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2021 Pre-registration > Chapter 1: GI system > Flashcards

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

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2
Q

Symptoms of coeliac disease?

A

Abdominal pain, bloating, diarrhoea = nutrient malabsorption

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3
Q

Management of coeliac disease?

A

Gluten free diet, can use steroids whilst awaiting specialist input

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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

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5
Q

Which bisphosphonate poses the highest risk of jaw necrosis?

A

Zolendronic acid

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6
Q

What is diverticulitis?

A

Small bulges/pockets that form in the colon. Diverticulitis is when these bulges/pockets become inflammed or infected.

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7
Q

Symptoms of diverticulitis?

A 
Lower abdominal pain 
Constipation 
Diarhhoea 
General malaise
Fever
Fatigue (infection like symptoms)
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8
Q

Diverticulitis is common in those over the age of ……

A

80yrs

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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

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10
Q

Lifestyle advise for diverticulitis?

A

minimum 30g of fibre to prevent symptomatic diverticulitis

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11
Q

What class of analgesics should be avoided in diverticulitis and why?

A

NSAIDS - risk of perforation

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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
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13
Q

MOA of bulk forming laxatives?

A

Retain fluid and increase faecal mass. Soften stool, stimulate peristalsis. Takes 2-3 days to work.

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14
Q

Counselling on when to take bulk forming laxatives?

A

Do not take immediately before bedtime

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15
Q

Adverse effects of bulk forming laxatives?

A

Bloating
Flatulence
Electrolyte disturbance e.g. hypokalaemia so caution in those with impaired disturbance already

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16
Q

Excessive laxative use can lead to….

A

Diarrhoea

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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

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18
Q

Drug interactions with cephalasporins?

A
  • DOAC/Warfarin - enhanced anticoagulant effect

- Aminoglycosides e.g. gentamicin - increased risk of nephrotoxicity

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19
Q

Metronidazole adverse effects?

A 
GI - n/v/d
Neuro - headache, ataxia
Taste disturbances, rash, pruritus
SJS 
Dark urine
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20
Q

Counselling points with metronidazole?

A

Take with food

Avoid alcohol during and 2 days after.

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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
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22
Q

Are cephalasporins safe in pregnancy?

A

Yes cefalexin is. Can be used for UTI in pregnancy

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23
Q

What are the two types of IBD (inflammatory bowel disease)?

A

Chrons

Ulcerative colitis

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24
Q

What is ulcerative colitis?

A

mucosal inflammation and ulcers restricted to colon and rectum

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25
Q

Symptoms of UC?

A

Bloody diarrhoea
Urgent need to defecate
Acute flare up: mouth ulcers, wt loss, fatigue, arthritis

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26
Q

Complications of UC?

A

Osteoporosis
Colorectal cancer
VTE
Toxic megacolon

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27
Q

Diagnosis tests for UC?

A 
FBC
TFT
LFT
Nutritional check
Inflammatory markers 
U+Es
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28
Q

What durgs are contra-indicated in acute UC / flare ups?

A

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

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29
Q

What is toxic megacolon?

A

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

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30
Q

The type of treatment/therapy for UC depnds on…

A

The site and severity of the disease.

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31
Q

Talk about the different parts of the colon and the corresponding treatment for inflammation?

A
  • 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
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32
Q

How long is steroid therapy for UC normally?

A

4-8weeks

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33
Q

Treatment for acute, mild-mod UC (proctitis and proctosigmoiditis + left sided colitis)?

A 
1) Topical aminosalicylate 
If no remission in 4 weeks
2) PO aminosalicylate 
inadequate response
3) +/- Topical/oral corticosteroids for 4-8weeks
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34
Q

Treatment for acute, mild-mod UC (extensive)?

A

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)

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35
Q

Treatment for mod-sev UC?

A
  • conventional therapies(aminosalicylates and steroids)

2) monoclonal antibodies

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36
Q

Acute, severe UC is a medical emergency. What treatment is immediately required?

A

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

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37
Q

How to maintain remission in mild/mod/severe UC?

A

Maintenance treatment with aminosalicylates (not steroids due to SE)

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38
Q

Treatment for maintaining remission in mild-mod inflam. exacerbation of proctitis or proctosigmoiditis?

A

Rectal aminosalicylate alone or in combination with oral aminosalicylate as part of a regimen

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39
Q

Treatment for maintaining remission in mild-mod inflam. exacerbation of left sided or extensive colitis?

A

low dose oral aminosalicylate (single doses are more effective) but inc SE

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40
Q

In those that have had two or more infl. exacerbations within 12months and required steroid treatment what can you give for remission?

A

oral azathioprine

mercaptopurine

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41
Q

What three classes of drugs are commonly used in UC?

A

Aminosalicylates
Corticosteroids
Monoclonal antibodies

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42
Q

Give examples of aminosalicylates

A

Mesalazine
Sulfasalazine
Olsalazine
Balsalazide

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43
Q

Which aminosalicylate is associated with urine/lens discolouration and what colour does it turn to?

A

Sulfasalazine - yellow/orange

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44
Q

Which two aminosalicylates can cause reversible oligospermIa as SE?

A

Sulfasalazine

Mesalazine

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45
Q

Patient counselling when providing aminosalicylates?

A

blood dyscrasias - report unexplained bleeding, bruising, purpura, malaise, fever, sore throat - check WBC, RBC, Platelet count

Nephrotoxic

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46
Q

How often does renal function need to be monitored with aminosalicylates?

A

Before, 3months, annually

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47
Q

In what hypersensitivity would aminosalicylates not be suitable?

A

Salicylate hypersensitivity e.g. aspirin = itch and hives

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48
Q

In what deficiency would aminosalicylates not be suitable?

A

G6PD

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49
Q

Which aminosalicylate requires liver function monitoring and how regular should this be?

A

Sulfasalazine - LFTs monthly for 3 months

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50
Q

Why should you not switch brands between preparations of aminosalicylates for UC?

A

Extent of effect varies and they are not bioequivalent

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51
Q

A junior doctor asks you how to switch from rectal foam to oral budesonide tablets, what do you suggest?

A

1 metred application of the foam = 2mg oral budesonide dose

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52
Q

Mesalazine comes in various brands. What advise would you give to patients with each?

A

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

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53
Q

What does mesalazine in particular interact with and why?

A

Lactulose as it lowers stool ph.

Mesalazine requires an acidic environment to release the drug. So it would make it ineffective

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54
Q

Give an example of a corticosteroid used in UC?

A

Budesonide

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55
Q

Directions on administration of budesonide?

A

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

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56
Q

MHRA warning with steroid use?

A

Serous risk of chrioretinopathy: report any blurred vision/visual changes or disturbances

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57
Q

SE of steroids?

A
  • adrenal suppression
  • psychiatric reactions
  • increased risk of infection
  • hypokalaemia
  • hyperglycaemia
  • insomnia
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58
Q

What is Chron’s disease?

A

Chronic inflammation from the mouth to the anus - extends through all layers.

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59
Q

Symptoms of chrons disease?

A

Abdominal pain
rectal bleeding
bloating
wt loss

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60
Q

Complications of chrons?

A

strictures, abscess, anaemia, malnutrition, cancers, growth failure and delayed puberty

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61
Q

What kind of extra-intestinal manifestations can Chrons lead to?

A

Abnormalities and arthritis of joints eyes liver skin

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62
Q

Chron’s is also a cause of ___________

A

secondary osteoporosis and those at high risk should be monitored for osteopenia (low BMD)

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63
Q

What lifestyle habits can be a trigger for Chrons?

A

Smoking

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64
Q

To induce remission in an exacerbation what drug treatment is suitable?

A

Corticosteroids - prednisolone or methyprednisolonr or iv hydrocortisone

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65
Q

In those who are unable to take conventional corticosteroids, what is the 2nd option?

A

Budesonide (more for distal/right sided colonic disease) or aminosalicylates

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66
Q

What are the differences between conventional corticosteroids (pred/methylpred/hydrocor) and budesonide?

A

Budesonide acts more locally so less systemic side effects but it also less effective

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67
Q

For severe chrons or exacerbation of chrons what two drugs are not suitable?

A

Budesonide

Aminosalicylate

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68
Q

How to treat acute flare/exacerbation of chrons?

A

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

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69
Q

What is the MHRA warning with lactulose?

A

Cardiac effects with overdose. Can cause QT prolongation TDP and cardiac arrest. Give naloxone in overdose.

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70
Q

How to maintain remission in chrons?

A

Immunosuppressants - azathioprine/mercaptopurine
or
Methotrexate

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71
Q

Why is TPMT activity monitoring important in immunosuppressant therapy like azathioprine?

A

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.

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72
Q

Give examples of supportive therapy used in Chrons?

A

Diarrhoea: investigate cause and give loperamide if required

Antispasmodics: mebeverine

Pain: paracetamol/opioids (no NSAIDS)

Fatigue: Anaemia, malabsorption, sleep/stress/anxiety (depends on cause)

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73
Q

Treatment for fistulating Chron’s?

A

if asymptomatic: no treatment

Antibiotic: metronidazole / ciprofloxacin (max 3 months due to risk of peripheral neuropathy)

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74
Q

How do monoclonal antibodies work in chrons?

A

Inhibit cytokines (pro inflammatory proteins) and TNF-a to reduce inflammation

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75
Q

What can be given for maintenance of remission after Chrons surgery?

A

Azathioprine + metronidazole (up to 3 months)

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76
Q

What is IBS?

A

A common, chronic, relapsing condition that affects those aged 20-30yrs.

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77
Q

Symptoms of IBS?

A 
Alternating constipation and diarrhoea
Bloating
Urgency
Straining
Mucus
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78
Q

Non-drug treatment for IBS?

A 
Diet control
Isphagula husk, oats  (soluble fibres)
Max 3 fresh fruits a day 
Review fibre intake 
Increase fluid intake (8 glasses/day)
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79
Q

What kind of fibre should be used in IBS?

A

Soluble - isphaghula husk or oats

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80
Q

What kind of fibre should be avoided in IBS?

A

Insoluble - bran and starch as they can exacerbate symptoms

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81
Q

In those with IBS and diarrhoea, what sweetener should be avoided?

A

Sorbitol

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82
Q

Which laxative should not be prescribed in IBS and why?

A

lactulose as causes bloating

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83
Q

What antispasmodic drugs are available OTC?

A

Alverine citrate
Mebeverine
Peppermint oil capsules

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84
Q

In those with persistent constipation (at least 12 months) and have had an inadequate response to laxatives, what would be the treatment?

A

linaclotide

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85
Q

What is the drug of choice for diarrhoea in IBS

A

1) Loperamide - advise to adjust dosage to allow a soft stool consistency

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86
Q

If abdominal pain or discomfort is not releieved by anti-spasmodics, anti-motility drugs and laxatives, what would be 2nd line option?

A

TCA - low dose e.g. amitryptiline (unlicensed)

if ineffective,

Give SSRI

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87
Q

What conditions can trigger IBS?

A

Anxiety, stress, depression

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88
Q

How do bulk forming laxatives work and give some examples.

A

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)

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89
Q

Give some contraindications of using bulk forming laxatives?

A 
Ulcerative colitis
Chrons
Opioid induced constipation
paralytic ileus
toxic megacolon
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90
Q

Cautions when prescribing laxatives?

A

fluid/electrolyte imbalances particularly hypokalaemia

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91
Q

Adverse effects of excessive laxative use?

A

bloating, abdominal pain, intestinal obstruction, electrolyte imbalance

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92
Q

In refractory constipation. You can use linaclotide - how would you counsel a patient on its administration?

A

30 mins before meals

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93
Q

Loperamide dose?

A

4mg stat then 2mg after every loose stool. Max 16mg per day (8capsules)

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94
Q

What two drugs used in IBS can cause allergic reactions as a side-effect?

A

Mebeverine and peppermint oil capsules

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95
Q

Which SSRI is the most associated with QT prolongation?

A

Citalopram

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96
Q

SSRIs are contraindicated in?

A

poorly controlled epilepsy and QT prolongation (citalopram only)

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97
Q

What is short bowel syndrome?

A

Increased resection of the bowel e.g. due to surgery

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98
Q

What complications can short bowel syndrome cause?

A

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

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99
Q

What drug formulations are unsuitable for short bowel syndrome?

A

enteric coated

MR

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100
Q

What drug formulations are suitable for short bowel syndrome?

A

uncoated, liquid, soluble

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101
Q

What is constipation?

A

Unsatisfactory defaecation. Resulting in: straining, incomplete evacuation, infrequent/difficult stool passage

NICE: hard stools and defeacation <3x a week

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102
Q

In what people types in constipation common?

A

Women, elderly, pregnant

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103
Q

New onset of constipation in those aged > _____yrs should provoke urgent investigation.

A

Over 50yrs

104
Q

What ALARM symptoms would prompt you to make a GP referral?

A 
Anaemia
Loss of wt
New dysphagia/heartburn 
Anorexia
Blood in stools 
>55yrs
105
Q

What non-drug treatment could you recommend to those with constipation?

A

Smaller meals

increase fibre intake: lentils, whole grains, fruits, veg

106
Q

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?

A

Few days and up to 4 weeks

107
Q

What artificial sweetener can help those in constipation but is avoided in IBD/IBS?

A

Sorbitol - causes diarrhoea

108
Q

Laxative abuse can lead to…

A

hypokalaemia - poses the risk of bradycardia, tachycardia, muscle weakness, cramps

109
Q

Give examples of some bulk-forming laxatives and how they work.

A

Bulk-forming laxatives increase peristalsis, increase stool water content and faecal mass. Examples: isphagula husk, methycellulose, sterculia, bran - good for small, hard stools

110
Q

Which bulk-forming laxative also works as a stool softener?

A

Methycellulose

111
Q

What type of constipation do we not give bulk-forming laxatives and why?

A

Opioid-induced

Risk of paralytic ileus, toxic megacolon

112
Q

How long does it take bulk-forming laxatives to work?

A

up to 72hrs

113
Q

How do stimulant laxatives work?

A

increase intestinal motility

114
Q

Due to the MOA of stimulant laxatives, what is a common side effect?

A

Abdominal pain.

115
Q

Give examples of stimulant laxatives

A 
Senna - yellow/red brown urine
Co-danthramer - red urine
Co-danthrusate 
Sodium picosulfate
Bisacodyl
116
Q

Which stimulant laxatives are reserved for palliative/terminally ill patients and why?

A

Co-danthramer
Co-danthrusate

Carcinogenic and genotoxic, colour urine red

117
Q

Which laxative acts both as a stimulant laxative and a stool softener?

A

Docusate

118
Q

Which suppositories are commonly used in babies with constipation?

A

glycerol - rectal stimulant and lubricant

119
Q

What is the aim of fibre intake daily?

A

30g

120
Q

Stepwise approach for chronic constipation according to NICE CKS?

A

1) Bulk-forming; isphagula husk (ensure adequate fluid intake)
2) Osmotic laxative e.g. macrogol, lactulose
3) Stimulant laxative e.g. senna

121
Q

What can be used for opioid-induced constipation?

A

Osmotic laxatives e.g. macrogol, lactulose

Stimulant laxatives e.g. Senna

122
Q

How do osmotic laxatives work and give examples.

A

increase amount of fluid in the bowel which then stimulates peristalsis. E.g. macrogol (movicol/laxido), phosphate and sodium citrate enemas, lactulose

123
Q

Which laxative is used for hepatic encephalopathy and why?

A

Lactulose - discourages the proliferation of ammonia producing organisms

124
Q

Which drug can be used for refractory constipation in IBS if others haven’t worked?

A

Linaclotide

125
Q

Give an example of a prokinetic laxative.

A

Prucalopride.

126
Q

How do faecal softeners work?

A

Decrease surface tension, increase penetration of intestinal fluid into faecal mass. E.g. docusate and glycerol

127
Q

What faecal softener is associated with anal seepage/lipoid pneumonia on aspiration and malabsorption of vitamin ADEK.

A

Liquid paraffin

128
Q

If response to other laxatives (osmotic/stimulant) is inadequate in opioid-induced constipation, what can be used?

A

Naloxegel and methylnaltrexone

129
Q

What can be used to treat faecal impaction (big hard stool stuck in colon and ahrd to expel)?

A

Macrogol high dose
+/- stimulant laxative
or
bisacodyl/glycerol suppositories

130
Q

1st line treatment for constipation in pregnancy/breast feeding?

A

Bulk-forming e.g. fybogel: isphagula husk

131
Q

If bulk-forming does not help those who are pregnant what other treatment options are suitable?

A

Osmotic laxatives: lactulose
Stimulant: senna, bisacodyl (short course)

Stimulant more effective than bulk forming but increased SE

132
Q

Avoid senna in pregnancy when ________

A

At term and if there is unstable pregnancy

133
Q

Treatment options for children with laxative?

A
  • Osmotic, for faecal impaction: <4yrs is unlicensed
  • 2nd line: stimulant laxative

If doesnt work in 2 weeks - risk of faecal impaction.

134
Q

Counselling points for isphagula husk?

A
  • Hypersensitivity reactions due to potent allergens
  • take with 150ml liquid
  • do not take immediately before bedtime
  • may take several days to work
135
Q

Magnesium salts cause _____

A

diarrhoea

136
Q

Aluminium causes ______

A

constipation

137
Q

docusate is licensed in those over ____yrs

A

12

138
Q

Counselling points with liquid paraffin.

A

anal seepage, lipoid pneumonia (do not give immediately before bed)

139
Q

Bisacodyl is a stimulant laxative. How long do tablets take to work and how long do suppositories take to work?

A

Tablets: 10-12hrs
Suppositories: 20-60mins

140
Q

Co-danthrasate and co-danthramer are stimulant laxatives. what are the counselling points and who should they be used in?

A

Avoid prolonged contact with skin due to local irritation.

Only for terminally ill as cancerogenic and genotoxic.

141
Q

Glycerol suppositories are suitable for those aged >_____

A

1 month

142
Q

Which laxative is prone to abuse - particularly by young women.

A

Senna - stimulant due to weight loss.

143
Q

Onset of action for senna?

A

8-12hrs, hence take ON for a normal bowel movement in the morning.

144
Q

Which laxative used for opioid-induced constipation needs reduction with CYP3A4 inhibitors?

A

Naloxogel 25mg OD to 12.5mg OD

145
Q

Which laxative can only be used in women with refractory constipation (tried others at highest dose for 6mths) and why?

A

prucalopride - not enough evidence of it working in men (NICE)

146
Q

What colour does the stimulant laxative danthrons turn urine?

A

Red

147
Q

Treatment options for opioid-induced constipation?

A

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
Q

If senna is used for constipation in pregnancy, it should be avoided at ____

A

term as it can stimulate contractions

149
Q

give examples of increasing fibre intake?

A

Fruit and veg
wholegrain cereal
Bread
Baked beans

150
Q

What is diarrhoea?

A

Frequent, loose, watery stools with associated symtpoms of nausea, dehydration, cramps, flatulence

151
Q

If diarrhoea lasts <14 days it is _____

A

Acute diarrhoea. Usueally resolves in 2-3 days

152
Q

Give some red flag symtpoms?

A 
Unexplained weight loss
Rectal bleeding
Persistent diarrhea
Systemically unwell
Recent abx treatment/hospital stay (c.diff)
Foreign travel
153
Q

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?

A

Ferrous sulphate as it can cause constipation that can lead to toxic megacolon and eventually sepsis.

154
Q

Aim of diarrhoea treatment?

A

Prevent dehydration

Fluid and electrolyte replacement - diarolyte (especially in infants, frail and elderly)

155
Q

When would diarrhoea be considered chronic?

A

> 2weeks

156
Q

Common causes of diarrhoea?

A

Food poisoning e.g. e.coli/campylobacter/salmonella

Rotavirus/norovirus

157
Q

Diarrhoea treatment?

A

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
Q

Loperamide should be avoided in:

A

bloody/suspected inflamamtory diarrhoea

significant abdominal pain

159
Q

1st line for faecal incontinence (inability to control bowel movements which then lead to leakage)?

A

Loperamide (unlicensed)

160
Q

what antibiotic can be used for for travellers diarrhoea prophylaxis?

A

Ciprofloxacin but not recommended routinely.

161
Q

How to reverse opioid overdose?

A

Naloxone and monitor for 48hrs due to CNS depression

162
Q

How does loperamide work?

A

Binds to opioid receptors in guts and slows down peristalsis

163
Q

Side effects of loperamide?

A

Nausea
Headache
Flatulence
Dizzy

164
Q

Loperamide contra-indications?

A

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
Q

Dyspepsia symptoms usually occur for…….

A

4 or more weeks do an endoscopy

166
Q

Symptoms of dyspepsia?

A 
N/V
Abdominal pain
Bloating
Reflux 
Heartburn
Pain/discomfor
167
Q

Causes of dyspepsia:

A

GORD - acid from stomach leaks into oesophagus
PUD
Pregnancy
Unidentified
Malignancy
Ulcers
Gastritis - inflammation of stomach lining

168
Q

What are ALARM symptoms?

A 
Anorexia
Loss of weight
Anaemia
Recent/new in >55
Malaena (blood in stools, blood when vomiting)
169
Q

Lifestyle advice for dyspepsia?

A 
Lose weight
Smoking cessation
Smaller meals
Avoid eating at night 
Reduce alcohol consumption
170
Q

Which drugs can cause heartburn/dyspepsia?

A 
A-blockers 
Antimuscuranics
Aspirin
Benzodiazepines
B-blockers
Bisphosphonates
CCB
Steroids
Nitrates
NSAIDs
Theophylline
TCA
171
Q

Treatment for initial management of dyspepsia - symptomatic relief?

A

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
Q

What management options are there for a patient with uninvestigated dyspepsia taking an NSAID?

A

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
Q

What management options are there for a patient with uninvestigated dyspepsia taking aspirin?

A

switch from aspirin to another antiplatelet e.g. clopidogrel (less GI se and more effective)

174
Q

How often should those with dyspepsia be reviewed?

A

Annually

175
Q

How do antacids work?

A

Neutralise stomach acid and provide immediate relief within 15-30mins

176
Q

Give exames of some antacids.

A

Aluminium: cause constipation
Magnesium: cause diarrhoea
liquid more effective than tablets

177
Q

Why are bismuth containg preps not often used?

A

Unless chelates, they can be neutoxic and cause encepahlopathy + constipating

178
Q

Calcium containing antacids can

A

Induce rebound acid secretion and cause hypercalcaemia

179
Q

how can simeticone help is dyspepsia?

A

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
Q

How do alginates work and give examples.

A

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
Q

Antacids should be avoided in those with _____

A

Fluid retention due to large amounts of sodium e.g. impaired renal function/heart failure and avoid with lithium

182
Q

How to counsel patients on taking antacids?

A

After each main meal/at bedtime PRN

183
Q

Interactions with antacids.

A
  • 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
Q

What is peptic ulcer disease?

A

Disruption in the gastric/duodenal epithelium =ulcers. Main symptom is abdominal pain

185
Q

What are the most common causes of peptic ulcer disease?

A 
H.pylori infection
NSAID use
Smoking
Alcohol
Stress
186
Q

Complications of peptic ulcer disease

A

GI perforation
GI obstruction
Haemmorhage

187
Q

Give some risk factors of developing peptic ulcer disease with an NSAID.

A 
>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
Q

What drugs can induce peptic ulcers?

A 
NSAIDS
Bisphosphonates
Aspirin 
SSRI
Steroids
Potassium chloride
Recreational drugs
189
Q

If gastric ulcers have been associated with NSAID use. How would this be managed?

A

8 weeks PPI/h2 receptor antagonist + hpylori eradication if positive

190
Q

Give the treatment options for gastro protection.

A

1 - PPI
2 - H2 receptor antagonist
3 - Misoprostol (limited use due to SE)

191
Q

How often should h.pylori eradication treatment be reviewed?

A

6-8 weeks

192
Q

how often should NSAID use be reviewed?

A

6 monthly and use on a PRN basis

193
Q

Bismuth salicylate can be used as a part of h.pylori eradication. In what age range would this not be suitable and why?

A

<16yrs - reyes syndrome

194
Q

Common side-effect of bismuth salicylate.

A

Blaack stools and black tongue

195
Q

Which chelate used to protect mucosa from acid attack can cause bezoars to form?

A

Sucralfate - take 1hr before meals/1hr gap between feeds

196
Q

How do h2-receptor antagonists work?

A

heal gastric and duodenal ulcers by reducing gastric acid output.

197
Q

What is the current issue with the use of ranitide and h2-rec antagonists which resulted in the recall of the drug?

A

Cancerogenic properties

198
Q

What would h2-receptor antagonists be cautioned in?

A

Gastric cancer as can mask effects

199
Q

Give examples of h2 receptor anatagonists.

A

Ranitidine
Famotidine
Cimetidine

200
Q

Side-effects oh h2-receptor antagonists?

A 
Headache
Rash
Dizziness
Diarrhoea
psych rx: halluciantions, confusion, depression
201
Q

Which h2-receptor antagonist is a potent enzyme inhibitor?

A

Cimetidine

202
Q

How do PPIs work?

A

Inhibit gastric acid secretion by blocking proton pump in gsatric parietal cells.

203
Q

Indications for PPI use?

A 
PUD
NSAID Associated ulcer
GORD
uninvestigated dyspepsia
Zollinger-Ellison syndrome (excessive gastric acid secretion) 
H.pylori eradication
Peptic ulcer bleeding
204
Q

MHRA warning associated with PPI?

A

Risk of lupus so avoid sun exposure, use SPF

205
Q

Give examples of PPIs.

A 
Omeprazole
Lansoprazole
Esomeprazole
Pantoprazole
Rabeprazole
206
Q

Counsel a patient on the administration of PPIs.

A

30-60minutes before food, do not chew or crush. avoid indigestion remedies 2 hrs before or after taking this medication

207
Q

PPIs should be avoided in pregnancy. True or false?

A

True howeever omeprazole not known to be harmful

208
Q

give a key interaction with PPIs and an antiplatelet drug/immunosuppressant drug

A

Clopidogrel and omeprazole (use lansoprazole instead) - reduced antiplatelet effect

Methotrexate: increased risk of toxicity

209
Q

Long term risks associated with PPI use?

A

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
Q

What other drugs used with PPI can increase the risk of hypomagnesaemia

A

Digoxin - inc risk of dig toxicity

211
Q

How long for PPIs to take full effect?

A

2-3 days so can use antacids in between

212
Q

Misoprostol can be used for gastric ulcers/NSAID-induced peptic ulcers/ prophylaxis of NSAID induced ulcers. What is the risk associated with it?

A

Can induce uterine contractions, cause abortion and birth defects - DO NOT USE UNLESS PREGNANCY EXCLUDED. If given, take with food.

213
Q

Side-effects of misoprostol?

A

Colic and diarrhoea

214
Q

Treatment options for GORD - chronic reflux.

A

1) PPI 8 weeks
2) H2 - receptor antagonist
3) switch PPI

215
Q

Treatment options for GORD - pregnancy.

A

1) Dietary and lifestyle
2) Antacid/alginate but not gaviscon advance
3) Omepraozle

216
Q

What is h.pylori and what is the aim?

A

Common cause of peptic ulcer disease, it is an infection. Aim is to reduce the risk of PUD, ulcer bleeding, malignancy and recurrence

217
Q

What test can be used to test for h.pylori?

A

Urea 13c breath test or stool helicobacter antigen test (SAT)

218
Q

State some issues of using the urea breath test after being on PPI or antibiotics.

A

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
Q

Drug treatment for h.pylori

A

Triple therapy regimen.

PPI + 2 antibiotics (choose carefully due to risk of resistance)

220
Q

H.pylori regimen.

A

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
Q

What is a food allergy?

A

Adverse immune reaction to food e.g. peanuts, fish, cows milk, soy, hens eggs, shellfish, nuts

222
Q

Treatment for food allergies?

A

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
Q

Give some causes for muscle spasms?

A

IBS
IBD (chrons/UC)
Bowel colic in palliative care

224
Q

Treatment for muscle spasms?

A

Antimuscuranics

Antispasmodics

225
Q

Give some indications for antimuscuranics.

A 
Arrhythmias
Asthma
motion sickness
urinary incontinence
parkinsonism
226
Q

Five examples of antispasmodics used in iBS

A

Alverine
Mebeverine
Peppermint oil capsules
- avoid in paralytic ileus but can help relieve pain

227
Q

How do antimuscuranics workand side effects

A

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
Q

What is the difference between hyoscine butylbromide and hyrobromide?

A

Hydrobromide - motion sickness (Kwells)

Butylbromide - Antispasmodic (Buscopan)

229
Q

Contraindications for antimuscuranics

A 
Prostate enlargement
Urinary retention 
Closed angle glaucome - risk of vision loss
Paralytic ileus
Toxic megacolon
230
Q

Caution in

A

Clonsesed angle glaucoma as can cause vision loss

231
Q

MHRA warning with hyoscine butylbromide?

A

Tablets not licensed in <6yrs

Risk of serious adv effects in those with cardiac disease: tachycardia

232
Q

OTC buscopan max doses

A

max single dose 20mg
max daily dose 80mg
max pack size 240mg

For ibs

233
Q

What is cholestasis and how do you treat it?

A

bile formation/flow impairment and treat with cholestyramine

234
Q

Signs and symptoms of liver impairment and cholestasis?

A 
abdominal pain
pale stools
dark urine
pruritus
yellow skin
235
Q

Treatment for gallstones/kidney stones?

A

hard mineral/fatty deposits . Do not treat if asymptomatic.

Drug tx - analgesia especially PR diclofenac/opioid

236
Q

What BMI is considered obese?

A

> /= 30kg/m2

237
Q

Which thyorid disorder can cause weight gain?

A

hyporthyroidism (weight gain, bradycarida, cold intolerances)

238
Q

What drug is the only one used for obesity in the UK?

A

Orlistat - reduced dietary absorption of fat (to maintain weight loss), discontinue after 12 weeks if wt loss not exceeded

239
Q

what side-effects can the use of orlistat produce?

A

malabsorption of fat soluble vitamins ADEK so use supplements

240
Q

What are anal fissures?

A

Tear/lining/ulcer on anal margin = bleeding bright red blood, sharp persistent pain, linear split

241
Q

1st line for acute anal fissures <6 weeks?

A

bulk forming laxatives or osmotic laxatives

burning pain - local anaesthetic lidocaine before bowel emptyin

242
Q

Treatment for burning pain before defaecating?

A

local anaesthetic lidocaine before bowel emptying

243
Q

1st line for chronic anal fissures >6 weeks?

A

GTN rectal ointment (SE headache) or PR diltiazem/nifedipine (relax muscle and increase blood supply)

244
Q

What are hemorrhoids?

A

Swelling of anal mucosal cushion with enlarged blood vessels found inside or outside anus

245
Q

Symptoms of hemmorrhoids?

A

bleeding after defecation
pain
swelling
itchy, sore skin

246
Q

Treatment for hemmorhoids?

A

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
Q

what is pancreatic insufficiency?

A

Reduced secretion of pancreatic enzymes = maldigestion/malnutrition/GI

248
Q

Causes of pancreatic insufficiency?

A 
Cystic fibrosis
Pancreatitis
Zollinger-ellison 
Coeliac disease
Tumours 
GI/pancreatic resection
249
Q

dietary advice for pancreatic insufficiency?

A

3 main meals and 2/3 snacks
avoid food that is hard to digest
No alcohol
Avoid reduced fat diets

250
Q

How to treat pancreatic insufficiency?

A

Pancreatin enzyme Creon- compensate for reduced/absent secretion and helps to digest enzymes/lipases/fats/carbs/proteins

251
Q

Creon counselling?

A

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
Q

Creon SE?

A

GI, Irritation (skin and buccal mucosa), hypersensitivity, hyperuricaemia

Contra ind: <15yrs

253
Q

What is a stoma?

A

Artifical opening of the abdomen surface allowed to divert the flow or faeces and urine into an external bag (ileostomy/colostomy)

254
Q

Due to changes in drug delivery with stoma, which preparations are unsuitable?

A
  • 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
Q

What diuretics and laxatives are suitable for stoma patients and which are not?

A

Give potassium sparing diuretic (as increases k+)

bulk forming laxatives

caution with stimulant laxatives

256
Q

Antidiarrhoeal drugs for stoma?

A

Loperamide (may need higher doses if short bowel)/ codeine

257
Q

What drug formulations would be more suitable for stoma?

A

soluble tabs
liquid capsules
uncoated tablets

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