Chronic Bowel Disorders Flashcards
what is coeliac disease?
autoimmune condition associated with chronic inflammation of small intestine unable to absorb nutrients
what nutrients are at high risk of not being absorbed in coeliac disease?
calcium and vit d
what are the 3 parts to treatment of coeliac disease?
1 gluten free
2 - assss risk for osteoporosis and treat bone disease
3 - vitamin and mineral supplements
Diverticulitis is when pockets (diverticula) develop in the lining of the intestine and become inflammed/infected. What are the 3 parts to management?
1 - high fibre diet
2 - bulk forming drugs to help with diarrohea or constipation
3 - antibiotics for signs of infection
name 4 complications of ulcerative colitis
- colorectal cancer
- secondary osteoporosis (corticosteroid, dietary changes)
- VTE
- toxic megacolon (deeper spread of inflammation)
what drugs should NOT be given to patients during a flare of UC?
loperamide and codiene - avoid anti-motility drug/antispasmodics: paralytic ileus = increased risk of toxic megacolon)
when would oral therapy, suppositories, enemas, and foam preperations be most appropriate for treatment of UC?
Oral - extensive (proximal) colitis
Suppositories - inflammtion of rectum (proctitis)
Enemas - inflammation up to descending colon (left-sided colitis)
Foam - inflammation of rectum and sigmoid colon (proctosigmoiditis)
first line treatment in proctitis (inflammation of rectum) and proctosigmoiditis (inflammtion of rectum and sigmoid)?
What-s the alternative?
1st - rectal aminosalicylate (mesalasine, sulfasalasine)
2nd - rectal corticosteroid or PO pred
first line treatment in extensive and left-sided colitis (up descending colon)?
what’s second line?
1st = high dose oral aminosalicaylate + rectal aminosalicylate or oral beclometasone if necessary
2nd = oral prednisolone
what’s 1st line for moderate-severe UC and what’s 2nd?
1st = oral prednisolone
2nd = monoclonal antibodies
what’s 1st line in treatment failure in mild-moderate UC?
what do you add in if no response after 2 - 4 weeks?
add oral pred after 4 weeks with aminosalicyate
add oral tacrolimus if no response after 2 - 4 weeks
what’s 1st line for severe acute UC?
what’s 2nd line option (if symptoms don’t improve/worsen in 72 hours)?
1st line = IV corticosteroid and assess need for surgery, or could use IV ciclosporin or surgery
2nd line = IV ciclosporin + IV corticosteroids or steroids
what’s an alternative to ciclosporin for management of acute severe UC?
infliximab
what’s an alternative to ciclosporin for management of acute severe UC?
infliximab
what are the differences in maintaining remission in proctitis and proctosigmoiditis compared to extensive colitis and left sided colitis?
Proctitis + proctosigmoiditis = rectal aminosalicylate alone or with oral aminosalicylate
Extensive + left-sided colitis = low-dose oral aminosalicylate + oral azathioprine/mercaptopurine if 2+ flare ups in 12 months that require steroids or if remisison not maintained by aminosalicylates + MAbs continued if effective
when is oral azathioprine/mercaptopurine added into maintained remission in extensive/left-sided UC?
if 2+ flare ups in 12 months needign steroids or if remission not maintained by aminosalicylates
when is oral azathioprine/mercaptopurine added into maintained remission in extensive/left-sided UC?
if 2+ flare ups in 12 months needign steroids or if remission not maintained by aminosalicylates
where in the body does Chron’s affect?
GI tract (mouth to anus)
name some lifestyle adivce you could give to someone with chron’s
- high fibre diet
- smoking cessation reduces risk of relapse
- loperamide or codeine treats diarrhoea - not in colitis
what’s the treatment for 1+ acute flare in 12 months/1st presentation of Chron’s?
what are the alternatives?
corticosteroids
alternatives = budesonide or aminosalicylate in patients with distal ileal, iliealcaecal or right sided disease
what’s the treatment for 2+ acute flare ups in 12 months? (or if corticosteroid dose cannot be reduced)
azathioprine or mercaptopurine
alternative = methotrexate
alternative = MAbs
what’s the maintenace of remission in Chrons disease with and without srugery?
without = azathioprine or mercaptopurine
alternative = methotrexate
after surgery = azathioprine or mercaptopurine OR aminosalicylate
what’s an interaction involving mesalazine you should counsel patients about?
lactulose - lactulose lowers stool pH in the intestines. This prevents sufficent release of the active ingredient EC or MR preperations
what should be monitored with aminosalicylates?
what are some general counselling points?
renal function
itching and hives, can get yellow/orange bodily fluids with sulfasalasine (stain contact lenses)
blood dyscrasias (unexplained bleeding, bruising, sore throat, fever)
what laxative isn’t recommended in IBS and why?
lactulose as it causes bloating
what classes of antibiotics can be used as 2nd line therapy for abdominal pain in IBS?
tricyclic antidespressants, SSRIs
what is linoclotide and when can it be used?
laxative to be used in IBS when unresponsive to other classes and have had constipation for 12 months
what vitamins and minerals are patients oftne deficient in who have short bowel syndrome?
vitamin A, B12, D, E & K, essential fatty acids, zinc, selenium, hypomagnesaemia
what formulations are unsuitable for patients with short bowel?
EC or MR
why may you need to give higher doses of warfarin, oral contraceptives and digoxin (or give IV) in patients with short bowel?
due to incomplete drug absorption
what is constipation defined as in NICE?
what are the red flag symptoms?
less than 3 times a week
red flags = new onset over 50 years, anaemia, abdominal pain, unexplained weight loss, overt ot occult blood
what are the 1st, 2nd, and 3rd line laxatives?
1st = bulk forming
2nd = osmotic
3rd = stimulant
what can excessive use of stimualnt laxatives lead to?
hypokalaemia, diarrhoea, lazy bowel
what stimulant laxative is genotoxic and carcinogenic?
what patient group is it used in?
Dantron
used in terminally ill patients only
what 2 laxativs can be considered if at least 2 laxatives from different classes have been treid at the highest tolerated recommended doses for at least 6 months and what classes are they?
- prucalopride (woman only) - selective 5HT-4 agonist
- lubiprostone (chloride channel agonist)
what laxative should you avoid in opioid induced constipation?
bulk forming
what’s the choice of osmotic laxative in chroninc constipation?
macrogol
what’s the 1st line laxative in children?
What can you add in?
macrogol - with diet/behaviour intervention
add stimulant if inadequate response
add lactulose or faecal softner if hard
what’s the 1st line laxative in pregnancy and breat feeding?
bulk forming - then osmotic if stools remain hard
what are the red flags for diarrohea?
unexplained weight loss, rectal bleeding, persistent diarrhoea, systemic illness, recent hospital treatment or abx, recent travel
what’s the adult dose for loperamide?
whats the max dose?
initially 4mg, then 2mg for up to 5 days, take a dose after each loose stool
max dose = 16mg
what can be given if loperamide overdose occurs?
naloxone
what is the MHRA warning surrounding loperamide?
serious cardiac adverse reactions with high doses (QT prolongation, torasde de pointes)
what 3 types of interaction do you need to bear in mind when giving antacids?
- impaired absorption of drugs - leave 2 hour gap (tetracyclines, quiolones - cipro., bisophosphonate
- damages EC coating by increasing gastric pH
- high sodium content - avoid in fluid retenton, avoid in HTN, HF, avoid in sodium-restircted diet (lithium)
what PPI is safe in pregnancy?
omeprazole
what are the long term risks of PPIs?
hypomagnesia, increased risk of c. diff and osteoporosis, rebount acid secretion
what are 2 interactions with omeprazole and what happens?
- clopidogrel = reduced antiplatelet effect
- methotrexate = decreased clearance of methotrexate
what are the treatment options to treat H. Pylori? (PAC, PAM, PMC)
1 week triple therapy: PPI BD + clarithromycin + amoxicillin OR metronidazole
- give metronidazole if penicillin allergic
- if pt treated with macrolide for other infection give amoxicillin + metronidazole
- give amoxicillin and clarithromycin if meronidazole used for recent infection
how do you diagnose H pylori and when should you not perform it?
do not perform within 4 weeks of antibacterial or 2 weeks of antisecretory drug
hyoscine butylbromide can be used to treat smooth muscle spasams by relaxing muscle and reducign gut motility, what’s the MHRA warning for hyoscine butylbromide injections?
risk of cardiac adverse effects - contraindicated in tachcardia, caution in cardiac disease
what condition is mebeverine and alverine contraindicated?
paralytic ileus
