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Pre-reg > Chapter 1- GI System > Flashcards

Chapter 1- GI System Flashcards

1
Q

Types of inflammatory bowel disorders and where they affects

A

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
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2
Q

What usually the treatment for inflammatory bowel disease

A

Mild- oral amonosalicylate

Moderate- oral corticosteroids

Severe- drugs that affect the immune response (ciclosporin, methotrexate, azathioprine)

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3
Q

What dietary advice should you give for coeliac disease

A

Avoid gluten- present in wheat, barley, rye

Consider vitamins and mineral supplements following medical assessment

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4
Q

Treatment for diverticulitis

A

High fibre diet
Bulk forming drugs for constipation
Antibacterial when there’s a sign of infection

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5
Q

Drug treatment for acute Crohn’s disease

A 
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

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6
Q

What’s used to maintain remission in Crohn’s disease

A

Azathioprine or mercaptopurine
Alternative: methotrexate

After surgery:
Azathioprine or mercaptopurine or aminosalicylates

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7
Q

What can be used to manage diarrhoea associated with Crohn’s disease

A

Codeine or loperamide

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8
Q

What’s the treatment of acute mild to moderate UC

A

Aminosalicylate

If not improved in 4 weeks add prednisolone

If still not improvement after 2-4 weeks add tacrolimus

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9
Q

Treatment of acute severe UC

A

Iv corticosteroids
If not appropriate ciclosporin (alternative: infliximab)

Second line is surgery

Monoclonal antibodies can also be used if no response to conventional treatment

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10
Q

Examples of aninosalcylates

A

Sulfasalazine
Meslazine
Balsalazide
Olsalazine

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11
Q

An important side effect of aminosalicylates that should be reported immediately

A

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

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12
Q

Side effects of aminosalycilate

A

Nausea Vomiting Diarrhoea Abdominal pain Headache

Blood dyscrasias
Nephrotixicity
Salicylate hypersensitivity
Yellow/orange bodily fluids with sulfasalazine

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13
Q

How can IBS be managed without drug treatment

A

High fibres
Increased fluid intake
Increase physical activity
Eat regularely and don’t skip meals

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14
Q

Drug treatment for IBS

A

Antispasmodic- alverine, mebrevine, peppermint oil)

Antimuscarinics- hyoscine butylbromide, atropine

Laxative (excluding lactulose as it causes bloating)

Antimotility- Loperimide

TCA- Abdo pain

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15
Q

How do antimotility drugs work

A

They bind to opioid receptors in the GI tract

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16
Q

What drug can be given for diarrhoea following a colon resection

A

Colestyramine

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17
Q

What can excessive laxative use lead to

A

Hypokalaemia
Diarrhoea
Lazy bowel

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18
Q

How can you treat constipation in children

A

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

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19
Q

How can you treat constipation in pregnancy

A

Dietary lifestyle changes

Bulk forming or lactulose laxative

Bisacodyl or Senna if stimulant effect is necessary

Docusate or glycerol suppository

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20
Q

Example of bulk forming laxative and how they work

A

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)

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21
Q

Example of stimulant laxative and how they work

A

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)

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22
Q

Example of faecal softener and how they work

A

Docusate, arachnid oil

Decrease surface tension and increase penetration of intestinal fluid into the faecal mass

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23
Q

Example of osmotic laxative and how they work

A

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

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24
Q

Laxative ladder

A

First bulk forming laxative

Then add or switch to osmotic laxative

If stools are soft but difficult to pass add a stimulant laxative

(BOS)

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25
Q

What should you prescribe and what should you avoid in opioid induced constipation

A

Osmotic and stimulant laxative

Avoid bulk forming laxative

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26
Q

What’s the laxative can be used for diarrhoea associated with diverticulitis disease

A

Fybogel

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27
Q

Which electrolyte imbalance can cause constipation

A

Aluminium

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28
Q

Which electrolyte imbalance can cause diarrhoea

A

Magnesium

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29
Q

What’s a risk of diarrhoea

A

Excessive water and electrolyte loss leading to dehydration

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30
Q

What’s the drug treatment of choice for diarrhoea

A

Anti motility drug- Loperamide

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31
Q

Maximum daily dose of loperamide

A

16mg

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32
Q

MHRA alert for loperamide

A

QT prolongation

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33
Q

Loperamide antidote

A

Naloxone

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34
Q

What’s dyspepsia

A 
Catergory including: 
Upper abdominal pain 
Fullness
Bloating 
Nausea
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35
Q

What are alarming features of dyspepsia

A 
Bleeding 
Dysphagia 
Recurrent vomiting 
Weight loss
Over 55 where unexplained ulcer
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36
Q

Treatment for dyspepsia

A

Antacid for symptomatic relief
PPI or H2 receptor antagonist if symptoms not relieved
Test h. Pylori if PPI ineffective

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37
Q

What do antacids usually contain

A

Aluminium or magnesium compounds

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38
Q

What’s the one week h. Pylori eradication regime

A

PPI twice daily

2 antibiotics out of:

  • clarithromycin
  • amoxicillin
  • metronidazole
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39
Q

How successful if the one week h pylori regime

A

85%

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40
Q

What test is used for h. Pylori

A

13C-urea breath test
Stool sample
Blood test

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41
Q

How can h2 receptor antagonist help with ulcers

A

They help heal ulcers by reducing gastric acid secretion and relieve symptoms

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42
Q

What can long term use of calcium containing antacids cause?

A

Hypercalaemia and alkalosis

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43
Q

Two main causes of gastric and duodenal ulcers

A

NSAIDs

H. Pylori

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44
Q

Classes and examples of anti secretory drugs and mucosal Protestants

A

1 chelates and complexes: sucralfafe

2 H2 receptor antagonist: ranitidine

3 PPI: lansoprazole

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45
Q

Risk factors for NSAID associated ulcers

A

Age
History of ulceration
Those with a serious co-morbidity

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46
Q

What are the symptoms of GORD

A 
Heart burn
Acid regurgitation 
Difficulty swallowing
Oesophageal inflammation 
Ulceration
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47
Q

Treatment for GORD

A

Mild:
Antacid, PPI or H2 receptor antagonist

Severe:
PPI

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48
Q

Treatment for GORD in pregnancy

A

Antacid

Ranitidine

Omeprazole

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49
Q

Examples of antispasmodics and their common use

A

Hyoscine butylbromide, alverine, mebeverine

Used in IBS and travel sickness

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50
Q

What’s is cholestasis and how does it present?

A

Impairment of bile formation and/or bile flow

Presents as: fatigue, pruritis,dark urine, pale stools, jaundice

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51
Q

What BMI is classed as obese?

A

> 30kg/m2

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52
Q

What OTC med can you get for obesity and how does it work

When should treatment be discontinued

A

Orlistat

Lipase inhibitor so reduces the absorption of dietary fat

After 12 weeks of weight loss has not exceeded 5% of starting weight

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53
Q

What is an anal fissure and how is it managed?

A

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

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54
Q

What’s a haemorrhoids

A

Abnormal swelling of the vascular mucosal anal cushions around the anus

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55
Q

What’s the treatment for haemorrhoids

A

Preparations containing local anaesthetic, corticosteroids, astringent, lubricant and antiseptics are available

Laxative to ensure stools are soft and easy to pass

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56
Q

What’s the treatment for pancreatic insufficiency and how does it work

A

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

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57
Q

What does the two week dual h. Pylori regime consist of

Why’s it not recommended

A

PPI and single antibacterial agent

More adverse effects and low eradication rate

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58
Q

What varies in terms of medication for patients with a stone

A
  • 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
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59
Q

Which antiemetic is mainly used for nausea and vomiting associated with reduced gut motility

A

Dopaminergic receptor

Domperidone, metoclopramide

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60
Q

Why must you leave a gap after taking antacids

A

They react with a few other medications

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61
Q

How does PPI differ from H2receptor antagonist

A

PPI suppress gastric acid production almost completely

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62
Q

Possible adverse effects of PPI

A 
GI Distubance ( c. Diff)
Hypo magnesium 
Nyponatreamia
Increased risk of fracture
Rebound acid secretion
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63
Q

What should be avoided during an acute flare up of UC

A

Anti motility drugs (loperimide/ codeine)

64
Q

What determines if the treatment for UC is oral or rectal?

A

The area affected and the severity

65
Q

Where are the different areas affected it UC

A

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

66
Q

What’s the treatment for acute UC for the different areas affected

A

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

67
Q

What’s used to maintain remission in UC

A

Aminosalicylates as steroids have too many side effects

Add azathioprine/ mercaptopurine if 2+ flare ups in 12 months

68
Q

Drugs involved in inflammatory bowel disease and examples

A

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

69
Q

Interaction with lactulose and mesalazine

A

Lactulose lowers stool pH preventing sufficient release of the active ingredient in E/C or M/R preparations

70
Q

Treatments for IBS and examples

A

Antispasmodics (alverine, mebreverine, peppermint oil)

Antimuscarinic (hyoscine butylbromide, atropine)

Laxatives (not lactulose)

Antimotility (loperamide)

Antidepressants for abdo pain

71
Q

What should you inform patients with Senna

A

Short term use and may colour the urine yellow or brown

72
Q

What does omeprazole interact with

A

Clopidogrel reduces antiplatelet effect

and methotrexate decreased clearance

73
Q

Antimuscarinic side effects

A

Can’t see cant pee can’t poo can’t spit

Blurry vision
Urinary retention
Constipation
Dry mouth

74
Q

What’s the treatment for NSAID induced ulcers

A

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

75
Q

MHRA alert on stimulant laxatives

A

Minimise it’s use due to GI adverse effects

76
Q

What’s cautioned for Antimuscarinic

A 
Down syndrome 
Elderly 
Children 
GORD
UC
77
Q

What’s contraindicated in Antimuscarinic

A

Myasthenia gravis
Paralytic ileus
Toxic mega colon
Prostatic enlargement

78
Q

Counselling points for peppermint oil

A

Capsules not to be chewed because it can irritate the throat

Sensitivity to menthol

79
Q

When is misoprostol used and when is it contraindicated

A

Treatment of nsaid induced ulcers

Contraindicated in Pregnancy

80
Q

Give an example of an astringent agent

A

Bismuth oxide

81
Q

When should you take colestyramine when on other meds

A

1 hour before

Or 4 hours after

82
Q

What’s the maximum amount of days you can use OTC ointment containing a steroid

A

7 days

83
Q

Who does IBS usually affect

A

Ages 20-30

More in women

84
Q

What supply is ranitidine allowed to be sold to the public

A

Not containing more than 1 weeks supply

85
Q

Colestyramine side effects

A 
Constipation 
Diarrhoea 
Increased tendency to bleed 
Nausea 
Reduced absorption of vitamin A D E K
GI discomfort 
Vomiting
86
Q

Common side effects of misoprostol

A

Nausea
Vomiting
Rash

87
Q

What medication is not recommended in diverticular disease

A

NSAIDs and opioids

88
Q

What medication is contraindicated during acute flare up of Ulcerative colitis

A

Anti motility drugs

Anti spasmodics

89
Q

What can be given to help with muscle spasms in IBS

A

Antispasmodics

Antimuscarinics

90
Q

Which laxative is not recommended in IBS and why?

A

Lactulose

Causes bloating

91
Q

Which laxative is given if the patient is unresponsive to different laxatives and has had constipation for 12 months

A

Linoclotide

92
Q

What changes can be made for incomplete drug absorption due to short bowel syndrome

A

Don’t give EC or MR preps
Un coated tablets more suitable
Liquid formulations suitable

Supplementation may be required

93
Q

What do NICE mark as being constipated

A

Emptying bowels less than 3 times a week

94
Q

What laxative is used is palliative care only

A

Dantron laxatives

  • co danthramer
  • co danthrusate

As Theyre carcinogenic

95
Q

Whats the serious adverse affect with high doses of loperamide

A

Cardiac affects

Qt prolongation

96
Q

What’s the MHRA alert for PPI

A

Very low risk of subacute cutaneous lupus erythrmatosus

97
Q

Long term use of PPI can cause hupomagnesaemia, when taking what drug is this exceptionally dangerous

A

Digoxin- can lead to toxicity

98
Q

What symptoms should you refer for dyspepsia or heartburn?

A 
Bleeding 
Weight loss 
Anaemia 
Vomiting 
Pain or difficulty swallowing 
Breathlessness 
Occurring more than twice a week 
Any person over 50
99
Q

Antacid ingredients available

A

Magnesium salts
Aluminium salts
Calcium carbonate
Sodium bicarbonate

100
Q

How do antacids and alginates work

A

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

101
Q

Antacids and alginates with which ingredient should be cautioned in what group of people?

A

Sodium

People with kidney and heart problems
Hypertension

102
Q

How can famotidine be sold OTC

A

Can only be sold to over 16

P medicine- max 14 days
GSL- max 6 days (12 tabs)

103
Q

What PPI can be sold OTC and to what age and for what reason?

A

Omeprazole 10mg and pantoprazole 20mg

Age > 18

For the relief of reflux like symptoms (heartburn)

For 4 weeks

104
Q

Which constipation/ diarrhoea symptoms should you refer to the pharmacist

A 
Child under 8
Pregnant women 
Taking other meds 
Tried treatment with no success 
Longer than 7 days 
Frail or elderly 
Repeated use
105
Q

When should IBS symptoms be referred to the pharmacist

A 
Blood in stool 
Under 16
Fever nausea or vomiting 
Adults over 45
Severe Abdo pain
106
Q

What can be purchased OTC for bloating and nausea, what age can it be sold from?

A

Domperidone

Age over 16

107
Q

OTC age restriction for motion sickness treatment

A

Hyoscine- 3 years +

Antihistamine- 5 years +

108
Q

How does oral thrush present

A

Typically creamy white soft elevated patches that can be wiped off

109
Q

OTC treatment available for oral thrush

A

Daktarin (miconazole)

110
Q

From what ages can daktarin be sold otc

A

Over 4 months

111
Q

Other drug interactions with daktarin (miconazole)

A

Warfarin

112
Q

From what age can chlorhexidine be given otc

A

Over 12

113
Q

What’s been seen as effective for treating travellers diarrhoea

A

Bismuth subsalicylates (slower than loperamide)

114
Q

What ages can hyoscine, mebrevine, alverine and peppermint oil be sold otc

A 
12
10
12
15
Respectively
115
Q

What effects can antacids have on tablets

A

It neutralises pH so can effect EC or MR tablets

116
Q

What are the ages of referral OTC for diarrhoea

A

Greater than one day for < 1 year olds

Greater than 2 days for < 3 years

Greater than 3 days in older children and adults

117
Q

What otc thrush treatment should pregnant women be offered

A

Clotrimazole

Not fluconazole

118
Q

What’s licensed otc for period pain

A

Ibuprofen
Naproxen (age 15-50)
Diclofenac

Antispasmodic (hyoscine)

119
Q

What can be sold otc for cystitis

A

Sodium or potassium salts (alkalinising agents)

48 hour sachet course

120
Q

When do you refer for cystitis

A 
All men 
Pregnant women 
Blood in urine 
Discharge (indicates infection)
Diabetic patients 
Longer than 2 days 
Failed medication
121
Q

When do you refer for thrush

A 
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
122
Q

Potential causes of vaginal thrush

A 
Pregnancy 
Diabetes 
Antibiotics 
Oral contraceptives 
Medication 
Clothing 
Toiletries 
Ora steroids 
Hiv infection
123
Q

To whom is the supply of miconazole (daktarin oral gel) not permitted

A

Infants less than 4 months or ones where their swallowing reflex is not yet successfully developed

124
Q

What ages can aciclovir (Zovirax) and peniciclovir (fenistil) be supplied

A

Aciclovir all ages

Peniciclovir over 12

125
Q

From what age can loperamide be supplied otc

A

12 OTC

18 for IBS

POM 4+

126
Q

What’s the onset of action for bulk forming, osmotic and stimulant laxatives

A

Bulk forming 12-72
Osmotic 24-48
Stimulant 6-12

127
Q

How does erythromycin effect stool

A

Causes diarrhoea

128
Q

What’s the maximum daily does of ranitidine as a P supply

A

300mg

129
Q

Warning label for co-danthrusate

A

Medicine may colour the urine red/ brown

130
Q

Symptoms of coeliac disease and what they’re at risk of

A

Diarrhoea, Abdo pain and bloating

Higher risk of malabsorption of calcium and vit d (fractures)

131
Q

Diverticulitis symptoms

A

Lower abdo pain
Constipation
Diarrhoea

132
Q

Long term complications of UC

A

Colorectal cancer
Secondary osteoporosis
VTE
Toxic mega colon

133
Q

What’s the most effective dosing for aminosalicylates

A

Single daily dose more effective that multiple daily doses but has more side effects

134
Q

Symptoms of Crohn’s disease

A 
Abdominal pain 
Diarrhoea 
Rectal bleeding 
Weight loss 
Low grade fever 
Fatigue
135
Q

Complications of Crohn’s disease

A 
Intestinal strictures 
Abscesses
Fistulae
Malnutrition 
Colorectal or small bowel cancer 
Growth failure and delayed puberty in children
Arthritis 
Secondary osteoporosis
136
Q

Lifestyle advice for people with Crohn’s disease

A

High fibre diet

Smoking cessation reduces risk of relapse

137
Q

What are symptoms of IBS and what is it aggravated by

A

Lower abdominal pain
Bloating
Alternating constipation and diarrhoea

Aggravated by stress, depression, anxiety, lack of dietary fibre.

138
Q

What is short bowel syndrome and what are the effects

A

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)

139
Q

Which laxatives do you advice to take at night and which do you not

A

Stimulant- take at night to pas stool in the morning

Bulk forming- not immediately before bed

140
Q

What’s the faecal softer that’s no longer used and why

A

Liquid paraffin

Harsh side effects

141
Q

Laxatives with stool softening properties

A

Methyl cellulose
Docusate
Glycerol

142
Q

If Atleast 2 laxatives from different classes have been tried at the highest tolerated doses for Atleast 6 months
What can be tried

A

Prucalopride

Lubiprostone

143
Q

Treatment for chronic constipation

A

Same BOS ladder

Except macrogol is the choice of osmotic laxative

144
Q

Red flag symptoms of constipation

A 
New onset in over 50 year old 
Anaemia 
Abdo pain
Unexplained weight loss
Overt or occult blood
145
Q

Red flag symptoms of diarrhoea

A 
Unexplained weight loss 
Rectal bleeding 
Persistent diarrhoea 
Systemic illness
Received recent hospital treatment or antibiotic 
Following foreign travel
146
Q

Antacids with low sodium preparation

A

Maalox and mucogel

Altacite plus

147
Q

Some antacid interactions

A

Impaired absorption of some drugs so leave a 2 hour gap (tetracyclines, quinolones, bisphosphonates)

Damages enteric coating by increasing gastric ph

High sodium content

148
Q

H2 receptor antagonist side effects

A 
Headache
Rashes
Dizziness 
Diarrhoea 
Psychiatric reactions
149
Q

What’s a common reason for misoprostol withdrawal

A

Diarrhoea

It’s a dose limiting side effect

150
Q

Who are high risk patients for developing nsaid induced ulcers

A 
65+
Previous history 
Certain meds 
Significant comorbidity
(Eg diabetes renal or heart failure)
151
Q

What does a reduced secretion of pancreatic enzymes cause

A

Maldigestion
Malnutrition
Gi symptoms

152
Q

Causes of reduced pancreatin

A

Cystic fibrosis
Pancreatitis
Coeliac disease
GI or pancreatic surgical resection

153
Q

What do topical preparations for heammorroids contain

A 
Local anaesthetic
Corticosteroids 
Astrigents 
Lubricants 
Antiseptics
154
Q

What dietary advice can you give to patients that have reduced secretion of pancreatic enzymes

A

Distribute food intake between 3 main meals and 2-3 snacks

Avoid food difficult to digest

Do not consume alcohol

Avoid reduced fat diets

155
Q

How to take pancreatin

A

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

156
Q

What can occur in cystic fibrosis with high dose pancreatin

A

Fibrosing colonopathy

157
Q

Common side effect of orlistat

A

Oily fatty stool

Steatorrhoea

Pre-reg (27 decks)

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