Chronic bowel disorders Flashcards
Clostridium difficile infection
• This infection is caused by accumulation of Clostridium difficile in the colon and the production of toxin. It usually follows antibiotic therapy with Ampicillin, Amoxicillin, Co-Amoxiclav, Cephalosporins, Clindamycin and Quinolones.
Clostridium difficile infection - treatment
Metronidazole, Vancomycin and Fidaxomicin.
Coeliac disease
• This is an autoimmune condition associated with chronic inflammation of the small intestine. Gluten (dietary protein) present in wheat, barley and rye activates an abnormal immune response in the intestinal mucosa. This results in malabsorption of nutrients.
Coeliac disease non-drug treatment
strict, life-long gluten-free diet (gluten-free items available on prescription).
Coeliac disease drug treatment
increased risk of malabsorption of key-nutrients e.g. Calcium + Vitamin D… so risk of ….Osteoporosis must be monitored.
- ADVISE PATIENTS NOT TO SELF-MEDICATE WITH OTC VITAMINS OR MINERAL SUPPLEMENTS
Chronic IBD include & symptoms
Crohn’s disease (affecting any part of the G.I. tract) and Ulcerative colitis (limited to the colon).
- Symptoms: abdominal pain, diarrhoea, rectal bleeding, weight loss, fever (Crohn’s disease).
Crohn’s disease
Extraintestinal Manifestations:
Anaemia (Iron), Malnutrition (weight loss), Vit. B12 deficiency, Arthritis, Eye (episcleritis), Skin (erythema nodosum), Liver abnormalities, Secondary Osteoporosis (Assess risk)
Crohn’s disease non-drug treatment
Smoking cessation
Crohn’s disease drug treatment - Acute Disease (induce remission)
Acute Disease (induce remission)
• 1 inflammatory exacerbation in 12 months: Corticosteroid (Prednisolone, Methylprednisolone or IV HC)
o Alternate (distal ileal, ileocaecal, right-sided colonic disease): Budesonide or Aminosalicylates (not in severe presentation)
• Second Line (2+ inflammatory exacerbation in 12 months): Corticosteroid + Azathioprine / Mercaptopurine
o Alternate (CI / TPMT deficient): Corticosteroid + Methotrexate
o Alternate (severe & failed response to others): Monoclonal Antibodies e.g. adalimumab, infliximab, vedolizumab
Crohn’s disease drug treatment - Maintenance of Remission:
Maintenance of Remission: Azathioprine / Mercaptopurine (not corticosteroids due to side effects). Alternate (if already used in treatment): Methotrexate
Crohn’s disease drug treatment - Diarrhoea in Crohn’s Disease (patient without colitis):
Diarrhoea in Crohn’s Disease (patient without colitis): Loperamide or Codeine. Alternate: Colestyramine
Crohn’s disease drug treatment - Fistulating Crohn’s Disease
When disease involves ileocolonic area. Fistula form between intestine & other organs. Perianal fistulae most common in pt.s (drug treatment)
• Symptom Improvement: Metronidazole (for 1month/3 max) AND/OR Ciprofloxacin
• Inflammation Control: Azathioprine / Mercaptopurine
• Maintenance: Azathioprine / Mercaptopurine
• Alternate to Abx + immunosuppressant: Infliximab (only after abscess drainage, fistulotomy + seton ins)
Crohn’s disease treatment -
Non-perianal fistulating crohn’s disease:
Surgery
Ulcerative Colitis Commonly presents in
15-25 year olds
Ulcerative Colitis Different Types:
- Proctitis
- Proctosigmoiditis
- Left Sided Colitis
- Extensive Colitis
• Proctitis treatment
suppositories
-First line: Rectal Aminosalicylate (more effective)
Alternate: Rectal Corticosteroids / Oral Prednisolone
• Proctosigmoiditis treatment
foam prep
-First line: Rectal Aminosalicylate (more effective)
Alternate: Rectal Corticosteroids / Oral Prednisolone
• Left Sided Colitis treatment
enemas
- First line: High dose oral Aminosalicylate + Rectal Aminoslaicylate or Oral Beclometasone
Alternate: Oral Prednisolone
• Extensive Colitis treatment
oral
-First line: High dose oral Aminosalicylate + Rectal Aminoslaicylate or Oral Beclometasone
Alternate: Oral Prednisolone
UC Symptoms:
bloody diarrhoea, urgent need to defaecate & abdominal pain
UC complications
Increased risk of colon cancer, Secondary Osteoporosis, VTE, Toxic Megacolon (avoid Loperamide + Opioid)
Truelove and Witts’ Severity Index -
–> classifies severity; Mild, Moderate, Severe
Assess –> Bowel movements, HR, Erythrocyte sedimentation rate, presence of pyrexia, melaena, anaemia
Treatment:
Acute Mild-Moderate UC
- First Line: Oral/Rectal Aminosalicylate with or without Corticosteroid
- Second Line (if no improvement within 4 weeks of aminosalicylate treatment) Stop beclometasone + Add Oral Prednisolone / Budesonide
- Third Line (If no improvement in further 2-4 weeks): Add Tacrolimus
Treatment:
Severe UC
(Medical Emergency = Hosp Admission required)
• First Line: IV Corticosteroids
Alternate: IV Ciclosporin (or Infliximab) or Surgery
• Second Line (no improvement within 72 hours): IV Ciclosporin + IV Corticosteroids or Surgery
Alternate to Ciclosporin: Infliximab (also used in maintenance of remission)
UC diarrhoea
Loperamide or Codeine (Contra-indicated in acute UC risk of toxic megacolon) - should be prescribed by specialist
UC Maintenance of Remission mild/moderate/severe
- First Line: Rectal or Oral Aminosalicylate (route depends on area affected)
- Second Line (2+ inflammatory exacerbation within 12 months requiring corticosteroid treatment): Azathioprine or Mercaptopurine. Last Resort is Surgery
Aminosalicylate’s - staining
- Orange/yellow staining of body fluids e.g. urine.
* Refrain from wearing their contact lenses as they may get stained.
Aminosalicylate’s - Patients should be advised to report any
• unexplained bleeding, bruising, purpura, sore throat, fever or malaise during treatment which could indicate a blood disorder. Stop immediately
Aminosalicylates examples
Balsalazide (caution asthma), Mesalazine, Olsalazine
Aminosalicylates SE
GI, N&V, headache, salicylate hypersensitivity, rash, uriticaria, interstitial nephritis, skin reactions & Lupus erythematosus-like syndrome
Aminosalicylates monitor
Renal function – Before treatment, at 3 months + then annually
Mesalazine
- No oral preparation of Mesalazine is more effective than the other, however the delivery characteristics of oral mesalazine preparations may vary.
- If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report any changes in symptoms.
Sulfasalazine - staining
- May colour the urine (harmless), discontinue if haematological abnormalities occur
- Stain soft contact lenses
Sulfasalazine SE
- Dose related SE: headache, malaise, nausea, vomiting, dyspepsia = < dose
- Other SE: insomnia, stomatitis, taste disturbance, tinnitus, GI side effects (common >4g daily)
Sulfasalazine Monitor
FBC & LFTs initial and monthly in first 3 months and Renal function
Sulfasalazine pregnancy
Risk of neonatal haemolysis in Third Trimester —> Give folate
Sulfasalazine Blood disorders
• haematological abnormalizes occur usually in first 3-6 months of treamtnet – discontinue if these occur
Sulfasalazine cautioned in
asthma
Monoclonal antibodies (e.g. infliximab)
• Increased risk of infection Patients must be screened for TB before treatment. If latent TB is diagnosed, appropriate treatment must be initiated prior to starting treatment.
- If TB is diagnosed during treatment, discontinue until infection resolved.
A common adverse effect is a flu-like infusion reaction which can be prevented or lessened by pre-treatment of an antihistamine and paracetamol with or without a corticosteroid.
Blood disorders: report signs. Also increased risk of malignancy.
Avoid in Breast-feeding.
Monitor closely for infection before, during and after treatment: increased risk of opportunistic infections.
Irritable bowel syndrome (IBS)
IBS is a common, chronic, relapsing and often life-long condition, mainly affecting people aged between 20 and 30 years. It is more common in women.
IBS symptoms
Symptoms include abdominal pain or discomfort, disordered defecation (either diarrhoea, or constipation with straining, urgency and incomplete evacuation), passage of mucus and bloating.
Symptoms are usually relieved by DEFECATION.
IBS Lifestyle advice
- Patients should be encouraged to increase physical activity, eat regularly, without missing meals or leaving long gaps between meals.
- Limit Fresh fruit consumption to no more than 3 portions per day.
- If an increase in dietary fibre is required, soluble fibre e.g. Isphagula Husk or foods high in soluble fibre such as oats are recommended.
- Intake of insoluble fibre (e.g. bran) should be reduced/discouraged as they can exacerbate symptoms. Avoid sorbitol (artificial sweetener) in patients with diarrhoea
- Fluid intake (mostly water) should be increased to atleast 8 cups/day.
IBS Drug treatment – many available OTC
- Antispasmodic drugs (Alverine citrate, Mebeverine hydrochloride + Peppermint Oil) can be taken in addition to dietary and lifestyle changes Peppermint Oil in pregnancy.
- A Laxative (excluding Lactose which causes bloating) can be used to treat constipation.
- Loperamide is the 1st line choice anti-motility drug for diarrhoea.
- A low dose TCA such as Amitriptyline can be used for abdominal pain/discomfort as a 2nd line for patients who have not responded to antispasmodics, anti-motility drugs or laxatives.
• Diverticular disease is where
diverticula (sac- like protrusions of mucosa through the muscular colonic wall) cause intermittent lower abdominal pain in the ABSENCE of inflammation or infection. Occurrence of diverticula increases with age, majority of patients > 50 years.
• Diverticulitis occurs when
the diverticula become inflamed and infected, causing marked lower abdominal pain with fever and general malaise, and occasionally, large rectal bleeds. Complicated diverticulitis associated with an abscess, free perforation, fistula, obstruction, or stricture.
Diverticular disease Treatment:
A high-fibre diet is recommended for the treatment of symptomatic diverticular disease.
Bulk- forming drugs have also been used, but evidence of their effectiveness is lacking.
Treatment of uncomplicated diverticulitis includes
a low residue diet and bowel rest. Antibacterial only recommended when patient presents with signs of infection or is immunocompromised, as there is no evidence to support routine administration.
Patients with complicated diverticulitis or with severe presentation, require
hospital admission, treatment with IV antibacterials (covering Gram-negative organisms and anaerobes) + bowel rest.
- Elective surgery to provide symptomatic relief or prevent recurrence, should be considered for patients following recovery from an episode of complicated diverticulitis. This includes episodes associated with free perforation, abscess, fistula, obstruction, or stricture.
Urgent sigmoid colectomy is required for patients with diffuse peritonitis or for those in whom non-operative management of acute diverticulitis fails
