Chapter 1: Gastro-intestinal system

Question 1

What are the three treatment options for C.diff?

Answer 1

Metronidazole, vancomycin and fidaomicin

Question 2

What is coeliac disease?

Answer 2

Coeliac disease is an autoimmune condition which is associated with chronic inflammation of the small intestine. Dietary proteins known as gluten activate an abnormal immune response.

Question 3

What is the recommended treatment for symptomatic diverticular disease?

Answer 3

A high-fibre diet is recommended for the treatment of symptomatic diverticular disease, although evidence support this is inconsistent and of low quality. Bulk-forming drugs have also been used.

Question 4

In a patient who is thiopurine methyl transferase (TPMT) deficient, which of the following can be given: azathioprine, mercaptopurine or methotrexate?

Answer 4

Methotrexate

Question 5

Why is loperamide and other anti-dirrahoeal drugs controlled-indicated in acute ulcerative colitis?

Answer 5

Increased risk of toxic megacolon

Question 6

Two important monitoring points for aminosalicylates

Answer 6

A blood count should be performed and drug stopped immediately If there is suspicion of a blood dyscrasia. Renal function should be monitored before treatment, at 3 months and then annually.

Question 7

Which laxative should be avoided in IBS?

Answer 7

Lactulose - as may cause bloating

Question 8

Patients with IBS who have not responded to laxatives from the different classes and who have had constipation for at least 12 months, can be treated with what?

Answer 8

Linaclotide

Question 9

What is the first line choice of anti-motility drug for the relief of diarrhoea in patients with IBS?

Answer 9

Loperamide

Question 10

What is the second line treatment option in patients with IBS who do not respond to antispasmodics?

Answer 10

A low-dose tricyclic antidepressant such as amitriptyline can be used for abdominal pain or discomfort

Question 11

Why is loperamide preferred to codeine in reducing intestinal motility in patients with short bowel syndrome?

Answer 11

Loperamide is preferred as it is not sedative and does not cause dependence or fat malabsorption.

Question 12

Why are high doses of loperamide often required in patients with short bowel?

Answer 12

Disrupted enterohepatic circulation and rapid gastrointestinal transit time.

Question 13

Co-phenotrope has traditionally been used to help decrease faecal output, why is its use limited?

Answer 13

Crosses the blood brain barrier and can produce central nervous system side effects, potential for dependence and anticholinergic effects.

Question 14

What type of laxative is macrogol?

Answer 14

Osmotic

Question 15

Laxative abuse can lead to what? (hint: electrolyte disturbance)

Answer 15

Hypokalaemia

Question 16

What type of laxative is isphaghula husk?

Answer 16

Bulk forming

Question 17

What is the time till onset of action for bulk forming laxatives?

Answer 17

Onset of action is up to 72 hours.

Question 18

Why must adequate fluid intake be maintained with bulk forming laxatives?

Answer 18

Important to avoid intestinal obstruction

Question 19

What type of laxative is Senna?

Answer 19

Stimulant

Question 20

What type of laxative is bisacodyl?

Answer 20

Stimulant

Question 21

Why is the use of co-danthramer and co-danthrusate limited to constipation in terminally ill patients?

Answer 21

potential carcinogenicity and evidence of genotoxicity

Question 22

What type of laxative is lactulose?

Answer 22

Osmotic

Question 23

How would you manage opioid induced constipation?

Answer 23

In patients with opioid induced constipation, an osmotic laxative and a stimulant laxative is recommended. Bulk-forming laxatives should be avoided.

Question 24

What is the first line laxative in pregnancy?

Answer 24

Bulk forming

Question 25

Magnesium containing antacids tend be to X whereas aluminium containing antacids may be X

Answer 25

``` Magnesium = laxative Aluminium = constipating ```

Question 26

What are the indications for simeticone?

Answer 26

Simeticone is added to an antacid as an antifoaming agent to relieve flactulence. These preparations may be useful for the relief of hiccup in palliative care.

Question 27

what is the MHRA advice concerning PPIs and risk of subacute cutaneous lupus erythematous (SLE)?

Answer 27

Very infrequent cases of SCLE have been reported in patients taking PPIs. Drug-induced SCLE can occur weeks, months or even years after exposure to the drug. If a patient treated with a PPI develops lesions then consider SCLE as a possible diagnosis and consider discontinuing PPI treatment.

Question 28

what was the recent MHRA alert about hyoscine butyl bromide injections (Feb2017) concerted with?

Answer 28

The MHRA advises that hysocine butyl bromide injection can cause serious adverse effects including tachycardia, hypotension and anaphylaxis - several reports have noted this is more likely to be fatal in patients with underlying coronary heart disease. It is contraindicated in patients with tachycardia and should be used with caution in patients with cardiac disease.

Question 29

What is cholestasis? How might it clinically present?

Answer 29

An impairment of bile formation and/or bile flow, which may clinically present with fatigue, pruritus, dark urine, pale stools and jaundice.

Question 30

What is the drug of choice in relieving cholstatic pruritus?

Answer 30

Colestyramine - not absorbed by the GI tract so forms an insoluble complex in the intestine with bile acids and reduces excess deposition in the dermal tissues.

Question 31

What are inborn errors of primary bile acid synthesis?

Answer 31

Group of diseases in which the liver does not produce enough primary bile acids due to enzyme deficiencies.