Clinical Flashcards
1
Q
Common conditions affecting GIT?
A
Oral cavity conditions
Dyspepsia
Gastritis
Malabsorption
Pancreatitis
Hepatitis
Biliary colic
IBD
IBS
Diverticulitis
Appendicitis
2
Q
Common symptoms of GI conditions?
A
Abdominal pain and discomfort
Nausea
Vomiting
Diarrhoea
Constipation
3
Q
Questions to ask for abdominal pain?
A
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating factors/ Relieving factors
Severity
SOCRATES
4
Q
What could sudden onset abdominal pain suggest?
A
Peritonitis
Appendicitis
Ectopic pregnancy
Renal or biliary colic
5
Q
What could cramp-like abdominal pain suggest?
A
Diverticulitis
IBS
Gastroenteritis
6
Q
What could colic-like abdominal pain suggest?
A
Appendicitis
Biliary or renal colic
Intestinal obstruction
7
Q
What could gnawing abdominal pain suggest?
A
Pancreatitis
Pancreatic cancer
8
Q
What could abdominal pain that radiates to the jaw, face or arm suggest?
A
Cardiovascular in origin
9
Q
What could abdominal pain that radiates from the centre to the RLQ suggest?
A
Appendicitis
10
Q
What could abdominal pain radiating to the back suggest?
A
Peptic ulcer
Pancreatitis
11
Q
Symptoms associated with abdominal pain that could suggest a more serious pathology?
A
Nausea
Vomiting
Weight loss
Melaena
Altered bowel habits
Haematemesis
12
Q
Symptoms of acute cholecystitis?
A
Colic-like pain
Severe in nature
Lasting 30 minutes to 8 hours
Nausea, vomiting, fever
13
Q
What is IBS classes as?
A
A functional bowel disorder (absence of abnormality)
14
Q
What percentage of adults are affected by IBS?
A
10-20%
15
Q
Does IBS affect men or women more?
A
Twice as many women affected
16
Q
Normal age of incidence for patients with IBS?
A
20-30 years old
17
Q
What quadrant does IBS affect?
A
LLQ
18
Q
IBS symptoms?
A
Abdominal pain and discomfort (relief of defecation)
Altered bowel habits
Diarrhoea
Constipation
Bloating
19
Q
How long must symptoms persist before diagnosing IBS?
A
6 months
20
Q
Causes of IBS?
A
No known cause
Multifactorial
Motility dysfunction
Diet
Genetics
Psychological factors
21
Q
Red flag symptoms in IBS?
A
Blood in stools
Fever
Nausea
Vomiting
Severe pain
Aged under 16
Aged over 45
Steatorrhoea
22
Q
IBS diet management?
A
Identify and avoid trigger food
Low FODMAP diet (as absorbed poorly by small intestine so can cause symptoms)
23
Q
What does FODMAP stand for?
A
fermentable oligosaccharides, disaccharides, monosaccharides and polyols,
24
Q
Lifestyle management for IBS?
A
Reduce stress and psychological distress
25
Drug management in IBS?
Antispasmodics
Loperamide
Laxatives
Low dose tricyclic or SSRI (second line) for refractory abdominal pain
Herbal medicine and probiotics (lacking evidence)
26
Diarrhoea definition?
Passage of three or more lose or liquid stools per day
27
Types of diarrhoea?
Acute
Persistent
Chronic
28
Time frame for acute diarrhoea?
< 14 days
29
Time frame for persistent diarrhoea?
> 14 days
30
Time frame for chronic diarrhoea?
> 4 weeks
31
Causes of diarrhoea?
Viruses
Bacteria
Parasites
Drug-induced
IBS
IBD
Coeliac disease
32
Drugs that can commonly cause diarrhoea?
Laxatives
Magnesium containing antacids
Metformin
33
RED flag symptoms in diarrhoea?
Change in long term bowel habits aged over 50
Following recent travel
Longer than 2-3 days in children or elderly
Blood or mucous present
Severe abdominal pain
Steatorrhoea
34
Diarrhoea management?
Oral rehydration solution
Rice based ORS
Loperamide
35
Loperamide dose for acute diarrhoea?
Initially 4 mg, followed by 2 mg for up to 5 days, dose to be taken after each loose stool; usual dose 6–8 mg daily; maximum 16 mg per day.
36
Loperamide dose for acute diarrhoea?
Initially 4 mg, followed by 2 mg for up to 5 days, dose to be taken after each loose stool; usual dose 6–8 mg daily; maximum 16 mg per day.
37
What does GORD stand for?
Gastro-oesophageal reflux disease
38
What is GORD?
Condition affecting the GI tract whereby the acidic contents of the stomach are able to flow back into the oesophagus
39
When does GOR become GORD?
When symptoms occurs twice or more a week
40
What is dyspepsia?
Pain or discomfort, including upper abdominal pain, heartburn, reflux, bloating, early satiety, fullness or nausea centred in the upper abdomen/GI tract.
Symptoms typically present for four weeks or more
41
Pathophysiology of GORD?
Reflux occurs when there is loss of tone of the lower oesophageal sphincter
42
Does genetics impact GORD?
Higher risk is immediate family member suffers
43
Can age impact GORD?
More likely with increasing age
44
Risk factors for GORD?
Family history
Age
Pregnancy
Obesity
Ascites
Stress
Smoking
Medication
45
Dietary triggers of GORD?
Spice
Fats
Chocolate
Mint
Caffeine
46
When are gastric contents more likely to reflux?
Gastric volume is increased
After meals if gastric emptying is impaired
Gastric contents are near the junction
Posture
Gastric pressure is increased
Tight clothes
47
Medications linked with GORD?
NSAIDs
CCBs
Nitrates
Antibiotics
Bisphosphonates
48
What is a hiatus hernia?
Structural abnormality where the superior part of the stomach protrudes slightly above the diaphragm through the diaphragmatic hiatus
49
What causes hiatus hernia?
Most often due to an abnormal relaxation or weakening of the sphincter
Caused by physical exertions which increase abdominal pressure e.g. coughing, vomiting
50
Risk factors for hiatus hernia?
Obesity
Pregnancy
Increasing age
51
Why can reflux occur with hiatus hernia?
The diaphragm aids in maintaining the anti-reflux barrier
52
Common symptoms of GORD?
Heartburn
Regurgitation
Waterbrash
53
What is heartburn?
A feeling of burning rising up from the stomach or lower chest towards the neck
54
What is waterbrash?
Acidification of the oesophagus causes sudden stimulation of saliva. Mouth fills with saliva
55
Atypical symptoms of GORD?
Chest pain
Cough
Asthma
Throat changes
Voice changes
56
GORD complications?
Reflux oesophagitis
Stricture
Barrett’s oesophagus
Adenocarcinoma
57
What is reflux oesophagitis?
Where the mucosal defences and unable to counteract the damage caused by acid, pepsin, and bile
58
Types of reflux oesophagitis?
Non -erosive
Erosive
59
What happens to the oesophagus in Barrett’s oesophagus?
Distal squamous epithelium converted to columnar epithelium
60
Prevalence of GORD in babies?
~40%
61
When may medical treatment be required in a baby with GORD?
Distressed behaviour
Gagging
Choking
Faltering growth
Chronic cough
Pneumonia
62
GORD treatment in breast-fed baby?
Feeding assessment
Alginate trial- gaviscon infant for 1-2 weeks
63
Maximum dose of gaviscon infant?
6 if < 4.5kg
12 if > 4.5kg
64
GORD treatment in bottle-fed baby?
More frequent but smaller feeds
Thickened formula e.g. Carobel
65
What percentage of the population experience dyspepsia at least once a week?
15-25%
66
Red flags in dyspepsia?
GI bleeding
Difficulty swallowing
Weight loss
Abdominal swelling
Vomiting
>50 with new onset
<18
67
Investigations involved with GORD?
Endoscopy
Biopsies
68
Aims of GORD treatment?
Manage symptoms
Treat underlying causes
Do not exacerbate co-morbidities
69
Lifestyle changes for dyspepsia?
Healthy eating
Weight reduction
Smoking cessation
70
General management principles of GORD?
Lifestyle changes
Avoid food triggers
Raise the bed head at night
Avoid large meals before bed
Withdrawal of trigger medication
71
Pharmacological options for dyspepsia?
Antacids
H2 receptor antagonist
PPIs
72
How do antacids work?
Neutralise HCl secreted by gastric parietal cells
73
Pros and cons of liquid antacids?
More effective but less convenient
74
Examples of antacids?
Aluminium hydroxide
Calcium carbonate
Magnesium salts
75
Which antacid salts can cause diarrhoea?
Magnesium
76
Which antacid salts can cause constipation?
Aluminium
Calcium
77
Antacids with high sodium content should be avoided in which conditions?
Heart failure
Renal failure
Cirrhosis
Oedema
78
Which antacid salt can accumulate in renal disease?
Aluminium
79
Antacid drug interactions?
Take two hours before or after other medications
Phenytoin, quinolones, doxycycline, iron, levothyroxine
80
Why do antacids have so many interactions?
Decrease absorption
81
How do alginates works?
Rafting agents
Increase viscosity of stomach contents and protect oesophageal mucosa from acid contents
82
Examples of H2 antagonists?
Famotidine
Cimetidine
Nizatidine
Ranitidine
83
How do H2 antagonists work?
Competitively block H2 receptors on the parietal cell reducing gastric acid secretion
84
Which H2 antagonist is associated with the most side effects?
Cimetidine
85
Cimetidine side effects?
CNS- slurred speech, confusion
Endocrine- gynaecomastia, galactorrhea
Blood dyscrasias
Liver toxicity
86
Cimetidine drug interactions?
Phenytoin
Carbamazepine
Theophylline
All levels increased
87
Why was ranitidine withdrawn from the UK market?
Link to increase in NDMA, a probable carcinogen
88
Examples of PPIs?
Esomeprazole
Lansoprazole
Omeprazole
Rabeprazole
Pantoprazole
89
How do PPIs work?
Irreversibly inactivate the hydrogen/potassium ATPase enzyme system thus suppressing both stimulated and basal acid secretion
90
Drugs that can cause or exacerbate GORD/dyspepsia?
alpha-blockers
anticholinergics
benzodiazepines
beta-blockers
bisphosphonates
calcium-channel blockers, corticosteroids
NSAIDs
nitrates
theophyllines
tricyclic antidepressants
91
What is misoprostol licensed for? (Gastro)
Benign gastric ulcer
Benign duodenal ulcer
NSAID-induced peptic ulcer
Prophylaxis of NSAID-induced peptic ulcer
92
Usual misoprostol treatment dose?
400 micrograms twice daily, alternatively 200 micrograms 4 times a day continued for at least 4 weeks or may be continued for up to 8 weeks if required, dose to be taken with breakfast (or main meals) and at bedtime.
93
Usual misoprostol prophylactic dose?
200 micrograms 2–4 times a day.
94
Cautions for misoprostol? (Gastro)
Conditions where hypotension might precipitate severe complications (e.g. cerebrovascular disease, cardiovascular disease); conditions which predispose to diarrhoea (e.g. inflammatory bowel disease)
95
Possible severe side effect of misoprostol?
Diarrhoea
96
How does misoprostol work for gastric ulcers?
Misoprostol is a synthetic prostaglandin analogue that has antisecretory and protective properties, promoting healing of gastric and duodenal ulcers
97
How does sucralfate work?
Sucralfate is a complex of aluminium hydroxide and sulfated sucrose which forms a barrier to protect the mucosa from acid, pepsin and bile attack in gastric and duodenal ulcers.
98
Licensed uses of sucralfate?
Benign gastric ulceration
Benign duodenal ulceration
Chronic gastritis
99
Cautions of sucralfate?
Following reports of bezoar formation associated with sucralfate, caution is advised in seriously ill patients, especially those receiving concomitant enteral feeds or those with predisposing conditions such as delayed gastric emptying.
100
When should sucralfate be taken?
1 hour before meals
101
Maximum daily dose of sucralfate?
8g
102
Functional vs uninvestigted dyspepsia?
Functional is where an endoscopy has been performed but nothing found to explain symptoms
103
Initial management of uninvestigated dyspepsia?
PPI for four weeks
Test for H.pylori
(If high risk for H.pylori then test first or in parallel with PPI)
104
Initial management of functional dyspepsia?
Test for H.pylori
If negative then PPI or H2 antagonist for four week
105
Follow up management of dyspepsia?
Assess for new alarm symptoms
Consider alternative diagnosis
Check adherence to both drugs and lifestyle measures
PPI or H2 can be continued at lowest dose to control symptoms (PRN can be considered)
106
How often should patients with dyspepsia be reviewed?
Annually
Encourage a step down approach of possible
Return to self-treatment with alginates or antacids
107
When to refer a dyspepsia patient to specialist care?
Unexplained or unresponsive Gastro oesophageal symptoms or if H.pylori not responsive to second line treatment
108
Definition of a peptic ulcer?
Disruption of the mucosal integrity of the stomach and/or duodenum leading to local defect or excavation due to active inflammation.
>5mm in size that reach the sub-mucosa
109
What causes a peptic ulcer to form?
An imbalance between the protective and destructive (gastric acid, Pepsis) factors present in the stomach and duodenum
110
The three major protective factors in the Gastro-duodenal defence mechanism?
Mucous/bicarbonate layer
Surface epithelial cells
Prostaglandins
111
What produces the mucous/bicarbonate layer in the gastro-duodenal system?
Epithelial cells
112
What does the mucous/bicarbonate layer in the gastro-duodenal system contain?
Water, lipids and glycoproteins (mucin)
113
Purpose of the mucous/bicarbonate layer in the gastro-duodenal system?
Sets up a pH gradient to prevent diffusion of ions and molecules
114
pH of the mucous/bicarbonate layer in the gastro-duodenal system?
1-2 at luminal surface
6-7 on epithelial surface
115
What do epithelial cells do to protect in the gastro-duodenal system?
Produce mucous
Have tight junctions to form a protective seal
Cells replaced quickly and undergoing constant turnover
116
What do prostaglandins do to protect the gastro-duodenal system?
High levels in the gastric mucosa
Regulate release of mucosal bicarbonate and mucous
Inhibit parietal cell secretion and maintain blood flow and epithelial cell repair and replacement
117
What type of peptic ulcer is most common?
Duodenal
118
What age are gastric ulcers most likely to occur?
60s
119
Where are 90% of duodenal ulcers located?
Within 3cm of the pylorus
120
Which type of peptic ulcer is most likely to represent a malignancy?
Gastric
121
Pain described in both types of peptic ulcer?
Epigastic described as burning or gnawing
Discomfort described as an ill defined aching or hunger pain
122
Typical pain pattern for a duodenal ulcer?
90 minutes to 3 hours after food
2/3 patients report pain awakening them at night
123
What frequency relieves duodenal ulcer pain?
Antacids
Food
124
Food can worsen pain causes by what kind of ulcer?
Gastric
125
Nausea and weight loss is most commonly associated with which type of ulcer?
Gastric
126
Main two causes of peptic ulcers?
H.pylori
NSAIDs
127
Other trigger factors for peptic ulcers?
Mental stress
Smoking
Corticosteroids
Zollinger-Ellison syndrome
Blood group O
128
How does H.pylori cause ulcers?
Bacteria produces urease which allows bacteria to survive in acidic environment
Produces surface factors that are chemotactic for immune cells
Makes proteases and lipases that break down mucous gel
129
How can NSAIDs cause gastric ulcers?
Prostaglandins and important in maintaining Gastro-duodenal integrity
Therefore when synthesis disrupted ulcers can form
130
What is Zollinger-Ellison syndrome?
tumors in the first part of the small intestine, the pancreas, or both. These tumors, called gastrinomas, release the hormone gastrin. This causes the stomach to release too much acid
131
Zollinger-Ellison syndrome treatment?
High dose PPIs
Surgery
Chemotherapy
132
Peptic ulcer complications?
Gastric outlet obstruction
Intestinal perforation and haemorrhage
133
Patients at high risk with an NDSAID?
>65 years
High doses
Other medications that increase pelvic ulcer risk
Serious co-morbidities
Heavy smokers
Excess alcohol
Previous ADR to NSAIDs
Prolonged need for NSAIDs
134
How to test for peptic ulcers?
Endoscopy
135
Do PPIs need to be stopped before endoscopy for peptic ulcer?
Yes- two weeks
136
Do H2 antagonists need to be stopped before endoscopy for peptic ulcer?
No
137
Do antibiotics need to be stopped before endoscopy for peptic ulcer?
Yes- two weeks
138
Gold-standard tests for H.pylori?
Urea breath test
Stool antigen
Endoscopy with biopsy
139
Aims of peptic ulcer treatment?
Promote ulcer healing
Manage symptoms
Treat H.pylori if appropriate
Reduce risk of complications and recurrence
Not exacerbate co-morbidities
140
Why should caffeine be avoided for peptic ulcer patients?
It is a gastric acid stimulant
141
Non-pharmacological management of peptic ulcers?
Healthy eating
Weight loss
Avoid trigger foods
Smaller meals
Evening meal 3-4 hours before bed
Raise bed head
Avoid smoking
Avoid alcohol
Avoid ulcerogenic drinks
Avoid caffeine
Stress management
142
When would an urgent endoscopy be needed for dyspepsia?
Dysphasia
Significant GI bleeding
Aged >55 with significant weight loss
143
Initial management of peptic ulcer?
Stop ulcer inducing medication if possible
Antacids can be used short term
Test for H.pylori
144
Initial management of a peptic ulcer when H.pylori positive without a history of NSAID use?
H.pylori eradication
145
Initial management of a peptic ulcer with a history of NSAID use?
PPI for eight weeks followed by H.pylori eradication of positive
146
Initial management of a peptic ulcer when H.pylori negative without a history of NSAID use?
PPI or H2 antagonist for 4-8 weeks
147
Follow up management of peptic ulcer if H.pylori positive?
Depending on size
Review 6-8 weeks after eradication and re-test
Repeat endoscopy to confirm healing
148
What to do if ulcer healed and NSAIDs still required?
Review NSAID every six months
Consider alternative analgesic
Prescribe Gastro protection
149
What happens if symptoms recur after ulcer treatment?
Low dose PPI may be used
150
H.pylori eradication method?
Triple therapy for 1 week
1 PPI
2 antibiotics
If ulcer large or complicated the continue for another 3 weeks
151
First-line H.pylori eradication?
Lansoprazole 30mg BD OR omeprazole 20-40mg BD
Amoxicillin 1g BD
Clarithromycin 500mg BD OR metronidazole 400mg BD
152
First-line H.pylori eradication of penicillin allergic?
Lansoprazole 30mg BD OR omeprazole 20-40mg BD
Clarithromycin 250mg BD
Metronidazole 400mg BD
153
Second-line treatment for H.pylori eradication?
Lansoprazole 30mg BD OR omeprazole 20-40mg BD
Amoxicillin 1g BD
Clarithromycin 500mg BD OR metronidazole 400mg BD (whichever not used first line)
154
Second-line H.pylori eradication if penicillin allergic?
Lansoprazole 30mg BD OR omeprazole 20-40mg BD
Metronidazole 400mg BD
Levofloxacin 250mg BD
155
When should a PPI be routinely prescribed with an NSAID?
Osteoarthritis
Rheumatoid arthritis
Anyone >45 with chronic lower back pain
156
When should a PPI be considered with an NSAID?
>65 years
Long term use
Other medications- antiplatelets, SSRIs, corticosteroids, nicorandil
157
Issues with long term PPIs?
C.diff
Bone fractures
158
What kind of condition is coeliac?
Autoimmune
159
Coeliac prevalence?
~1%
160
Symptoms of coeliac disease?
Bloating
Diarrhoea
Flatulence
Constipation
Tiredness
Headaches
Sudden weight loss
Hair loss
Anaemia
Osteoporosis
Rash
neurological disorder
161
Rash seen in coeliacs?
Dermatitis herpetiformis
162
What is this a symptoms of?
Coeliac disease
163
Most common presentation during coeliac diagnosis?
Diarrhoea
164
Two common proteins in gluten responsible for coeliac disease?
Gliadin
Glutenin
165
How much gluten can a coeliac patient tolerate?
20 parts per million
166
Coeliac disease is what immune cell mediated?
T-cell (CD4+)
167
Antibodies involved in coeliac disease?
IgA
IgG
168
What genes are involved in coeliac disease?
HLA-DQ2 (90%)
HLA-DQ8 (10%)
169
How are MHC II molecules involved in coeliac disease?
The specific genes found for patients with these MHC II molecules make them bind to charged particles.
Gluten is not a charged particle but can be deaminated by transglutaminase enzymes
They bind to gluten and recognise it as foreign
170
How to diagnose coeliac disease?
Serum analysis for anti-gliadin/transglutamidase antibodies
ELISA
Intestine biopsy
HLA typing
171
What is a common deficiency in coeliac patients?
Calcium
172
Symptoms of vomiting?
Nausea
Retching
Emesis
173
Possible causes of nausea and vomiting?
Pregnancy
Motion sickness
Gastroenteritis
Appendicitis
Cholecystitis
Cholelithiasis
Peptic ulcers
Migraine
174
Nausea affects what percentage of pregnant women?
70%
175
Vomiting affects what percentage of pregnant women?
60%
176
What trimester is nausea and vomiting most common?
First
177
What causes nausea and vomiting in pregnancy?
A surge in hormone levels
178
Self-care measures for nausea and vomiting?
Rest
Avoid triggers
Eat plain biscuits or crackers
Eat bland small meals which are low in carbohydrates and fats and high in protein
Cold meals may be better tolerated
Drink little and often
Ginger
Acupressure
179
First line drug treatments for nausea and vomiting in pregnancy?
Cyclizine
Promethazine
Prochlorperazine
Chlorpromazine
Doxylamine/pyridoxine (Xonvea)
180
What is the only licensed drug for nausea and vomiting in pregnancy?
Doxylamine/pyridoxine (Xonvea)
181
Second line antiemetics in pregnancy?
Metoclopramide
Ondansetron
Domperidone
182
Why can nausea and vomiting due to pregnancy not be managed OTC?
Lack of licensing
Safety concerns
183
Symptoms of motion sickness?
Nausea
Pallor
Abdominal discomfort
Vomiting
184
What is habituation in regards to motion sickness?
Symptoms normally improve after a prolonged exposure to the motion
185
Who is motion sickness most common in?
Children
186
What causes motion sickness?
Inability of brain to process conflicting information from sensory nerve terminals regarding movement and position
187
Number of migraine sufferers in the UK?
5 million
188
Most common age for migraines?
Adolescence
189
Migraine symptoms?
Headache
Nausea and vomiting
Visual disturbance
190
OTC medications for migraine-induced nausea and vomiting?
Buccal prochlorperazine
Buclizine in migralieve
191
What can nausea and vomiting in a baby under 1 month be a sign of?
Hirschsprung’s disease
192
What is Hirschsprung’s disease?
the nerves that control this movement are missing from a section at the end of the bowel, which means poo can build up and form a blockage
193
Conditions to eliminate in infants presenting with nausea and vomiting?
Hirschsprung’s disease
Feeding problems
194
Conditions to exclude when presenting with nausea and vomiting?
Gastritis
Migraines
Medication induced
Excess alcohol
Pregnancy
195
Medications that can cause nausea and vomiting?
Cytotoxics
NSAIDs
Opiates
Iron
Antibiotics
SSRIs
Theophylline
Digoxin
196
Red flag symptoms for nausea and vomiting?
Suspected pregnancy
Vomiting for more than 24 hours in a child under one year
Children who fail to respond to OTC treatment
Unexplained nausea and vomiting in any age group
Moderate to severe abdominal pain
Haematemesis
197
Drugs licensed for motion sickness?
Cyclizine
Cinnarizine
Promethazine
Hyoscine
Scopolamine
198
Why was Domperidone removed from OTC sale and when?
License revoked in 2014 due to risk of serious cardiac side effects
199
How does prochlorperazine work for nausea and vomiting?
Works by blocking dopamine receptors located in the chemoreceptor trigger zones
200
What is OTC prochlorperazine licensed for?
Nausea and vomiting associated with migraines
18 years +
201
Buccal prochlorperazine dosing?
3-6mg BD
202
Side effects of Buccal prochlorperazine?
Drowsiness
Dizziness
Dry mouth
Insomnia
Agitation
Skin reactions
203
Buccal prochlorperazine interactions?
Crossed BBB so potentiates side effects of CNS depressants and alcohol
204
Buccal administration?
Place tablet between upper lip and gum
Allow to dissolve gently. Will soften and form a gel like substance in 1-2 hours
Takes between 3-5 hours to fully dissolve
Do not chew, crush or shallow
205
Side effects of antihistamine motion sickness treatment?
Dry mouth
Constipation
Sedation
206
Antihistamine motion sickness treatment interactions?
Alcohol
Opioids
Hypnotics
Antidepressants
207
Cautions for antihistamine motion sickness treatment?
Angle-closure glaucoma
Enlarged prostate
208
What age is Cyclizine licensed for in motion sickness?
> 6 years
209
What age is cinnarizine licensed for in motion sickness?
>5 years
210
What age is promethazine licensed for in motion sickness?
>5 years
211
What length journeys are antihistamine based motion sickness treatments recommended for?
Longer journeys
212
Stugeron dosing for those aged over 12 years?
2 tablets two hours before you travel and 1 tablet every eight hours during your journey.
213
Stugeron dosing for ages 5-12 years?
1 tablet two hours before you travel and half a tablet every 8 hours during your journey.
214
Avomine dose for adults?
2 tablets
215
Avomine dose for children over 10?
1 tablet
216
Avomine dose for children aged 5-10?
Half a tablet
217
How does Hyoscine work to prevent motion sickness?
Affects your inner ear and brain to control vomiting and relaxes muscles in the walls of the stomach
218
Side effects of Hyoscine hydro bromide?
Dry mouth
Sedation
Other anticholinergic side effects
219
Hyoscine hydrobromide interactions ?
TCAs
Neuroleptics
Antimuscarinics
220
Cautions for Hyoscine hydrobromide?
Angle-closure glaucoma
Enlarged prostate
221
Age Joyrides are licensed for?
>3 years
222
Age kwells kids are licensed for?
>4 years
223
Age kwells are licensed for?
> 10 years
224
Age scopoderm is licensed for?
>10 years
225
Recommended travel durations for Hyoscine?
Less than 4 hours excluding scopoderm
226
Kwells kids dose for ages 4-10 years?
½-1 tablet every 6 hours if required. Do not take more than 1½-3 tablets in 24 hours.
227
Kwells kids dose for children over 10 years?
1-2 tablets every 6 hours if required. Do not take more than 3-6 tablets in 24 hours.
228
When to take kwells?
Tablets to be taken up to 30 minutes before the start of the journey to prevent travel sickness, or at the onset of nausea.
229
Kwells dose for adults?
1 tablet every 6 hours if required. Do not take more than 3 tablets in 24 hours.
230
Joy rides doses for children?
20 minutes before journey.
7 - 12 years: 1 -2 tablets.
4 - 7 years: 1 tablet. Maximum 2 tablets in 24 hours.
3 – 4 years: half a tablet. Maximum 1 tablet in 24 hours.
231
Joy rides dose for ages 13 years and over?
2 tablets 20 minutes before start of the journey. Maximum 4 tablets in 24 hours.
232
How long do scopoderm patches work for?
72 hours
233
How long before a journey should a scopoderm patch be applied?
5-6 hours
234
Where should a scopoderm patch be placed?
clean, dry, hairless area of skin behind the ear, taking care to avoid any cuts or irritation
235
Normal bowel habit?
Three times a day to three times a week
236
Signs of bowel obstruction?
Constipation
Colicky abdominal pain
Abdominal distension
Vomiting
237
Lifestyle advice for constipation?
Increase fibre
Exercise
Drink more
Reduce alcohol
238
What can overuse of stimulant laxatives cause?
Loss of muscular activity in the bowel wall (atonic colon)
239
Drugs that can cause constipation?
Opioids
Antacids (aluminium)
Antimuscarinics
Phenytoin
Antidepressants
Antihistamines
Levodopa
Verapamil
Calcium supplements
Bendroflumethiazide
Iron
Laxative abuse
240
When to refer for constipation?
Change in bowel habits that last > 2 weeks
Abdominal pain, vomiting, bloating
Weight loss
Blood in stools
Prescribed medication suspected to be the cause
Failure of OTC treatment
241
What are first line laxatives?
Bulk forming
242
How do bulk forming laxatives work?
Swelling in the gut to increase faecal mass and stimulate peristalsis
243
How long do bulk forming laxatives take to work?
Can be several days
244
Why is it important to increase fluid intake with bulk forming laxatives?
Can cause intestinal obstruction
245
When are bulk forming laxatives not considered appropriate?
Opioid-induced constipation
246
Why are bulk forming laxatives not suitable for opioid-induced constipation?
The problem relates to decreased motility of the gut
247
How to osmotic laxatives work?
Maintaining the volume of fluid in the bowel
248
How long do osmotic laxative take to work?
1-2 days
249
Examples of osmotic laxatives?
Lactulose
Macrogol
250
Side effects of lactulose?
Flatulence
Cramps
Abdominal discomfort
251
How do glycerin suppositories work?
Have an osmotic and irritant effect
252
How long to glycerin suppositories take to work?
Within 1 hour
253
How do stimulant laxatives work?
Stimulate nerves in the colon and rectum and increasing peristalsis
254
Example of stimulant laxatives?
Bisacodyl
Senna
Picosulfate
255
Age for stimulant laxatives?
12 plus
256
How long should stimulant laxatives be used for?
No longer than one week
257
How long to stimulant laxatives take to work?
Orally 6–12 hours
Rectally 15-60 minutes
258
Example of a stool softener?
Docusate
259
How does docusate work?
Lowers surface tension at the oil-water interface of the faeces, enabling water and lipids to enter and soften the stool
Also has stimulant effects
260
How long does docusate take to work?
1-2 days
261
Who is constipation most common in?
Women
Elderly
Pregnancy
262
What is chronic constipation?
Symptoms present for at least three months
263
Example of a prokinetic laxative?
Prucalopride
264
Constipated stools are usually which type on the Bristol stool chart?
1 or 2
265
Conditions that can cause constipation?
Hypothyroidism
Depression
Parkinson’s
Angina or recent MI
Recent surgery
Haemorrhoids
Pregnancy
266
Risk factors for C.diff?
Advanced age
Underlying morbidity
Use of PPIs
Antibiotic use
267
When to refer for diarrhoea?
Dehydration suspected
> 1 day in under 1
> 2 days in under 3 and elderly
>3 days in older children and adult
Severe vomiting
After a course of antibiotics
Fever
Food poisoning outbreak
Travel abroad
Drug induced
Change in bowel habit
Blood or mucus in stool
Elderly or underlying condition
Weak immune system
Pregnancy
268
Maximum daily dose of loperamide for adults?
12mg
269
Maximum daily dose of loperamide for those aged 12-18 years?
6mg
270
What is classed as chronic diarrhoea?
> 4 weeks
271
What is classed as persistent diarrhoea?
> 14 days
272
What is classed as acute diarrhoea?
<14 days
273
Drugs associated with diarrhoea?
Laxatives
Allopurinol
Angiotensin-II blockers
Antibiotics
Chemo
Magnesium
Antacid
NSAIDs
PPIs
SSRIs
274
Complications of diarrhoea?
Dehydration
Negative quality of life
275
How long does viral diarrhoea usually last?
2-3 days
276
How long does untreated bacterial diarrhoea usually last?
3-7 days
277
Red flags for acute diarrhoea?
Blood in stool
Recent hospital treatment
Recent antibiotic use
Weight loss
Evidence of dehydration
Nocturnal symptoms
278
Features of dehydration?
Increase heart rate
Reduced skin tugor
Dryness of mucous membranes
Delayed capillary refill time
Decreased urine output
Hypotension
Altered mental status
279
How does loperamide work?
Acts via opioid receptors
Slows GI tract time
Increases capacity of gut
280
Possible side effects of loperamide?
Cramps
Nausea and vomiting
Tiredness
Dry mouth
281
Drugs that can exacerbate incontinence?
Alpha-1 antagonists (doxazosin)
Antipsychotic
Anticholinergics
Anti-Parkinson’s
Antidepressants
Benzodiazepines
Beta blockers
Diuretics
HRT
282
What to rule out with nocturnal enuresis?
UTIs
Constipation
Diabetes
283
Physiological Causes of nocturnal enuresis?
Insufficient secretion of ADH at night
Impaired brain arousal
Bladder dysfunction
284
Non-pharmacological management of nocturnal enuresis?
Adequate fluid intake
Appropriate toileting especially before bed
Healthy diet
Rewards system
Enuresis alarm
285
Drug of choice for nocturnal enuresis?
Desmopressin
286
When to offer desmopressin for nocturnal enuresis?
If rapid onset or short term improvement is the priority of treatment or an alarm is inappropriate
287
Desmopressin dose for nocturnal enuresis?
200mcg desmotabs or 120mcg desmomelt to start
If not completely dry in one to two weeks can double dose
Assess at four weeks and if positive then continue for three months
288
How does desmopressin work?
It is an analogue of ADH
Selective to V2 in distal kidney tubule to increase water reabsorption
289
Advice for taking desmopressin?
Risk of hyponatraemic convulsions
Avoid fluid overload
Stop taking during episodes of diarrhoea and vomiting until fluid balance normal
Advise to limit fluid intake one hour before dose and 12 hours after
290
How do Antimuscarinics work for incontinence?
M3 cholinergic receptors are responsible for the parasympathetic detrusor contraction in the bladder
So they prevent this action
291
Second line drug therapy for nocturnal enuresis?
Antimuscarinics
292
Third line drug therapy for nocturnal enuresis?
Imipramine
293
Types of incontinence?
Stress
Urgency
Overflow
Mixed
294
What is stress incontinence?
Leaks when bladder put under stress (sneeze, cough)
295
What causes stress incontinence?
Poorly functioning urethral sphincter muscle or hypermobility of the bladder neck or urethra
Caused by weakening or damage
296
Another name for urgency incontinence?
Overactive bladder
297
What is urgency incontinence?
A sudden urge to urinate
298
What is overflow incontinence?
Bladder doesn’t fully empty
299
What causes urgency incontinence?
Overactivity if the detrusor muscles
300
What causes overflow incontinence?
Often caused by obstruction or blockage in the bladder
301
Non-pharmacological management of incontinence?
Reduce caffeine intake
Moderate fluids
Lose weight if needed
Pelvic floor exercises
Bladder training
Surgery
302
First line drug treatment for incontinence in women?
Oxybutynin
Tolterodine
Solifenacin
303
Why are Antimuscarinics often discontinued?
Side effects
304
When to avoid Antimuscarinics?
Close-angle glaucoma
Diagnosis of dementia
Prostate enlargement
QT prolongation
305
How do B3 agonists work for incontinence?
B3 receptors in bladder wall
Activation inhibits detrusor muscle
306
When should mirabegron be used for incontinence?
If Antimuscarinics do not work, are unsuitable or intolerable side effects
307
Major safety warning for mirabegron?
Contraindicated for severe uncontrolled hypertension
Regular monitoring of BP required
308
How does duloxetine work for incontinence?
Increased levels of 5-HT and NE in sacral spinal cord leads to increased urethral tone
Results in stronger urethral closure during urine storage with physical stress
309
When should duloxetine be offered for incontinence?
Second line for stress incontinence only if they prefer drug treatment to surgery
310
Why did duloxetine fail US approval for stress incontinence?
Liver toxicity
Suicidal events
311
Who are UTIs most common in?
Women
312
Who are UTIs most serious in?
Men
313
What is the name of an upper urinary tract infection?
Pyelonephritis
314
Types of lower UTIs?
Cystitis
Urethritis
Prostatitis
315
Usual cause of urethritis?
Sexually transmitted
316
Symptoms of a UTI?
Increased urinary frequency
Dysuria
Haematuria
Fever
Confusion
Flank pain (pyelonephritis)
317
Why do multistix test for nitrites?
Bacteria can convert nitrates to nitrites
318
How to diagnose uncomplicated cystitis?
Simple history
Uniralysis
319
First line antibiotic treatment for UTI?
Nitrofurantoin 100mg MR BD
3 days women
7 days men
320
Nitrofurantoin should be avoided in a GFR less than?
45
321
Second line treatment for UTI?
Trimethoprim 200mg BD
Women 3 days
Men 7 days
322
UTI treatment for EBSL producing organisms?
Pivmecillinam
Fosfomycin
323
First line treatment for UTI in pregnancy?
Nitrofurantoin MR 100mg BD for seven days (not at term)
Or
Amoxicillin 500mg TDS for seven days
324
When should Nitrofurantoin not be used during pregnancy?
At term
325
What is classed as a recurrent UTI?
More than 3 UTIs in a year
326
Red flags in recurrent UTIs?
Haematuria
327
Usual course length for prostatitis?
2 weeks. Can continue a further 2 weeks if required
328
First line drug treatment for prostatitis?
Ciprofloxacin 500mg BD
329
Why should quinolones be avoided with NSAIDs?
Increased seizure risk
330
Acute pyelonephritis treatment?
331
Another name for travel health?
Emporiatrics
332
Main areas of travel health?
Pre-travel health assessments and advice
Medicines and medical related goods to manage/prevent health problems
Vaccinations
Management of health problems in returning travellers
333
Two types of IBD?
Ulcerative colitis
Crohn’s disease
334
What is CUTE?
colitis of uncertain type or etiology
335
Possible causes of IBD?
Genetics
Environment
Smoking
OCP
Appendectomy
Antibiotics
NSAIDs
Diet
Infection
Gut microflora
Host immunity
336
Main differences between Crohn’s disease and ulcerative colitis?
Crohn’s is in patches
UC is continuous
Crohn’s can affect any part of GI tract
UC only affects large intestine
337
What part of the GI tract can Crohn’s disease affect?
All of it
338
What can Steatorrhoea occur with Crohn’s but not ulcerative colitis?
Crohn’s can affect the small intestine
339
Aims of treatment for IBD?
Reduce risk of colorectal cancer
Control and relieve symptoms
Minimise toxicity
Address psychological issues
Replenish nutrients
Treat complications
Improve quality of life
Maintain remission
Promote mucosal healing
Reduce intestinal inflammation
340
What are parts of the GI tract not affected by Crohn’s disease called?
Skip lesions
341
Peak age of onset for Crohn’s?
15-30
And
60-80
342
When are corticosteroids used in IBD?
To induce remission, not for maintenance
343
When should aminosalicylates be used in Crohn’s disease?
Third line
344
When should aminosalicylates be used in ulcerative colitis?
First line
345
Examples of aminosalicylates?
Mesalazine, sulfasalzine, olsalazine, balsalazine
346
Which aminosalicylates are pro-drugs?
Sulfasalazine, olsalazine, balsalazine
347
How are aminosalicylate pro-drugs metabolised?
By bacteria in the gut to form 5-ASA
