Chapter 1: Gastrointestinal Flashcards
What is inflammatory bowel disease?
Includes Crohn’s disease (affecting any part of the digestive tract) and Ulcerative colitis (limited to the colon)
What is coeliac disease?
- Autoimmune condition associated with chronic inflammation of small intestine unable to absorb nutrients.
- CAUSE: adverse reaction to gluten
Symptoms of coeliac disease?
- diarrhoea, abdominal pain and bloating
- higher risk of malabsorption of key nutrients (calcium and vitamin D –> increased risk of osteoporosis)
Treatment for coeliac disease?
- strict life long gluten free diet
- assess for risk of osteoporosis and treating bone disease
- vitamin and mineral supplements following medical assessment
What is diverticular disease and diverticulitis?
- 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)
What is Ulcerative Colitis?
- 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
-
Long term complications of UC?
- colorectal cancer
- secondary osteoporosis (corticosteroid medication, dietary change)
- venous thromboembolism (VTE)
- toxic megacolon
What is contraindicated during acute flare ups of UC?
- loperamide/codeine phosphate (avoid anti-motility drug/antispasmodics: paralytic ileus = increased risk of toxic megacolon)
What is extensive colitis (proximal) and how should it be treated?
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)
How should left sided coitis be treated?
(inflammation up to the descending colon (distal colon)
ENEMAS (RECTAL)
How should proctosigmoiditis be treated?
(inflammation of rectum and sigmoid colon)
FOAM PREPARATIONS (foam prep and suppositories are easier to retain than liquid enemas)
How should proctitis be treated?
(inflammation of the rectum)
SUPPOSITORIES
First line and alternative treatment for acute mild-moderate UC?
FIRST LINE =AMINOSALICTYLATE (RECTAL)
Alternative = rectal corticosteroid or oral prednisolone
First line and alternative for extensive colitis - left sided colitis?
FIRST LINE = HIGH DOSE ORAL AMINOSALICYLATE + RETAL AMINOSALICYLATE OR ORAL BECLOMETASONE IF NECESSARY
Alternative = oral prednisolone alone
FIrst line treatment and alternative for subacute (moderate-severe UC?
ORAL PREDNISOLONE
Alternative = monoclonal antibodies
Initial treatment failure in all extents of acute mild-moderate UC?
- Add oral prednisolone (after 4 weeks with aminosalicylate)
- Add oral tacrolimus if no response after 2-4 weeks
What to do during severe acute UC following immediate hospital admission: life threatning medical emergency?
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
What should NOT be used in maintaining remission in UC?
Do not use corticosteroids as they have too many side effects
Use aminosalicylates
What is used to maintain remission in proctitis/proctosigmoiditis?
- Rectal aminosalicylate alone or with oral aminosalicylate (can give oral aminosalicylate alone if patients prefer not to use enemas/suppositories but not as effective)
What is used to maintain remission in extensive colitis/left sided colitis?
- 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
What is Crohn’s disease?
- 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
Complications of crohn’s disease?
- 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
Lifestyle advice for crohn’s disease?
- high fibre diet
- smoking cessation reduces risk of relapse
- loperamide or codeine phosphate treats diarrhoea - not in colitis!
- smoking cessation
Treatment for 1+ acute flare up of crohns in 12 months/first presentation
CORTICOSTEROID (prednisolone, methylprednisolone, IV hydrocortisone)
Alternative: budesonide or aminosalicylate in patients with distal ileal, ileocaecal, or right sided colonic disease
Treatment for 2+ acute flare ups of crohn’s disease in 12 months (OR if corticosteroid dose cannot be reduced)
- 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
What is used to maintain remission in crohn’s disease?
- azathioprine or mercaptopurine
- alternative: methotrexate
*never use steroids in remission
What is used to maintain remission in crohns after surgery?
- azathioprine or mercaptopurine OR aminosalicylates
3 classes of drugs used in IBD?
- aminosalicylates
- corticosteroids
- drugs that affect the immune system
List of aminosalicylates?
- 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)
List of corticosteroids?
- beclometasone (adjunct to aminosalicylate in mild-moderate UC)
- budesonide
- hydrocortisone
- methylprednisolone
- oral prednisolone
List of drugs that affect the immune system
- azathiopurine
- ciclosporin
- mercaptopurine
- methotrexate
- monoclonal antibodies e.g infliximab
Aminosalicylates mechanism of action?
Mechansim of action is not entirely understood bu thought to reduce cytokine and free radical formation and inhibit prostaglandin synthesis
Aminosalicylate side effects and interactions?
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)
IBS symptoms?
- 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
Drugs used in IBS for GI spasms?
ANTISPASMODICS
- alverine
- mebeverine
- peppermint oil (heartburn, local irritation of mouth/oesophagus)
ANTIMUSCARINICS
- hyoscine butylbromide
- atropine
- dicycloverine
- propantheline bromide
Drugs used in IBS for constipation?
LAXATIVES
- lactulose NOT recommended; causes bloating
- linoclotide (unresponsive to different laxative classes and have had constipation fo 12 months)
What is the first line for diarrhoea in IBS?
LOPERAMIDE (antimotility)
What can be used in IBS second line for abdominal pain/discomfort?
ANTIDEPRESSANT
- tricylcic
- SSRI
What is short bowel syndrome?
Characterised by malabsorption following extensive resection of the small bowel
- malabsorption and malnutrition
- inadequate digestion
- incomplete drug absorption
What does malabsorption and malnutitrion lead to and how is it treated?
= deficiency of vitamin A, B12, D, E and K, essential fatty acids, zinc, selenium, hypomagnesaemia
SUPPLEMENTATION
What does inadequate digestion lead to and how is it treated?
= diarrhoea
LOPERAMIDE
What does incomplete drug absorption lead to and how is it treated?
= 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)
Constipation symptoms?
- 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
Constipation red flags?
New onset constipation in over 50 yrs, anaemia, abdominal pain, unexplained weight loss, overt or occult blood (hidden blood in stools)
Laxative classes?
STIMULANT STOOL SOFTENER BULK FORMING OSMOTIC LUBIPROSTONE AND PRUCALOPRIDE ,METHYLNALTEXONE AND NALOXEGOL
Stimulant laxatives?
Bisacodyl Glycerol suppositories Sodium picosulfate Co-danthramer Co-danthrusate Senna Docusate Sodium
Bulk forming laxatives?
Ispaghula husk
Sterculia
Methylcellulose
Osmotic laxatives?
Magnesium hydroxide
Lactulose
Macrogol 3350
What are the first line laxatives for short duration constipation?
- BULK FORMING
- first line after dietary measures, ideal for small, hard stools and fiber-deficient diets
Bulk forming laxatives drug action, side effects and counselling points?
- 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)
What are the second line laxatives for short duration constipation if stools remain hard?
OSMOTIC LAXATIVES
Osmotic laxatives drug action and side effetcts?
- 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
Third line laxative?
STIMULANT: add if stools are soft but difficult to pass/incomplete emptying (*only got short term use of 1 week)
Stimulant laxartive drug action, side effects and counselling points?
- 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
Stimulant (co-danthramer, co-danthrusate)
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
What are faecal softeners?
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)
Lubiprostone and prucalopride
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
What is used in opioid-induced constipation?
- 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
What is used in chronic constipation?
- same stepped approach as short duration laxative except MACROGOL is choice osmotic laxative
Constipation in children?
- FIRST LINE = macrogol with diet/behaviour intervention
- add stimulant laxative if inadequate response
- add lactulose or faecal softener if stools remain hard
Constipation in pregnancy?
- 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)
Constipation in breastfeeding?
FIRST LINE LAXATIVE = bulk forming if dietary measrues fail
- laculose or macrogol (osmotic) if stools remain hard
- alternative: stimulant e.g. bisacodyl or senna
Diarrhoea symptoms and red flags?
- 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
What is first line for diarrhoea?
ORAL REHYDRATION THERAPY
- replaces electrolyte and fluid depletion. DIORALYTE (contains ingredients like glucose, rice powder, sodium chloride and potassium chloride)
Other Anti-diarrhoeals?
- 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
Loperamide mechanism of action?
Antipropulsive. Prolongs the duration of intestinal transit by binding to opioid receptors in the GI tract
Loperamide use and dosage info?
- 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
Loperamide side effects and contraindications?
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)
What is dyspepsia?
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
Urgent endoscopic referral?
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
What initial treatment is given for uninvestigated dyspepsia?
- antacids for some symptomatic relief
- PPI for 4 weeks if symptoms persist
- h pyloir test if no response to PPI
Treatment in investigated functional dyspepsia?
- h pylori test
- PPI or H2 antagonist for 4 weeks
Antacid action?
- neutralises stomach acid
- provides immediate symptom relief in 15-30 mins
Alginates action?
- forms viscous gel raft on top of stomach contents to prevent reflux
- protect oesophageal mucosa
Antacids examples?
- 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
Alginates examples?
- alginic acid
- sodium alginate
How to take Antacids/alginates?
- take after each main meal and at bedtime or when required
Antacid interactions?
- 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
PPI mechanism of action?
Inhibit gastric acid secretion by blocking hydrogen-potassium ATPase (proton pump) of the gastric parietal cell.
It is the most effectie antisecretory drug
PPI examples?
- esomeprazole
- lansoprazole (take 30-60 mins before food)
- omeprazole (safe in pregnancy)
- pantoprazole
- ## rabeprazole
How to take PPIs, cautions and dose?
- 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
PPI side effects, long term use and interactions?
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
H2 receptor antagonis mechanism of action?
reduces gastric acid secretion by blocking h2 receptors in the gastric parietal cell. It is an antisecretory drug
H2 receptor antagonist examples?
- cimetidine (enzyme inhibitor)
- famotidine
- nizatidine
- ranitidine (safest in pregnancy)
H2 receptor antagonist side effects and cautions?
s/es
- headaches, rashes, dizziness, diarrhoea
- psychiatric reactions: confusion, depression, hallucinations in the elderly or very ill patients
cautions
- masks symptoms of gastric cancer
What is used in the treatment of gastric and duodenal ulceration?
- 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
H pylori ulcers treatment?
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
NSAID induced ulcers treatment?
- 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
NSAID induced ulcers prophylaxis?
- 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
Gastro-oesophageal reflux disease (GORD) treatment?
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
How is h pylori diagnosed?
13C-urea breath test kits
- do not perform test wthin 4 weeks of antibacterial
- or 2 weeks of treatment with antisecretory drug
Food allergy symptoms and common causes?
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
Food allergy treatment?
- 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)
Gastro-intestinal smooth muscle spasm causes?
- IBS
- IBD
- bowel colic in palliative care
GI smooth muscle spasm treatment?
antispasmodics or antimuscarinics
Antimuscarinics mechanism of action?
- 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
Antimuscarinics examples
- atropine (outdated not used much anymore)
- dicycloverine
- hyoscine butylbromide
- propantheline bromide
*hyoscine hydrobromide has different indications and is commonly used in motion sickness
Antimuscarinic side effects?
“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
Antimuscarinic drug cautions and c/is?
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
Hyoscine butylbromide injection?
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
Antispasmodics mechanism of action?
Direct relaxants of intestinal smooth muscle
Antispasmodics examples?
- mebeverine*
- alverine* (dizziness; driving warning)
- c/is paralytic ileus
- peppermint oil (heartburn. Local irritation of mouth/oesophagus. Counselling: swallow capsules hole
What are anal fissures?
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
Anal fissure treatment?
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
Anal fissure treatment?
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
What are Haemorrhoids ?
Swellings of the anal mucosal cushion containing enlarged blood vessels, found inside or outside the anus
Haemorrhoid symptoms, risk factors and lifestyle advice?
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
Haemorrhoids treatment?
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
What are reduced exocrine secretions ?
- pancreatic insufficiency, reduced secretions of pancreatic enzymes = maldigestion, malnurition and GI symptoms
Reduced exocrine secretions causes?
- cystic fibrosis, chronic pancreatitis, Zollinger-Ellison syndrome, coeliac disease, obstructive pancreatic tumours and GI or pancreatic surgical resection
Reduced exocrine secretions dietary advice ?
- 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
What is pancreatin?
Supplements to compensate for reduced or absent pancreatic enzyme secretion. They assist with the digestion of starch, fat and protein
(CREON)
How to take pancreatin?
- 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
Pancreatin side effects and cautions?
- 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
Pancreatin c/is and counselling
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
What is a stoma?
- 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
What are people with a stoma vulnerable to?
- 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
Types of stoma?
- colostomy
- ileostomy
- urostomy
- gastrostomy
- jejunostomy
- duodenostomy
- caecostomy
- prefix before the ‘stomy’ gives an indication of what part of the GI tract is involved
stoma care - what preparations are unsuitable ?
- 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
What is given in stoma care (medication) ?
- PPI to reduce gastric acid secretion and stoma output
- high doses of loperamide needed or add codeine
List of drugs to be avoided in stoma patients?
- 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
What type of waste product and bag does a descending colostomy have?
- fairly firm to solid waste product
- closed pouch bag
What sort of waste product and bag does a transverse colostomy have ?
- semi-liquid and soft waste product
- drainable pouch with open and end clip
What sort of waste product and bad does an ileostomy have?
- liquid and continuous intestinal enzymes
- drainable pouch with open and end clip
What sort of waste product and bag does a urostomy have?
- urine
- drainable pouch with tap
How to take care of the area arounf the stoma?
- 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
Stoma counselling and advice?
- 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
