Chapter 1: GI system Flashcards
1
Q
What is coeliac disease?
A
Autoimmune condition that results in the inflammation of the small intestines. This occurs due to triggers such as gluten: wheat, rye, barley = malabsorption of nutrients
2
Q
Symptoms of coeliac disease?
A
Abdominal pain, bloating, diarrhoea = nutrient malabsorption
3
Q
Management of coeliac disease?
A
Gluten free diet, can use steroids whilst awaiting specialist input
4
Q
Why should those with coeliac disease not buy vitamins OTC?
A
They need levels checked to ensure they are getting vitamins based on their individual needs. E.g. calcium, vitamin D - assess risk of osteoporosis
5
Q
Which bisphosphonate poses the highest risk of jaw necrosis?
A
Zolendronic acid
6
Q
What is diverticulitis?
A
Small bulges/pockets that form in the colon. Diverticulitis is when these bulges/pockets become inflammed or infected.
7
Q
Symptoms of diverticulitis?
A
Lower abdominal pain Constipation Diarhhoea General malaise Fever Fatigue (infection like symptoms)
8
Q
Diverticulitis is common in those over the age of ……
A
80yrs
9
Q
Treatment of diverticulitis?
A
Asymptomatic = no specific tx
If constipated - give bulk forming laxatives e.g. isphagula husk, methycellulose
If in pain - analgesia like paracetamol
10
Q
Lifestyle advise for diverticulitis?
A
minimum 30g of fibre to prevent symptomatic diverticulitis
11
Q
What class of analgesics should be avoided in diverticulitis and why?
A
NSAIDS - risk of perforation
12
Q
Abx treatment for acute diverticulitis?
A
5 days of abx. Combo of: Co-amoxiclav OR Cefalexin + Metronidazole OR Trimethoprim + metronidazole OR Ciprofloxacin + Metronidazole
13
Q
MOA of bulk forming laxatives?
A
Retain fluid and increase faecal mass. Soften stool, stimulate peristalsis. Takes 2-3 days to work.
14
Q
Counselling on when to take bulk forming laxatives?
A
Do not take immediately before bedtime
15
Q
Adverse effects of bulk forming laxatives?
A
Bloating
Flatulence
Electrolyte disturbance e.g. hypokalaemia so caution in those with impaired disturbance already
16
Q
Excessive laxative use can lead to….
A
Diarrhoea
17
Q
In those that are penicillin allergic, which generation of cephalasporins would they mostly react to and which will they react to the least?
A
Most react to 1st generation and least reaction with 3rd gen
18
Q
Drug interactions with cephalasporins?
A
- DOAC/Warfarin - enhanced anticoagulant effect
- Aminoglycosides e.g. gentamicin - increased risk of nephrotoxicity
19
Q
Metronidazole adverse effects?
A
GI - n/v/d Neuro - headache, ataxia Taste disturbances, rash, pruritus SJS Dark urine
20
Q
Counselling points with metronidazole?
A
Take with food
Avoid alcohol during and 2 days after.
21
Q
Interactions with metronidazole?
A
Alcohol - disulfiram like reaction Anticoagulants - Enhanced effect Ciclosporin - increased levels Cimetidine - increased conc Lithium - Increased toxicity Phenytoin - Increased levels
22
Q
Are cephalasporins safe in pregnancy?
A
Yes cefalexin is. Can be used for UTI in pregnancy
23
Q
What are the two types of IBD (inflammatory bowel disease)?
A
Chrons
Ulcerative colitis
24
Q
What is ulcerative colitis?
A
mucosal inflammation and ulcers restricted to colon and rectum
25
Symptoms of UC?
Bloody diarrhoea
Urgent need to defecate
Acute flare up: mouth ulcers, wt loss, fatigue, arthritis
26
Complications of UC?
Osteoporosis
Colorectal cancer
VTE
Toxic megacolon
27
Diagnosis tests for UC?
```
FBC
TFT
LFT
Nutritional check
Inflammatory markers
U+Es
```
28
What durgs are contra-indicated in acute UC / flare ups?
Anti-spasmodics/anti-motility drugs e.g. loperamide/codeine (as can cause constipation and paralytic ileus (intestinal muscles fail to contract) which leads to toxic megacolon) - but can be used as anti-diarrhoeals under specialist
29
What is toxic megacolon?
colon stops working and gas and faeces become trapped = life threatening widening of the large intestine. This can cause colon rupture and lead to a blood infection such as sepsis
30
The type of treatment/therapy for UC depnds on...
The site and severity of the disease.
31
Talk about the different parts of the colon and the corresponding treatment for inflammation?
- Proctitis - rectum infl = use suppositories
- Proctosigmoiditis - sigmoid colon and rectum infl = use foam preps (easier to retain than liquid)
- Left-sided/distal colitis - distal colon infl - use enemas
- Extensive/proximal colitis - affects total colon - use oral preps
32
How long is steroid therapy for UC normally?
4-8weeks
33
Treatment for acute, mild-mod UC (proctitis and proctosigmoiditis + left sided colitis)?
```
1) Topical aminosalicylate
If no remission in 4 weeks
2) PO aminosalicylate
inadequate response
3) +/- Topical/oral corticosteroids for 4-8weeks
```
34
Treatment for acute, mild-mod UC (extensive)?
1) If enemas/suppositories not preferred, can give high dose PO aminosalicylate but may not be as effective
2) Topical aminosalicylate + high dose PO aminosalicylate
Not tolerated within 4 weeks
3) Stop topical aminosalicylate and give high dose oral aminosalicylate + PO corticosteroid (4-8weeks)
35
Treatment for mod-sev UC?
- conventional therapies(aminosalicylates and steroids)
| 2) monoclonal antibodies
36
Acute, severe UC is a medical emergency. What treatment is immediately required?
IV steroids e.g. hydrocortisone/methylprednisolone to induce remission
if contra-indicated, give:
- IV ciclosporin (unlicensed)
or SURGERY
IF NO IMPROVEMENT IN 72HRS:
IV ciclosporin + IV corticosteroids
or SURGERY
37
How to maintain remission in mild/mod/severe UC?
Maintenance treatment with aminosalicylates (not steroids due to SE)
38
Treatment for maintaining remission in mild-mod inflam. exacerbation of proctitis or proctosigmoiditis?
Rectal aminosalicylate alone or in combination with oral aminosalicylate as part of a regimen
39
Treatment for maintaining remission in mild-mod inflam. exacerbation of left sided or extensive colitis?
low dose oral aminosalicylate (single doses are more effective) but inc SE
40
In those that have had two or more infl. exacerbations within 12months and required steroid treatment what can you give for remission?
oral azathioprine
| mercaptopurine
41
What three classes of drugs are commonly used in UC?
Aminosalicylates
Corticosteroids
Monoclonal antibodies
42
Give examples of aminosalicylates
Mesalazine
Sulfasalazine
Olsalazine
Balsalazide
43
Which aminosalicylate is associated with urine/lens discolouration and what colour does it turn to?
Sulfasalazine - yellow/orange
44
Which two aminosalicylates can cause reversible oligospermIa as SE?
Sulfasalazine
| Mesalazine
45
Patient counselling when providing aminosalicylates?
blood dyscrasias - report unexplained bleeding, bruising, purpura, malaise, fever, sore throat - check WBC, RBC, Platelet count
Nephrotoxic
46
How often does renal function need to be monitored with aminosalicylates?
Before, 3months, annually
47
In what hypersensitivity would aminosalicylates not be suitable?
Salicylate hypersensitivity e.g. aspirin = itch and hives
48
In what deficiency would aminosalicylates not be suitable?
G6PD
49
Which aminosalicylate requires liver function monitoring and how regular should this be?
Sulfasalazine - LFTs monthly for 3 months
50
Why should you not switch brands between preparations of aminosalicylates for UC?
Extent of effect varies and they are not bioequivalent
51
A junior doctor asks you how to switch from rectal foam to oral budesonide tablets, what do you suggest?
1 metred application of the foam = 2mg oral budesonide dose
52
Mesalazine comes in various brands. What advise would you give to patients with each?
Pentasa tabs: can be halved/quartered and dispersed in water
Pentasa granules: - place on tip of tongue and wash dose with water/orange juice, do not chew
Salofalk granules: - place on tip of tongue and wash dose with water, do not chew
53
What does mesalazine in particular interact with and why?
Lactulose as it lowers stool ph.
| Mesalazine requires an acidic environment to release the drug. So it would make it ineffective
54
Give an example of a corticosteroid used in UC?
Budesonide
55
Directions on administration of budesonide?
Take in the morning, 30mins before breakfast
If granules: tip of tongue and wash down with water - do not chew
If orodispersible: place on tip of tongue, press against roof of the mouth, dissolve and swallow with saliva - do not eat/drink/oral hygiene 30mins after
56
MHRA warning with steroid use?
Serous risk of chrioretinopathy: report any blurred vision/visual changes or disturbances
57
SE of steroids?
- adrenal suppression
- psychiatric reactions
- increased risk of infection
- hypokalaemia
- hyperglycaemia
- insomnia
58
What is Chron's disease?
Chronic inflammation from the mouth to the anus - extends through all layers.
59
Symptoms of chrons disease?
Abdominal pain
rectal bleeding
bloating
wt loss
60
Complications of chrons?
strictures, abscess, anaemia, malnutrition, cancers, growth failure and delayed puberty
61
What kind of extra-intestinal manifestations can Chrons lead to?
Abnormalities and arthritis of joints eyes liver skin
62
Chron's is also a cause of ___________
secondary osteoporosis and those at high risk should be monitored for osteopenia (low BMD)
63
What lifestyle habits can be a trigger for Chrons?
Smoking
64
To induce remission in an exacerbation what drug treatment is suitable?
Corticosteroids - prednisolone or methyprednisolonr or iv hydrocortisone
65
In those who are unable to take conventional corticosteroids, what is the 2nd option?
Budesonide (more for distal/right sided colonic disease) or aminosalicylates
66
What are the differences between conventional corticosteroids (pred/methylpred/hydrocor) and budesonide?
Budesonide acts more locally so less systemic side effects but it also less effective
67
For severe chrons or exacerbation of chrons what two drugs are not suitable?
Budesonide
| Aminosalicylate
68
How to treat acute flare/exacerbation of chrons?
1) Corticosteroids: methylpred/pred/iv hydrocortisone
2) Budesonide - less effective and less SE
3) Aminosalicylate: mesalazine, sulfasalazine
4) Immunosuppressants: azathioprine, mercaptopurine (TPMT levels and skin cancer risk)
5) Methotrexate
6) Biologics
69
What is the MHRA warning with lactulose?
Cardiac effects with overdose. Can cause QT prolongation TDP and cardiac arrest. Give naloxone in overdose.
70
How to maintain remission in chrons?
Immunosuppressants - azathioprine/mercaptopurine
or
Methotrexate
71
Why is TPMT activity monitoring important in immunosuppressant therapy like azathioprine?
The enzyme thiopurine methyltransferase (TPMT) metabolises thiopurine drugs (azathioprine, mercaptopurine, tioguanine); the risk of myelosuppression is increased in patients with reduced activity of the enzyme, particularly for the few individuals in whom TPMT activity is undetectable. Manufacturer advises consider measuring TPMT activity before starting azathioprine, mercaptopurine, or tioguanine therapy. Seek specialist advice for those with reduced or absent TPMT activity.
72
Give examples of supportive therapy used in Chrons?
Diarrhoea: investigate cause and give loperamide if required
Antispasmodics: mebeverine
Pain: paracetamol/opioids (no NSAIDS)
Fatigue: Anaemia, malabsorption, sleep/stress/anxiety (depends on cause)
73
Treatment for fistulating Chron's?
if asymptomatic: no treatment
| Antibiotic: metronidazole / ciprofloxacin (max 3 months due to risk of peripheral neuropathy)
74
How do monoclonal antibodies work in chrons?
Inhibit cytokines (pro inflammatory proteins) and TNF-a to reduce inflammation
75
What can be given for maintenance of remission after Chrons surgery?
Azathioprine + metronidazole (up to 3 months)
76
What is IBS?
A common, chronic, relapsing condition that affects those aged 20-30yrs.
77
Symptoms of IBS?
```
Alternating constipation and diarrhoea
Bloating
Urgency
Straining
Mucus
```
78
Non-drug treatment for IBS?
```
Diet control
Isphagula husk, oats (soluble fibres)
Max 3 fresh fruits a day
Review fibre intake
Increase fluid intake (8 glasses/day)
```
79
What kind of fibre should be used in IBS?
Soluble - isphaghula husk or oats
80
What kind of fibre should be avoided in IBS?
Insoluble - bran and starch as they can exacerbate symptoms
81
In those with IBS and diarrhoea, what sweetener should be avoided?
Sorbitol
82
Which laxative should not be prescribed in IBS and why?
lactulose as causes bloating
83
What antispasmodic drugs are available OTC?
Alverine citrate
Mebeverine
Peppermint oil capsules
84
In those with persistent constipation (at least 12 months) and have had an inadequate response to laxatives, what would be the treatment?
linaclotide
85
What is the drug of choice for diarrhoea in IBS
1) Loperamide - advise to adjust dosage to allow a soft stool consistency
86
If abdominal pain or discomfort is not releieved by anti-spasmodics, anti-motility drugs and laxatives, what would be 2nd line option?
TCA - low dose e.g. amitryptiline (unlicensed)
if ineffective,
Give SSRI
87
What conditions can trigger IBS?
Anxiety, stress, depression
88
How do bulk forming laxatives work and give some examples.
Work by retaining fluid in the bowels, increase faecal mass and stimulate peristalsis (takes 2-3 days to work)
E.g. methycellulose, isphagula husk (preferred over bran)
89
Give some contraindications of using bulk forming laxatives?
```
Ulcerative colitis
Chrons
Opioid induced constipation
paralytic ileus
toxic megacolon
```
90
Cautions when prescribing laxatives?
fluid/electrolyte imbalances particularly hypokalaemia
91
Adverse effects of excessive laxative use?
bloating, abdominal pain, intestinal obstruction, electrolyte imbalance
92
In refractory constipation. You can use linaclotide - how would you counsel a patient on its administration?
30 mins before meals
93
Loperamide dose?
4mg stat then 2mg after every loose stool. Max 16mg per day (8capsules)
94
What two drugs used in IBS can cause allergic reactions as a side-effect?
Mebeverine and peppermint oil capsules
95
Which SSRI is the most associated with QT prolongation?
Citalopram
96
SSRIs are contraindicated in?
poorly controlled epilepsy and QT prolongation (citalopram only)
97
What is short bowel syndrome?
Increased resection of the bowel e.g. due to surgery
98
What complications can short bowel syndrome cause?
1) Nutritional deficiencies - A, B, D, E, K, Zinc, Fatty acids, Selenium, magnesium
2) Diarrhoea - use loperamide
3) Antimotility drugs: loperamide/codeine but lop prefferred
4) drug absorption - may need higher doses of levothyroxine, contraception, digoxin, warfarin
99
What drug formulations are unsuitable for short bowel syndrome?
enteric coated
| MR
100
What drug formulations are suitable for short bowel syndrome?
uncoated, liquid, soluble
101
What is constipation?
Unsatisfactory defaecation. Resulting in: straining, incomplete evacuation, infrequent/difficult stool passage
NICE: hard stools and defeacation <3x a week
102
In what people types in constipation common?
Women, elderly, pregnant
103
New onset of constipation in those aged > _____yrs should provoke urgent investigation.
Over 50yrs
104
What ALARM symptoms would prompt you to make a GP referral?
```
Anaemia
Loss of wt
New dysphagia/heartburn
Anorexia
Blood in stools
>55yrs
```
105
What non-drug treatment could you recommend to those with constipation?
Smaller meals
| increase fibre intake: lentils, whole grains, fruits, veg
106
A patient states that they have increased their fibre intake in their diet. They ask you how long it will take for them to see a change in their bowel habits, what do you say?
Few days and up to 4 weeks
107
What artificial sweetener can help those in constipation but is avoided in IBD/IBS?
Sorbitol - causes diarrhoea
108
Laxative abuse can lead to...
hypokalaemia - poses the risk of bradycardia, tachycardia, muscle weakness, cramps
109
Give examples of some bulk-forming laxatives and how they work.
Bulk-forming laxatives increase peristalsis, increase stool water content and faecal mass. Examples: isphagula husk, methycellulose, sterculia, bran - good for small, hard stools
110
Which bulk-forming laxative also works as a stool softener?
Methycellulose
111
What type of constipation do we not give bulk-forming laxatives and why?
Opioid-induced
| Risk of paralytic ileus, toxic megacolon
112
How long does it take bulk-forming laxatives to work?
up to 72hrs
113
How do stimulant laxatives work?
increase intestinal motility
114
Due to the MOA of stimulant laxatives, what is a common side effect?
Abdominal pain.
115
Give examples of stimulant laxatives
```
Senna - yellow/red brown urine
Co-danthramer - red urine
Co-danthrusate
Sodium picosulfate
Bisacodyl
```
116
Which stimulant laxatives are reserved for palliative/terminally ill patients and why?
Co-danthramer
Co-danthrusate
Carcinogenic and genotoxic, colour urine red
117
Which laxative acts both as a stimulant laxative and a stool softener?
Docusate
118
Which suppositories are commonly used in babies with constipation?
glycerol - rectal stimulant and lubricant
119
What is the aim of fibre intake daily?
30g
120
Stepwise approach for chronic constipation according to NICE CKS?
1) Bulk-forming; isphagula husk (ensure adequate fluid intake)
2) Osmotic laxative e.g. macrogol, lactulose
3) Stimulant laxative e.g. senna
121
What can be used for opioid-induced constipation?
Osmotic laxatives e.g. macrogol, lactulose
| Stimulant laxatives e.g. Senna
122
How do osmotic laxatives work and give examples.
increase amount of fluid in the bowel which then stimulates peristalsis. E.g. macrogol (movicol/laxido), phosphate and sodium citrate enemas, lactulose
123
Which laxative is used for hepatic encephalopathy and why?
Lactulose - discourages the proliferation of ammonia producing organisms
124
Which drug can be used for refractory constipation in IBS if others haven't worked?
Linaclotide
125
Give an example of a prokinetic laxative.
Prucalopride.
126
How do faecal softeners work?
Decrease surface tension, increase penetration of intestinal fluid into faecal mass. E.g. docusate and glycerol
127
What faecal softener is associated with anal seepage/lipoid pneumonia on aspiration and malabsorption of vitamin ADEK.
Liquid paraffin
128
If response to other laxatives (osmotic/stimulant) is inadequate in opioid-induced constipation, what can be used?
Naloxegel and methylnaltrexone
129
What can be used to treat faecal impaction (big hard stool stuck in colon and ahrd to expel)?
Macrogol high dose
+/- stimulant laxative
or
bisacodyl/glycerol suppositories
130
1st line treatment for constipation in pregnancy/breast feeding?
Bulk-forming e.g. fybogel: isphagula husk
131
If bulk-forming does not help those who are pregnant what other treatment options are suitable?
Osmotic laxatives: lactulose
Stimulant: senna, bisacodyl (short course)
Stimulant more effective than bulk forming but increased SE
132
Avoid senna in pregnancy when ________
At term and if there is unstable pregnancy
133
Treatment options for children with laxative?
- Osmotic, for faecal impaction: <4yrs is unlicensed
- 2nd line: stimulant laxative
If doesnt work in 2 weeks - risk of faecal impaction.
134
Counselling points for isphagula husk?
- Hypersensitivity reactions due to potent allergens
- take with 150ml liquid
- do not take immediately before bedtime
- may take several days to work
135
Magnesium salts cause _____
diarrhoea
136
Aluminium causes ______
constipation
137
docusate is licensed in those over ____yrs
12
138
Counselling points with liquid paraffin.
anal seepage, lipoid pneumonia (do not give immediately before bed)
139
Bisacodyl is a stimulant laxative. How long do tablets take to work and how long do suppositories take to work?
Tablets: 10-12hrs
Suppositories: 20-60mins
140
Co-danthrasate and co-danthramer are stimulant laxatives. what are the counselling points and who should they be used in?
Avoid prolonged contact with skin due to local irritation.
| Only for terminally ill as cancerogenic and genotoxic.
141
Glycerol suppositories are suitable for those aged >_____
1 month
142
Which laxative is prone to abuse - particularly by young women.
Senna - stimulant due to weight loss.
143
Onset of action for senna?
8-12hrs, hence take ON for a normal bowel movement in the morning.
144
Which laxative used for opioid-induced constipation needs reduction with CYP3A4 inhibitors?
Naloxogel 25mg OD to 12.5mg OD
145
Which laxative can only be used in women with refractory constipation (tried others at highest dose for 6mths) and why?
prucalopride - not enough evidence of it working in men (NICE)
146
What colour does the stimulant laxative danthrons turn urine?
Red
147
Treatment options for opioid-induced constipation?
1) Osmotic/Docusate + stimulant
2) Danthrons (palliative care only)
3) Methylnaltrexone/Naloxegel
NICE 2020: nalmenedene - does not reduce opioid effect but decreases constipation effect of opioids
No bulk forming due to obstruction and painful colic
148
If senna is used for constipation in pregnancy, it should be avoided at ____
term as it can stimulate contractions
149
give examples of increasing fibre intake?
Fruit and veg
wholegrain cereal
Bread
Baked beans
150
What is diarrhoea?
Frequent, loose, watery stools with associated symtpoms of nausea, dehydration, cramps, flatulence
151
If diarrhoea lasts <14 days it is _____
Acute diarrhoea. Usueally resolves in 2-3 days
152
Give some red flag symtpoms?
```
Unexplained weight loss
Rectal bleeding
Persistent diarrhea
Systemically unwell
Recent abx treatment/hospital stay (c.diff)
Foreign travel
```
153
Patient X has been confirmed with C.Diff. Current drug hx states he is taking the following meds:
- ferrous sulphate
- paracetamol
- ibuprofen
- levothyroxine
Which one are you likely to hold and why?
Ferrous sulphate as it can cause constipation that can lead to toxic megacolon and eventually sepsis.
154
Aim of diarrhoea treatment?
Prevent dehydration
| Fluid and electrolyte replacement - diarolyte (especially in infants, frail and elderly)
155
When would diarrhoea be considered chronic?
>2weeks
156
Common causes of diarrhoea?
Food poisoning e.g. e.coli/campylobacter/salmonella
| Rotavirus/norovirus
157
Diarrhoea treatment?
1) Fluid + Electrolyte replenishment: caution in those with CVS issues such as hypertension/oedema sa do nto want to overload
2) severe dehydration: IV fluids, U+Es (hospital admission)
3) if rapid control: antimotility drug loperamide
158
Loperamide should be avoided in:
bloody/suspected inflamamtory diarrhoea
| significant abdominal pain
159
1st line for faecal incontinence (inability to control bowel movements which then lead to leakage)?
Loperamide (unlicensed)
160
what antibiotic can be used for for travellers diarrhoea prophylaxis?
Ciprofloxacin but not recommended routinely.
161
How to reverse opioid overdose?
Naloxone and monitor for 48hrs due to CNS depression
162
How does loperamide work?
Binds to opioid receptors in guts and slows down peristalsis
163
Side effects of loperamide?
Nausea
Headache
Flatulence
Dizzy
164
Loperamide contra-indications?
Ulcerative colitis
AB-associated colitis
No gut motility
Abdominal distension - eg liver issues/heartfailure as there is already water retention and this would exacerbate further
165
Dyspepsia symptoms usually occur for.......
4 or more weeks do an endoscopy
166
Symptoms of dyspepsia?
```
N/V
Abdominal pain
Bloating
Reflux
Heartburn
Pain/discomfor
```
167
Causes of dyspepsia:
GORD - acid from stomach leaks into oesophagus
PUD
Pregnancy
Unidentified
Malignancy
Ulcers
Gastritis - inflammation of stomach lining
168
What are ALARM symptoms?
```
Anorexia
Loss of weight
Anaemia
Recent/new in >55
Malaena (blood in stools, blood when vomiting)
```
169
Lifestyle advice for dyspepsia?
```
Lose weight
Smoking cessation
Smaller meals
Avoid eating at night
Reduce alcohol consumption
```
170
Which drugs can cause heartburn/dyspepsia?
```
A-blockers
Antimuscuranics
Aspirin
Benzodiazepines
B-blockers
Bisphosphonates
CCB
Steroids
Nitrates
NSAIDs
Theophylline
TCA
```
171
Treatment for initial management of dyspepsia - symptomatic relief?
1) Uninvestigated: PPI for 4 weeks/ant acids and test for h.pylori
2) Functional dyspepsia: test for h.pylori and if negative use PPI for 4 weeks/h2-receptor antagonist
172
What management options are there for a patient with uninvestigated dyspepsia taking an NSAID?
if unable to stop NSAID e.g. gout attack. The either reduce dose or switch to e.g. coxib (less GI SE) or paracetamol + use long term gastroprotection
173
What management options are there for a patient with uninvestigated dyspepsia taking aspirin?
switch from aspirin to another antiplatelet e.g. clopidogrel (less GI se and more effective)
174
How often should those with dyspepsia be reviewed?
Annually
175
How do antacids work?
Neutralise stomach acid and provide immediate relief within 15-30mins
176
Give exames of some antacids.
Aluminium: cause constipation
Magnesium: cause diarrhoea
liquid more effective than tablets
177
Why are bismuth containg preps not often used?
Unless chelates, they can be neutoxic and cause encepahlopathy + constipating
178
Calcium containing antacids can
Induce rebound acid secretion and cause hypercalcaemia
179
how can simeticone help is dyspepsia?
Helps smaller bubbles form together and expel. Helps in flatulence as it is antifoaming and can also be useful for hiccups in palliative care.
180
How do alginates work and give examples.
often used in combination with antacids. They increase the viscosity of stomach contents and protect oesophageal mucosa from acid reflux by forming a raft
- alginic acid
- sodium alginate
181
Antacids should be avoided in those with _____
Fluid retention due to large amounts of sodium e.g. impaired renal function/heart failure and avoid with lithium
182
How to counsel patients on taking antacids?
After each main meal/at bedtime PRN
183
Interactions with antacids.
- Impaired absorption of drugs so leave a 2 hr gap: bisphosphonates, quinolones and tetracyclines
- Damages enteric coating by increasing gastric PH e.g. aspirin
- High sodium content (avoid in liver/kidney impairment, hypertension, heart failure and with lithium as (sodium restricted diet))
184
What is peptic ulcer disease?
Disruption in the gastric/duodenal epithelium =ulcers. Main symptom is abdominal pain
185
What are the most common causes of peptic ulcer disease?
```
H.pylori infection
NSAID use
Smoking
Alcohol
Stress
```
186
Complications of peptic ulcer disease
GI perforation
GI obstruction
Haemmorhage
187
Give some risk factors of developing peptic ulcer disease with an NSAID.
```
>65
High dose NSAID
Previous ulcers
Drugs: anticoagulants/steroids/SSRI
Co-morbidity: CVS disease, hypertension, diabetes, renal/hepatic imp
Smoking
Ex. alcohol consumption
ADR to NSAIDS
```
188
What drugs can induce peptic ulcers?
```
NSAIDS
Bisphosphonates
Aspirin
SSRI
Steroids
Potassium chloride
Recreational drugs
```
189
If gastric ulcers have been associated with NSAID use. How would this be managed?
8 weeks PPI/h2 receptor antagonist + hpylori eradication if positive
190
Give the treatment options for gastro protection.
1 - PPI
2 - H2 receptor antagonist
3 - Misoprostol (limited use due to SE)
191
How often should h.pylori eradication treatment be reviewed?
6-8 weeks
192
how often should NSAID use be reviewed?
6 monthly and use on a PRN basis
193
Bismuth salicylate can be used as a part of h.pylori eradication. In what age range would this not be suitable and why?
<16yrs - reyes syndrome
194
Common side-effect of bismuth salicylate.
Blaack stools and black tongue
195
Which chelate used to protect mucosa from acid attack can cause bezoars to form?
Sucralfate - take 1hr before meals/1hr gap between feeds
196
How do h2-receptor antagonists work?
heal gastric and duodenal ulcers by reducing gastric acid output.
197
What is the current issue with the use of ranitide and h2-rec antagonists which resulted in the recall of the drug?
Cancerogenic properties
198
What would h2-receptor antagonists be cautioned in?
Gastric cancer as can mask effects
199
Give examples of h2 receptor anatagonists.
Ranitidine
Famotidine
Cimetidine
200
Side-effects oh h2-receptor antagonists?
```
Headache
Rash
Dizziness
Diarrhoea
psych rx: halluciantions, confusion, depression
```
201
Which h2-receptor antagonist is a potent enzyme inhibitor?
Cimetidine
202
How do PPIs work?
Inhibit gastric acid secretion by blocking proton pump in gsatric parietal cells.
203
Indications for PPI use?
```
PUD
NSAID Associated ulcer
GORD
uninvestigated dyspepsia
Zollinger-Ellison syndrome (excessive gastric acid secretion)
H.pylori eradication
Peptic ulcer bleeding
```
204
MHRA warning associated with PPI?
Risk of lupus so avoid sun exposure, use SPF
205
Give examples of PPIs.
```
Omeprazole
Lansoprazole
Esomeprazole
Pantoprazole
Rabeprazole
```
206
Counsel a patient on the administration of PPIs.
30-60minutes before food, do not chew or crush. avoid indigestion remedies 2 hrs before or after taking this medication
207
PPIs should be avoided in pregnancy. True or false?
True howeever omeprazole not known to be harmful
208
give a key interaction with PPIs and an antiplatelet drug/immunosuppressant drug
Clopidogrel and omeprazole (use lansoprazole instead) - reduced antiplatelet effect
Methotrexate: increased risk of toxicity
209
Long term risks associated with PPI use?
Hypomagnesaaemia
bone fracture risk - esp in elderly (>1year) and those at risk of osteoporosis e.g. menopausal and increased risk with steroid use : Use vitamin d and calcium supplements
Risk of c.diff - hold whilst on abx
Can mask symptoms of gastric cancer
210
What other drugs used with PPI can increase the risk of hypomagnesaemia
Digoxin - inc risk of dig toxicity
211
How long for PPIs to take full effect?
2-3 days so can use antacids in between
212
Misoprostol can be used for gastric ulcers/NSAID-induced peptic ulcers/ prophylaxis of NSAID induced ulcers. What is the risk associated with it?
Can induce uterine contractions, cause abortion and birth defects - DO NOT USE UNLESS PREGNANCY EXCLUDED. If given, take with food.
213
Side-effects of misoprostol?
Colic and diarrhoea
214
Treatment options for GORD - chronic reflux.
1) PPI 8 weeks
2) H2 - receptor antagonist
3) switch PPI
215
Treatment options for GORD - pregnancy.
1) Dietary and lifestyle
2) Antacid/alginate but not gaviscon advance
3) Omepraozle
216
What is h.pylori and what is the aim?
Common cause of peptic ulcer disease, it is an infection. Aim is to reduce the risk of PUD, ulcer bleeding, malignancy and recurrence
217
What test can be used to test for h.pylori?
Urea 13c breath test or stool helicobacter antigen test (SAT)
218
State some issues of using the urea breath test after being on PPI or antibiotics.
Dont perform within 2 weeks of PPI use
Dont perform within 4 weeks of antibiotic use
= false negatives
re-test after atlaest 4 weeks of treatment
219
Drug treatment for h.pylori
Triple therapy regimen.
| PPI + 2 antibiotics (choose carefully due to risk of resistance)
220
H.pylori regimen.
7 days
1) No penicillin allergy
PPI BD + amoxicillin 1g BD + clarithromycinn 500mg BD/metronidazole 400mg BD
2) If penicillin allergy: PPI + Clari + Metro
3) If used clari already - then go for metro
4) if used metro already - then go for clari
5) If allergic to penicillin and recently exposed to clari, then use PPi + Metro + Tetracycline 500mg QDS
221
What is a food allergy?
Adverse immune reaction to food e.g. peanuts, fish, cows milk, soy, hens eggs, shellfish, nuts
222
Treatment for food allergies?
Avoid allergen
Chlorphenamine 4mg every 4-6hrs (v drowsy)
Sodium croglicate: adjunct to dietary avoidance
If anaphylaxis: Epipen every 5 minutes and call 999
223
Give some causes for muscle spasms?
IBS
IBD (chrons/UC)
Bowel colic in palliative care
224
Treatment for muscle spasms?
Antimuscuranics
| Antispasmodics
225
Give some indications for antimuscuranics.
```
Arrhythmias
Asthma
motion sickness
urinary incontinence
parkinsonism
```
226
Five examples of antispasmodics used in iBS
Alverine
Mebeverine
Peppermint oil capsules
- avoid in paralytic ileus but can help relieve pain
227
How do antimuscuranics workand side effects
Block muscuranic receptors allowing the sympathetic nervous system to dominate.
= pupil dilation, bronchodilation (hence used in asthma copd, Constipation, dry mouth, constipation, urinary retention, increased hr, confusion, drowsiness
228
What is the difference between hyoscine butylbromide and hyrobromide?
Hydrobromide - motion sickness (Kwells)
| Butylbromide - Antispasmodic (Buscopan)
229
Contraindications for antimuscuranics
```
Prostate enlargement
Urinary retention
Closed angle glaucome - risk of vision loss
Paralytic ileus
Toxic megacolon
```
230
Caution in
Clonsesed angle glaucoma as can cause vision loss
231
MHRA warning with hyoscine butylbromide?
Tablets not licensed in <6yrs
| Risk of serious adv effects in those with cardiac disease: tachycardia
232
OTC buscopan max doses
max single dose 20mg
max daily dose 80mg
max pack size 240mg
For ibs
233
What is cholestasis and how do you treat it?
bile formation/flow impairment and treat with cholestyramine
234
Signs and symptoms of liver impairment and cholestasis?
```
abdominal pain
pale stools
dark urine
pruritus
yellow skin
```
235
Treatment for gallstones/kidney stones?
hard mineral/fatty deposits . Do not treat if asymptomatic.
| Drug tx - analgesia especially PR diclofenac/opioid
236
What BMI is considered obese?
>/= 30kg/m2
237
Which thyorid disorder can cause weight gain?
hyporthyroidism (weight gain, bradycarida, cold intolerances)
238
What drug is the only one used for obesity in the UK?
Orlistat - reduced dietary absorption of fat (to maintain weight loss), discontinue after 12 weeks if wt loss not exceeded
239
what side-effects can the use of orlistat produce?
malabsorption of fat soluble vitamins ADEK so use supplements
240
What are anal fissures?
Tear/lining/ulcer on anal margin = bleeding bright red blood, sharp persistent pain, linear split
241
1st line for acute anal fissures <6 weeks?
bulk forming laxatives or osmotic laxatives
burning pain - local anaesthetic lidocaine before bowel emptyin
242
Treatment for burning pain before defaecating?
local anaesthetic lidocaine before bowel emptying
243
1st line for chronic anal fissures >6 weeks?
GTN rectal ointment (SE headache) or PR diltiazem/nifedipine (relax muscle and increase blood supply)
244
What are hemorrhoids?
Swelling of anal mucosal cushion with enlarged blood vessels found inside or outside anus
245
Symptoms of hemmorrhoids?
bleeding after defecation
pain
swelling
itchy, sore skin
246
Treatment for hemmorhoids?
Constipation: bulk forming
pain: analgesia (no opioids/nsaids - already rectally bleeding)
Topical: local anaesthetics e.g. lidocaine for pain, anf for inflammation: steroid (max 7 days)
247
what is pancreatic insufficiency?
Reduced secretion of pancreatic enzymes = maldigestion/malnutrition/GI
248
Causes of pancreatic insufficiency?
```
Cystic fibrosis
Pancreatitis
Zollinger-ellison
Coeliac disease
Tumours
GI/pancreatic resection
```
249
dietary advice for pancreatic insufficiency?
3 main meals and 2/3 snacks
avoid food that is hard to digest
No alcohol
Avoid reduced fat diets
250
How to treat pancreatic insufficiency?
Pancreatin enzyme Creon- compensate for reduced/absent secretion and helps to digest enzymes/lipases/fats/carbs/proteins
251
Creon counselling?
Take with meals/snacks before or after as inactivated by gastric acid.
Enteric coated = high pancreatin levels.
Pancreatin inactivated by heat so don't mix with ex. hot food/drinks and do not keep for more than 1hr.
Mix with soft food/liquid e.g. apple juice and swallow immediately (can open up capsules)
Ensure adequate hydration
252
Creon SE?
GI, Irritation (skin and buccal mucosa), hypersensitivity, hyperuricaemia
Contra ind: <15yrs
253
What is a stoma?
Artifical opening of the abdomen surface allowed to divert the flow or faeces and urine into an external bag (ileostomy/colostomy)
254
Due to changes in drug delivery with stoma, which preparations are unsuitable?
- E/C and MR
- Sorbitol containing - diarrhoea
- Inc susceptibility to GI effects so --Mg/Alu/NSAIDS/opioids/Iron (sore skin and loose stools) so give iM
- u+es depletion: inc risk of dig toxicity
255
What diuretics and laxatives are suitable for stoma patients and which are not?
Give potassium sparing diuretic (as increases k+)
bulk forming laxatives
caution with stimulant laxatives
256
Antidiarrhoeal drugs for stoma?
Loperamide (may need higher doses if short bowel)/ codeine
257
What drug formulations would be more suitable for stoma?
soluble tabs
liquid capsules
uncoated tablets
