Chapter 1- GI System Flashcards
Types of inflammatory bowel disorders and where they affects
Coeliac disease- inflammation of the small intestine
Diverticulitis- bulges in the colon
INFLAMMATORY BOWEL DISEASE
- Crohn’s disease affects the GI tract
- Ulcerative colitis affects colon and rectum
What usually the treatment for inflammatory bowel disease
Mild- oral amonosalicylate
Moderate- oral corticosteroids
Severe- drugs that affect the immune response (ciclosporin, methotrexate, azathioprine)
What dietary advice should you give for coeliac disease
Avoid gluten- present in wheat, barley, rye
Consider vitamins and mineral supplements following medical assessment
Treatment for diverticulitis
High fibre diet
Bulk forming drugs for constipation
Antibacterial when there’s a sign of infection
Drug treatment for acute Crohn’s disease
Mono therapy (1 exacerbation) corticosteroids aminosalicylates or budesonide as an alternative
Add on therapy (2+ exacerbation) - added if there are 2 or more exacerbation in a year
Azathioprine or metcaptopurine
Methotrexate as an alternative
What’s used to maintain remission in Crohn’s disease
Azathioprine or mercaptopurine
Alternative: methotrexate
After surgery:
Azathioprine or mercaptopurine or aminosalicylates
What can be used to manage diarrhoea associated with Crohn’s disease
Codeine or loperamide
What’s the treatment of acute mild to moderate UC
Aminosalicylate
If not improved in 4 weeks add prednisolone
If still not improvement after 2-4 weeks add tacrolimus
Treatment of acute severe UC
Iv corticosteroids
If not appropriate ciclosporin (alternative: infliximab)
Second line is surgery
Monoclonal antibodies can also be used if no response to conventional treatment
Examples of aninosalcylates
Sulfasalazine
Meslazine
Balsalazide
Olsalazine
An important side effect of aminosalicylates that should be reported immediately
Blood disorders so report any unexplained bleeding, bruising, sore throat, fever
Blood count should be done and drug stopped of suspicion of a blood dyscrasia
Side effects of aminosalycilate
Nausea Vomiting Diarrhoea Abdominal pain Headache
Blood dyscrasias
Nephrotixicity
Salicylate hypersensitivity
Yellow/orange bodily fluids with sulfasalazine
How can IBS be managed without drug treatment
High fibres
Increased fluid intake
Increase physical activity
Eat regularely and don’t skip meals
Drug treatment for IBS
Antispasmodic- alverine, mebrevine, peppermint oil)
Antimuscarinics- hyoscine butylbromide, atropine
Laxative (excluding lactulose as it causes bloating)
Antimotility- Loperimide
TCA- Abdo pain
How do antimotility drugs work
They bind to opioid receptors in the GI tract
What drug can be given for diarrhoea following a colon resection
Colestyramine
What can excessive laxative use lead to
Hypokalaemia
Diarrhoea
Lazy bowel
How can you treat constipation in children
Intake of fluids containing sorbitol (prune, pear, apple)
Diet should be reviewed
First line: Macrogol
Add stimulant laxative if inadequate
Add lactulose or faecal softer if stools remain hard
How can you treat constipation in pregnancy
Dietary lifestyle changes
Bulk forming or lactulose laxative
Bisacodyl or Senna if stimulant effect is necessary
Docusate or glycerol suppository
Example of bulk forming laxative and how they work
Isphagula husk (fybogel), methyl cellulose (celevac)
They increase faecal mass to stimulate peristalsis
Work within 24 hours and Can take days to reach full effect (72 hours)
Example of stimulant laxative and how they work
Senna, bisacodyl, glycerol suppository
Increase intestinal motility (added if stools are soft but difficult to pass)
Works within 6-12 hours and for short term use (~1 week)
Example of faecal softener and how they work
Docusate, arachnid oil
Decrease surface tension and increase penetration of intestinal fluid into the faecal mass
Example of osmotic laxative and how they work
Lactulose, macrogol
Increase amount of water in the large bowel, draw fluid into the bowel and retains what’s already in the bowel. Can take upto 2-3 days (48 hours for lactulose) to work
Laxative ladder
First bulk forming laxative
Then add or switch to osmotic laxative
If stools are soft but difficult to pass add a stimulant laxative
(BOS)
What should you prescribe and what should you avoid in opioid induced constipation
Osmotic and stimulant laxative
Avoid bulk forming laxative
What’s the laxative can be used for diarrhoea associated with diverticulitis disease
Fybogel
Which electrolyte imbalance can cause constipation
Aluminium
Which electrolyte imbalance can cause diarrhoea
Magnesium
What’s a risk of diarrhoea
Excessive water and electrolyte loss leading to dehydration
What’s the drug treatment of choice for diarrhoea
Anti motility drug- Loperamide
Maximum daily dose of loperamide
16mg
MHRA alert for loperamide
QT prolongation
Loperamide antidote
Naloxone
What’s dyspepsia
Catergory including: Upper abdominal pain Fullness Bloating Nausea
What are alarming features of dyspepsia
Bleeding Dysphagia Recurrent vomiting Weight loss Over 55 where unexplained ulcer
Treatment for dyspepsia
Antacid for symptomatic relief
PPI or H2 receptor antagonist if symptoms not relieved
Test h. Pylori if PPI ineffective
What do antacids usually contain
Aluminium or magnesium compounds
What’s the one week h. Pylori eradication regime
PPI twice daily
2 antibiotics out of:
- clarithromycin
- amoxicillin
- metronidazole
How successful if the one week h pylori regime
85%
What test is used for h. Pylori
13C-urea breath test
Stool sample
Blood test
How can h2 receptor antagonist help with ulcers
They help heal ulcers by reducing gastric acid secretion and relieve symptoms
What can long term use of calcium containing antacids cause?
Hypercalaemia and alkalosis
Two main causes of gastric and duodenal ulcers
NSAIDs
H. Pylori
Classes and examples of anti secretory drugs and mucosal Protestants
1 chelates and complexes: sucralfafe
2 H2 receptor antagonist: ranitidine
3 PPI: lansoprazole
Risk factors for NSAID associated ulcers
Age
History of ulceration
Those with a serious co-morbidity
What are the symptoms of GORD
Heart burn Acid regurgitation Difficulty swallowing Oesophageal inflammation Ulceration
Treatment for GORD
Mild:
Antacid, PPI or H2 receptor antagonist
Severe:
PPI
Treatment for GORD in pregnancy
Antacid
Ranitidine
Omeprazole
Examples of antispasmodics and their common use
Hyoscine butylbromide, alverine, mebeverine
Used in IBS and travel sickness
What’s is cholestasis and how does it present?
Impairment of bile formation and/or bile flow
Presents as: fatigue, pruritis,dark urine, pale stools, jaundice
What BMI is classed as obese?
> 30kg/m2
What OTC med can you get for obesity and how does it work
When should treatment be discontinued
Orlistat
Lipase inhibitor so reduces the absorption of dietary fat
After 12 weeks of weight loss has not exceeded 5% of starting weight
What is an anal fissure and how is it managed?
A year or ulcer in the lining of the anal canal
Managed with a laxative and analgesic (local anaesthetic)
Long term a GTN rectal ointment is added
What’s a haemorrhoids
Abnormal swelling of the vascular mucosal anal cushions around the anus
What’s the treatment for haemorrhoids
Preparations containing local anaesthetic, corticosteroids, astringent, lubricant and antiseptics are available
Laxative to ensure stools are soft and easy to pass
What’s the treatment for pancreatic insufficiency and how does it work
Pancreatin (eg: creon)
Contains the digestive enzymes lipase, amylase and protease to respectively digest fats, carbs and protein so that they can be absorbed
Taken with meals and snacks
What does the two week dual h. Pylori regime consist of
Why’s it not recommended
PPI and single antibacterial agent
More adverse effects and low eradication rate
What varies in terms of medication for patients with a stone
- EC or MR preparations unsuitable
- Laxative: bulk forming or small dose of Senna
- Antidiarrhoeal: loperamide or opioid
- Antacids: constipation or diarrhoea more likely from Al or Mg products
- Diuretics: can cause dehydration or hypokalaemia
- Digoxin: hypokalaemia
- Potassium: liquid preparations preferred
- Analgesics: opioid can cause constipation and NSAID bleeding so paracetamol used
- Iron: oral route may cause loose stools and sore skin, IM route used
Which antiemetic is mainly used for nausea and vomiting associated with reduced gut motility
Dopaminergic receptor
Domperidone, metoclopramide
Why must you leave a gap after taking antacids
They react with a few other medications
How does PPI differ from H2receptor antagonist
PPI suppress gastric acid production almost completely
Possible adverse effects of PPI
GI Distubance ( c. Diff) Hypo magnesium Nyponatreamia Increased risk of fracture Rebound acid secretion
What should be avoided during an acute flare up of UC
Anti motility drugs (loperimide/ codeine)
What determines if the treatment for UC is oral or rectal?
The area affected and the severity
Where are the different areas affected it UC
Extensive colitis: affects most the colon
Left- sided colitis: infects upto the descending colon
Procrosigmoidotis: inflammation of revtum and sigmoid colon
Proctitis: inflammation of the rectum
What’s the treatment for acute UC for the different areas affected
Proctitis and proctosigmoidtitis= aminosalicylate (rectal)
Alternative: rectal or oral steroid
Extensive colitis and left-sided colitis=
High dose oral amonosalicylate (+ rectal amonosalicylate or oral beclometasone)
Alternative: oral pred
What’s used to maintain remission in UC
Aminosalicylates as steroids have too many side effects
Add azathioprine/ mercaptopurine if 2+ flare ups in 12 months
Drugs involved in inflammatory bowel disease and examples
Drugs to reduce inflammation Aminosalicylates: mesalazine sulfasalazine
Corticosteroids: pred, beclometasone, hydrocortisone, budesonide
Drugs that affect the immune system:
Azathioprine, ciclosporin, methotrexate, infliximab
Abx can be included
Interaction with lactulose and mesalazine
Lactulose lowers stool pH preventing sufficient release of the active ingredient in E/C or M/R preparations
Treatments for IBS and examples
Antispasmodics (alverine, mebreverine, peppermint oil)
Antimuscarinic (hyoscine butylbromide, atropine)
Laxatives (not lactulose)
Antimotility (loperamide)
Antidepressants for abdo pain
What should you inform patients with Senna
Short term use and may colour the urine yellow or brown
What does omeprazole interact with
Clopidogrel reduces antiplatelet effect
and methotrexate decreased clearance
Antimuscarinic side effects
Can’t see cant pee can’t poo can’t spit
Blurry vision
Urinary retention
Constipation
Dry mouth
What’s the treatment for NSAID induced ulcers
Withdraw NSAID
PPI (alternative h2 receptor antagonist or misoprostol)
Test for H. Pylori
If history of upper GI bleeds: continue PPI and switch to cox 2 selective inhibitor
MHRA alert on stimulant laxatives
Minimise it’s use due to GI adverse effects
What’s cautioned for Antimuscarinic
Down syndrome Elderly Children GORD UC
What’s contraindicated in Antimuscarinic
Myasthenia gravis
Paralytic ileus
Toxic mega colon
Prostatic enlargement
Counselling points for peppermint oil
Capsules not to be chewed because it can irritate the throat
Sensitivity to menthol
When is misoprostol used and when is it contraindicated
Treatment of nsaid induced ulcers
Contraindicated in Pregnancy
Give an example of an astringent agent
Bismuth oxide
When should you take colestyramine when on other meds
1 hour before
Or 4 hours after
What’s the maximum amount of days you can use OTC ointment containing a steroid
7 days
Who does IBS usually affect
Ages 20-30
More in women
What supply is ranitidine allowed to be sold to the public
Not containing more than 1 weeks supply
Colestyramine side effects
Constipation Diarrhoea Increased tendency to bleed Nausea Reduced absorption of vitamin A D E K GI discomfort Vomiting
Common side effects of misoprostol
Nausea
Vomiting
Rash
What medication is not recommended in diverticular disease
NSAIDs and opioids
What medication is contraindicated during acute flare up of Ulcerative colitis
Anti motility drugs
Anti spasmodics
What can be given to help with muscle spasms in IBS
Antispasmodics
Antimuscarinics
Which laxative is not recommended in IBS and why?
Lactulose
Causes bloating
Which laxative is given if the patient is unresponsive to different laxatives and has had constipation for 12 months
Linoclotide
What changes can be made for incomplete drug absorption due to short bowel syndrome
Don’t give EC or MR preps
Un coated tablets more suitable
Liquid formulations suitable
Supplementation may be required
What do NICE mark as being constipated
Emptying bowels less than 3 times a week
What laxative is used is palliative care only
Dantron laxatives
- co danthramer
- co danthrusate
As Theyre carcinogenic
Whats the serious adverse affect with high doses of loperamide
Cardiac affects
Qt prolongation
What’s the MHRA alert for PPI
Very low risk of subacute cutaneous lupus erythrmatosus
Long term use of PPI can cause hupomagnesaemia, when taking what drug is this exceptionally dangerous
Digoxin- can lead to toxicity
What symptoms should you refer for dyspepsia or heartburn?
Bleeding Weight loss Anaemia Vomiting Pain or difficulty swallowing Breathlessness Occurring more than twice a week Any person over 50
Antacid ingredients available
Magnesium salts
Aluminium salts
Calcium carbonate
Sodium bicarbonate
How do antacids and alginates work
Antacids- alkaline so mix with stomach acid to neutralise content
Alginates- Rafting agents
Floats on the surface of the stomach content like a raft preventing content going up to the oesophagus
Antacids and alginates with which ingredient should be cautioned in what group of people?
Sodium
People with kidney and heart problems
Hypertension
How can famotidine be sold OTC
Can only be sold to over 16
P medicine- max 14 days
GSL- max 6 days (12 tabs)
What PPI can be sold OTC and to what age and for what reason?
Omeprazole 10mg and pantoprazole 20mg
Age > 18
For the relief of reflux like symptoms (heartburn)
For 4 weeks
Which constipation/ diarrhoea symptoms should you refer to the pharmacist
Child under 8 Pregnant women Taking other meds Tried treatment with no success Longer than 7 days Frail or elderly Repeated use
When should IBS symptoms be referred to the pharmacist
Blood in stool Under 16 Fever nausea or vomiting Adults over 45 Severe Abdo pain
What can be purchased OTC for bloating and nausea, what age can it be sold from?
Domperidone
Age over 16
OTC age restriction for motion sickness treatment
Hyoscine- 3 years +
Antihistamine- 5 years +
How does oral thrush present
Typically creamy white soft elevated patches that can be wiped off
OTC treatment available for oral thrush
Daktarin (miconazole)
From what ages can daktarin be sold otc
Over 4 months
Other drug interactions with daktarin (miconazole)
Warfarin
From what age can chlorhexidine be given otc
Over 12
What’s been seen as effective for treating travellers diarrhoea
Bismuth subsalicylates (slower than loperamide)
What ages can hyoscine, mebrevine, alverine and peppermint oil be sold otc
12 10 12 15 Respectively
What effects can antacids have on tablets
It neutralises pH so can effect EC or MR tablets
What are the ages of referral OTC for diarrhoea
Greater than one day for < 1 year olds
Greater than 2 days for < 3 years
Greater than 3 days in older children and adults
What otc thrush treatment should pregnant women be offered
Clotrimazole
Not fluconazole
What’s licensed otc for period pain
Ibuprofen
Naproxen (age 15-50)
Diclofenac
Antispasmodic (hyoscine)
What can be sold otc for cystitis
Sodium or potassium salts (alkalinising agents)
48 hour sachet course
When do you refer for cystitis
All men Pregnant women Blood in urine Discharge (indicates infection) Diabetic patients Longer than 2 days Failed medication
When do you refer for thrush
First occupancy Pregnancy 2 attacks in 6 months History of std Under 16 or over 60 Vaginal bleeding Ulcers or blisters No improvement after 7 days of treatment
Potential causes of vaginal thrush
Pregnancy Diabetes Antibiotics Oral contraceptives Medication Clothing Toiletries Ora steroids Hiv infection
To whom is the supply of miconazole (daktarin oral gel) not permitted
Infants less than 4 months or ones where their swallowing reflex is not yet successfully developed
What ages can aciclovir (Zovirax) and peniciclovir (fenistil) be supplied
Aciclovir all ages
Peniciclovir over 12
From what age can loperamide be supplied otc
12 OTC
18 for IBS
POM 4+
What’s the onset of action for bulk forming, osmotic and stimulant laxatives
Bulk forming 12-72
Osmotic 24-48
Stimulant 6-12
How does erythromycin effect stool
Causes diarrhoea
What’s the maximum daily does of ranitidine as a P supply
300mg
Warning label for co-danthrusate
Medicine may colour the urine red/ brown
Symptoms of coeliac disease and what they’re at risk of
Diarrhoea, Abdo pain and bloating
Higher risk of malabsorption of calcium and vit d (fractures)
Diverticulitis symptoms
Lower abdo pain
Constipation
Diarrhoea
Long term complications of UC
Colorectal cancer
Secondary osteoporosis
VTE
Toxic mega colon
What’s the most effective dosing for aminosalicylates
Single daily dose more effective that multiple daily doses but has more side effects
Symptoms of Crohn’s disease
Abdominal pain Diarrhoea Rectal bleeding Weight loss Low grade fever Fatigue
Complications of Crohn’s disease
Intestinal strictures Abscesses Fistulae Malnutrition Colorectal or small bowel cancer Growth failure and delayed puberty in children Arthritis Secondary osteoporosis
Lifestyle advice for people with Crohn’s disease
High fibre diet
Smoking cessation reduces risk of relapse
What are symptoms of IBS and what is it aggravated by
Lower abdominal pain
Bloating
Alternating constipation and diarrhoea
Aggravated by stress, depression, anxiety, lack of dietary fibre.
What is short bowel syndrome and what are the effects
Characterised by malabsorption following extensive resection of the small bowel
Malabsorption and malnutrition
Inadequate digestion- diarrhoea
Incomplete drug absorption (e/c, m/r not suitable, liquid preferred)
Which laxatives do you advice to take at night and which do you not
Stimulant- take at night to pas stool in the morning
Bulk forming- not immediately before bed
What’s the faecal softer that’s no longer used and why
Liquid paraffin
Harsh side effects
Laxatives with stool softening properties
Methyl cellulose
Docusate
Glycerol
If Atleast 2 laxatives from different classes have been tried at the highest tolerated doses for Atleast 6 months
What can be tried
Prucalopride
Lubiprostone
Treatment for chronic constipation
Same BOS ladder
Except macrogol is the choice of osmotic laxative
Red flag symptoms of constipation
New onset in over 50 year old Anaemia Abdo pain Unexplained weight loss Overt or occult blood
Red flag symptoms of diarrhoea
Unexplained weight loss Rectal bleeding Persistent diarrhoea Systemic illness Received recent hospital treatment or antibiotic Following foreign travel
Antacids with low sodium preparation
Maalox and mucogel
Altacite plus
Some antacid interactions
Impaired absorption of some drugs so leave a 2 hour gap (tetracyclines, quinolones, bisphosphonates)
Damages enteric coating by increasing gastric ph
High sodium content
H2 receptor antagonist side effects
Headache Rashes Dizziness Diarrhoea Psychiatric reactions
What’s a common reason for misoprostol withdrawal
Diarrhoea
It’s a dose limiting side effect
Who are high risk patients for developing nsaid induced ulcers
65+ Previous history Certain meds Significant comorbidity (Eg diabetes renal or heart failure)
What does a reduced secretion of pancreatic enzymes cause
Maldigestion
Malnutrition
Gi symptoms
Causes of reduced pancreatin
Cystic fibrosis
Pancreatitis
Coeliac disease
GI or pancreatic surgical resection
What do topical preparations for heammorroids contain
Local anaesthetic Corticosteroids Astrigents Lubricants Antiseptics
What dietary advice can you give to patients that have reduced secretion of pancreatic enzymes
Distribute food intake between 3 main meals and 2-3 snacks
Avoid food difficult to digest
Do not consume alcohol
Avoid reduced fat diets
How to take pancreatin
With meal/ snacks or immediately after and it’s deactivated by gastric acid
Use E/C to deliver higher pancreatin levels
Do not mix with excessively hot food or drinks (inactivated by heat)
If mixed with food or liquid do not keep for more than 1 hour
What can occur in cystic fibrosis with high dose pancreatin
Fibrosing colonopathy
Common side effect of orlistat
Oily fatty stool
Steatorrhoea
