Chapter 1 Gastro-Intestinal System- conditions Flashcards
Conditions and treatment (119 cards)
1
Q
What is coeliac disease
A
Autoimmune disease associated with chronic inflammation in the small intestines leading to poor absorption
2
Q
Cause of coeliac disease
A
Adverse reaction to gluten and other dietary proteins found in wheat rye and barley activate an immune reaponse in the intestinal wall mucosa
3
Q
Symptoms of coeliac disease
A
Diarrhoea
Abdo pain
Bloating
Malabsorption of nutrients e.g calcium and vitamin d
4
Q
Treatment for coeliac disease (lifestyle)
A
Lifelong gluten free diet
Assess risk of osteoporosis and treat woth supplements accordingly
5
Q
Definition of diverticulitis
A
Diverticula become inflamed
6
Q
Definition of diverticulitis
A
Small bulges (diverticula) develop in the lining of the intestine
7
Q
Definition of acute diverticular disease
A
When the diverticula becomes inflamed or infected
8
Q
Symptoms of diverticular disease
A
Severe lower abdo pain Fever Change in bowel habits Rectal bleeding Lower abdo tenderness
9
Q
Complications of diverticular disease
A
Abscess
10
Q
What is diverticulosis
A
Asymptomatic where the diverticula are present in the small intestines
11
Q
Prevelence of diverticular disease (age group)
A
Over 40
12
Q
Treatment of diverticular disease (lifestyle + symptom control)
A
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
13
Q
What is IBS
A
Inflammatory bowel disease includes crohns disease and ulcerative colitis
14
Q
Definition of ulcerative colitis
A
Mucosal inflammation and ulcers in the colon and rectum
15
Q
Prevalence of ulcerative colitis (age)
A
15-25 most common
16
Q
Symptoms of ulcerative colitis including Acute flare ups
A
Bloody diarrhoea possibly with mucus or pus
Abdo pain
Urgent need to defecate
Acute flare ups: mouth ulcers, arthritis, sore skin, weight loss, fatigue
17
Q
Long term complications of UC
A
Colorectal cancer
Secondary osteoporosis due to exposure to corticosteroid meds and dietary changes such as avoiding dairy
Vte
Toxic megacolon
18
Q
What is megacolon
A
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
19
Q
Contra-indications of UC flare ups
A
Loperamide
Codeine
Antimotility drugs means bowel dtop moving possibly causing toxic megacolon
20
Q
1st and 2nd line treatment for acute mild to moderate UC- proctitis (inflammation of the rectum)
A
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.
21
Q
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
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.
22
Q
1st and 2nd line treatment for acute mild to moderate UC- extensive colitis (inflammation of the ascending (proximal) colon
A
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.
23
Q
Which healthcare setting should acute severe UC be referred to
A
Referred to a hospital a& e because this is seen as a medical emergency
24
Q
First, second and third line treatment for acute severe UC?
A
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.
25
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.
26
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.
27
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.
28
Can methotrexate be used to maintain UC
Seen in practice but no evidence to support its use
29
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.
30
What are the symptoms of Crohns disease
Abdominal pain
Diarrhoea, rectal bleeding
Weight loss, low grade fever, fatigue
31
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.
32
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.
33
What lifestyle advice is given to patients with Crohns disease
High fibre diet
| Smoking cessation
34
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)
35
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
36
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
37
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.
38
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.
39
What is irritable bowel syndrome
Common life-long chronic condition affecting the digestive tract
40
what is the prevalence of irritable bowel syndrome (age and sex)
more commonly women aged 20-30
41
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.
42
What lifestyle factors can aggravate Irritable bowel syndrome
Stress
Anxiety
Depression
Lack of dietary fibre
43
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.
44
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].
```
45
When is psychological intervention used in irritable bowel syndrome
After 12 months unsuccessful drug treatment
46
What is short bowel syndrome
Characterised by malabsorption following extensive resection of the small bowel
47
What are the characteristics of short bowel absorption
1. Malabsorption and malnutrition: deficiency in vitamin A, B12, D, E, K, essential fatty acids, zinc, selenium and hypomagnesaemia
2. Inadequate digestion resulting diarrhoea
3. Incomplete drug absorption
48
When and why is colestraymine used in short bowel syndrome
In patients with an intact colon and less than 100 cm of ileum resected, colestyramine can be used to bind the unabsorbed bile salts and reduce diarrhoea. When colestyramine is given to these patients, it is important to monitor for evidence of fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies.
49
What are the consequences of poor drug absorption in short bowel syndrome
Which type of drug preparations are unsuitable and suitable for these pts
Give examples of some medication that need to be given in highdr doses due to this
e.g warfarin, oral contraceptives, levothyroxine or digoxin
enteric coated and modified release preparations are unsuitable for these pts
soulble and uncoated tablets are suitable. Also liquid formulations depending on osmolarity
The intestine is where most of the drug is absorbed so reducing this means less is absorbed
50
Which PPI is used in short bowel syndrome and why
Drugs that reduce gastric acid secretion reduce jejunostomy output. Omeprazole is readily absorbed in the duodenum and upper small bowel, but if less than 50 cm of jejunum remains, it may need to be given intravenously. Use of a proton pump inhibitor alone does not eliminate the need for further intervention for fluid control (such as antimotility agents, intravenous fluids, or oral rehydration salts).
Octreotide [unlicensed indication] reduces ileostomy diarrhoea and large volume jejunostomy output by inhibiting multiple pro-secretory substances. There is insufficient evidence to establish its role in the management of short bowel syndrome.
51
How are growth factors used in short bowel syndrome
Growth factors can be used to facilitate intestinal adaptation after surgery in patients with short bowel syndrome, thus enhancing fluid, electrolyte, and micronutrient absorption.
Teduglutide is an analogue of endogenous human glucagon-like peptide 2 (GLP-2) which is licensed for use in the management of short bowel syndrome. It may be considered after a period of stabilisation following surgery, during which intravenous fluids and nutritional support should have been optimised.
52
Which anti-motility drugs are used for short bowel syndrome
Loperamide hydrochloride and codeine phosphate reduce intestinal motility and thus exert antidiarrhoeal actions. Loperamide hydrochloride is preferred as it is not sedative and does not cause dependence or fat malabsorption. High doses of loperamide hydrochloride [unlicensed] may be required in patients with a short bowel due to disrupted enterohepatic circulation and rapid gastrointestinal transit time. If the desired response is not obtained with loperamide hydrochloride, codeine phosphate may be added to therapy.
Co-phenotrope has traditionally been used alone or in combination with other medications to help decrease faecal output. Co-phenotrope crosses the blood–brain barrier and can produce central nervous system side-effects, which may limit its use; the potential for dependence and anticholinergic effects may also restrict its
53
What is constipation
find it hard to poo or you go to the toilet less often than usual.
54
Symptoms associated with constipation
infrequent stools, difficult stool passage, or seemingly incomplete defaecation.
This can result in excessive straining, lower abdo pain/discomfort and bloating
55
What are the red flag symptoms of constipation
New onset constipation in over 50 year olds, anaemia, abdo pain, unexplained weight loss, overt or occult blood e.g red, black or tarry stool
56
What lifestyle advice should be given to a patient experiencing constipation
In all patients with constipation, an increase in dietary fibre, adequate fluid intake and exercise is advised. Diet should be balanced and contain whole grains, fruits and vegetables. Fibre intake should be increased gradually (to minimise flatulence and bloating). The effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks. Adequate fluid intake is important (particularly with a high-fibre diet or fibre supplements), but can be difficult for some people (for example, the frail or elderly). Fruits high in fibre and sorbitol, and fruit juices high in sorbitol, can help prevent and treat constipation.
57
Name the 4 laxative classes
Osmotic
Bulk forming
Faecal softner
Stimulant
58
Describe the 3 step wise apprach to laxative prescribing including short term and chronic for constipation
Step 1: Bulk-forming laxatives e.g ispaghula husk, methylcellulose and sterculia.
Step 2: If stool remains hard or difficult to pass add or switch to an osmotic laxative.g macrogol or lactulose
If stools are soft but difficult to pass or a sensation of inadequate emptying add a stimulant laxative e.g bisacodyl, sodium picosulfate, and members of the anthraquinone group (senna, co-danthramer and co-danthrusate).
Step 3: In chronic constipation consider short-term trial of prucalopride if symptoms persist and specific prescribing criteria are met [if at least two laxatives from different classes have been tried at the highest tolerated recommended doses for at least 6 months, and failed to relieve symptoms, where invasive treatment such as suppositories or manual disimpaction is being considered].
59
How many months is considered short term constipation?
Up to 3 months
60
Contra-indications for laxatives
Don't prescribe:
Intestinal obstruction or perforation
Paralytic ileus
Toxic megacolon
61
What are the cautions associated with laxatives
Crohns disease and UC
Fluid/electrolyte imbalance
History of prolonged laxatives
62
Which laxatives are prescribed for opioid induced constipation
Osmotic or docusate soudium + stimulant
Alternatively in lack of response to the above a peripheral opioid receptor antagonist e.g Mthylnaltrexone/ methylnaltrexone
63
Which type of laxative should be avoided in opioid induced constipation
bulk forming laxatives cause obstruction and painful colic
64
Which laxatives are only used in pallative pts
Co-danthramer
Co-danthrusate
Due to the potential carcinogenicity (based on animal studies) and evidence of genotoxicity
65
What is prescribed for children with constipation that are not faecally impacted
1st line : macrogol with diet/ behaviour intervention
Add a stimulant laxative if an inadequate response
Add a lactulose or faecal softner e.g docusate sodium if stools remain hard
66
What is prescribed for pregnant women experiencing constipation
First line: bulk forming if fibre supplements fail
Osmotic laxatives e.g lactulose
Bisacodyl or senna (avoid senna near term because it can cause uterine contractions)
Docusate sodium or glycerol suppositories
67
What is prescribed for breast feeding women experiencing constipation
1st line is bulk forming if dietary measures fail
lactulose or macriogol if stools remain hard
Alternatively stimulant e.g bisacdyl or senna
68
How is constipation treated in children with faecal impaction
Treatment of faecal impaction may initially increase symptoms of soiling and abdominal pain. In children over 1 year of age with faecal impaction, an oral preparation containing a macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) is used to clear faecal mass and to establish and maintain soft well-formed stools, using an escalating dose regimen depending on symptoms and response. If disimpaction does not occur after 2 weeks, a stimulant laxative can be added or if stools are hard, used in combination with an osmotic laxative such as lactulose. Long-term regular use of laxatives is essential to maintain well-formed stools and prevent recurrence of faecal impaction; intermittent use may provoke relapses.
69
What is diarrhoea
where you frequently pass watery or loose poo. Acute diarrhoea lasts uder 14 days
70
Symptoms of diarrhoea
```
frequent loose water stools
cramps
nausea
flactulence
Dehydration
```
71
Red flag symptoms for diarrhoea
unexplained weight loss, rectal bleeding, persistent diarrhoea, a systemic illness, has received recent hospital treatment or antibiotic treatment, or following foreign travel (other than to Western Europe, North America, Australia or New Zealand).
72
Which antibiotic can be used to prevent travellers diarrhoea
Ciprofloxacin
73
First line treatment for diarrhoea
Oral replacement therapy
replaces electrolyte and fluid depletion
Diarolyte contains glucose, rice power, sodium chloride and potassium chloride
74
What is the main antimotility drug used for diarrhoea
Loperamide
75
what antimotility drug can be used for travellers diarrhoea
loperamide
76
When is the drug Racecadotril used
adjunct to rehydration for the symptomatic treatment of uncomplicated acute diarrhoea in adults and children over 3 months.
77
4 drugs used for diarrhoea
codeine phosphate, co-phenotrope, methylcellulose, rifaximin.
78
What is dyspepsia
It is persistent or recurrent pain in the upper abdomen
79
Causes of dyspepsia
Indigestion
GORD
Gastritis
Gastric and duodenal ulcers
80
Symptoms of dsypepsia
Upper abdo pain, fullness, early satiety, bloating, belching and nausea
81
What are the red flag symptoms for a patient with dyspepsia to have an endoscopic referral
Anaemia (as a result GI bleeding)
Loss of weight
Anorexia
Recently changed, unexplained new dyspepsia in over 55 year old unresponsive to treatment
Malaena (blood in stool), dysphagia, haematemesis or recurrent vomiting
82
What lifestyle advice can be given to pts experiencing dyspepsia, GORD or peptic ulcer disease
```
Smoking cessation
raising bed
eating 3-4 hours before going to bed
healthy diet
reduce alcohol
reduce stress and anxiety
weight loss if obese
avoid trigger foods
```
83
Name drug classes that can cause dyspepsia and GORD and what should be done if this is case
Drugs that may cause dyspepsia, such as alpha-blockers, antimuscarinics, aspirin, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, nitrates, non-steroidal anti-inflammatory drugs (NSAIDs), theophyllines, and tricyclic antidepressants, should be reviewed.
The lowest effective dose should be used and if possible, stopped.
84
How is uninvestigated dyspepsia treated
Antacids for symptom relief
PPI for 4 weeks if symptoms persist
H.pylori if there is no response to PPI- If at high risk of H. pylori infection this should be done
85
How is investigated functional dyspepsia treated
Functional dyspepsia is confirm by endoscopy
H.pylori tested first
If negative then treated with a PPI or H2 antagonist for 4 weeks
86
How often are. the reviews for dyspepsia pts and what should be encouraged
annually
stepping down treatment or stopping
returning to self care such as antacids
87
What is gastric and duodenal ulcers (peptic ulcers), where in the body does it happen and how to they happen
The duodenal ulcers means the ulceer is located in the first part of the intestine- right after the stomach.
Gastric ulcers are located in the stomach
This is when sores develop in the intestinewhich can lead to perforation leading to a GI bleed
Drugs such as NSAIDS and infections such as H. pylori can cause the ulcer
88
What risk factors are associated with peptic ulcers
Over 65
NSAIDS- high dose, long term use or bad reaction to NSAIDS
history of peptic ulcers
Heavy smoker
Heavy alcohol consumption
co-morbidity such as hypertension, diabetes, CVD
other drugs that increase the risk of gastro-intestinal adverse-effects (e.g. anticoagulants, corticosteroids, selective serotonin reuptake inhibitors)
89
What is the initial management of NSAID induced peptic ulcers
Stop NSAID
| PPI OR H2 antagonist for 8 weeks
90
What is the initial management of peptic ulcers in pts with no history of NSAID use and negative for H.pylori
PPI or H2 antagonist for 4- 8 weeks
91
What is the initial management of H.pylori induced peptic ulcers
1 Week triple therapy: PPI BD + Clarithromycin + amoxicillin OR metronidazole
If the pt is being treated for another infection with a macrolide then give without clarithromycin
If the pt is being treated for another infection with a metronidazole then give without metronidazole
IF pt has penicillin allergy give without amoxicillin
If pt recently treated with both clarithromycin and metronidazole use a tetraceycline or levofloxacin (unlicensed)
92
How often shpuld patients with peptic ulcer disease be reviewed
Annually
| encoraged to step down treatment
93
Describe the follow up management for pts with h.pylori positive peptic ulcer
a review 6-8 weeks after starting the eradication therapy
| a review 6-8 weeks after treatment to check for ulcer healing
94
Describe the follow up managemnt for a pt ho had had an NSAID induced peptic ulcer
If the ulcer is healed and the patient is to continue taking NSAIDs, the potential harm from NSAID treatment should be discussed. The need for NSAIDs should be reviewed at least every 6 months, and use on a limited, 'as-needed' basis trialled. Consider reducing the dose, substituting the NSAID with paracetamol, or use of an alternative analgesic or low dose ibuprofen.
In patients with previous ulceration, for whom NSAID continuation is necessary, or those at high risk of gastro-intestinal side effects, consider a cyclo-oxygenase (COX)-2 inhibitor
Gastric protection should be co-prescribed- PPI or H2-receptor antagonist or misoprostol- has bad s/e
95
When should Misoprostol be avoided and what are its side effects
Teratogenic- avoid in pregnancy
| colic and diarrhoea are dose limiting s/e
96
What is GORD
Gastrointestinal oesophageal reflux disease is where acid from the stomach leaks upto the oesophagus
97
Symptoms of GORD
heartburn and acid regurgitation. Less common symptoms such as chest pain, hoarseness, cough, wheezing, asthma and dental erosions can also occur if acid reflux reaches the oropharynx and/or respiratory tract.
98
Risk factors for GORD
These include consumption of trigger and fatty foods, pregnancy, hiatus hernia, family history of GORD, increased intra-gastric pressure from straining and coughing, stress, anxiety, obesity, drug side-effects, smoking and alcohol consumption.
99
What are the complications associated with GORD
oesophageal inflammation (oesophagitis), ulceration, haemorrhage and stricture formation, anaemia due to chronic blood loss, aspiration pneumonia, and Barrett’s oesophagus
100
Initial management for a pt experiencing GORD
In patients with an endoscopy confirmed diagnosis of GORD, a proton pump inhibitor (PPI), should be offered for 4 or 8 weeks. If there is no response to a PPI, then offer a histamine2-receptor antagonist (H2-receptor antagonist).
Severe oesophagitis should be treated with a PPI for 8 weeks
101
How is GORD managed in pregnancy
Heartburn and acid reflux are symptoms of Dyspepsia in pregnancy commonly caused by GORD. Dietary and lifestyle advice should be given as first-line management. If this approach fails to control symptoms, an antacid or an alginate can be used. If this is ineffective or symptoms are severe omeprazole or ranitidine (unlicensed) may help to control symptoms.
102
How is GORD managed in children
Mild to moderate GORD is managed by thickened feeds and alginates
103
For pts with recurrent GORD or peptic ulcer disease what is precibed
For patients diagnosed with GORD or peptic ulcer disease in whom symptoms recur after initial treatment, a PPI should be given at the lowest dose that can achieve symptom control and self management on an “as-needed” basis should be discussed.
104
What should be prescribed if initial treatment for severe oesophagitis fails
a higher dose of the same PPI should be used or switching to another PPI should be considered taking into account patient preference, tolerability, underlying health conditions and possible interactions with other drugs.
For patients with severe oesophagitis that fail to respond to long term maintenance PPI therapy a clinical review and switching to another PPI can be considered and/or specialist advice can be sought.
Patients with severe oesophagitis or who have had dilatation of an oesophageal stricture should remain on long-term PPI therapy taking into consideration the factors mentioned above.
105
For pts with refractory GORD what should be prescribed
prescribing a further course of the initial PPI dose for 1 month, double the initial PPI dose for 1 month or the addition of a H2-receptor antagonist at bedtime for nocturnal symptoms or for short term use. The patient's adherence to initial management should also be checked and lifestyle advice reinforced.
106
How is H.pylori tested for
The urea (13C) breath test, Stool Helicobacter Antigen Test (SAT), or laboratory-based serology where its performance has been locally validated, are recommended for the diagnosis of gastro-duodenal infection with H. pylori. PHE advise that the urea (13C) breath test and SAT should not be performed within 2 weeks of treatment with a proton pump inhibitor or within 4 weeks of antibacterial treatment, as this can lead to false negatives.
The test is based on the ability of H.pylori to break down urea to CO2 which is eliminated in the breath
107
what is an anal fissure
a tear or ulcer in the lining on the anal canal immediately within the anal margin
108
Symptoms of anal fissure
bright red bleeding
sharp persistent pain on defecation
linear split in the anal mucosa (the fissure)
109
what is the treatment for acute anal fissures (under 6 weeks)
if stools are soft and easily passed: bulk forming laxatives
Alternatively osmotic laxative
if prolonged burning pain following defacation: short term local anaesthetic e.g lidocaine. applied before emptying bowel
110
what is the treatment for chronic anal fissures (over 6 weeks)
glyceryl trinitrate rectal ointment- s/e headache
| Alternatively oral or topical (preffered) diltiazem, nifedipine
111
What are haemorrhoids
swellings of the anal cushion containing enlarged blood vessels, found inside or outside the anus
112
what are the symptoms associated with haemorrhoids
pain after defeacation
bleeding after defecation
swellings
itchy sore skin around the anus
113
risk factors for haemorrhoids
pregnancy
| constipation
114
Lifestyle advice for haemorrhoids
increased fluid/fibre intake
| perianal hygiene
115
What does the treatment for haemorrhoids consist of
existing constipation e.g bulk forming laxatives
pain relief: simple analgesics avoid opioids and NSAIDS
Topical preparations: Usually contains multiple ingredients: local anaesthesia, corticosteroids, astringents, lubticants, antiseptics
local pain: local anaesthetics for a few days e.g lidocaine, cinchocaine, pramocaine
Local perianal inflammation: preps with corticosteroids max 7 days
e.g hydrocortisone, flucortisone, prednisolone
Excludes e.g HSV, perinanl thrush
116
What is pancreatin insuffiency
reduced secretions of pancreatic enzymes= maldigestion, malnutrition and GI symptoms
117
Causes of pancreatic insufficiency
Cystic fibrosis, chronic pancreatitis, Zollinger-Ellison syndrome, coeliac disease, obstructive pancreatic tumors and GI/ pancreatic surgical resection
118
Dietary advice for pancreatic insufficiency
Distribute food intake between three main meals and 2 to 3 snacks
avoid foods tht are difficult to digest: legumes and high fibre
dont consume alcohol
avoid reduced fat diets
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Fcators to consider when a pt has a stoma bag
E/C and M/R preperations are unsitable. Also preparations containing sorbitol due to the laxative effect
They are more vulnerable to GI side effects e.g Mg and Al anatcids, NSAIDS, Opioids, Iron so they should be given IV
PPI reduce gastric acid ecretion and stoma output
They are vulnerable to water and electrolyte depletion: diuretics= water and potassium loss
hypokaleamia= risk of digoxin toxcity
avoid laxatives: use bulk forming or hig fibre diet
high dioses of loperamide needed or codeine
