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Chapter 1: Gastrointestinal Flashcards

1
Q

What is inflammatory bowel disease?

A

Includes Crohn’s disease (affecting any part of the digestive tract) and Ulcerative colitis (limited to the colon)

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2
Q

What is coeliac disease?

A
  • Autoimmune condition associated with chronic inflammation of small intestine unable to absorb nutrients.
  • CAUSE: adverse reaction to gluten
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3
Q

Symptoms of coeliac disease?

A
  • diarrhoea, abdominal pain and bloating

- higher risk of malabsorption of key nutrients (calcium and vitamin D –> increased risk of osteoporosis)

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4
Q

Treatment for coeliac disease?

A
  • strict life long gluten free diet
  • assess for risk of osteoporosis and treating bone disease
  • vitamin and mineral supplements following medical assessment
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5
Q

What is diverticular disease and diverticulitis?

A
  • Small bulges or pockets (diverticular) develop in the lining of the intestine. Diverticulitis is when the pockets become inflamed or infected
  • Symptoms: lower abdominal pain, constipation, diarrhoea
  • Treatment: high-fibre diet, bulk forming drugs (treats diarrhoea or constipation), antibiotics (diverticulitis if signs of infection/immunocompromised)
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6
Q

What is Ulcerative Colitis?

A
  • Included in Inflammatory Bowel Disease (IBD), mucosal inflammation and ulcers restricted to colon and rectum.
  • symptoms: alternates between actue flare ups and remission,
    • bloody diarrhoea (may contain mucus or pus)
    • abdominal pain, urgent need to defecate
    • acute flare up: mouth ulcers, arthritis, sore skin, weight loss, fatigue

-

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7
Q

Long term complications of UC?

A
  • colorectal cancer
  • secondary osteoporosis (corticosteroid medication, dietary change)
  • venous thromboembolism (VTE)
  • toxic megacolon
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8
Q

What is contraindicated during acute flare ups of UC?

A
  • loperamide/codeine phosphate (avoid anti-motility drug/antispasmodics: paralytic ileus = increased risk of toxic megacolon)
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9
Q

What is extensive colitis (proximal) and how should it be treated?

A

Inflammation affects up to most of the ascending (proximal) colon; includes pan-colitis which affects the total colon

ORALLY

*(rectal vs oral treatment depends on the area affected and severity)

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10
Q

How should left sided coitis be treated?

A

(inflammation up to the descending colon (distal colon)

ENEMAS (RECTAL)

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11
Q

How should proctosigmoiditis be treated?

A

(inflammation of rectum and sigmoid colon)

FOAM PREPARATIONS (foam prep and suppositories are easier to retain than liquid enemas)

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12
Q

How should proctitis be treated?

A

(inflammation of the rectum)

SUPPOSITORIES

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13
Q

First line and alternative treatment for acute mild-moderate UC?

A

FIRST LINE =AMINOSALICTYLATE (RECTAL)

Alternative = rectal corticosteroid or oral prednisolone

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14
Q

First line and alternative for extensive colitis - left sided colitis?

A

FIRST LINE = HIGH DOSE ORAL AMINOSALICYLATE + RETAL AMINOSALICYLATE OR ORAL BECLOMETASONE IF NECESSARY

Alternative = oral prednisolone alone

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15
Q

FIrst line treatment and alternative for subacute (moderate-severe UC?

A

ORAL PREDNISOLONE

Alternative = monoclonal antibodies

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16
Q

Initial treatment failure in all extents of acute mild-moderate UC?

A
  • Add oral prednisolone (after 4 weeks with aminosalicylate)

- Add oral tacrolimus if no response after 2-4 weeks

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17
Q

What to do during severe acute UC following immediate hospital admission: life threatning medical emergency?

A

FIRST LINE = IV CORTICOSTEROID + assess need for surgery
Alternative: IV ciclosporin OR surgery

SECOND LINE = symptoms don’t improve/worsen in 72 hours IV ciclosporin + IV corticosteroids OR surgery
Alternative to ciclosporin: infliximab

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18
Q

What should NOT be used in maintaining remission in UC?

A

Do not use corticosteroids as they have too many side effects

Use aminosalicylates

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19
Q

What is used to maintain remission in proctitis/proctosigmoiditis?

A
  • Rectal aminosalicylate alone or with oral aminosalicylate (can give oral aminosalicylate alone if patients prefer not to use enemas/suppositories but not as effective)
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20
Q

What is used to maintain remission in extensive colitis/left sided colitis?

A
  • low dose oral aminosalicylate (single daily dose more effective than multiple daily doses but has more side effects)
  • oral azathiopurine/mercaptopurine (if 2+ acute flare ups in 12 months that required systematic corticosteroids or if remission not maintained by aminosalicylates, or after severe flare up)
  • monoclonal antibodies continued if effective/tolerated during actue flare up
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21
Q

What is Crohn’s disease?

A
  • Inflammation of GI tract from mouth to anus (another IBD)
  • symptoms: alternates between acute flare-ups and remission
    • abdominal pain
    • diarrhoea, rectal bleeding
    • weight loss, low grade fever, fatgue
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22
Q

Complications of crohn’s disease?

A
  • intestinal strictures, abscesses, fistulae
  • malnutrition, anaemia
  • colorectal cancer, small bowel cancers
  • growth failure and delayed puberty in children (due to corticosteroid use)
  • arthritis, abnormalities of joints, liver, eyes, and skin.
  • secondary osteoporosis
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23
Q

Lifestyle advice for crohn’s disease?

A
  • high fibre diet
  • smoking cessation reduces risk of relapse
  • loperamide or codeine phosphate treats diarrhoea - not in colitis!
  • smoking cessation
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24
Q

Treatment for 1+ acute flare up of crohns in 12 months/first presentation

A

CORTICOSTEROID (prednisolone, methylprednisolone, IV hydrocortisone)
Alternative: budesonide or aminosalicylate in patients with distal ileal, ileocaecal, or right sided colonic disease

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25
Q

Treatment for 2+ acute flare ups of crohn’s disease in 12 months (OR if corticosteroid dose cannot be reduced)

A
  • azathiopurine or mercaptopurine (unlicensed and check TPMT levels first)
  • alternative: methotrexate if not tolerated
  • alternative if other therapies fail/cannot be taken: monocolnal antibodies under specialist supervision in severe flare ups (inliximab or adalimumab either monotherapy or in combo with steroid/immunosuppressant)
  • if STILL unsuccesful, Vedolizumab or Ustekinumab is recommended for moderate to severe active crohns disease when others not worked/tolerated
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26
Q

What is used to maintain remission in crohn’s disease?

A
  • azathioprine or mercaptopurine
  • alternative: methotrexate

*never use steroids in remission

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27
Q

What is used to maintain remission in crohns after surgery?

A
  • azathioprine or mercaptopurine OR aminosalicylates
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28
Q

3 classes of drugs used in IBD?

A
  • aminosalicylates
  • corticosteroids
  • drugs that affect the immune system
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29
Q

List of aminosalicylates?

A
  • balsalazide (pro drug of 5-ASA)
  • mesalazine (5-ASA)
  • olsalazone (dimer or 5-ASA; cleaves lower in bowel)
  • sulfasalazine (5-aminosalicylic acid (5-ASA) and sulfapyridine (carrier)
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30
Q

List of corticosteroids?

A
  • beclometasone (adjunct to aminosalicylate in mild-moderate UC)
  • budesonide
  • hydrocortisone
  • methylprednisolone
  • oral prednisolone
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31
Q

List of drugs that affect the immune system

A
  • azathiopurine
  • ciclosporin
  • mercaptopurine
  • methotrexate
  • monoclonal antibodies e.g infliximab
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32
Q

Aminosalicylates mechanism of action?

A

Mechansim of action is not entirely understood bu thought to reduce cytokine and free radical formation and inhibit prostaglandin synthesis

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33
Q

Aminosalicylate side effects and interactions?

A

S/Es

  • blood dyscasias, pt counselling: report unexplained bleeding, bruising, sore throat, fever
  • nephrotoxicity; monitor renal function
  • salicylate hypersensitivity e.g. itching and hives
  • yellow/orange bodily fluids with sulfasalazine ( warn patients soft contact lenses may be stained)

Interactions
- lactulose and mesalazine (lactulose lowers stool pH in the intestines. This prevents sufficient release of the active ingredient in E/C or M/R preps)

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34
Q

IBS symptoms?

A
  • lower abdominal pain/colic
  • bloating
  • alternating constipation and diarrhoea

Aggrevated by stress, depression and anxiety, lack of dietary fibre. Commonly affects young adult women between 20 and 30

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35
Q

Drugs used in IBS for GI spasms?

A

ANTISPASMODICS

  • alverine
  • mebeverine
  • peppermint oil (heartburn, local irritation of mouth/oesophagus)

ANTIMUSCARINICS

  • hyoscine butylbromide
  • atropine
  • dicycloverine
  • propantheline bromide
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36
Q

Drugs used in IBS for constipation?

A

LAXATIVES

  • lactulose NOT recommended; causes bloating
  • linoclotide (unresponsive to different laxative classes and have had constipation fo 12 months)
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37
Q

What is the first line for diarrhoea in IBS?

A

LOPERAMIDE (antimotility)

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38
Q

What can be used in IBS second line for abdominal pain/discomfort?

A

ANTIDEPRESSANT

  • tricylcic
  • SSRI
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39
Q

What is short bowel syndrome?

A

Characterised by malabsorption following extensive resection of the small bowel

  1. malabsorption and malnutrition
  2. inadequate digestion
  3. incomplete drug absorption
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40
Q

What does malabsorption and malnutitrion lead to and how is it treated?

A

= deficiency of vitamin A, B12, D, E and K, essential fatty acids, zinc, selenium, hypomagnesaemia

SUPPLEMENTATION

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41
Q

What does inadequate digestion lead to and how is it treated?

A

= diarrhoea

LOPERAMIDE

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42
Q

What does incomplete drug absorption lead to and how is it treated?

A

= higher doses for warfarin, oral contraceptives and digoxin or give IV

  • e/c or m/r formulations not suitable
  • uncoated tablets, soluble tablets are suitable
  • liquid formulations may be suitable (depends on osmolarity, excipients and volume requried)
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43
Q

Constipation symptoms?

A
  • infrequent stools
  • difficulty passing stools
  • sensation of incomplete emptying

NICE CKS definition: less than 3 times a week

Associative symptoms:

  • excessive straining
  • lower abdominal pain or discomfort
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44
Q

Constipation red flags?

A

New onset constipation in over 50 yrs, anaemia, abdominal pain, unexplained weight loss, overt or occult blood (hidden blood in stools)

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45
Q

Laxative classes?

A 
STIMULANT 
STOOL SOFTENER
BULK FORMING
OSMOTIC
LUBIPROSTONE AND PRUCALOPRIDE 
,METHYLNALTEXONE AND NALOXEGOL
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46
Q

Stimulant laxatives?

A 
Bisacodyl
Glycerol suppositories 
Sodium picosulfate 
Co-danthramer
Co-danthrusate 
Senna 
Docusate Sodium
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47
Q

Bulk forming laxatives?

A

Ispaghula husk
Sterculia
Methylcellulose

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48
Q

Osmotic laxatives?

A

Magnesium hydroxide
Lactulose
Macrogol 3350

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49
Q

What are the first line laxatives for short duration constipation?

A
  • BULK FORMING

- first line after dietary measures, ideal for small, hard stools and fiber-deficient diets

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50
Q

Bulk forming laxatives drug action, side effects and counselling points?

A
  • swells in gut to increase faecal mass to stimulate perisrtalsis.
  • works within 24 hours but takes 2-3 days for full effect

s/es
- bloating, cramping, flatulence and gut obstruction

counselling

  • maintain adequate fluid intake to avoid gut obstruction
  • swallow with plenty of water and not immediately before bed

*contains potent allergens = hypersensitivity reactions (ispaghula husk)

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51
Q

What are the second line laxatives for short duration constipation if stools remain hard?

A

OSMOTIC LAXATIVES

52
Q

Osmotic laxatives drug action and side effetcts?

A
  • increases water in colon by drawing fluid from the body or retains fluid administered with
  • lactulose causes osmotic diarrhoea of low faceal pH
  • magrogols sequester (isolate) fluid in bowel
  • works within 2-3 days, 48 hours for lactulose

s/es

  • discomfort, flatulence, cramps, nausea when starting lactulose
  • nausea reduced by administering with water, fruit juice or meals
53
Q

Third line laxative?

A

STIMULANT: add if stools are soft but difficult to pass/incomplete emptying (*only got short term use of 1 week)

54
Q

Stimulant laxartive drug action, side effects and counselling points?

A
  • increases intestinal motility by irritating the gut lining
  • glycerol suppositories work in about 15-30 mins
  • works within 6-12 hrs usually

s/es

  • abdominal cramps.
  • senna colours urine yellow/brown
  • excessuve use = hyPOkalaemia, diarrhoea, lazy bowel

counselling

  • take at night to pass stool in morning
  • moisten suppositories with water before use

*NOT CO-DANTHRAMER/CO-DANTHRUSATE

55
Q

Stimulant (co-danthramer, co-danthrusate)

A

DANTRON is genotoxic and carcinogenic

s/es

  • carcinogenic: used in terminally ill patients
  • red urine
  • local irritation/excoriation; avoid prolonged contact with skin in incontient patient
56
Q

What are faecal softeners?

A

LIQUID PARAFFIN - traditional lubricant. Not recommended

Harsh side effects:

  • anal seepage, lipiod pneumonia, granulomatous disease of GI tract
  • malabsorption of fat-soluble vitamins A,D,E,K

Other laxatives with stool softening properties

  • methylcellulose (bulk forming)
  • docusate sodium (weak stimulant)
  • glycerol (rectal stimulant)
57
Q

Lubiprostone and prucalopride

A 
If at least 2 laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months :
consider prucalopride (women only) or lubiprostone
58
Q

What is used in opioid-induced constipation?

A
  • osmotic or docusate sodium + stimulant
  • co-danthramer or co-danthrusate (palliative care only)
  • methynaltrexone/neloxegol (peripheral opioid recepror antagonist when response to laxatives inadequate)

*Avoid bulk forming laxatives = obstruction, painful colic

59
Q

What is used in chronic constipation?

A
  • same stepped approach as short duration laxative except MACROGOL is choice osmotic laxative
60
Q

Constipation in children?

A
  • FIRST LINE = macrogol with diet/behaviour intervention
  • add stimulant laxative if inadequate response
  • add lactulose or faecal softener if stools remain hard
61
Q

Constipation in pregnancy?

A
  • FIRST LINE LAXATIVE = bulk forming if fibre supplements fail
  • osmotic laxatives e.g. lactulose
  • bisacodyl or senna if a stimulant effect is necessary (avoid senna near term/history of unstable pregnancy; can stimulate uterine contractions)
  • docusate sodium or glycerol supps (stimulant)
62
Q

Constipation in breastfeeding?

A

FIRST LINE LAXATIVE = bulk forming if dietary measrues fail

  • laculose or macrogol (osmotic) if stools remain hard
  • alternative: stimulant e.g. bisacodyl or senna
63
Q

Diarrhoea symptoms and red flags?

A
  • frequent loose watery stools

associative symptoms;
- cramps, nausea, flatulence, dehydration

Red flags:
- unexplained weight loss, rectal bleeding, persistent diarrhoea, systemic illness, received recent hospital treatment or antibiotics (possible c diff), or following foreign travel (except western europe, australia, north america, or new zealand

64
Q

What is first line for diarrhoea?

A

ORAL REHYDRATION THERAPY
- replaces electrolyte and fluid depletion. DIORALYTE (contains ingredients like glucose, rice powder, sodium chloride and potassium chloride)

65
Q

Other Anti-diarrhoeals?

A
  • codeine (antimotility drug; opioid)
  • co-phenotrope (adjunct to rehydration; atropine - antimuscarinic/diphenoxylate - opioid)
  • loperamide (antimotility drug; opioid derivative - standard treatment)
  • loperamide with simeticone (anti-flatulence agent; for asssociated abdominal colic)
  • kaolin (intestinal adsorbents not recommended in acute diarrhoea)
  • kaolin with morphine (contains morphine;opioid)
  • methylcellulose (bulk forming laxative used to treat both constipation and diarrhoea)
  • racecadotril (adjunct to rehydration in 3+ months)
  • rifamixin (used in travellers diarrhoea)
  • antibacterials occasionally used for prophylaxis against travellers diarrhoea but routine use is NOT recommended
66
Q

Loperamide mechanism of action?

A

Antipropulsive. Prolongs the duration of intestinal transit by binding to opioid receptors in the GI tract

67
Q

Loperamide use and dosage info?

A
  • standard treatment for rapid control of symptoms (not recommended under 12 yrs)
  • ADULT DOSE: initially 4mg then 2mg for up to 5 days, take a dose after each loose stool. MAX 16MG A DAY (EIGHT 2MG caps)

MHRA/CHM ADVICE (september 2017): serious cardiac adverse reactions with high doses (large overdoses); misuse or abuse
QT prolongation, torsade de pointes (abnormal heart rhytmn), cardiac arrest and fatalities.

  • pharmacists* remind patients not to take more than recommended dose on label. Give naloxone if overdose symptoms occur
  • repeated treatment may be indicated
  • patients must be monitored for 48 hours for possible CNS depression
68
Q

Loperamide side effects and contraindications?

A

S/es
- dizziness, flatulence, headache and nausea

Contraindications

  • active UC (IBD)
  • antibiotic-associated colitis (e.g. with clindamycin treatment)
  • conditions where peristalsis is inhibited (no gut motlility)
  • conditions where abdominal distension develops

*Avoid in blood diarrhoea or inflammatory diarrhoea (fever, severe abdominal pain)

69
Q

What is dyspepsia?

A

Group of upper abdominal symptoms

  • upper abdominal pain
  • fullness
  • early satiety
  • bloating
  • belching
  • nausea

Causes:

  • indigestion (functional; uncertain origin)
  • GORD (heartburn, acid regurgitation, oesophagitis)
  • gastritis
  • gastric or duodenal ulcers
70
Q

Urgent endoscopic referral?

A

Anaemia (as a result of GI bleeding)
Loss of weight
Anorexia
Recently changed, unexplained new dyspepsia in 55+ unresponsive to treat
Malaena (blood in stool), dysphagia, haematemesis or recurrent vomitting

71
Q

What initial treatment is given for uninvestigated dyspepsia?

A
  • antacids for some symptomatic relief
  • PPI for 4 weeks if symptoms persist
  • h pyloir test if no response to PPI
72
Q

Treatment in investigated functional dyspepsia?

A
  • h pylori test

- PPI or H2 antagonist for 4 weeks

73
Q

Antacid action?

A
  • neutralises stomach acid

- provides immediate symptom relief in 15-30 mins

74
Q

Alginates action?

A
  • forms viscous gel raft on top of stomach contents to prevent reflux
  • protect oesophageal mucosa
75
Q

Antacids examples?

A
  • aluminium salt (constipating - long acting)
  • calcium salt (induce rebound acid secretion)
  • magnesium salt (laxating - long acting)
  • potassium salt
  • sodium salt

Low Na+ preparations: Maalox and mucogel, altacite plus

liquid preps are more effective than tablets

76
Q

Alginates examples?

A
  • alginic acid

- sodium alginate

77
Q

How to take Antacids/alginates?

A
  • take after each main meal and at bedtime or when required
78
Q

Antacid interactions?

A
  • impaired absorption of drugs - leave a 2 hour gap: tetracyclines, quinolones (ciprofloxacin), biphosphonates
  • damages enteric coatings by increasing gastric pH
  • high sodium content –> fluid retention; avoid in hypertension, heart, liver or kidney failure. Avoid in sodium-restricted diet e.g lithium
79
Q

PPI mechanism of action?

A

Inhibit gastric acid secretion by blocking hydrogen-potassium ATPase (proton pump) of the gastric parietal cell.
It is the most effectie antisecretory drug

80
Q

PPI examples?

A
  • esomeprazole
  • lansoprazole (take 30-60 mins before food)
  • omeprazole (safe in pregnancy)
  • pantoprazole
  • ## rabeprazole
81
Q

How to take PPIs, cautions and dose?

A
  • swallow whole, do not chew or crush
  • do not take indigestion remedies 2 hours before or after you take this medicine

CAUTIONS

  • masks symptoms of gastric cancer
  • increased risk of fractures and risk of osteoporosis
  • increased risk of GI infections - c.diff (reduced acidity)

DOSE
- lowest effective dose for shortest period

82
Q

PPI side effects, long term use and interactions?

A

s/es

  • GI upset: abdominal pain, constipation, diarrhoea, nausea
  • MHRA advice: very low risk of subacute cutaneous lupus erythematosus, lesions occur, especially on sun exposed areas, with arthralgia. Counsel patients to avoid sun exposure. Consider stopping PPI

Long-term use:

  • hypomagnesaemia (predispose to digoxin toxicity)
  • fractures
  • rebound acid secretion, protracted dyspepsia after stopping

Interactions:

  • omeprazole + clopidogrel = reduced antiplatelet effect; discourage concomitant use
  • omeprazole + methotrexate = decreased clearance of methotrexate
83
Q

H2 receptor antagonis mechanism of action?

A

reduces gastric acid secretion by blocking h2 receptors in the gastric parietal cell. It is an antisecretory drug

84
Q

H2 receptor antagonist examples?

A
  • cimetidine (enzyme inhibitor)
  • famotidine
  • nizatidine
  • ranitidine (safest in pregnancy)
85
Q

H2 receptor antagonist side effects and cautions?

A

s/es

  • headaches, rashes, dizziness, diarrhoea
  • psychiatric reactions: confusion, depression, hallucinations in the elderly or very ill patients

cautions
- masks symptoms of gastric cancer

86
Q

What is used in the treatment of gastric and duodenal ulceration?

A
  • PPIs
  • H2 receptor antagonists
  • misoprostol (synthetic prostaglandin analogue, teratogenic; avoid in pregnancy) *colic and diarrhoea are dose limiting side effects. diarrhoea is common and can occasionally be sever and require withdrawal
  • sucralfate (chelates and complexes)
  • bezoar formation; 1 hour before meals/1 hour gap between enteral feeds
87
Q

H pylori ulcers treatment?

A

1 WEEK TRIPLE THERAPY: PPI (BD) + CLARITHROMYCIN + AMOXICILLIN OR METRONIDAZOLE

Proton pump inhibitor BD
Amoxicillin
- if patient allergic to penicillcin give pmc
Clarithromycin
- if patient treated with macrolide for other infection give pam
Metronidazole
- if used to treat other infection recently give pam

*possible combinations PAC, PAM or PMC

88
Q

NSAID induced ulcers treatment?

A
  • WITHDRAW NSAID IF POSSIBLE
  • PPI or alternative H2 antagonist /misoprostol
  • test for hpylori on healing - if positive: eradication therapy
  • if non-selective NSAID continued: continue PPI or misoprostol. If history of upper GI bleeding: continue PPI + switch to cox-2 inhibitor
89
Q

NSAID induced ulcers prophylaxis?

A
  • high risk patients: 65+, previous history, taking certain medicines, significant co-morbidity e.g. liver, kidney, heart disease and diabetes
  • at risk: PPI or alternative h2
  • 3 or more risk factors: PPI with cox-2 selective NSAID
90
Q

Gastro-oesophageal reflux disease (GORD) treatment?

A

Mild symptoms

  • antacid +alginates
  • h2 receptor antagonists/PPI
  • maintain remission by e.g. intermittent treatment

Severe symptoms

  • PPI for 4-6 weeks
  • maintain remission with lower dose PPI, intermittent PPI or substituting with a h2 receptor antagonist

Pregnancy

  • antacids or alginates
  • ranitidine if above ineffective
  • omeprazole reserved for severe or complicated gord

Children

  • common in infant and resolves after age 12-18 months
  • mild to moderate GORD thickened feeds or alginates
91
Q

How is h pylori diagnosed?

A

13C-urea breath test kits

  • do not perform test wthin 4 weeks of antibacterial
  • or 2 weeks of treatment with antisecretory drug
92
Q

Food allergy symptoms and common causes?

A

Symptoms

  • cutaneous e.g. rashes, hives
  • GI e.g. colic, vomiting, diarrhoea
  • respiratory e.g. breathing problems
  • anaphylaxis

Causes:
- peanuts, tree nuts, cows milk, soy, hens eggs, fish and shellfish

93
Q

Food allergy treatment?

A
  • strict avoidance of food item
  • sodium cromoglicate as adjunct to diertay avoidance
  • chlorphenamine is licensed for symptomatic control of food allergy
  • food induced anaphylaxis: adrenaline (epipen)
94
Q

Gastro-intestinal smooth muscle spasm causes?

A
  • IBS
  • IBD
  • bowel colic in palliative care
95
Q

GI smooth muscle spasm treatment?

A

antispasmodics or antimuscarinics

96
Q

Antimuscarinics mechanism of action?

A
  • reduces intestinal motility
  • stimulation of muscarinic receptors causes a wide range of parasympathetic “rest and digest” effects
  • antimuscarinic drugs block muscarinic receptors and cause the opposite effect
97
Q

Antimuscarinics examples

A
  • atropine (outdated not used much anymore)
  • dicycloverine
  • hyoscine butylbromide
  • propantheline bromide

*hyoscine hydrobromide has different indications and is commonly used in motion sickness

98
Q

Antimuscarinic side effects?

A

“cant see, cant pee, cant poo, cant spit” = blurred vision, urinary retention, constipation, dy mouth

  • tachycardia, palpitations, arrhythmias (increases heart rate)
  • pupil dilation
  • reduced bronchial secretions
  • angle-closure glaucoma (raises intra-ocular pressure)
  • confusion in the elderley
  • drowsiness; impairs driving
99
Q

Antimuscarinic drug cautions and c/is?

A

Cautions:

  • susceptibility to angle-closure glaucoma
  • conditions causing tachycardia e.g. hyperthyroidism
  • cv diseases e.g. arrhythmias, chf

C/is

  • prostatic enlargement
  • paralytic ileus, GI obstruction, toxic megacolon
  • mysathenia gravis (characterised by muscle weakness)
  • narrow angle (closed angle) glaucoma
100
Q

Hyoscine butylbromide injection?

A

MHRA/CHM advice: risk of serious adverse effects in patients with underlying cardiac disease. Tachycardia hypotension, anaphylaxis (likely fatal in coronary heart disease)

  • c/i in tachycardia. Caution in cardiac disease
  • monitor patients and have resuscitation equipment readily available
101
Q

Antispasmodics mechanism of action?

A

Direct relaxants of intestinal smooth muscle

102
Q

Antispasmodics examples?

A
  • mebeverine*
  • alverine* (dizziness; driving warning)
  • c/is paralytic ileus
  • peppermint oil (heartburn. Local irritation of mouth/oesophagus. Counselling: swallow capsules hole
103
Q

What are anal fissures?

A

A tear or ulcer in the lining of the anal canal, immediately within the anal margin

Symptoms:

  • bleeding (bright red blood)
  • sharp, persistent pain on defecation
  • linear split in the anal mucosa ie anal fissure
104
Q

Anal fissure treatment?

A

Acute anal fissures (< 6 weeks)

  • ensure soft stools and easily passed: BULK FORMING LAXATIVE
  • alternative: osmotic
  • prolonged burning pain following defecation: SHORT TERM TOPICAL LOCAL ANAESTHETIC e.g. lidocaine, applied before empyting bowel

Chronic anal fissures ( > 6 weeks)

  • GTN rectal ointment (side effect: headache)
  • alternative: oral or topical (preferred) diltiazem, nifedipine
105
Q

Anal fissure treatment?

A

Acute anal fissures (< 6 weeks)

  • ensure soft stools and easily passed: BULK FORMING LAXATIVE
  • alternative: osmotic
  • prolonged burning pain following defecation: SHORT TERM TOPICAL LOCAL ANAESTHETIC e.g. lidocaine, applied before empyting bowel

Chronic anal fissures ( > 6 weeks)

  • GTN rectal ointment (side effect: headache)
  • alternative: oral or topical (preferred) diltiazem, nifedipine
106
Q

What are Haemorrhoids ?

A

Swellings of the anal mucosal cushion containing enlarged blood vessels, found inside or outside the anus

107
Q

Haemorrhoid symptoms, risk factors and lifestyle advice?

A

Symptoms

  • pain after bowel movement (with external piles_
  • bleeding after bowel movement (bright red blood)
  • swellings (lumps i.e. haemorrhoids)
  • itchy sore skin around anus

Risk factors

  • pregnancy
  • constipation

Lifestyle advice

  • increased fluid/fibre intake
  • constipation
108
Q

Haemorrhoids treatment?

A

EXISTING CONSTIPATION
- e.g. bulk forming laxative

PAIN RELEIF
- simple analgesics (avoid opioids, avoid NSAIDs in rectal bleeding)

TOPICAL PREPARATIONS
- often contain multiple ingredients: local anaesthetics, corticosteroids, astringents, lubricants, antiseptics

LOCAL PAIN
- preparations wit local anaesthetics - max few days e.g. lidocaine, cinchocaine, pramocaine

LOCAL PERIANAL INFLAMMATION
- preparations with corticosteroids - max 7 days e.g. hydrocortisone, flucortolone, predinsolone. Exculde infections e.g. HSV, perianal thrush

109
Q

What are reduced exocrine secretions ?

A
  • pancreatic insufficiency, reduced secretions of pancreatic enzymes = maldigestion, malnurition and GI symptoms
110
Q

Reduced exocrine secretions causes?

A
  • cystic fibrosis, chronic pancreatitis, Zollinger-Ellison syndrome, coeliac disease, obstructive pancreatic tumours and GI or pancreatic surgical resection
111
Q

Reduced exocrine secretions dietary advice ?

A
  • distribute food intake between 3 main meals and 2-3 snacks
  • avoid foods that are difficult to digest; legumes (peas, beans and lentils) and high fibre foods
  • do not consume alcohol
  • avoid reduced fat diets
112
Q

What is pancreatin?

A

Supplements to compensate for reduced or absent pancreatic enzyme secretion. They assist with the digestion of starch, fat and protein

(CREON)

113
Q

How to take pancreatin?

A
  • take with meals or immediately before/after as pancreatin inactivated by gastric acid.
  • acid suppressor e.g. PPI symptoms present despote high pancretin dose
  • enteric coated preparations deliver higher pancreatin levels
  • do not mix with excessively hot food or drinks. pancreatin inactivated by heat.
  • if mixed with food or liquids, do not keep for more than 1 hour
114
Q

Pancreatin side effects and cautions?

A
  • GI side effects (common)
  • irritation: perioral skin and buccal mucosa. Excessive doses = perianal irritation, hyperuricaemia, hyperuricosuria, skin irriation and hypersensitivity reactions when handling
  • fibrosing colonopathy in cystic fibrosis with high dose pancreatin. Risk factors: male children, more severe cf and laxative use. If new or changing abdominal symptoms - exclude colonic damage
115
Q

Pancreatin c/is and counselling

A

c/is
- nutrizym 22/ pancrease HL in children aged 15 or under with cf: associated with colon strictures

counselling:
- ensure adequate hydration at all times with high strength preps

116
Q

What is a stoma?

A
  • surgically created artificial opening formed by bringing part of the GI tract out to the surface of the abdomen - this directs faeces or urine to an external pouch
  • stomas are usually used when a whole section or part of the GI tract is damaged an needs to be removed
  • They may be permanent or temporary
117
Q

What are people with a stoma vulnerable to?

A
  • vulnerable to GI side effects - e,g. Mg and Al antacids, NSAIDs, opioids, iron; given IM
  • vulnerable to water and electrolyte depletion
    • diuretics = excessive dehydration and potassium loss
    • hypokalaemia = increased risk of digoxin toxcitity
    • avoid laxatives; increase fluid/fibre intake or try bulk-forming laxatives
118
Q

Types of stoma?

A
  • colostomy
  • ileostomy
  • urostomy
  • gastrostomy
  • jejunostomy
  • duodenostomy
  • caecostomy
  • prefix before the ‘stomy’ gives an indication of what part of the GI tract is involved
119
Q

stoma care - what preparations are unsuitable ?

A
  • ec and mr preps unsuitable. also avoid pres containing sorbitol; laxative effect
  • soluble preparations are preferable as they dissolve quicker, resulting in more complete absorption
120
Q

What is given in stoma care (medication) ?

A
  • PPI to reduce gastric acid secretion and stoma output

- high doses of loperamide needed or add codeine

121
Q

List of drugs to be avoided in stoma patients?

A
  • analgesics (e.g. opioids)
  • antacids (e.g. magnesium, aluminium or calcium salts)
  • antisecretory drugs
  • antidiarrhoeal drugs (e.g. loperamide)
  • digoxin
  • diuretics - advisable to use K sparing if necessary
  • iron preparations
  • laxatives
  • potassium supplements
122
Q

What type of waste product and bag does a descending colostomy have?

A
  • fairly firm to solid waste product

- closed pouch bag

123
Q

What sort of waste product and bag does a transverse colostomy have ?

A
  • semi-liquid and soft waste product

- drainable pouch with open and end clip

124
Q

What sort of waste product and bad does an ileostomy have?

A
  • liquid and continuous intestinal enzymes

- drainable pouch with open and end clip

125
Q

What sort of waste product and bag does a urostomy have?

A
  • urine

- drainable pouch with tap

126
Q

How to take care of the area arounf the stoma?

A
  • use fitted ostomy system and/or skin barrier protection to prevent irritation
  • keep area shaved
  • stop use of irritant soap or perfume, wash with warm water and use non-perfumed soap
127
Q

Stoma counselling and advice?

A
  • refer patient to stoma nurse for a chance in appliance if skin irritation around the stoma site occurs; advise to leep the area as dry as possible
  • advise patients to use rehydration sachets (rather than plain water) for the replacement of electrolytes
  • regular medicines reviews can reduce complications

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