Chronic bowel disorders, constipation, and laxatives Flashcards
1
Q
What are the most common symptoms in bowel disorders? (ADRs)
A
A - Abdominal Pain
D - Diarrhoea
R - Rectal bleeding (not always)
2
Q
What substance causes coeliac disease?
A
Gluten
3
Q
In which foods is gluten commonly found?
A
Wheat, Barley and Rye
4
Q
What is coeliac disease?
A
Coeliac disease is an autoimmune condition triggered by the consumption of gluten, whereby the body releases antibodies upon ingestion of gluten (thinking its a foreign substance) causing the destruction of the small intestine
5
Q
Which organ is damaged in coeliac disease?
A
Small intestine
6
Q
Why do secondary diseases develop after coeliac disease?
A
Since the antibodies destroy the small intestine upon digestion of gluten, the small intestine is no longer able to absorb nutrients like calcium, vitamin D, folic acid and iron
7
Q
Name two conditions that occur as a result of coeliac disease.
A
- Anaemia - caused by malabsorption of folic acid and iron -> leading to folic acid deficiency anaemia and iron deficiency anaemia respectively
- Osteoporosis - caused by malabsorption of calcium and vitamin D
8
Q
Gave an overview of coeliac disease:
1. Trigger
2. Physiological response
3. Secondary disease
A
- Triggered by gluten contained in wheat, barley, and rye. E.g., pasta, cakes, cereals, and bread
- The body releases antibodies against gluten due to an autoimmune response leading to the destruction of the small intestine
- Causes malabsorption of important nutrients like iron, folic acid, vitamin D and calcium
9
Q
Describe Coeliac disease. FOUR facts
A
1) Autoimmune condition associated with chronic inflammation of small intestines
2) The immune response is triggered by dietary protein known as gluten present in [wheat, barley and rye]
3) Gluten activates an abnormal immune response in the intestines which can lead to malabsorption of nutrients [e.g., calcium, vitamin D, folic acid, iron]
4) Treatment is aimed at eliminating symptoms
10
Q
What are the symptoms of coeliac disease (CD)?
ABCD
A
A - Abdominal Pain
B - Bloating
C - Constipation
D - Diarrhoea
11
Q
What is the aim of the treatment for coeliac disease?
A
To reduce complications from nutrient malabsorption (e.g., calcium, vitamin D, folic acid, and iron), thus reducing the risk of OSTEOPOROSIS/BONE DISEASE/ANAEMIA
12
Q
What is the concern with young children having coeliac disease?
A
Due to the malnutrition and poor absorption of calcium/vitamin D/folic acid/iron it inhibits the growth of young children, thus children often present with defects in their growth
13
Q
What is the non-drug treatment of coeliac disease? (avoid what is causing it!)
A
A STRICT, lifelong, gluten free diet is the ONLY effective treatment of coeliac disease
14
Q
What is the drug treatment of coeliac disease?
A
1) Supplementation with calcium, vitamin D, and folic acid
2) Advice patients not to self medicate with OTC vitamins or minerals, should be discussed with a healthcare professional
3) Osteoporosis and bone disease treatment
4) Confirmed cases of refractory coeliac disease (poses the patient at risk of cancer) should be referred to a specialist centre
5) Prednisolone (initial management, while awaiting specialist advice) - short time to help to reduce the inflammation
15
Q
What is the cause of diverticulosis, diverticular disease, and diverticulitis?
A
Lack of fibre
Age (increased risk @ >40 years)
Genetics
16
Q
What happens if you lack enough fibre in your diet?
A
A lack of fibre in the diet will reduce the peristaltic movement of the stool through the LARGE intestine (/colon), thus the faeces will scrape through the walls of the large intestine causing irritation of the colon and leading to diverticula (small bulges on the colon).
17
Q
What is diverticula?
A
They are small bulges on the walls of the colon (large intestine) caused by pressure of the stool due to reduced peristaltic movement
18
Q
What is diverticulosis?
A
Patient has diverticula with no symptoms (diverticulNOOOOOsis)
19
Q
What is diverticular disease?
A
Patient has diverticula with symptoms (e.g., ADRs)
20
Q
What is Diverticulitis?
A
Patient has diverticular with SEVERE symptoms including SEVERE abdominal pain and SEVERE rectal bleeding, leading to inflammation and infection (look for vital signs e.g., high temperature).
(Diverticul’ITIS’)
21
Q
What are the treatment for diverticulosis/diverticular disease/diverticulitis?
(Think BPSA)
A
B - Bulk forming laxatives (contains FIBRE)
P - Paracetamol
S - Surgery (usually for diverticulitis)
A - Antispasmodics (for diverticular disease)
22
Q
Explain diverticulOsis.
1. What are the symptoms?
2. What is the pathophysiology?
3. What age does it present at?
A
- Asymptomatic condition
- Presence of diverticula [small pouches protruding from the walls of the large intestine]
- Age dependent usually 40+
23
Q
What is the difference between diverticular disease and diverticulitis?
A
They are both caused by the presence of diverticula but differ in severity.
Diverticulitis is MORE severe than diverticular disease, whereby diverticulitis has INFLAMMATION and INFECTION. Although, not advised antibiotics are sometimes given in diverticulitis
24
Q
Explain diverticular disease
A
Diverticular disease is a condition where diverticula are present and cause symptoms such as abdominal tenderness, constipation, diarrhoea, rectal bleeds, intermittent lower abdominal pains WITHOUT inflammation or infection.
Symptoms may overlap with other conditions e.g., [IBS, colitis - inflammation of the colon]
Prevalence: increases with age, mainly patient over 40
25
What is acute diverticulitis?
Diverticula suddenly become inflamed and infected
26
What are the signs and symptoms of acute diverticulitis?
Name SIX
1. Constant lower abdominal pain
2. Fever
3. Significant rectal bleeding
4. Sudden changes in bowel habits
5. Abdominal tenderness
6. Abdominal mass
27
What is complicated acute diverticulitis?
Diverticulitis associated with complications
28
What are the complications present in complicated acute diverticulitis?
Abscess
Bowel perforation (holes in the colon, causing leaks in the system)
Intestinal obstruction
Sepsis
29
What is a treatment of complicated acute diverticulitis?
Emergency or elective surgery (e.g., colonoscopy)
30
What is the non-drug treatment of diverticular disease and diverticulosis?
Think of FIVE
1) Diet and lifestyle changes
2) Eat healthy, balanced diet, increase fibre
3) Weight loss
4) Smoking cessation
5) Exercise
31
What is the drug treatment of diverticulosis?
No symptoms = no treatment (diagnosis from endoscopy)
Bulk forming laxatives for patients with constipation
32
What is the drug treatment of diverticular disease?
Antibacterial agents are NOT recommended (no inflammation and no infection)
Bulk forming laxatives when a high fibre diet is unsuitable or patients with persistent constipation
Simple analgesics (e.g., paracetamol for abdominal pain)
Antispasmodics (for abdominal cramps) - e.g., buscopan
33
What analgesia is not recommended in diverticular disease/diverticulitis? Why?
NSAIDs and opioids
They can cause diverticular proliferation
34
What is the drug treatment of acute diverticulitis?
Simple analgesia [e.g., paracetamol]
Refer patients with complicated acute diverticulitis
Consider a watchful waiting and a no antibacterial prescribing strategy
Treatment with aminosalicylates or prophylactic antibacterials are not recommended
Recommend urgently to hospital if there is any significant rectal bleeding
35
What causes inflammatory bowel disease?
IBD is an autoimmune condition triggered by many environmental factors such as smoking, infection, anxiety, and stress causing an inflammatory response. IBD can also have an underlining genetic cause.
36
What are the environmental triggers for IBD?
Smoking
Stress
Infection
Air pollution
Drugs
Diet
37
Explain the pathophysiology of IBD
The body releases antibodies to respond to environmental triggers or an underlining genetic condition leading to the inflammation of the GI tract (Crohn's disease) or the colon (ulcerative colitis)
38
Where does inflammation occur in Crohn's disease?
GI tract
39
Where does inflammation occur in ulcerative colitis?
Large intestine/colon
40
What is the difference between Crohn's disease and ulcerative colitis?
Both are long term conditions which involve inflammation of the gut
Crohn's disease affects the whole GI tract, whilst ulcerative colitis only impacts the large intestine/colon
Mnemonic:
Crohn's ~ chronological order: from top to bottom (throughout the GI tract)
Ulcerative COLitis ~ ulcers in the colon (only in the colon)
41
What is inflammatory bowel disease?
Inflammatory bowel disease is a term used to define 2 conditions: Crohn's disease and ulcerative colitis
IBD is caused by genetics, external triggers, and problems with the immune system
42
What are the symptoms of Crohn's disease?
The symptoms depend on the site of the disease, but they may include:
1. A - Abdominal pain
2. D - Diarrhoea
3. R- Rectal bleeding
4. Fever
5. Weight loss
6. Anal fissure
43
What are the complications of Crohn's disease?
Name 10.
1. Stricture (narrowing of the GI tract) - leads to difficulty in passing food leading to vomiting and sickness
2. Perforation (holes in the GI tract: oesophagus, small intestines, bowels). Contents of GI tract leak out and cause infection or abscess in abdomen (can be serious and life threatening)
3. Fistula: abnormal connection between two body parts e.g., intestines and perianal skin, bladder, and vagina
4. Cancer (higher risk of developing colon cancer than general population) - colorectal and bowel cancer
5. Malnutrition (think Coeliac disease - difficulties in absorption of nutrients)
6. Anaemia (low absorption of iron and folic acid)
7. Growth failure and delayed puberty in children (malabsorption of calcium and vitamin D)
8. Osteoporosis (low vitamin D and calcium)
9. Arthritis
10. Abnormalities of joints, eyes, liver, and skin
44
What is the non-drug treatment of inflammatory bowel disease?
1. Diet change
2. Stop smoking
3. Stress Management
45
What drugs are used to treat in IBD?
[IBD ACT BAD]
1. Amino salicylates: e.g., mesalazine, balsalazide, olsalazine and sulphasalazine (sulphasalazine may stain some soft contact lenses) - reduce inflammation in the gut
2. Medicines affecting the immune response [immunosuppressants]: methotrexate, azathioprine, mercaptopurine [reduce activity of the immune system]
3. Biologic therapy (monoclonal antibodies): infliximab, adalimumab, golimumab. Require specialist supervision
4. Corticosteroids: used when symptoms are severe but not for maintenance (oral prednisolone, methylprednisolone, budesonide, hydrocortisone)
5. Antibiotics
6. Other medications - these include medications to treat diarrhoea and constipation.
46
IBD ACT BAD
A - Amino salicylates
C - Corticosteroids
T - Thiopurine
B - Biologics
A - Antibiotics
D - Diarrhoea (& constipation anti drugs (antidiarrheal drugs C/I in acute UC))
47
What medication are C/I in acute UC?
Antidiarrheal drugs
48
Name a S/E of sulphasalazine
Sulphasalazine is one of the older amino salicylates, hence has more S/Ef. It can stain some soft contact lenses (orange/red/yellow colour) and bodily fluids.
[GPHC EXAM QUEST]
49
How do amino salicylates work?
They reduce inflammation in the gut
50
How do immunosuppressants work?
They reduce the activity of the immune system
51
When are corticosteroids used in IBD?
They are used when symptoms are severe but not for maintenance
52
Is the treatment for UC and Crohn's the same?
No - they use the same drugs but have differing guidelines
53
What is ulcerative colitis?
Ulcerative colitis is a chronic inflammatory condition.
It is associated with significant morbidity and it is a life-long disease
Commonly presented between the ages of 15 and 25.
54
What is the treatment of acute mild to moderate ulcerative colitis?
(Proctitis/Proctosigmoiditis and left sided ulcerative colitis/Extensive ulcerative colitis)
1) Proctitis - 1st line [topical amino salicylates] - if no improvement within 4 weeks add [oral amino salicylates], if no improvement add oral or topical corticosteroids for 4-8 weeks
2) Proctosigmoiditis and left sided ulcerative colitis: 1st line topical amino salicylates
3) Extensive ulcerative colitis: 1st line [topical amino salicylates and high dose oral amino salicylates]
55
What is proctitis?
Inflammation of the lining of the rectum
56
What is proctosigmoiditis/ left sided ulcerative colitis?
Inflammation of the rectum and the lower segment of colon located right above the rectum known as the sigmoid colon.
57
Are amino salicylates used more commonly in UC or Crohn's?
Ulcerative colitis
58
What is the treatment of acute severe ulcerative colitis?
This is a life-threatening condition and it is treated by IV corticosteroids and infliximab.
59
What drug therapy is used for remission in mild, moderate, or severe ulcerative colitis?
1. Use amino salicylates
2. Avoid corticosteroids due to s/e
3. Oral azathioprine or mercaptopurine are used when there are two or more inflammatory exacerbations in a 12 month period that required a systemic corticosteroids
60
What is the treatment of proctitis?
(simplified version)
1. Topical amino salicylates
2. Oral amino salicylates
3. Topical corticosteroids for 4 -8 weeks
61
What are the complications of ulcerative colitis?
1. Colon cancer
2. Secondary osteoporosis
3. Venous thromboembolism
4. Toxic megacolon
62
What is toxic megacolon?
Widening of colon (rare but life-threatening)
63
What is the drug treatment for IBD?
High fibre or low residue diets should be used
Anti-mobility drugs (codeine/loperamide)
Cholestyramine: can improve diarrhoea
64
What is the drug treatment for ulcerative colitis?
1) Amino salicylates
2) Corticosteroids (duration 4-8 weeks)
3) Enemas, rectal foams, and suppositories
4) Anti-diarrhoeal drugs (loperamide or codeine phosphate): use C/I in acute ulcerative colitis [can increase the risk of toxic megacolon]
5) Macrogol laxative - e.g.,
65
What are anti-diarrhoeal drug?
Loperamide and codeine phosphate
66
Why are anti-diarrhoeal drugs C/I in acute UC?
Increased risk of toxic megacolon
67
Give examples of the newer amino salicylates.
Mesalazine, Balsalazide, and olsalazine
They have less S/E
68
What is an important S/E of amino salicylates?
Bone marrow suppression: report any unexplained bleeding, bruising, purpura, sore throat, fever, or malaise
[GPHC EXAM QUEST]
69
What are the signs and symptoms of bone marrow suppression?
Unexplained bleeding, bruising, purpura, sore throat, fever, or malaise
70
What monitoring is required with aminosalycilates and why?
Due to the risk of bone marrow suppression, a full blood count is required and the drug should be stopped immediately is suspicion of blood dyscracia (blood disorders).
Monitor renal function (nephrotoxicity) before starting, at 3 months of treatment, and then annually during treatment
71
What is the other important S/E of amino salicylates after bone marrow suppression with sulfasalazine?
Orange/yellow stain of bodily fluids (vomiting, urine. sweat)
[GPHC EXAM QUEST]
72
Name THREE S/E of amino salicylates.
1. Nephrotoxicity
2. Salicylate hypersensitivity
3. yellow/orange bodily fluids with sulfasalazine [soft lenses may be stained]
73
What triggers/causes Irritable Bowel Syndrome (IBS)?
The factors that trigger IBS include: stress, anxiety, alcohol, spicy/fatty food, caffeine
IBS is caused by mainly lifestyle triggers.
74
What are the symptoms of IBS?
[ABCD]
A- Abdo pain/cramps
B- Bloating
C- Constipation
D - Diarrhoea
Bowel incontinence
Flatulence
Passing mucus
Lethargy
75
What is IBS?
Irritable bowel syndrome is a long term chronic condition of the bowel. It mainly impacts people aged between 20-30 years. It is more common in women.
76
In what population is IBS more prevalent in?
Female, aged between 20-30 years.
77
How are the symptoms of IBS relieved and triggered?
Symptoms worsen by eating triggering foods and relieve by defaecation.
78
What is the non-drug treatment of IBS?
Think FIVE
1. Diet and lifestyle changes
2. Increase physical activity, eat regularly without missing meals
3. Limit fresh fruit consumption
4. If increase in fibre required, then use soluble fibre (e.g., oats, sterculia, and ispaghula husk). Avoid insoluble fibre (e.g., bran) and resistant starch because they exacerbate the symptoms
5. Increase water intake (at least 8 cups daily). Reduce caffeine, alcohol, and fizzy drinks.
79
What is the difference between soluble and insoluble fibre?
Soluble fibre is easier to digest
80
What drugs are used to treat IBS?
The drug treatment depends on the severity, but many can be bought OTC.
1. Antispasmodics and antimuscarinics
2. Treatment of constipation
3. Linaclotide
4. Treating diarrhoea
5. Treating bloating
6. Antidepressants
7. Cognitive behavioural therapy (CBT)
81
When are antispasmodics and antimuscarinics used in IBS? How do they work? Give examples.
They are used for abdominal pain and GI spasms.
They work by relaxing the muscle in the gut.
Examples include: mebeverine, hyoscine, and peppermint oil.
82
How is constipation treated in IBS?
Increase the fibre
Use laxatives
Avoid lactulose (can cause bloating and cause obstruction)
83
What are the benefits of using linaclotide in IBS?
Linaclotide is shown to reduce pain, bloating, and constipation for moderate to severe IBS associated with constipation.
84
How is diarrhoea treated in IBS?
Loperamide
85
How is bloating treated in IBS?
Peppermint oil
86
When do antidepressants come into use in IBS?
They are usually last line. They are used unlicensed and they counter some of the anti-muscarinic side effects. Examples include TCAs (amitriptyline) and SSRIs (fluoxetine)
87
How does CBT help in IBS?
CBT helps to relax and alleviate stress and anxiety.
88
What causes constipation?
Inadequate fibre
Inadequate fluid intake
Medications
Medical conditions
Pregnancy
89
How does inadequate fibre cause constipation? Give examples
Fibre adds bulk to stools and improves bowel function E.g., fruit, vegetables, cereals, and whole bread
90
What medications cause constipation?
Painkillers e.g., codeine and morphine
Some antacids [contains aluminium]
Some antidepressants
Iron tablets
91
What medical conditions can cause constipation?
Underactive thyroid
IBS
Some bowel disorders
92
How does pregnancy cause consitpation?
Pregnancy leads to hormonal changes and slow down bowel movement
Growth of the foetus
93
What are the RED FLAGS for constipation?
1. New onset of constipation (50+ years)
2. Anaemia
3. Abdominal pain
4. Unexplained weight loss
5. Blood in the stool [black and/or mixed in the stool] - this can be sign of a serious GI bleed or cancer
94
Why is blood in the stool worrying?
Possibility of cancer or serious GI bleed
95
What are the different types of laxatives?
[BOSS][GPHC EXAM QUESTION]
B- Bulk
O - Osmotic
S- Stimulant
S - Softeners
Other laxatives include: linaclotide, prucalopride
96
Give examples of bulk forming laxatives?
Bran, ispaghula husk, sterculia, methyl cellulose (also acts as faecal softener)
97
How does methylcellulose work for constipation?
Bulk forming laxative and faecal softener
98
Give examples of osmotic laxatives?
[L's are lOSt]
Macrogols (Laxido), lactulose
99
Give examples of stimulant laxatives?
Bisacodyl
Sodium Pico sulphate
Glycerol
Senna
Co-danthramer
Docusate sodium (acts as a stimulant and stool softener)
100
How does docusate sodium work for constipation?
Stimulant Laxative
Faecal softener
101
Give examples of stool softeners
Liquid paraffin [GPHC exam quest]
Docusate sodium
Peanut (arachis) enemas
102
Which laxative influences electrolytes?
Stimulant
Osmotic
103
How do bulk forming laxatives work?
Increase bulk in the stool like fibre
The stool volume is larger and thicker inducing peristaltic movement more easily.
104
How long do bulk forming laxatives take to work?
Onset of action up to 72 hours
105
What are the side effects of bulk forming laxatives?
Intestinal Obstruction
Bloating
Cramping
Flatulence
106
How to avoid instestinal obstruction with bulk forming laxatives
Maintain adequate fluid intake
107
When are bulk forming laxatives used?
[Think 7]
1. Colostomy
2. Ileostomy
3. haemorrhoids
4. Anal fissures
5. IBS
6. Diverticular disease
7. Ulcerative colitis
108
What laxatives have multiple modes of action for tackling constipation?
Docusate sodium (acts as a stimulant and stool softener)
methyl cellulose (acts as a bulk forming laxative and faecal softener)
109
What stimulant laxatives are reserved for terminally ill patients? Why?
Co-danthramer and co-danthrusate is only reserved for temrinally ill patients to treat constipation due to its carcinogenicity and it colours the urine red.
110
How do stimulant laxatives work?
Stimulant laxatives increase stimulant motility, therefore they can cause abdominal cramps as a S/E
111
What are the S/E of stimulant laxatives?
Abdominal cramp
112
When should stimulant laxatives be avoided?
Intestinal obstruction
Abuse risk which can cause hypokalaemia
113
When is the onset of action of stimulant laxatives?
Onset 8-12 hours (bedtime dose recommended)
(Bisacodyl - 6 hours)
Stimulant laxative suppositories act quicker 20-60 minutes
114
How long do stimulant laxative suppositories take to work?
20 - 60 minutes
115
What is the risk of abusing stimulant laxatives?
Hypokalaemia
116
How do faecal softeners work?
They decrease the surface tension and increase penetration of liquid into faecal mass. They soften and wet faeces
117
Why are faecal softeners not used as often?
They can cause anal seepage
118
What is a side effect of liquid paraffin?
Can cause malabsorption of fat soluble vitamins [ADEK] + cause anal seepage
119
What is the most commonly used stool softener and why?
Docusate sodium [stool softener and stimulant]
It also has weak stimulant activity
120
What type of laxatives are peanut (arachis) enemas? How do they work?
Faecal softener
Soften and lubricate faeces
121
What are the two types of osmotic laxatives?
Lactulose and Macrogol 3350
122
How do osmotic laxatives work?
Osmotic laxatives work by increasing the amount of water in the large bowel either by drawing fluid from body into the bowel or maintaining fluid in the bowel
123
How long do osmotic laxatives take to work?
Lactulose can take up to 2 days for maximal effect, they are not suitable for immediate relief (use a suppository instead)
124
What are the side effects of lactulose?
Abdominal pain
Bloating
Electrolyte imbalance
125
Does macrogol or lactulose act facter?
Macrogol
126
What are the stronger osmotic laxatives? When are they used?
Phosphate enemas & Magnesium Salts
They are used to clear the bowel more quickly e.g., during irrigation
127
What laxative is used to treat hepatic encephalopathy?
Lactulose - osmotic laxative
128
What is the lactulose used for? Give TWO indications
Constipation
Hepatic encephalopathy
129
What does of lactulose is used for constipation in a person aged 1-11 months?
2.5 mL BD
Adjusted according to response
130
What does of lactulose is used for constipation in a person aged 1-4 years?
2.5 - 10 mL BD
Adjusted according to response
131
What does of lactulose is used for constipation in a person aged 5-17 years?
5 - 20 mL BD
Adjusted according to response
132
What does of lactulose is used for constipation an adul?
15mL BD
Adjusted according to response
133
What does of lactulose is used for hepatic encephalopathy in an adult?
30 - 50 mL TDS
Adjusted to produce 2-3 soft stools per day
134
What can laxative abuse cause?
Hypokalaemia
135
What is the first line treatment for constipation?
Dietary and lifestyle advice
136
What are the MHRA updates for 2020 stimulant laxatives?
1. Advice on new pack size restriction (up to 20 standard strength tabs, 10 maximum-strength tabs, 100mL syrups)
2. Revised recommended ages for use
3. Safety warnings for OTC stimulant laxatives [bisacodyl, senna, sodium pico sulphate]- orally and rectally administered
4. The first line treatment is dietary advice
5. Stimulants laxatives are only to be used if other laxatives (bulk and osmotic) and ineffective
6. Children < 12 should not use stimulant laxatives without advise from prescriber [NOT OTC]
7. Large pack of stimulant laxatives will no longer be available from the general sale outlets (e.g., newsagents and supermarkets)
137
Which drugs cause constipation?
Very Old AUNTIes get constipation
V- verapamil
O - opiates
A - Antimuscarinics
A - Antihistamines
A - Anti-epileptics
A - Antispasmodics
A - Antipsychotics
A - Antidepressants
A - Antacids [aluminium]
138
What element causes diarrhoea?
Magnesium
139
What element causes constipation?
Aluminium
140
What is the management of constipation?
SPC is BOS
S - Short duration of constipation
P - Pregnancy/breastfeeding
C - Chronic constipation
SPC is BOS
B - Bulk forming laxatives - 1st line
O - Osmotic - 2nd line
S - Stimulant - 3rd line
141
In which situations do you avoid bulk forming laxatives?
Faecal impaction (OS)
Opioid induced constipation (OS/Naloxegol/Methylnatrexone)
Children (OS) O = Macrogol 3350
Mnemonic: Children don't FOChOS
142
What patient and carer advice would you give for a bulk forming laxative?
Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed. The full effect may take a few days to develop.
[The laxative will absorb water in the stomach - not ideal for this to happen while laying down]
143
What is diarrhoea?
Abnormal passing of loose or liquid stools with increased frequency, increased volume or both.
144
What are the two types of dirrhoea?
Acute diarrhoea last < 14 days (but symptoms usually improve in 2 - 4 days)
Chronic diarrhoea > 14 days
145
What are the causes of diarrhoea?
Infection (salmonella, norovirus, C. difficile, E. coli)
Gastroenteritis
S/E of drug
Symptoms of GI disorder
146
What drugs cause diarrhoea?
C - Colchicine
A - Antibiotics
L - Laxatives
M - Magnesium [antacids]
D - Digoxin
Mnemonic: CALM Diarrhoea
147
What is the aim of treatment for diarrhoea?
To prevent dehydration and fluid/electrolyte depletion (esp. in infants/frail/elderly)
148
What are the signs of dehydration?
Tiredness
Headaches
Light headedness
Muscular cramps
Sunken eyes
Dry mouth and tongue
Weakness
Confusion
Reduced urine output
149
When do you refer patients with diarrhoea? What are the red flags?
[GPHC exam quest]
Unexplained weight loss
Rectal bleeding
Persistent diarrhoea
Systemic illness
Has received recent hospital or antibiotics treatment
Recent foreign travel [other than Western Europe, North America, Australia and New Zealand]
150
When do you stop clindamycin if the patient is experiencing diarrhoea?
If there are signs of colitis
151
How do you treat diarrhoea?
Drink lots of water to prevent dehydration and eat as normal as possible
Most bouts settle on their own within a few days without the need for medication
Oral Rehydration Salts (ORS) is the main stay of treatment for acute diarrhoea, IV is recommended for more severe cases of diarrhoea and dehydration
Loperamide is the standard treatment for rapid control (also used for mild-moderate traveller's diarrhoea) - Learn doses (OTC)
Kaolin with morphine may also be used (abuse risk)
Ciprofloxacin is used occasionally for the prophylaxis of traveller's diarrhoea, but the routine use is not recommended
152
What is the primary aim for diarrhoea treatment?
Prevention of dehydration
153
What drug treatments are used for diarrhoea?
Loperamide is the standard treatment for rapid control (also used for mild-moderate traveller's diarrhoea) - Learn doses (OTC)
Kaolin with morphine may also be used (abuse risk)
Ciprofloxacin (quinolone) is used occasionally for the prophylaxis of traveller's diarrhoea, but the routine use is not recommended - 'just in case medication'
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What is dyspepsia?
Dyspepsia is an umbrella term for:
Upper GI symptoms which typically present for 4 or more weeks
Upper abdominal pain or discomfort
Heartburn
Acid reflux
Nausea and vomiting
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What causes dyspepsia?
Excessive acid [GORD, peptic ulcer disease, gastro-oesophageal malignancy, side effects from drugs, lifestyle]
156
What are the symptoms of dyspepsia?
Upper abdominal pain
Heartburn
Gastric reflux
Early satiety
Bloating
Nausea/vomiting
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How long do the symptoms last for dyspepsia?
4 or more weeks
158
What are the red flags for dyspepsia?
Bleeding
Dysphagia
Recurrent vomiting
Weight loss
55 + (unexplained recent onset not responding to treatment)
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What age is a red flag for dyspepsia?
55 years +
160
What is the lifestyle advice for dyspepsia?
Healthy eating
Weight loss (if obese)
Avoiding trigger foods
Eating the evening meal 3-4 hours before going to bed
Raising the head of the bed
Smoking cessation
Reducing alcohol intake
Reduce stress/anxiety/depression
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What exacerbates dyspepsia?
Stress
Anxiety
Depression
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What is required for diagnosing patients presenting with red flag symptoms?
Urgent endoscopic investigation
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What are the two types of dyspepsia?
Mnemonic: FUN
F - Functional dyspepsia [no ulcer]. Dyspepsia symptoms but no underlining cause. Normal endoscopic findings [majority of the patients]
UN - Un-Investigated dyspepsia. Symptoms in patients who have not had an endoscopy
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What drugs cause dyspepsia?
Alpha blockers
Aspirin
Benzodiazepines
Beta blockers
Bi-phosphonates
calcium-channel blockers
corticosteroids
nitrates
NSAIDs
Theophylline
TCAs
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What would you do if a drug is causing dyspepsia?
The lowest effective dose should be given and if possible stopped
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What can you use for short-term treatment of dyspepsia?
Antacids and/or alginates may be used for short-term symptom control, but long-term, continuous use is not recommended.
Antacids and/or alginates are nor very strong, therefore PPIs or H2 antagonists may be used instead.
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What is the initial management for un-investigated dyspepsia?
Offer PPI for 4 WEEKS
Test for H. Pylori and treat if present
Offer H2 antagonists if inadequate response to PPI
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What is the initial management for functional dyspepsia?
Lifestyle advice
Test for H. Pylori and treat if present
Leave a two week washout after a PPI use before testing for H. Pylori
If no H. Pylori, treat with PPI or histamine receptor antagonist for 4 weeks.
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What should the follow up treatment be for dyspepsia (functional and un-investigated) ?
If symptoms persist following initial management continue with PPI or H2 antagonists [use the lowest dose and can use when required]
170
What do you do with a patient with un-investigated dyspepsia who is unable to stop NSAIDs?
Reduce the NSAID dose and use long-term protection with acid suppression therapy or
Switch to an alternative to the NSAID e.g., paracetamol or a selective cyclo-oxygenase (COX-2) inhibitor e.g., celecoxib [consider risk of CV events]
In patients with un-investigated dyspepsia taking aspirin and unable to stop drug consider switching from aspirin to an alternative antiplatelet therapy.
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What do you in a patient with un-investigated dyspepsia taking aspiring and unable to stop?
Consider switching from aspirin to an alternative antiplatelet therapy. E.g., clopidogrel, aspirin, dipyridamole
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What are the symptoms of GORD?
Heartburn
Acid regurgitation
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What is the difference between GORD and dyspepsia?
GORD includes symptoms of acid regurgitation
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What are the less common symptoms of GORD? And when do they happen?
They happen if acid reaches the respiratory tract [These are more serious]. Symptoms include:
Chest pain
Hoarseness
Cough
Wheezing
asthma
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What are the causes of GORD?
Fatty foods
Pregnancy
Hiatus Hernia
Family history of GORD
Increased intra-gastric pressure from straining and coughing
Stress
Anxiety
Obesity
Drug S/e
Smoking
Alcohol consumption
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What are the complications of GORD?
Oesophageal inflammation (oesophagitis)
Ulceration
Haemorrhage and stricture formation
Anaemia due to chronic blood loss
Aspiration pneumonia [food into the lungs]
Barrett's oesophagus [oesophagus damaged by acid reflux]
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What drugs are used to treat GORD?
Antacids
Alginates
H2 receptor antagonists
PPI
NB: Initial drug treatment and follow up similar to dyspepsia
178
How do alginates work for GORD?
They form a raft and stop regurgitation
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Give an example of an alginate
Gaviscon
180
What drugs are used to treat GORD in pregnancy?
1] Diet and lifestyle [first line management]
2] Antacids or alginates
3] Omeprazole [for severe symptoms] or Ranitidine [unlicensed]
181
Why is ranitidine discontinued?
Contained impurity linked to cancer
182
What is the only PPI safe in pregnancy?
Omeprazole
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When is omeprazole used in pregnancy in GORD?
If the patient experiences severe symptoms
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What is the issue with using antacids in pregnancy for GORD?
Antacids with a high sodium content can cause pre-eclampsia
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How is GORD managed in children?
Infants: change of frequency and volume of of feed. Use a feed thickener (prevents reflux). Can also consider gaviscon infant sachets
Older children (> 12 years): treat like adults - give gaviscon sachets
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What counselling and patient advice would you give for a patient with GORD?
Avoid precipitating factors (e.g., spicy foods, coffee, alcohol, smoke)
Eat small meals, slowly and avoid eating at bedtime. Reduce spicy and fatty foods.
Sleep with head raised, lose weight (if obese)
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What are the key points for antacids?
[GPHC QUEST]
Ingredient and sodium content vary (very important). Avoid high sodium antacids in hypertension, sodium restricted diet and liver or kidney failure.
Aluminium (constipating) and magnesium (laxative)
Liquids more effective than tabs - the liquid form is absorbed quicker
Give when symptoms occur or are expected to occur [between meals and at bedtime] - additional doses may be given
Can damage enteric coating on some MR tabs
Sodium bicarbonate not suitable for patients with high BP/salt restriction diets/fluid retention patients and patients on LITHIUM (decreases lithium concentration)
Affect absorption of certain drugs e.g., tetracyclines [take after 2 hours]
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Why is sodium bicarbonate not suitable for patients on lithium?
Decreases lithium concentration and lithium has a narrow therapeutic range.
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What is the onset for antacids?
They provide quick symptom relief in 15-30 minutes and effects don't last long
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What are the ingredients for antacids? [SCAM - you have been scammed for short effects]
S - Sodium bicarbonate
C - Calcium carbonate
A - Aluminium hydroxide
M - Magnesium hydroxide
Main ingredients: sodium, calcium, aluminium, magnesium
191
Can you use antacids with other medicines simultaneously?
[ANTI]
ANTI = ANTI mixing with other meds (affect absorption of certain drugs e.g., tetracyclines take 1-2 hours before or after)
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What is the definition of low sodium content?
Low sodium is defined as < 1 mmol/tablet or 10mL dose
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Which antacids have a low sodium content?
Co-magaldrox - alu + mag (e.g., MAALOX & MUCOGEL)
Co-Simalcite [e.g., Altacite plus - simeticone + hydrotalcite]
Mnemonic: MAM [Mucogel. Altacite +. Maalox] - the Co are low in sodium
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What antacids have a high sodium content?
Magnesium carbonate
Magnesium trisilicate
Sodium alginate with potassium carbonate e.g., gaviscon advance [contains potassium and double sodium compared to gaviscon original]
195
When are high sodium content antacids avoided?
HTN
Sodium restricted diet
Liver or kidney failure
CVD
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Give examples of PPIs (Proton Pump Inhibitors)
Omeprazole
Pantoprazole
Esomeprazole
Lansoprazole
Rabeprazole
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What are the indications for PPIs?
Gastric ulcers
Duodenal ulcers
H. Pylori
Dyspepsia
GORD
NSAID associated ulcers
Zollinger-Ellison Syndrome
198
What monitoring is required for PPIs?
Measure serum magnesium concentrations especially when used with other drugs that can cause hypomagnesaemia or digoxin
199
What MHRA warning do PPIs have?
Lupus
200
When are the cautions with PPI use?
Risk of fractures
Risk of GI infections (C. diff)
Mask symptoms of gastric cancer
Risk of osteoporosis
201
Why are magnesium levels measured in someone taking a PPI?
Can cause digoxin toxicity (like hypokalaemia)
202
Mnemonic for PPI cautions
[MC GOLF]
Magnesium
Cancer [mask symptoms]
GI infections
Osteoporosis [take ca2 and vitamin d)
Lupus [low risk] - sensitivity to skin (specially from sunlight)
Fractures
203
What are the cautions caused with the use of proton pump inhibitors?
Increase fractures [especially high doses over 1 year in elderly]
Increase risk of GI infections [e.g., C diff, N&V, etc]
Mask symptoms of gastric cancer [in adults]
Causes hypomagnesaemia [learn symptoms of hypomagnesaemia e.g., convulsions, muscle pain/weakness]
204
What is the MHRA advice with PPIs?
Low risk of subacute cutaneous lupus erythematous (SCLE)
Lesions appear on skin when exposed to the sun, advice patients to avoid exposing the skin to the sun
Consider discontinuing medications if possible
Most cases resolve once PPI is stopped
205
Which PPI is safe in pregnancy?
Omeprazole
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What are the important interactions for omeprazole use?
Clopidogrel - omeprazole and esomeprazole decrease efficacy of clopidogrel - avoid
Mnemonic: Avoid CLOE
Methotrexate - omeprazole decreases the clearance of methotrexate [high dose] - use with caution or avoid
Monitor magnesium with digoxin
207
What is the updated breastfeeding statement with PPIs?
Previously was avoid
Current: specialist sources indicate use with caution. Likely to be present in breastmilk, but the amount is too small to be harmful
208
What is the H. Pylori overview test and treat strategy?
Symptoms: Burning pain in tummy
Test: Urea 13C (commonly used), SAT (Stool Antigen Test) - common, or blood test
To perform the test the patient should not have used a PPI in the past two weeks and abx in the past four weeks (risk of false positives)
Treat: Triple therapy for 7 days
1st line: PPI + 2 Abx
2nd line: PPI + 2 Abx
3rd line: specialist referral
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What are the requirements for testing a patient with H Pylori? Why? Which tests?
No PPI in the past two weeks
No Abx in the past four weeks
Due to risk of false positives
Urea 13C and SAT
210
Which tests for H. Pylori require a washout period?
Urea 13C and SAT
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