Chapter 1: GI system Flashcards
Are patients with coeliac disease recommended to self medicate with OTC vitamin and mineral supplements?
No. Although recommended daily intake of Calcium is 1000mg and Vit D 10ug if this is not achieved through diet.
What are coeliac patients at increased risk of?
Malabsorption
Vitamin and mineral deficiency - could increase the risk of osteoporosis
Risk of OS causes need for active treatment of bone disease and should be part of ongoing treatment.
What is diverticular disease?
What conditions might its symptoms overlap with?
Diverticula (sac-like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain with constipation, diarrhoea, or occasional large rectal bleeds. in the absence of inflammation or infection.
Diff D: IBS, colitis, and malignancy
What is the treatment for diverticular disease
- symptomatic diverticular disease
- uncomplicated diverticulitis
- complicated severe D
- Symp DD: Constipation= high fibre diet or bulking forming laxatives paracetamol for pain and antispasmodics
- Uncomp D: low residue diet and bowel rest. Antibacterials only if pt has infection, inflammation or is immunocompromised.
- Complicated severe ppt: hospital IV antibacterials for anaerobes and G-ve bacteria as well as bowel rest
What is not recommended in uncomplicated diverticular disease?
Antibiotics
unless the patient presents with signs of infection/immunocompromised
Nsaids or opioids
What is the treatment for complicated diverticular disease?
Hospital admission, IV antibacterials covering gram negative and anaerobes
Bowel rest
True or false: There is sufficient evidence to justify the role of fibre, rifaximin, antispasmodics, mesalazine, and probiotics in the prevention or treatment of diverticulitis.
False
What is the advantage of the newer aminosalicylates (mesalazine, balsalazide, olsalazine) over sulfasalazine?
Avoids the sulfonamide-related side effects of sulfasalazine; NOT DOSE RELATED: male infertility (reversible), haemolytic anaemia, hypersensitivity, bone marrow suppression, hepatitis and DRUG DOSE RELATED: n+v, dyspepsia, malaise, headache
5-ASA however still causes same SE as sulfasalazine such as blood dyscrasias and lupus like syndrome
Sulfasalazine is a combination of what two compounds?
5-ASA and sulfapyridine
Sulfapyridine acts only as a carrier to the colonic site of action but still causes side effects
What compound is mesalazine?
What is Balsalazide?
What is olsalazine?
5-ASA
prodrug of 5-ASA
dimer of 5-ASA
Non operative management of acute Diverticulitis FAILS or diffuse peritonitis requires ..
URGENT sigmoid colectomy is required
What are extraintestinal manifestations? Crohns
When people with IBD develop conditions affecting the joints, eyes or skin. e.g. arthritis, osteoporosis
- In a patient with a first presentation or single inflammatory Crohn’s exacerbation in a 12 month period, what is used?
- If this is not suitable, or if the patient has right-sided colonic disease, what could be used? When would these not be appropriate and why?
- Corticosteroid - prednisolone, methylprednisolone or IV hydrocortisone
- Budesonide or aminosalicylates. Not appropriate if severe presentation as they are less effective (even though they have fewer side effects)
Budesonide less effective but fewer SE than corticosteroids as systemic effect limited. ASA less effective than corticosteroid or budesonide but preferable due to fewer SE.
When would you add in additional treatment (on top of steroid monotherapy) in a Crohn’s disease exacerbation?
What would you add?
2 or more inflammatory exacerbations in 12 months, or if the steroid dose cannot be reduced
Azathioprine or mercaptopurine
Is mercaptopurine licensed in severe UC and CD?
No
- What can be added to a steroid to induce remission in a Crohn’s patient?
- If these are not suitable, what could be used?
- Azathioprine
Mercaptopurine can be added but unlicensed
- Methotrexate
What test do you need to do before starting someone on azathioprine or mercaptopurine?
TPMT levels
If activity is deficient, it may not be suitable
What monoclonal antibodies are licensed for Crohn’s?
Adalimumab
Infliximab- active fistulating CD
Vedolizumab - rec for mod-sev active crohns disease when other two unsuitable/CI
- What is used for maintenance of remission for Crohn’s?
2. What would be second line and when would you use this?
- Azathioprine or Mercaptopurine (unlicensed)
2. Methotrexate if the patient required it to induce remission, or if azathioprine/mercaptopurine is unsuitable
Should steroids be used for the maintenance of remission for Crohn’s?
No- only to induce remission
What can be used to manage Crohn’s associated diarrhoea?
Loperamide, codeine phosphate, colestyramine
What antibiotics can be used (alone or in combination) to improve symptoms of fistulating Crohn’s?
Metronidazole and ciprofloxacin (unlicensed)
If metronidazole is given for fistulating Crohn’s, how long for and what are the associated risks?
1 month (no longer than 3) due to risk of peripheral neuropathy
What is used to control the inflammation in fistulating Crohn’s disease (and continued for maintenance)? How long should they be on this for?
Azathioprine or mercaptopurine (unlicensed) or infliximab. Infliximab should be used after ensuring that all sepsis is actively draining.
At least 1 year
Can you use loperamide and codeine phosphate in acute UC?
No- contraindicated as it increases the risk of toxic megacolon but can be used in non acute UC
What type of laxative may be useful for proximal faecal loading in proctitis?
Macrogol containing osmotic laxative
Acute treatment to induce UC remission generally consists of ?
In acute mild-mod extensive UC can oral and rectal ASA be given 1st line?
ASA +/- corticosteroid
YES. Oral and rectal ASA in combo can be used 1st line in pt with acute mild-mod extensive UC - this is assoc with higher rates of improvement in disease activity
What ASA have rectal preparations?
Mesalazine or sulfasalazine
What is first line treatment for patients with acute exacerbation mild-moderate left-sided or extensive UC?
BNF: High induction dose of an oral ASA, with additional rectal ASA/oral Beclometasone if necessary.
Online BnF: topical ASA 1st line. If no remission in 4 weeks add ^dose oral ASA or switch to ^dose oral ASA and 4-8 weeks of topical corticosteroid. If response inadequate stop topical treatment and offer oral ASA and 4-8 weeks of oral corticosteroid.
Oral pred. alone is rec for pts who cannot tolerate/decline/CI ASA or in pts with subacute left-sided or extensive ulcerative colitis.
Mild to moderate UC:
In patients being treated with aminosalicylates for UC, when would you add in oral prednisolone?
No improvements within 4 weeks of initial therapy
If patient is on beclometasone, discontinue this
Why does oral budesonide have fewer systemic side effects than corticosteroids? (UC)
It exerts its action topically in the colon
UC
True or false:
Budesonide is licensed for inducing remission in mild to moderate UC if aminosalicylates are not suitable
True
Are corticosteroids suitable for maintenance treatment of UC?
No because of their side effects G - Glaucoma (topical) L - Limb muscle atrophy/myopathy U - Peptic Ulcer C - Cataract (systemic) O - OS (dose/duration dep) C - Cushings (moon face, fat, striae) O - Osteonecrosis R - Retardation of growth in children + ^BP (^mineralocorticoid => salt and water retention. and ^vascular reactivity) T - Thinning skin = easy bruising I - Infections <= immunosuppression C - changes in mood/psyche O - oedema (mineralocorticoid action salt water retention) I - impaired healing of wounds D - Diabetes Mellitus (^hyperglycaemia) S - Suppression of HPA (long term use; acute adrenal insufficiency if steroids withdrawn)
What should be given in acute severe UC?
IV corticosteroids
IV ciclosporin is an alternative (unlicensed)
Infliximab
Assess for surgery
What monoclonal antibodies are used for acute UC?
Adalimumab, golimumab, infliximab, vedolizumab
What can be used to maintain remission after an acute exacerbation of proctitis/proctosigmoiditis?
Rectal aminosalicylate can be started alone or in combination with oral aminisalicylate
What can be used to maintain remission after an acute exacerbation of left-sided or extensive UC?
Low dose oral ASA
Oral azathioprine or mercaptopurine [unlicensed indications] can be considered to maintain remission, if there has been 2 or more inflammatory exacerbations in 12-months that required tx with systemic corticosteroids, or if remission is not maintained by ASAs, or following a single acute severe episode.
True or false:
When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing, but may result in more side-effects.
True
What are the red flag side effects of aminosalicylates?
Agranulocytosis Bone marrow disorders Neutropenia Cardiac inflammation Renal impairment - nephrotoxicity
What are the monitoring requirements for aminosalicylates?
Renal function should be monitored before starting treatment, at 3 months, and then annually
Patients should report any unexplained bleeding/bruising/fever/malaise during treatment
FBC - drug should be stopped immediately if any indication of blood dyscrasia (disease/disorder of the blood)
Within what time period during starting sulfasalazine treatment do haematological abnormalities often occur?
Within the first 3-6 months of starting treatment
Discontinue if these occur
What should patients on sulfasalazine be aware of if they wear contact lenses?
May stain the lenses yellow/orange
What should a patient be screened for if starting vedolizumab?
TB
Contraindicated in those with TB
What is alverine citrate used for?
GI spasms
Dysmenorrhoea
Why would lactulose not be suitable in a patient with IBS?
Causes bloating
In IBS patients who have had constipation the last 12 months but have not responded to laxatives, what can be used?
Linaclotide
What is 1st line for diarrhoea in IBS?
Loperamide
What is co-phenotrope used for and what is a main side effect of it?
Decreases faecal output
Opioid that crosses BBB
Patients on colestyramine long term may need supplements of vitamins A, D, K, and folic acid. Why?
Can intefere with absorption of fat soluble vitamins
What is the advice around taking colestyramine with other drugs?
Manufacturer advises take other drugs at least 1 hour before, or 4–6 hours after, colestyramine.
What role does teduglutide have in short bowel syndrome?
Teduglutide is an analogue of human glucagon-like peptide-2 (GLP-2), which preserves mucosal integrity by promoting growth and repair of the intestine.
In patients with short bowel syndrome/stoma, what kinds of preparations would be unsuitable and why? (hint- types of release)
Enteric-coated and modified-release preparations are unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy, as there may not be sufficient release of the active ingredient.
Methylcellulose is a type of what laxative?
Bulk forming (also acts as a faecal softener)
Sterculia is a type of what laxative?
Bulk forming
When is onset of action for bulk forming laxatives?
___________ has onset of action of 8 to 12 hours. Note that ___________ has an onset of action of 10-12 hours
Within 72 hours
Senna has onset of action of 8 to 12 hours. Note that bisacodyl has an onset of action of 10-12 hours
Bisacodyl is what type of laxative?
Stimulant
Sodium picosulfate is what type of laxative?
Stimulant
Senna is what type of laxative?
Stimulant
Docusate sodium is what type of laxative?
Stimulant laxative and faecal softener
What is co-danthramer and co-danthrusate used for and what patient group is it limited to? Why?
Constipation in palliative care
Carcinogenicity and genotoxicity risks
Arachis oil enema would be contraindicated in patients with what allergy?
Peanuts
What are the warnings associated with liquid paraffin as a lubricant?
Anal seepage and the risks of granulomatous disease of the gastro-intestinal tract or of lipoid pneumonia on aspiration.
Should not be taken immediately before going to bed
What is lubiprostone used for?
Licensed for the treatment of chronic idiopathic constipation in adults whose condition has not responded adequately to lifestyle changes
What is prucalopride used for?
It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
What is 1st line for short duration constipation where dietary measures have not helped?
If stools are soft but difficult to pass, what would be more appropriate?
- Bulk forming
2. Stimulant laxative
- In patients with opioid induced consitipation, what would be appropriate?
- If these do not work, what can then be used?
- Osmotic laxative and stimulant laxative
Docusate sodium can be used to soften the stools - Naloxegol
Methylnaltrexone bromide
What type of laxative should be avoided in opioid induced constipation?
Bulk forming
What is 1st line medication for constipation in pregnancy after dietary measures?
Bulk forming laxative
Or lactulose [osmotic)
Stimulant effect: bisacodyl/senna but do not use senna near term or if history of unstable pregnancy. Stimulants more effective than bulk but SE diarrhoea/abdo discomfort reduce acceptability.
Docusate sodium and glycerol suppositories can also be used
True or false:
Stimulant laxatives are more effective than bulk-forming laxatives but more likely to cause side-effects
True
What is 1st choice for constipation in breast feeding after dietary requirements?
Bulk forming laxative
Lactulose or macrogol can be used if stools remain hard. alternative, a short course of a stimulant laxative such as bisacodyl or senna can be considered.
- What is 1st line for constipation in children after dietary measures?
- If response is inadequate, what can be tried?
- If stools remain hard, what can be used?
- Macrogol 3350 with KCL, sodium bicarbonate and NaCl
- Add or change to a stimulant laxative
- Lactulose or docusate
In children with chronic constipation, should laxatives be continued after regular bowel patterns has been established?
How should laxatives be stopped?
Yes- for several weeks after and then tapered gradually according to response over months
How many days classifies acute diarrhoea? How long do symptoms last? What could be the causes?
Less than 14 days but symptoms usually improve in 2-4 days. Can result from infection, drug SE or acute symptom of chronic GI disorder, accumulation of non absorbed osmotically active solutes in GI lumen (eg lactase deficiency) or GI effects of secretory stimuli or when intestinal motility/morphology is altered
What is the maximum daily licensed dose for loperamide?
16mg
Adult dose 4mg initially followed by 2mg up to 5 days. dose taken after each loose stool. usually 6-8mg daily.
What is the MHRA advice regarding loperamide?
What can be given in event of an overdose?
Serious cardiac ADR with high doses associated with abuse.
QT prolongation, torsades de points, cardiac arrest.
Overdose: naloxone antidote. loperamide duration is longer than naloxone (1-3) hours so repeated treatment may be indicated. Monitor for 48 hrs for possible CNS depression.
Pharmacists should advise pts not to take more than recommended dose on label
Is kaolin recommended for acute diarrhoea?
No - insufficient evidence to recommend adsorbent preparations
What role do antacids play in dyspepsia?
Symptomatic relief
What is a side effect of magnesium?
Laxative effect
What is a side effect of aluminium?
Constipation
Why is bismuth containing antacids not recommended ?
Neurotoxic, causing encephalopathy, tends to be constipating
What are the side effects associated with calcium containing antacids?
Can induce rebound acid secretion
Hypercalcaemia
Alkalosis
Constipation
What role do alginates play with an antacid?
Can protect mucosa from acid reflux
Some form a viscous gel raft that floats to surface of stomach contents
What would be a standard treatment for a H.Pylori patient who is not penicillin allergic?
7 day course
1. PPI + Amox AND choice of: clarithromycin or metronidazole (exclude amox if pen allergy, keep clarithromycin and metronidazole)
2. (switch latter for 2nd treatment of ongoing symptoms)
2. for pt who received prev treatment with clarithromycin and metronidazole
PPI + Amox + tetracycline [unlicenced] OR levofloxacin [unlicenced]
Would you continue with PPI cover after treatment of H.Pylori?
What is the exception to this?
No
However if the ulcer is large or complicated by haemorrhage or perforation, then it is continued for a further 3 weeks
H.Pylori treatment:
What antibiotics are prone to resistance during the course?
Clarithromycin and metronidazole
What is the disadvantage over 2 week triple therapy for H.Pylori over 1 week?
Even though the eradication rate is higher, adverse effects and poor compliance are common problems
What could be used as an alternative to metronidazole in H.Pylori treatment?
Tinidazole
What would be the dose of ranitidine in prophylaxis against NSAID related ulcers?
What would be an alternative?
300mg BD
Misoprostol
In patients with NSAID related ulcer where the NSAID can be discontinued, which of the following promotes the most rapid healing:
H2 receptor antagonists
Misoprostol
PPI
PPI
What is sucralfate used for?
Gastric/duodenal ulceration
Gastritis
Prophylaxis of stress ulceration
What is the main caution with sucralfate?
Bezoar formation- solid mass of indigestible material that accumulates and can cause a blockage
In Zollinger-Ellison syndrome, should a PPI or a H2 receptor antagonist be used?
PPIs as they are more effective
What is the only H2 receptor antagonist that can be given IV?
Ranitidine
What can be used to reduce the degradation of pancreatic enzyme supplements in CF patients?
PPI
What can PPIs increase the risk of?
Increases risk of fractures and osteoporosis so consider preventative therapy if appropriate
Increases risk of GI infections e.g. C Diff
May mask the symptoms of gastric cancer
What 2 electrolytes can drop if on PPIs?
Sodium and magnesium
Do PPIs or H2 receptor antagonists provide more relief of GORD symptoms?
PPIs
For mild symptoms of GORD, what can be used?
Antacids
May need PPI or H2 receptor antagonist but should be titrated down to a level which maintains remission
For severe symptoms of GORD, what should be used?
PPI - re-assess if still symptomatic after 4-6 weeks
Should be titrated down to a level which maintains remission
- How do you manage GORD in pregnancy?
2. If this is ineffective, what can be tried?
- Diet and lifestyle changes
Antacid/alginate - Ranitidine
When would you give a pregnant lady omeprazole for GORD?
Severe or complicated reflux disease.
How should a child with oesophagitis be treated?
H2 receptor antagonist
If this does not work, omeprazole
What is licensed as an adjunct to dietary avoidance in patients with food allergy?
(hint- not an epi-pen)
Sodium cromoglicate
What antihistamine is licensed for the symptomatic control of food allergy?
Chlorphenamine
Buscopan contains what active ingredient?
Hyoscine butylbromide
Kwells contains what active ingredient?
Hyoscine hydrobromide
What is the MHRA alert associated with hyoscine butylbromide injection (IM, IV, SC)?
Serious SE such as tachycardia, hypotension, anaphylaxis (which is likely to be fatal in patients with CHD)
CI patients with tachycardia and should be used in caution in those with cardiac disease
What is cholestasis?
An impairment of bile formation and/or bile flow
What is the drug of choice for cholestatic pruritus?
Colestyramine
What is the drug of choice for intrahepatic cholestatic pruritus in pregnancy?
Ursodeoxycholic acid
Can you give NSAIDs in patients with symptomatic gallstones?
Yes
What is the recommended medicine to use for primary biliary cholangitis?
(progressive destruction of bile ducts within the liver)
Ursodeoxycholic acid
What is the MHRA alert associated with obeticholic acid?
Serious liver injuries in patients with mod-severe hepatic impairment
Need to be adequately dose adjusted according to LFTs
What is used for oesophageal varice bleeding?
Terlipressin
Vasopressin
Orlistat is licensed in patients with what BMI?
BMI of 30
or BMI of 28 in the presence of other risk factors
When should discontinuation of Orlistat be considered? (when do you know it is not effective)
After 12 weeks if weight loss has not exceeded 5% since starting the treatment
How does Orlistat work?
Lipase inhibitor so reduces absorption of dietary fat
What vitamin may you need to be on if taking Orlistat and why?
D as orlistat may reduce absorption of fat soluble vitamins
What laxatives should be used in acute anal fissures and why?
Bulk forming
Osmotic can be an alternative
To make sure stools are soft and easily passed
When would an anal fissure be classed as chronic?
6 weeks or longer
What topical preparation can be used in acute anal fissures?
Local anaesthetic e.g. lidocaine
What topical preparation can be used in chronic anal fissures?
GTN rectal ointment Diltiazem ointment Nifedipine ointment (Unlicensed)
If a patient with haemorrhoids is suffering from constipation, what type of laxative should be used?
Bulk forming
What type of analgesics should not be used in haemorrhoid patients and why?
Opioids as they cause constipation
Topical rectal preparations containing local anaesthetics such as lidocaine should only be used for a few days- why?
May cause sensitisation of the anal skin
Topical corticosteroids are suitable for short term use in haemorrhoid patients- what is the max number of days this should be used for?
No more than 7 days
If a pregnant lady with haemorrhoids is suffering from constipation, what type of laxative should be used?
Bulk forming
Are topical haemorrhoidal preparations licensed in pregnancy?
No
How do you manage exocrine pancreatic insufficiency?
Pancreatin - contains lipase, amylase and protease
What is the risk of CF patients taking high dose pancreatic enzymes?
What is therefore the guidelines of how many units of lipase to have a day?
Fibrosing colonopathy (presents with abdominal pain, vomiting etc)
No more than 10,000 units/kg/day of lipase
In stoma patients, why should medicine preparations containing sorbitol be avoided?
Laxative effects
What would be the most appropriate diuretic to use in stoma patients and why?
Potassium sparing
Diuretics should be used with caution in patients with an ileostomy or with urostomy as they may become excessively dehydrated and potassium depletion may easily occur.
What is the danger with using laxatives in a stoma patient?
If they do need a laxative after increasing fluid intake and dietary fibre, what can be used?
May cause rapid and severe loss of water and electrolytes.
Bulk forming laxatives
If this does not work, a small dose of stimulant e.g. senna with caution
What is the danger with stoma patients taking digoxin?
Patients with a stoma are particularly susceptible to hypokalaemia if taking digoxin, due to fluid and sodium depletion. Potassium supplements or a potassium-sparing diuretic may be advisable with monitoring for early signs of toxicity.
Why should daily doses of liquid formulations be split in stoma patients?
To avoid osmotic diarrhoea
What 3 antibiotics can you use for C.Diff infection?
1st line: Metronidazole
2nd line: Vancomycin
3rd line: Fidaxomicin
What is the suggested duration of antibiotic treatment for C.Diff?
10-14 days
If a patient has an aspirin sensitivity, would aminosalicylates be appropriate for them?
No - sulfasalazine and mesalazine are derivatives of salicylates, like aspirin.
What colour does your urine turn if on sulfasalazine?
Yellow/orange
What age is Mintec peppermint capsules licensed for?
> 18 years
What age is Colpermin peppermint capsules licensed for?
> 15 years
Liquid paraffin is indicated for constipation, but what is its main side effects?
Lipoid pneumonia on aspiration
Anal seepage
Granulomatous disease risk of GI tract
What is the MHRA advice surrounding PPIs?
Very low risk of subacute cutaneous lupus erythematosus. Drug-induced SCLE can occur weeks to years after exposure to the drug.
If a patient on PPIs develops lesions in sun-exposed areas accompanied with arthralgia;
- Advise them to avoid sun exposure
- Consider SCLE as a possible diagnosis
What antiplatelet interacts with omeprazole?
Clopidogrel
What is the administration counselling points for isphaghula?
Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
What are some counselling points for taking antacids?
- best taken when symptoms occur usually between meals or at bedtime.
- preferably not be taken at the same time as other drugs since they may impair absorption.
- Antacids can damage enteric coatings on tablets.
- The words ‘low Na+’ added after some preparations
indicates a sodium content of less than 1mmol per tablet or 10ml dose. This is directed for people with HTN.
What is the advice given to patients around taking Pancreatin?
=> Ensure adequate hydration receiving higher-strength pancreatin preparations.
=> Pancreatin is inactivated by gastric acid: therefore best taken with food (or immediately before/after food).
=> Enteric-coated preparations deliver a higher enzyme conc in the duodenum-
=> Manufacturer advises GR granules should be mixed with slightly acidic soft food / liquid such as apple juice, and then swallowed immediately without chewing
True or false:
Coeliacs are at a higher risk of malabsorption of key nutrients such as calcium and Vitamin D
True - important to assess for osteoporosis
What are long term complications of ulcerative colitis?
Colorectal cancer
Osteoporosis - from dietary change, corticosteroid medication
VTE
Toxic megacolon
The use of loperamide or codeine in an acute flare up of UC increases the risk of what?
Toxic megacolon
What are the complications of Crohn’s Disease?
Intestinal strictures, abscesses, fistulae
Malnutrition
Anaemia
Colorectal and small bowel cancers
Growth failure and delayed puberty in children
Arthritis
Secondary osteoporosis - from steroid meds
Can you use loperamide and codeine for diarrhoea in Crohn’s?
Yes
What is the patient counselling with ASA?
Report any unexplained bleeding, bruising
Salicylate hypersensitivity e.g. itching, hives
Yellow/orange bodily fluids - may stain contact lenses
What is the interaction between lactulose and mesalazine?
The manufacturers of some mesalazine GR and MR suggest that preparations that lower stool pH (e.g. lactulose) might prevent the release of mesalazine.
What are the red flag symptoms of constipation?
New onset in > 50 years
Anaemia
Abdominal pain
Unexplained weight loss
True or false:
Excessive use of stimulant laxatives causes hyperkalaemia
False- causes hypokalaemia
What kind of laxative is co-danthramer?
Stimulant
What kind of laxative should you avoid in opioid-induced constipation?
Bulk forming
What are the red flag symptoms of dyspesia?
Anaemia
Loss of weight
Recent/unexplained dyspepsia in 55+ unresponsive to treatment
Malaena (blood in stool)
What is a side effect of calcium salt antacids?
Can induce rebound acid secretion and constipation
What classes of drugs do antacids interact with?
Tetracyclines - CNS SE
Quinolones - convulsions
Bisphosphonates - increased risk GI ulcers
What groups of patients are antacids cautioned in?
Fluid retention can occur due to high sodium content so cautioned in hypertension, heart, liver or kidney failure
Avoid in sodium restricted diet e.g. lithium
What PPI is safe in pregnancy?
Omeprazole
What is the advice with enteral feeds and food when taking sucralfate?
Administration of sucralfate and enteral feeds should be separated by 1 hour and for administration by mouth, sucralfate should be given 1 hour before meals.
What is the advice surrounding when to do a 13C urea breath test in terms of if the patient has had antibacterial therapy/antisecretory drug?
Do not perform test within 4 weeks of antibacterial
Do not perform test within 2 weeks of antisecretory drug
What are the side effects of antimuscarinics?
Blurred vision Arrhythmias Pupil dilation (mydriasis) Urinary retention Constipation Dry mouth Angle-closure glaucoma Drowsiness, confusion
Do antimuscarinics cause dry eyes?
No
When should pancreatin be given and why?
Immediately before meals as pancreatin is inactivated by gastric acid
True or false:
Enteric coated pancreatin delivers higher pancreatin levels
True
What is the advice with pancreatin and mixing with food and drink?
Pancreatin is inactivated by heat
If mixed with foods or liquids, do not keep for more than 1 hour
All the antibiotic and PPI triple therapies are BD dosing. What combination is the exception to this?
Omeprazole 20mg BD
Amoxicillin 500mg TDS
Metronidazole 400mg TDS
Treatment of coeliac disease
Avoid gluten
Prednisolone in refractory coeliac disease
What is diverculosis and treatment?
Asymptomatic
Forms diverticula= small pouches protruding from large intestine
Treatment
Bulking forming laxatives if they have constipation
What is acute diverticulitis
Sudden inflammation of diverticula
Can be infected = pain, fever, rectal bleeding
What is complicated acute diverticulitis
Abscess, bowel perforation, fistula, intestinal obstruction, haemorrhage, sepsis
What is treatment for acute diverticulitis
Paracetamol if no systemic symptoms, antibacterials if needed and low fibre diet generally in diverticulitis
What is not recommended in complicated acute diverticulitis
Aminosalicylates and propylactic antibacterials
What are symptoms of Coeliac disease? What is the best non drug treatment?
Diarrhoea, bloating, abdominal pain.
Best no drug treatment is life long strict diet of GF food avoiding wheat, barley and rye ingredients
Corticosteroid side effects
Adrenal suppression, hypothyroidism, striae, acne, moon face, glaucoma, OS, DB
Dose of prednisolone for inducing remission in acute phase of IBD?
40mg once daily oral prednisolone used to induce remission in the acute phase of UC and Crohn’s - reasonable compromise between efficacy and toxic effects. This dose should be reduced gradually by 5mg every 7 days over a period of 8 weeks to prevent early relapse.
Diverticulosis BNF definition
asymptomatic condition characterised by presence of diverticula. Prevalence difficult to determine but age dependent with majority of patients >40yrs
NSAIDs and opioid analgesics are not recommended in Diverticular disease - why?
because their use may increase risk of diverticular perforation
Difference between Crohns vs UC
Crohns: chronic IBD transmural granulamatous inflammation can affect any part of GI tract. ‘skip’ lesions. Stricture. feeling of abdominal mass. ^risk in smokers. Recurrent attacks and periods of remission. Symptom: abdominal pain, diarrhoea, fever, weight loss and rectal bleeding.
UC: diffuse mucosal inflammation in relapsing-remitting pattern. Presents in 15-25yo with continuous extending pattern from rectum upwards to varying degree. Symptoms: bloody diarrhoea, urgent need to defecate, and abdominal pain.
What are the complications of Crohns disease
intestinal strictures, abscesses in intestine/adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, growth failure and delayed growth in children. Extra intestinal manifestations of arthritis and abnormalities in joints, eyes, liver and cause of secondary OS. Those at greater risk should be monitored for osteopenia and assessed for risk of fractures.
What is Fistulating Crohn’s disease
Complication involving fistula between intestine and adjacent structures eg perinala skin, bladder and vagina. occur in 1 in 4 pateints mostly when disease involves ileoclonic area.
Crohns non drug treatment?
Smoking cessation, attention to nutrition, surgery consider in pts with early disease limited to distal ileum or severre/chronic acitve disease
Crohns maintianing remission following surgery
Azathiprine or mercaptopurine (unlicensed) can be used ASA can also be considered but budesonide or enteral nutrition should not be used.
UC complications
^ risk of colorectal cancer, secondary OS, Venous thromboembolism and toxic megacolon
UC severity measured
Truelove and Witts Severity Index to asseess bowel movments, heart rate, ESR and pyrexia, melaena or anaemia.
UC: If the inflammation is distal, a __________ preparation is adequate but if the inflammation is extended, ___________ medication is required
Rectal - Either suppositories or enemas can be offered, taking into account the patient’s preferences. Rectal foam preparations and suppositories can be used when patients have difficulty retaining liquid enemas.
Systemic
When used to maintain remission, single daily doses of oral aminosalicylates can be _________effective than multiple daily dosing
When used to maintain remission, single daily doses of oral aminosalicylates can be more effective than multiple daily dosing but may result in more side effects
IN UC use of corticosteroids how long would course generally be?
The duration of corticosteroid course (usually 4 to 8 weeks) depends on the corticosteroid chosen
UC - What is 1st-line treatment for patients with a mild-to-mod initial ppt or inflammatory exacerbation of proctitis ?
What would be 2nd line?
- ASA 1st line. Rectal ASA alone more effective for proctitis and proctosigmoiditis. Ifremission notachieved in 4 weeks add oral ASA. Monotherapy oral ASA for those who do not prefer enemas/suppositories (tho less effective).If response remains inadequate, consider addition of a topical or an oral corticosteroid for 4 to 8 weeks.
- Rectal corticosteroid or oral prednisolone can be considered in pt intolerant/decline/CI to ASA.Oral prednis. should be considered for the treatment of pts with subacute proctitis or proctosigmoiditis.
SE ASA pt advised to report any
Blood disorders - report unexplained bleeding, bruising, purpura, sore throat, fever, malaise during treatment. Blood count done and drug stopped if suspected blood dyscrasias
Is any one preparation of mesalazine better than the other?
No evidence to show that any one oral preparation of mesalazine is more effective than the other. If switched pt should report any changes in symptoms.
IBS describe
chronic condition in 20-30yo mostly women. Symptoms abdominal pain/discomfort, disordered, passage of mucus and bloating
IBS self management
high fibre diet, exercise.
What antispasmodics are used as intestinal smooth muscle relaxants in IBS
alverine, mebeverine, peppermint oil
What drug classes are used in IBS
antispasmodics (alverine, mebeverine, peppermint oil) and antimuscarinics (dicycloverine, hyosciene and propantheline)
All antispasmodics should be avoided in
PARALYTIC ILEUS - condition where the gut (intestinal) muscles are paralysed.
Colonisation of C Diff in colon often follows antibiotic therapy - which drugs are hazardous?
Ampicillin, Amoxicillin Coamoxiclav 2nd gen & 3rd gen cephalosporins clindamycin quinolones
misconceptions about bowel habits have led to excessive laxative use. abuse may lead to
hypokalaemia. Before prescribing laxatives it is important to be sure that the patient is constipated and that the constipation is not secondary to an underlying undiagnosed complaint.
If dietary and lifestyle changes do not control constipation in PREGNANCY which class of drugs can be used?
1st line bulk laxative
2nd line osmotic (lactulose)
3rd line stimulant (bisacodyl/senna)
use of senna should be avoided near term or if there is a history of unstable pregnancy.
Docusate sodium and glycerol suppositories can also be used.
Stimulant laxatives are more effective than bulk-forming laxatives but are more likely to cause SE (diarrhoea and abdominal discomfort), reducing their acceptability to patients
Light liquid paraffin
less suitable for prescribing. SE: anal seepage of paraffin and consequent anal irritation after prolonged use;lipoid pneumonia
What is constipation
is defaecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defaecation. It can occur at any age and is commonly seen in women, the elderly, and during pregnancy.
non drug advice for constipation
- ^ in dietary fibre, adequate fluid intake and exercise.
- Balanced Diet contain whole grains, fruits and veg.
- Fibre intake should be ^ gradually (to minimise flatulence and bloating).
- Effects of high-fibre diet seen in a few days - 4 weeks.
- Adequate fluid intake is important (particularly with a high-fibre diet or fibre supplements), but can be difficult for some people (frail or elderly).
- Fruits high in fibre and sorbitol, and fruit juices high in sorbitol, can help prevent and treat constipation.
bulk forming laxatives; examples, onset of action, symptoms
bran, ispaghula husk, methylcellulose and sterculia.
USEFUL FOR adults with small hard stools if fibre cannot be increased in the diet.
Onset up to 72 hours.
Symptoms of flatulence, bloating, and cramping may be exacerbated.
Adequate fluid intake must be maintained to avoid intestinal obstruction.
Methylcellulose, ispaghula husk and sterculia may be used in pts who cannot tolerate bran. Methylcellulose also acts as a faecal softener.
stimulant laxatvie
bisacodyl, sodium picosulfate, and members of the anthraquinone group (senna, co-danthramer and co-danthrusate).
Increase intestinal motility and often cause abdo cramp; avoid in intestinal obstruction
Which class has onset of action up to 72 hours? A. Stimulant laxative B. Bulkforming laxative C. Osmotic laxative D. Faecal softener
B. Bulk forming laxative
use of co-danthramer and co-danthrusate is limited to constipation in..
What kind of drug is this?
terminally ill patients because of potential carcinogenicity (based on animal studies) and evidence of genotoxicity.
- Example of stimulant laxative
Which drug acts both as stimulant laxative and faecal softener? A. Methylcellulose B. Co-danthramoer C. Docusate sodium D. Sterculia
C. Docusate sodium
Glycerol suppositories act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of glycerol. True or False
True
Methylcellulose also acts as a stimulant laxative.
False - it acts as a faecal softener and is a bulk forming laxative
Faecal softeners are claimed to act by
decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass. Enemas containing arachis oil (ground-nut oil, peanut oil) lubricate and soften impacted faeces and promote a bowel movement. Liquid paraffin has also been used as a lubricant for the passage of stools but manufacturer advises that it should be used with caution because of its adverse effects
What drugs have faecal softening properties? but are not actually faecal softeners.
Docusate sodium and glycerol suppositories
__________ laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.
Examples of this drug class?
Osmotic
Lactulose is a semi-synthetic disaccharide which is not absorbed from the gastro-intestinal tract.
Macrogols (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) are inert polymers of ethylene glycol which sequester fluid in the bowel
Is lactulose absorbed from the GI tract?
no - Lactulose is a semi-synthetic disaccharide which is not absorbed from the gastro-intestinal tract.
Which laxative is useful in the treatment of hepatic encephalopathy and why?
Lactulose produces an osmotic diarrhoea of low faecal pH, and discourages the proliferation of ammonia-producing organisms. It is therefore useful in the treatment of hepatic encephalopathy.
giving fluid with __________ may reduce the dehydrating effect sometimes seen with osmotic laxatives.
Macrogols
Linaclotide is a
- indication
- MOA
guanylate cyclase-C receptor agonist licensed for the treatment of mod-sev IBS associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain.
Prucalopride is a
selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response.
Bowel cleansing preparations are used
before colonic surgery, colonoscopy or radiological examination to ensure the bowel is free of solid contents
Examples of bowel cleansing preparations
macrogol 3350 with anhydrous sodium sulfate, KCl, Na bicarbonate and NaCl, citric acid with Mg carbonate, Mg citrate with Na picosulfate and Na acid phosphate with Na phosphate.
True or false
Bowel cleansing treatments are treatments for constipation.
FALSE
In the management of short-duration constipation (where dietary measures are ineffective) treatment should be started with
bulk-forming laxative, ensuring adequate fluid intake. If stools remain hard, add or switch to an osmotic laxative. If stools are soft but difficult to pass or the person complains of inadequate emptying, a stimulant laxative should be added.
[ELDERLY] Constipation is a common cause of distress and is almost invariable after an opioid analgesic. It should be prevented if possible by regular administration of laxatives;
faecal softener with a peristaltic stimulant (e.g. co-danthramer) or lactulose solution with a senna preparation should be used. Methylnaltrexone bromide is licensed for the treatment of opioid-induced constipation.
In patients with opioid-induced constipation what is recommended?
osmotic laxative (or docusate sodium to soften the stools) and a stimulant laxative is recommended. Bulk-forming laxatives should be avoided.
What kind of constipation should bulk laxatives eg loperamide be avoided in?
Opioid induced constipation. Opioids prevent peristalsis of the fibre-increased bulk, which exacerbates abdominal pain and, in some cases, contributes to bowel obstruction.
Naloxegol is recommended for..
Naloxegol is recommended for the treatment of opioid-induced constipation when response to other laxatives is inadequate.
Manufacturer advises that in patients receiving palliative care, methylnaltrexone bromide should be used as
an adjunct to existing laxative therapy.
The treatment of faecal impaction depends on the stool consistency. In patients with hard stools, a high dose of an
oral macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride) may be considered.
Faecal impaction: In those with soft stools, or with hard stools after a few days treatment with a macrogol, an oral __________laxative should be started or added to the previous treatment. what if this is ineffective?
STIMULANT.
If the response to oral laxatives is inadequate, for soft stools consider rectal administration of bisacodyl, and for hard stools rectal administration of glycerol alone, or glycerol plus bisacodyl.
Faecal impaction: If the response to oral laxatives is inadequate
If the response to oral laxatives is inadequate, for soft stools = use rectal bisacodyl.
For hard stools = rectal glycerol, or glycerol + bisacodyl.
Alternatively, a docusate Na or Na citrate enema.
If still insufficient Na acid phosphate with Na phosphate or arachis oil retention enema.
Hard faeces: helpful to give the arachis oil enema overnight before giving a Na acid phosphate with Na phosphate/citrate enema the following day. Enemas may need to be repeated several times to clear hard impacted faeces.
In the management of chronic constipation, treatment should be
- bulk-forming laxative, + good hydration.
- Add or change to an osmotic laxative eg macrogol.
- Lactulose if macrogols are not effective/tolerated.
- Still inadequate, add stimulant laxative.
Laxative dose should be adjusted gradually to produce one or two soft, formed stools per day.
Chornic constipation: If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months, the use of
prucalopride (in women only) should be considered. If treatment with prucalopride is not effective after 4 weeks, the patient should be re-examined and the benefit of continuing treatment reconsidered.
How should laxatives be withdrawn when patient starts to get regular bowel movements?
Laxatives can be slowly withdrawn when regular bowel movements occur without difficulty, according to the frequency and consistency of stools.
If a combo of laxatives has been used, reduce + stop one laxative at a time; stimulant laxative should be reduced first.
However, it may be necessary to also adjust the dose of the osmotic laxative to compensate.
Constipation in pregnancy non medication
If dietary and lifestyle changes fail, fibre supplements in the form of bran or wheat are likely to help women experiencing constipation in pregnancy.
The first-line treatment for children with constipation requires
use of a laxative in combo with dietary modification or with behavioural interventions. Diet modification alone not recommended as 1st-line.
Constipation in children dietary information
^in dietary fibre, adequate fluid intake, and exercise. balanced diet contain fruits+veg , high-fibre bread, baked beans, and wholegrain breakfast cereals. Unprocessed bran (bloating and flatulence and reduces the absorption of micronutrients) is not recommended.
Treatment of faecal impaction may initially increase symptoms of soiling and abdominal pain in
A. adults
B. children
b. Children
Main aim of diarrhoea
Reverse fluid and electrolyte depletion especially in infants, frail and elderly. Oral rehydration preparations used to replenish lost electrolyes
Antimotility drugs such as loperamide are used in uncomplicated diarrhoea but not in children under
3 yrs
Is routine prophylaxis against traveller’s diarrhoea recommended?
No but ciprofloxacin can be used.
loperamide can also be used for mild-mod travellers’ diarrhoea where toilet amenities are limited/unavailable but should be avoided in bloody/suspected inflammatory diarrhoea and cases of significant abdominal pain
Diarrhoea is
the abnormal passing of loose or liquid stools, with increased frequency, increased volume, or both.
Diarrhoea red flag symptoms
unexplained weight loss, rectal bleeding, persistent diarrhoea, a systemic illness, has received recent hospital treatment or antibiotic treatment, or following foreign travel (other than to Western Europe, North America, Australia or NZ).
Oral rehydration therapy
is the mainstay of treatment for acute diarrhoea to prevent or correct diarrhoea dehydration and to maintain the appropriate fluid intake once rehydration is achieved
in patients with severe dehydration and in those unable to drink, immediate admission to hospital and
urgent replacement treatment with an intravenous rehydration fluid is recommended
Loperamide is 1st line in
standard treatment when rapid control of symptoms of diarrhoea.
Travellers’ Diarrhoea
Faecal incontinence [unlicenced] after underlying cause of incontinence has been addressed
Racecadotril is licensed as an adjunct to rehydration for the symptomatic treatment of
uncomplicated acute diarrhoea in adults and children over 3 months.
loperamide not recommended for children under
12 yrs - acute diarrhoea
18 yrs - acute diarrhoea associated with IBS
loperamide SE
GI disorders, headache, nausea
beware of serious cardiac adverse rxns in high doses associated with abuse/misuse
Dyspepsia describes a range of upper gastro-intestinal symptoms, which are typically present for
4 or more weeks. Symptoms: upper abdo pain or discomfort, heartburn, gastric reflux, bloating, n+v. Underlying cause (e.g. GORD, Peptic ulcer disease, malignancy, or drug SE), but majority of pts are likely to have functional dyspepsia, no underlying cause.
Uninvestigated dyspepsia describes symptoms in patients who
have not had an endoscopy.
Dyspepsia symptoms in pregnancy are commonly due to
gastro-oesophageal reflux disease
Dyspepsia lifestyle measures
Healthy eating, weight loss (if obese), avoiding trigger foods, eating smaller meals, eating evening meal 3–4 hours before bed, raising the head of the bed, Smoking cessation, reducing alcohol. Assess for stress, anxiety, or depression symptoms.
Drugs that may cause dyspepsia
a-blockers, antimuscarinics, aspirin, benzodiazepines, beta-blockers, bisphosphonates, CCB, corticosteroids, nitrates, NSAIDs, theophyllines, and tricyclic antidepressants
dyspepsia can be treated with antacids?
Antacids and/or alginates may be used for short-term symptom control, but long-term, continuous use is not recommended.
For uninvestigated dyspepsia
proton pump inhibitor should be taken for 4 weeks
investigate H Pylori
Functional dyspepsia action
test H Pylori => negative =>
PPI or histamine2 rec antagonist could be taken for 4 weeks
In patients with uninvestigated dyspepsia taking an NSAID and unable to stop the drug, consider
reducing NSAID dose and using long-term gastro-protection with acid suppression therapy, or switching to an alternative to the NSAID: paracetamol or selective COX2 inhibitor or antiplatelet drug
COX 2 selective inhbitors
celecoxib, rofecoxib
An __________review should be performed for patients with dyspepsia to assess their symptoms and treatment.
annual. A ‘step down’ approach/stopping treatment, should be encouraged. Return to self-treatment with antacid and/or alginate therapy may be appropriate.
Testing for H. pylori is recommended in the following patients in line with Public Health England (PHE) Guidance
- Uncomplicated dyspepsia + no alarm symptoms, unresponsive to lifestyle changes and antacids, following 1 month PPI course
- Pt at high risk of H. pylori infection; elderly, North African ethnicity, living in a high risk area, or in parallel with a course of a PPI
- Previously untested pts with a history of peptic ulcers or bleeds
- Prior to initiating NSAIDs in pts with history of peptic ulcers or bleeds
- Pts with unexplained iron-deficiency anaemia after endoscopic investigation has excluded malignancy, and other causes have been investigated.
recommended tests for the diagnosis of gastro-duodenal infection with H. pylori
The urea (13C) breath test, Stool Helicobacter Antigen Test (SAT), or laboratory-based serology
PHE advise urea (13C) breath test and SAT should not be performed within 2 weeks of treatment with a PPI or within 4 weeks of antibacterial treatment, as can lead to false negatives.
In patients with functional dyspepsia, routine retesting after H. pylori eradication is recommended or not recommended
not recommended.
Orlistat MOA
Orlistat = potent, specific and long-acting inhibitor of GI lipases. Estimated orlistat 60mg TDS blocks the absorption of approximately 25% of dietary fat. acts in lumen of stomach and small intestine by forming a covalent bond with the active serine site of the gastric and pancreatic lipases. The inactivated enzyme is thus unavailable to hydrolyse dietary fat, in the form of TG, into absorbable free fatty acids and monoglycerides.
