Gastro

Question 1

Bright blood rectal bleed indicates

Answer 1

bleed from somewhere near anus:
haemorrhoids
anal fissure
Refer to GP for routine check

Question 2

Drugs that can cause diarrhoea

Answer 2

Abx
Acarbose
Biguanides
Bile salts
Colchicine
Cytotoxics
Dipyridamole
Iron preparations
Laxatives
Leflunomide
magnesium preparations
Metoclopramide
Misoprostol
NSAIDs
Olsalazine
Orlistat
PPI
Ticlopinide

Question 3

Symptoms IBS

Answer 3

abdominal pain or discomfort
disordered defaecation (diarrhoea, constipation, straining, incomplete emptying)
passage mucus
bloating

symptoms usually relieved by defaecation

Question 4

Treatment IBS

Answer 4

non-P:
long gaps between meals
limiting fresh fruits (max 3 portions/day)
soluble fibres (ispaghula or oats)
drink lots clear fluid - avoid caffeine, alcohol, fizzy drinks
P treatment:
antispasmodic drugs : alverine citrate, mebeverine, peppermint oil) (antimuscarinic: dicycloverine (available as P with antacids) and Hyoscine butylbromide
laxatives for constipation (AVOID LACTULOSE - bloating)
Loperamide for diarrhoea

Question 5

Treatment H. Pylori - pt not allergic to penicillin

Answer 5

All ORAL 7 DAYS
choice of PPI: Lansorpazole 30mg, Omeprazole 20-40mg, esomeprazole 20mg Pantoprazole 40mg, rabeprazole 20mg
1. PPI BD + Amoxicillin 1g BD + Metronidazole 400mg BD OR Clarithromycin 500mg BD (depends on previous treatment pt received)
2. PPI BD + Amoxicillin 1g BD + Metronidazole 400mg BD OR clarithromycin 500 mg BD (whichever wasn’t used as 1st line)
3. If clarithromycin or metronidazole ineffective use tetracycline 500mg QDS or levofloxacin 250mg BD
last line: rifabutin OR furazolidone

Question 6

Treatment H.Pylori - Allergic to penicillin

Answer 6

ALL ORAL 7 DAYS
choice of PPI: Lansorpazole 30mg, Omeprazole 20-40mg, esomeprazole 20mg Pantoprazole 40mg, rabeprazole 20mg
1. PPI BD + Clarithromycin 250mg BD + Metronidazole 400mg BD
2. (pt prev on clarithromycin) PPI BD + Bismuth subsalicylate 525mg QDS + metronidazole 400mg BD + tetracycline 500mg QDS
3. (2nd line for pt NOT on fluoroquinolones before) PPI BD + Levofloxacin 250mg BD + Metronidazole 400mg BD
3. (2nd line for pt on fluoroquinolones before) PPI BD + Bismuth subsalicylate 525mg QDS + metronidazole 400mg BD + tetracycline 500mg QDS
last line: Rifabutin OR furazolidone

Question 7

Testing for H.Pylori

Answer 7

• pt with uncomplicated dyspepsia and no red flag after 4 weeks of PPI
• pt high risk: older people, North African ethnicity, living in a known risk area
• Hx of peptic ulcers/bleeds
• Pt with unexplained iron-deficient anaemia after endoscopy has excluded malignancy.
  DO NOT DO TEST within 2 wks of PPI or 4 wks of abx has could lead to false-negative result

Question 8

PPI and clopidogrel

Answer 8

PPI inhibit CYP2C9 which metabolises clopidogrel - affects clinical efficacy clopidogrel (decreases efficacy)
X C/I: OMEPRAZOLE AND ESOMEPRAZOLE X
CAUTION: pantoprazole, lansoprazole and rabeprazole

Question 9

Azathioprine counselling

Answer 9

Hypersensitivity reaction - inc malaise, dizziness, vomiting, diarrhoea, fever, rigors, myalgia, arthralgia, rash, hypotension, renal dysfunction - STOP + REFER
bone marrow suppression - inexplicable bruising or bleeding, infection - REFER
Nausea - can be better if dividing daily dose, taking with food, antiemetics, decrease dose

Question 10

Azathioprine monitoring

Answer 10

TPMT before treatment - C/I in pt with absent TPMT activity

FBC ev week for 1st 4 wks then ev 3 mths

Question 11

Azathioprine S/E

Answer 11

common: bone marrow depression, inc risk infection, leucopenia, pancreatitis, thrombocytopenia