
1. Macrogol 3350 with KCL, sodium bicarbonate and NaCl (if you forget, remember peadiatric movicol exists)
2. Add or change to a stimulant laxative (OTC restrictions changed for stimulant laxatives Aug 2020)
3. Lactulose or docusate (lactulose has a high sugar content)
119
In children with chronic constipation, should laxatives be continued after regular bowel patterns has been established?How should laxatives be stopped?
Yes- for several weeks after and then tapered gradually according to response
120
What is the duration of acute diarrhoea
Less than 14 days
121
What is the maximum daily licensed dose for loperamide?
16mg (8 x 2mg capsules)
122
What is the MHRA advice regarding loperamide?
Reports of serious cardiac adverse reactions with high doses associated with abuse QT prolongation, torsades de points, cardiac arrest
123
Is kaolin recommended for acute diarrhoea?
No
124
What role do antacids play in dyspepsia?
Symptomatic relief
125
What is a side effect of magnesium?
Laxative effect
126
What is a side effect of aluminium?
Constipation
127
Why are bismuth containing antacids not recommended?
Neurotoxic, causing encephalopathy, tends to be constipating
128
What are the side effects associated with calcium containing antacids?
Can induce rebound acid secretion
Hypercalcaemia
Alkalosis
Constipation
129
What role do alginates play with an antacid?
Can protect mucosa from acid reflux
Some form a viscous gel raft
130
What would be a standard treatment for a H.Pylori patient who is not penicillin allergic?
7 day course of PPI + 2Abx.
See table below
131
Would you continue with PPI cover after treatment of H.Pylori?What is the exception to this?
No However if the ulcer is large or complicated by haemorrhage or perforation, then it is continued for a further 3 weeks
132
H.Pylori treatment:What antibiotics are prone to resistance during the course?
Clarithromycin and metronidazole
133
What is the disadvantage over 2 week triple therapy for H.Pylori over 1 week?
Even though the eradication rate is higher, adverse effects and poor compliance are common problems
134
What could be used as an alternative to metronidazole in H.Pylori treatment?
Tinidazole
135
In patients with NSAID related ulcer where the NSAID can be discontinued, which of the following promotes the most rapid healing:
H2 receptor antagonists (remember Ranitidine is no longer available)
Misoprostol
PPI
PPI
136
What is sucralfate used for?
Gastric/duodenal ulceration
Gastritis
Prophylaxis of stress ulceration
137
What is the main caution with sucralfate?
Bezoar formation- solid mass of indigestible material that accumulates and can cause a blockage
138
In Zollinger-Ellison syndrome, should a PPI or a H2 receptor antagonist be used?
PPIs as they are more effective
139
What can be used to reduce the degradation of pancreatic enzyme supplements in CF patients?
PPI
140
What can PPIs increase the risk of?
Increases risk of fractures and osteoporosis so consider preventative therapy if appropriateIncreases risk of GI infections e.g. C DiffMay mask the symptoms of gastric cancer
141
What 2 electrolytes can drop if on PPIs?
Sodium and magnesium
142
For mild symptoms of GORD, what can be used?
Antacids
May need PPI or H2 receptor antagonist but should be titrated down to a level which maintains remission
Ranitidine no longer available
143
For severe symptoms of GORD, what should be used?
PPI - re-assess if still symptomatic after 4-6 weeks
Should be titrated down to a level which maintains remission
144
How do you manage GORD in pregnancy?
Diet and lifestyle changes
Antacid/alginate
145
When would you give a pregnant lady omeprazole for GORD?
Severe or complicated reflux disease.
146
How should a child with oesophagitis be treated?
PPI
147
What is licensed as an adjunct to dietary avoidance in patients with food allergy?(hint- not an epi-pen)
Sodium cromoglicate
148
What antihistamine is licensed for the symptomatic control of food allergy?
Chlorphenamine
149
Buscopan contains what active ingredient?
Hyoscine butylbromide
150
Kwells contains what active ingredient?
Hyoscine hydrobromide
151
What is the MHRA alert associated with hyoscine butylbromide injection (IM, IV, SC)?
Can cause serious side effects such as tachycardia, hypotension, anaphylaxis (which is likely to be fatal in patients with CHD)It is therefore contraindicated in patients with tachycardia and should be used in caution in those with cardiac disease
152
What is cholestasis?
An impairment of bile formation and/or bile flow
153
What is the drug of choice for cholestatic pruritus?
Colestyramine
154
What is the drug of choice for intrahepatic cholestatic pruritus in pregnancy?
Ursodeoxycholic acid
155
Can you give NSAIDs in patients with symptomatic gallstones?
Yes
156
What is the recommended medicine to use for primary biliary cholangitis?(progressive destruction of bile ducts within the liver)
Ursodeoxycholic acid
157
What is the MHRA alert associated with obeticholic acid?
Serious liver injuries in patients with moderate-severe hepatic impairment Need to be adequately dose adjusted according to LFTs
158
What is used for oesophageal varice bleeding?
Terlipressin & Vasopressin
159
When should discontinuation of Orlistat be considered? (when do you know it is not effective)
After 12 weeks if weight loss has not exceeded 5% since starting the treatment
160
How does Orlistat work?
Lipase inhibitor so reduces absorption of dietary fat
161
What vitamin may you need to be on if taking Orlistat and why?
D as orlistat may reduce absorption of fat soluble vitamins
162
What laxatives should be used in acute anal fissures and why?
Bulk forming
Osmotic can be an alternative To make sure stools are soft and easily passed
163
When would an anal fissure be classed as chronic?
6 weeks or longer
164
What topical preparation can be used in acute anal fissures?
Local anaesthetic e.g. lidocaine
165
What topical preparation can be used in chronic anal fissures?
GTN rectal ointment
Diltiazem ointment
Nifedipine ointment(Unlicensed)
166
If a patient with haemorrhoids is suffering from constipation, what type of laxative should be used?
Bulk forming
167
What type of analgesics should not be used in haemorrhoid patients and why?
Opioids as they cause constipation
168
What pain relief class of medicines should be avoided in patients with rectal bleeding?
NSAIDs
169
Topical rectal preparations containing local anaesthetics such as lidocaine should only be used for a few days- why?
May cause sensitisation of the anal skin
170
Topical corticosteroids are suitable for short term use in haemorrhoid patients- what is the max number of days this should be used for?
No more than 7 days
171
If a pregnant lady with haemorrhoids is suffering from constipation, what type of laxative should be used?
Bulk forming
172
Are topical haemorrhoidal preparations licensed in pregnancy?
No
173
How do you manage exocrine pancreatic insufficiency?
Pancreatin - contains lipase, amylase and protease
174
What is the risk of CF patients taking high dose pancreatic enzymes?What is therefore the guidelines of how many units of lipase to have a day?
Fibrosing colonopathy (presents with abdominal pain, vomiting etc)No more than 10,000 units/kg/day of lipase
175
In stoma patients, why should medicine preparations containing sorbitol be avoided?
Laxative effects
176
What would be the most appropriate diuretic to use in stoma patients and why?
Potassium sparing
Diuretics should be used with caution in patients with an ileostomy or with urostomy as they may become excessively dehydrated and potassium depletion may easily occur.
177
What is the danger with using laxatives in a stoma patient?If they do need a laxative after increasing fluid intake and dietary fibre, what can be used?
May cause rapid and severe loss of water and electrolytes.
Bulk forming laxatives
If this does not work, a small dose of stimulant e.g. senna with caution
178
What is the danger with stoma patients taking digoxin?
Patients with a stoma are particularly susceptible to hypokalaemia if taking digoxin, due to fluid and sodium depletion. Potassium supplements or a potassium-sparing diuretic may be advisable with monitoring for early signs of toxicity.
179
Why should daily doses of liquid formulations be split in stoma patients?
To avoid osmotic diarrhoea
180
What 3 antibiotics can you use for C.Diff infection?
1st line: Metronidazole
2nd line: Vancomycin (use first line if severe)
3rd line: Fidaxomicin
181
What is the suggested duration of antibiotic treatment for C.Diff?
10-14 days
182
If a patient has an aspirin sensitivity, would aminosalicylates be appropriate for them?
No - sulfasalazine and mesalazine are derivatives of salicylates, like aspirin.
183
What colour does your urine turn if on sulfasalazine?
Yellow/orange
184
What age is Mintec peppermint capsules licensed for?
\> 18 years
185
What age is Colpermin peppermint capsules licensed for?
\>15 years
186
Liquid paraffin is indicated for constipation, but what is its main side effects?
Lipoid pneumonia
Granuloma
187
What is the MHRA advice surrounding PPIs?
Very low risk of subacute cutaneous lupus erythematosus
Drug-induced SCLE can occur weeks, months or even yearsafter exposure to the drug.If a patient on PPIs develops lesions in sun-exposed areasaccompanied with arthralgia;- Advise them to avoid sun exposure- Consider SCLE as a possible diagnosis
188
What antiplatelet interacts with omeprazole?
Clopidogrel
189
What is the administration counselling points for isphaghula?
Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
have with at least 150ml of water
190
What are some counselling points for taking antacids?
They are best taken when symptoms occur or are expected, usually between meals or at bedtime. They should preferably not be taken at the same time as other drugs since they may impair absorption. Antacids can damage enteric coatings on tablets. The words ‘low Na+’ added after some preparations indicates a sodium content of less than 1mmol per tablet or 10ml dose. This is directed for people with hypertension.
191
What is the advice given to patients around taking Pancreatin?
It is important to ensure adequate hydration at all times in patients receiving higher-strength pancreatin preparations.Pancreatin is inactivated by gastric acid therefore manufacturer advises pancreatin preparations are best taken with food (or immediately before or after food).Enteric-coated preparations deliver a higher enzyme concentration in the duodenum- Manufacturer advises gastro-resistant granules should be mixed with slightly acidic soft food or liquid such as apple juice, and then swallowed immediately without chewing
192
True or false:Coeliacs are at a higher risk of malabsorption of key nutrients such as calcium and Vitamin D
True - important to assess for osteoporosis
193
What are long term complications of ulcerative colitis?
Colorectal cancer, Osteoporosis - from dietary change, corticosteroid medication,VTE,Toxic megacolon
194
The use of loperamide or codeine in an acute flare up of UC increases the risk of what?
Toxic megacolon
195
What are the complications of Crohn's Disease?
Intestinal strictures, abscesses, fistulae, Malnutrition Anaemia, Colorectal and small bowel cancers, Growth failure and delayed puberty in children, Arthritis, Secondary osteoporosis - from steroid meds
196
Can you use loperamide and codeine for diarrhoea in Crohn's?
Yes
197
What is the patient counselling with aminosalicylates?
Report any unexplained bleeding, bruising Salicylate hypersensitivity e.g. itching, hivesYellow/orange bodily fluids - may stain contact lenses
198
What is the interaction between lactulose and mesalazine?
The manufacturers of some mesalazine gastro-resistant and modified-release medicines suggest that preparations that lower stool pH (e.g. lactulose) might prevent the release of mesalazine.
199
What are the red flag symptoms of constipation?
New onset in \> 50 years
Anaemia
Abdominal pain
Unexplained weight loss
Change in bowel habit
200
True or false: Excessive use of stimulant laxatives causes hyperkalaemia
False- causes hypokalaemia
201
What kind of laxative is co-danthramer?
Stimulant
202
What kind of laxative should you avoid in opioid-induced constipation?
Bulk forming
203
What are the red flag symptoms of dyspesia?
Anaemia
Loss of weight
Recent/unexplained dyspepsia in 55+
unresponsive to treatment
Malaena (blood in stool)
204
What is a side effect of calcium salt antacids?
Can induce rebound acid secretion and constipation
205
What classes of drugs do antacids interact with?
Tetracyclines
Quinolones
Bisphosphonates
206
What groups of patients are antacids cautioned in?
Fluid retention can occur due to high sodium content so cautioned in hypertension, heart, liver or kidney failureAvoid in sodium restricted diet e.g. lithium
207
What PPI is safe in pregnancy?
Omeprazole
208
Is Cimetidine an enzyme inducer or inhibitor?
Enzyme inhibitor
209
What is the advice with enteral feeds and food when taking sucralfate?
Administration of sucralfate and enteral feeds should be separated by 1 hour and for administration by mouth, sucralfate should be given 1 hour before meals.
210
What are the side effects of antimuscarinics?
Blurred vision Arrhythmias Pupil dilation (mydriasis) Urinary retention Constipation Dry mouth Angle-closure glaucoma Drowsiness, confusion
211
Do antimuscarinics cause dry eyes?
No
212
When should pancreatin be given and why?
Immediately before meals as pancreatin is inactivated by gastric acid
213
True or false:Enteric coated pancreatin delivers higher pancreatin levels
TRUE
214
What is the advice with pancreatin and mixing with food and drink?
Pancreatin is inactivated by heatIf mixed with foods or liquids, do not keep for more than 1 hour
215
How often is the PPI dosing in H Pylori treatment?
BD
216
All the antibiotic and PPI triple therapies are BD dosing. What combination is the exception to this?
Omeprazole 20mg BD Amoxicillin 500mg TDS Metronidazole 400mg TDS
217
What is coeliac disease?
It is a autoimmune condition= chronic inflammation of the small intestine
218
What is coeliac disease caused by?
Gluten= rye, wheat and barley
219
What are symptoms of coeliac disease?
Diarrhoea, bloating and abdominal pain
220
Treatment of coeliac disease
Avoid gluten Prednisolone in refractory coeliac disease
221
What is diverculosis and treatment?
Asymptomatic Forms diverticula= small pouches protruding from large intestineTreatmentBulking forming laxatives if they have constipation
222
What is acute diverticulitis
Sudden inflammation of diverticula Can be infected = pain, fever, rectal bleeding
223
What is complicated acute diverticulitis
Access, bowel perforation, fistula, intestinal obstruction, haemorrhage, sepsis
224
What is treatment for acute diverticulitis
Paracetamol if no systemic symptoms, antibacterials if needed and low fibre diet generally in diverticulitis
225
What is treatment for complicated acute diverticulitis
Hospital
226
What is not recommended in complicated acute diverticulitis
Aminosalicylates and propylactic antibacterials
227
What is first line treatment for Coeliacs disease
Life long gluten free diet
228
What drugs are used in IBD
Aminosalicylates: **Sulfaslazine**, sulfapyridine, **mesalazine**, balsalazide, olsalazine
Cytokine modulators: Infliximab, adalimumab, golimumab
