Chapter 1 Gastro-Intestinal System- conditions Flashcards
Conditions and treatment
What is coeliac disease
Autoimmune disease associated with chronic inflammation in the small intestines leading to poor absorption
Cause of coeliac disease
Adverse reaction to gluten and other dietary proteins found in wheat rye and barley activate an immune reaponse in the intestinal wall mucosa
Symptoms of coeliac disease
Diarrhoea
Abdo pain
Bloating
Malabsorption of nutrients e.g calcium and vitamin d
Treatment for coeliac disease (lifestyle)
Lifelong gluten free diet
Assess risk of osteoporosis and treat woth supplements accordingly
Definition of diverticulitis
Diverticula become inflamed
Definition of diverticulitis
Small bulges (diverticula) develop in the lining of the intestine
Definition of acute diverticular disease
When the diverticula becomes inflamed or infected
Symptoms of diverticular disease
Severe lower abdo pain Fever Change in bowel habits Rectal bleeding Lower abdo tenderness
Complications of diverticular disease
Abscess
What is diverticulosis
Asymptomatic where the diverticula are present in the small intestines
Prevelence of diverticular disease (age group)
Over 40
Treatment of diverticular disease (lifestyle + symptom control)
High fibre diet- gradual to avoid flactulence and bloating
Hydration
Exercise
Smoking cessation
Bulk forming laxatives to treat diarrhoea or constipation
Paracetamol for abdo pain
Antispasmodics to reduce abdo cramps
Avoid nsaids and opioids because they can cause diverticulat perforation
What is IBS
Inflammatory bowel disease includes crohns disease and ulcerative colitis
Definition of ulcerative colitis
Mucosal inflammation and ulcers in the colon and rectum
Prevalence of ulcerative colitis (age)
15-25 most common
Symptoms of ulcerative colitis including Acute flare ups
Bloody diarrhoea possibly with mucus or pus
Abdo pain
Urgent need to defecate
Acute flare ups: mouth ulcers, arthritis, sore skin, weight loss, fatigue
Long term complications of UC
Colorectal cancer
Secondary osteoporosis due to exposure to corticosteroid meds and dietary changes such as avoiding dairy
Vte
Toxic megacolon
What is megacolon
Colon stops working so gas and faeces get trapped causing life threatening widening of the intestines. This can cauae the colon to rupture causing an infection in thr blood
Contra-indications of UC flare ups
Loperamide
Codeine
Antimotility drugs means bowel dtop moving possibly causing toxic megacolon
1st and 2nd line treatment for acute mild to moderate UC- proctitis (inflammation of the rectum)
1st line: Topical aminosalicyclates
If no remission in 4 weeks add an oral aminosalicyclates
If response remains inadequate, consider addition of a topical or an oral corticosteroid for 4 to 8 weeks
Monotherapy with an oral aminosalicyclates can be considered for patients who prefer not to use enemas or suppositories, although this may not be as effective. If remission is not achieved within 4 weeks, adding a topical or an oral corticosteroid for 4 to 8 weeks should be considered.
A topical or an oral corticosteroid for 4 to 8 weeks should be considered for patients in whom aminosalicyclates are unsuitable.
1st and 2nd line treatment for acute mild to moderate UC- Proctosigmoiditis (inflammation of the rectum and sigmoid colon) and left-sided ulcerative colitis
A topical aminosalicylate is recommended as first-line
If remission is not achieved within 4 weeks, consider adding a high-dose oral aminosalicylate, or switching to a high-dose oral aminosalicylate and 4 to 8 weeks of a topical corticosteroid.
If response remains inadequate, stop topical treatment and offer an oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
Monotherapy with a high-dose oral aminosalicylate can be considered for patients who prefer not to use enemas or suppositories, although this may not be as effective.
If remission is not achieved within 4 weeks, an oral corticosteroid for 4 to 8 weeks in addition to the high-dose aminosalicylate should be offered.
A topical or an oral corticosteroid for 4 to 8 weeks should be considered for patients in whom aminosalicylates are unsuitable.
1st and 2nd line treatment for acute mild to moderate UC- extensive colitis (inflammation of the ascending (proximal) colon
A topical aminosalicylate and a high-dose oral aminosalicylate are recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of extensive ulcerative colitis. If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid. An oral corticosteroid for 4 to 8 weeks should be considered for patients in whom aminosalicylates are unsuitable.
Which healthcare setting should acute severe UC be referred to
Referred to a hospital a& e because this is seen as a medical emergency
First, second and third line treatment for acute severe UC?
Intravenous corticosteroids (such as hydrocortisone or methylprednisolone) should be given to induce remission while assessing the need for surgery. If intravenous corticosteroids are contra-indicated, declined or cannot be tolerated, then intravenous ciclosporin [unlicensed indication] or surgery should be considered. A combination of intravenous ciclosporin with intravenous corticosteroids, or surgery is second line therapy for patients who have little or no improvement within 72 hours of starting intravenous corticosteroids or whose symptoms worsen despite treatment.
Infliximab can be used to treat acute exacerbations of severely active ulcerative colitis if ciclosporin is contra-indicated or clinically inappropriate.
For patients with severe acute UC who have an initial response to steroids followed by deterioration, what should be done?
Stool cultures should be taken to exclude the presence of pathogens; cytomegalovirus activation should be considered.
What treatments are used to manage remission of mild to moderate proctitis or proctosigmoiditis UC?
A low-dose of oral aminosalicylate
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.
When is azathioprine and mercaptopurine used to manage remission of UC (unlicensed indication)
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.
Can methotrexate be used to maintain UC
Seen in practice but no evidence to support its use
What is Crohns disease
Inflammation of the GI tract from the mouth to the anus.
It is characterised by thickened areas of the gastro-intestinal wall with inflammation extending through all layers, deep ulceration and fissuring of the mucosa, and the presence of granulomas; affected areas may occur in any part of the gastro-intestinal tract, interspersed with areas of relatively normal tissue.
What are the symptoms of Crohns disease
Abdominal pain
Diarrhoea, rectal bleeding
Weight loss, low grade fever, fatigue
Complications associated with Crohns disease
Complications of Crohn’s disease include intestinal strictures, abscesses in the wall of the intestine or adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in children. Crohn’s disease may also be associated with extra-intestinal manifestation: the most common are arthritis and abnormalities of the joints, eyes, liver and skin. Crohn’s disease is also a cause of secondary osteoporosis and those at greatest risk should be monitored for osteopenia and assessed for the risk of fractures.
What is fistulating Crohns disease
Fistulating Crohn’s disease is a complication that involves the formation of a fistula between the intestine and adjacent structures, such as perianal skin, bladder, and vagina. It occurs in about one quarter of patients, mostly when the disease involves the ileocolonic area.
What lifestyle advice is given to patients with Crohns disease
High fibre diet
Smoking cessation
What medication is first line used to treat an acute flare up in 12 months/ first presentation of Crohns disease
Corticosteroid: prednisolone, methylprednisolone, IV hydrocortisone
Alternatively
budesonide in pts with distal ileal, ileocaecal or right-sided colonic disease (not as effective as steroids but less s/e due to limited systemic exposure)
Alternatively: aminosalicyclates such as sulfasalazine and mesalazine (not as effective as budesonide or steroids)
What medication is used to treat a pt with 2 or more acute flare ups in a 12 month period of Crohns disease, or a pt who can’t tolerate corticosteroids
Azathiopurine or Mercaptopurine
Alternatively: methotrexate
Alternatively: MABS under specialist supervision
What medication is used for maintenance of remission in crohns disease?
Azathioprine or mercaptopurine [unlicensed indications] as monotherapy
Alternatively methotrexate if it was used to induce remission or the above is unsuitable
What medds are used for maintenance of remission after surgery in Crohns disease?
Azathioprine in combination with up to 3 months’ postoperative metronidazole [unlicensed indication] should be considered to maintain remission in patients with ileocolonic Crohn’s disease who have had complete macroscopic resection within the previous 3 months. Azathioprine alone should be considered for patients who cannot tolerate metronidazole.
Which antimotility medications are used for diarrhoea in Crohns patients
Loperamide hydrochloride or codeine phosphate can be used to manage diarrhoea associated with Crohn’s disease in those who do not have colitis.Colestyramine is licensed for the relief of diarrhoea associated with Crohn’s disease.
What is irritable bowel syndrome
Common life-long chronic condition affecting the digestive tract
what is the prevalence of irritable bowel syndrome (age and sex)
more commonly women aged 20-30
Symptoms assocaited with irritable bowel syndrome
Symptoms include abdominal pain or discomfort, disordered defaecation (either diarrhoea, or constipation with straining, urgency, and incomplete evacuation)
passage of mucus
bloating
Symptoms are usually relieved by defaecation.
What lifestyle factors can aggravate Irritable bowel syndrome
Stress
Anxiety
Depression
Lack of dietary fibre
Non- pharmacological treatment for irritable bowel syndrome
Regular physical activity
Regular meals
limiting fresh fruit consumption to no more than 3 portions per day.
If an increase in dietary fibre is required, soluble fibre such as ispaghula husk, or foods high in soluble fibre such as oats, are recommended. Intake of insoluble fibre (e.g. bran) and ‘resistant starch’ should be reduced or discouraged as they may exacerbate symptoms.
Fluid intake (mostly water) should be increased to at least 8 cups each day and the intake of caffeine, alcohol and fizzy drinks reduced.
The artificial sweetener sorbitol should be avoided in patients with diarrhoea. Where probiotics are being used, continue for at least 4 weeks while monitoring the effect.
What type of drugs including examples are used for irritable bowel syndrome
Antispasmodic drugs such as alverine citrate, mebeverine hydrochloride and peppermint oil (heartburn, local irritation of mouth/ oesophagus) A laxative (excluding lactulose as it may cause bloating) can be used to treat constipation. Patients who have not responded to laxatives from the different classes and who have had constipation for at least 12 months, can be treated with linaclotide. Loperamide hydrochloride is the first-line choice of anti-motility drug for relief of diarrhoea. A low-dose tricyclic antidepressant, such as amitriptyline hydrochloride [unlicensed indication], can be used for abdominal pain or discomfort as a second-line option in patients who have not responded to antispasmodics, anti-motility drugs, or laxatives. A selective serotonin reuptake inhibitor may be considered in those who do not respond to a tricyclic antidepressant [unlicensed indication].
When is psychological intervention used in irritable bowel syndrome
After 12 months unsuccessful drug treatment
What is short bowel syndrome
Characterised by malabsorption following extensive resection of the small bowel
What are the characteristics of short bowel absorption
- Malabsorption and malnutrition: deficiency in vitamin A, B12, D, E, K, essential fatty acids, zinc, selenium and hypomagnesaemia
- Inadequate digestion resulting diarrhoea
- Incomplete drug absorption