Gastro-intestinal Disorders Flashcards
What are the symptoms of gastric reflux? (5 points)
- heart burn
- acid taste in mouth
- flatulence
- nausea, biliousness
- gastric pain
What are the possible causes of gastric reflux? (8 points)
- hiatus hernia- requires radiological diagnosis
- obesity or pregnancy
- foods and drugs
- bacteria e,g, H. Pylori
- bending over
- stress and anxiety
- tight clothes
- old age
What are the general advice for lifestyle management of gastric reflux? (10 points)
- normal weight for age and height
- control caffeine alcohol, fat and spice in diet
- have small regular meals slowly - relax
- no meals less than 4H before bedtime
- exercise regularly, go for short walk after meal
- stop smoking
- raise head of bed
- avoid right clothes around waist/abdomen
- avoid bending over, slumping or stooping
What are the different types of medication used to manage gastric reflux? (6 points)
- antacids
- alginates
- dimethicone
- peppermint oil
- H2 antagonists
- PPIs
What are antacids? (4 points)
- metal salts which neutralise acid in stomach
- should be taken 1 hour after meals where gastric emptying has slowed so the effect can last up to 3 hours
- affects the absorption of EC tablets, drugs like warfarin, digoxin, tetracycline.
- liquids are more effective than tablets, tablets need to be chewed well
Why shouldn’t antacids be taken before meals?
-gastric emptying is fast during the meal so the effect may only last 30 min
What are the different metal salts used in antacids? (4 points)
- sodium bicarbonate
- aluminium salts
- magnesium slats
- calcium carbonate
What are the properties of sodium bicarbonate used as an antacid? (3 points)
- water soluble quick but short acting neutraliser
- avoid in sodium restrictive diets
- long term use may cause systemic alkalosis and renal damage
What are the properties of aluminium salts in antacids? (3 points)
- e.g. aluminium hydroxide
- can cause constipation
- avoid if concerned about dementia due to assoc. between Al in drinking water and senile dementia
What are the characteristics of magnesium salts used in antacids? (4 points)
- e.g. Trisilicate
- can cause osmotic diarrhoea
- Mg hydroxide is a potent acid neutraliser but trisilicate has poor buffering capacity
- caution in renal damage as hyper Mg can occur in high doses
What are the characteristics of calcium carbonate used in antacids? (3 points)
- potent long acting acid neutraliser
- long term use may cause acid rebounds hypercalcaemia
- may cause milk-alkali syndrome if taken with too much milk
What are alginates? (5 points)
- e.g. Gaviscon, mylanta plus.
- forms protective coat on top of acids
- take after meals and chew tablets thoroughly.
- medicines taken after the alginate may sit on foam layer and not be absorbed
- bicarbonate components in some alginate preparations does not provide an antacid effect, it is there to release CO2 so the foam can float on top of gastric fluid.
- alginates are approved in pregnancy
What is diemethicone or simethicone? (2 points)
- e.g. degas
- surfactant which reduces surface tension causing gas bubbles to coalesce and burst causing belching
What is peppermint oil? (2 points)
- carminative antispasmodic which inhibits GI smooth muscle
- menthol is the main constituent of peppermint oil and may act as a CCB and be useful in IBS
What are the H2 antagonists? (3 points)
- e.g. Ranitidine
- these antagonise acid production
- tablets are taken over a 2 week period to prevent over medication or failure to seek help with recurrent symptoms
- dose is low for dyspepsia and does not treat ulcers
- max 2 tablets in 24 hours
What are PPIs? (9 points)
- e.g. Omeprazole
- systemically blocks the enzyme causing acid release
- helpful for short term relief of elude symptoms
- only recommend in symptomatic patients, not to be used for prevention
- suitable for patients with symptoms 2 or more x a week but less than once daily
- start at lowest effective dose 30 min before meal preferably mane
- if symptoms do not improve in 14 days or worsen. Refer
- patients over 50 years with first time/longstanding and frequent symptoms should be referred
- interactions with ketonconazole, itraconazole, warfarin, phenytoin, diazepam, clapping real due to P450 interaction
When should gastric reflux be referred? (9 points)
- acute so tach pain or changed pain
- 45Y + weight loss, vomiting (carcinoma?)
- difficulty or pain on swallowing, regurgitation (oesophageal carcinoma?)
- blood in stool, vomiting, coffee ground poo
- jaundice
- anaemia
- pain radiating to arms (heart attack, angina?)
- OTC failure (e.g. >7 days)
- children
What are the symptoms of gastric reflux in infants? (3 points)
- regurgitation of milk after feeds (via mouth or nose or both)
- effortless vomiting or projectile
- may occur with or without crying and distress
How is infantile gastric reflux managed?
- refer for investigation
- dr may prescribe alginate to thicken feeds, antacids, medications to enhance stomach emptying and peristaltic movement
What is gastric reflux?
-when gastric contents like acid, reflux into the oseiohagus and irritate the sensitive mucosa
What are the symptoms of peptic ulcer? (6 points)
- dull, gnawing, mild to severe pain which may radiate towards back
- pain relieved by food, vomiting, rest, Antacids, milk
- hunger pain occurs 1-3 hours after food, may wake px up early in the morning
- exacerbations and remissions of pain
- weight loss, nausea, vomiting
- blood in vomit (coffee grounds) and stools (not common)
How are peptic ulcers managed? (9 points)
- refer for investigation
- aim for normal weight for age and height
- reduce caffeine, alcohol, fat, and spice in diet
- don’t skip meals, have 3 balanced and regular meals a day
- manage stress
- exercise regularly
- stop smoking
- avoid drugs that can aggravate symptoms like NSAIDs, corticosteroids
- adhere to medical management
What are the symptoms of gastritis or dyspepsia? (6 points)
- sudden onset
- brief duration
- malaise, loss of appetite
- feeling of fullness
- vertigo
- nausea, vomiting
What causes gastritis or dyspepsia? (2 points)
- over-indulgence of food, alcohol
- irritants like spicy food, caffeine, alcohol, smoking, allergenic foods, NSAIDs
How is gastritis or dyspepsia managed? (2 points)
- antacids and simethicone
- h2 antagonists or PPIs
What is constipation? (2 points)
- reduced frequency of defecation
- passage of hard dry stools
What are the pharmacist roles in diagnosing constipation?
-determine what is normal for the patient and then determine if a significant change in bowel habit has occurred
What are some common questions relating to the diagnosis of constipation? (5 points)
- bowel habits: normal, changes, frequency, hard/dry, straining, heeds call to toilet
- associated symptoms e.g, abdo discomfort, blood in stools
- diet, (fluid and fibre)
- exercise
- medication
What components of the diet might cause constipation? (3 points)
- inadequate fluid e,g, tea has tannins, caffeine can dehydrate
- inadequate fibre. Dry fibre must have plenty of fluid
- too much ingestion of cheese, calcium and iron
How can medications cause constipation? (2 points)
- laxative abuse causing lazy colon
- prescription medicines have constipation as a side effect
What are examples of medicines that cause constipation as a side effect? (15 points)
- opiates
- anticholinergics
- antidepressants
- sedating antihistamines
- NSAIDs
- SSRIs
- lipid lowering agents
- antacids (Al and Ca)
- diuretics
- psychotropics
- levodopa
- clozapine
- anti hypertensives (especially CCBs like verapamil)
When should constipation be referred? (6 points)
- change in bowel habit more than 2 weeks
- abdo pain, vomiting, bloating (faecal impaction? Cancer?
- blood in stools
- laxative abuse
- OTC failure
- if prescribed meds are the issue
What lifestyle advice can be given to patients suffering from constipation? (4 points)
- exercise regularly
- drink adequate fluids (6-8 glasses of water or juice per day)
- adequate fibre in diet
- heed call to toilet
What are the different types of laxative medication? (5 points)
- stimulant
- surfactants/softeners
- bulk laxatives
- osmotic laxatives
- other
What are examples of stimulant laxatives? (3 points)
- anthraquinone laxatives e,g, senna, aloe, cascara, rhubarb, frangula, danthron
- bisacodyl
- castor oil
What are the general treatment principles with stimulant laxatives? (7 points)
- increase peristalsis
- assoc with griping pain in abdomen
- work within 6-12 hours
- should not be used for more than 1 week
- suitable for when frequency is a problem, but stools are still soft
- senna first line, bisacodyl second line
- not suitable for general sales due to risk of misuse
What are the anthraquinone laxatives? (4 points)
- e.g. Senna:
- the main active compounds are sennosides A and B which are products and metabolised by gut micro flora to produce the active compound rheinanthrone
- reduces fluid absorption in colon forming softer stools
- accelerates colonic transport
What is different about danthron? (2 points)
- synthetic anthraquinone laxative (the others are natural)
- associated with carcinogenicity in rats and not available without a rx
What is bisacodyl? (5 points)
- dephenylmethane derivative
- inhibits Na+/K+ ATPase pump allowing water to accumulate in colon
- oral bisacodyl works in 6-10 hours
- suppository works in 15-69 minutes
- not suitable for general sale due to risk of misuse
What is caster oil? (4 points)
- prodrug of ricinoleic acid: alters fluid and electrolyte movement
- inhibits Na+/K+ ATPase and stimulates Adenyl cyclase to allow water to accumulate in colon
- increases colonic activity and mucosal permeability
- drastic purgative and tastes vile
What are surfactant laxatives? (3 points)
- aka stool softeners such as docusate sodium and poloxamer 188
- lubricates faeces and makes them more water permeable
- possible cAMP action to enhance water transport into the colon
What are the general principles regarding bulk laxative treatment? (8 points)
- choice laxative for long term regular use
- swells in gut increasing faecal mass and stimulates peristalsis
- efficacy depends on water holding capacity and use as substrate for colonic bacteria which hold water to create soft, soggy and heavy stools
- takes several days to work
- take with plenty of water, usually in the morning
- granules and powder can be mixed with juice or water
- take care to avoid mineral deficiencies
- flatulence may occur initially
What is dietary fibre?
The non absorbable portion of plants including celluloses, pectin, gums, mucilages and liginin
What are the different types of bulk laxatives? (4 points)
- bran fibre
- isphagula husk fibre, psyllium
- sterculia
- methyl cellulose
What is bran fibre? (4 points)
- produces soft, bulky stools and normalises transit
- raw bran is better than cooked meal however intestinal obstruction has occurred when unprocessed bran has been ingested
- the phytate in the bran can chelate zinc
- avoid in patients with gluten intolerance
What is isphagula husk fibre, psyllium ? (2 points)
- derived from outside of plantango seeds
- psyllium can cause allergies following inhaltional and dermal exposure
What is sterculia?
Bulk laxative from the karaya gum of sterculia shrub
What is methyl cellulose? (2 points)
- semisynthetic bulk laxative which forms viscous solution with water
- can increase faecal excretion of copper and magnesium
What are the two main types of osmotic laxatives?
- sorbitol
- lactulose
What is sorbitol? (4 points)
- hyperosmolar effect which softens stools
- acts in a few hours, but regular use may cause dehydration
- salts are not palatable
- used as sweetener in many liquid medicines and can cause diarrhoea and flatulence
What is lactulose? (4 points)
- metabolised by bacteria into lactic and other acids
- results in osmotic effect which softens stools
- lower pH contracts colonic muscle
- often used to manage chronic constipation especially in those taking opiates.
What are examples of other laxatives? (4 points)
- liquid paraffin or mineral oil
- Epsom salts
- Glauber’s salts
- Glycerin
What is liquid paraffin? (10 points)
- coats and softens faces and prevents water absorption out of colon
- Associated with many adverse effects
- long term use impairs absorption of vitamins,
- may cause anal leakage and irritation
- may be aspirated into airways and cause lipid penumonitis
- accumulation in lymph nodes my spleen, liver and adipose tissues
- has caused granulatomas in rectal tissue
- traces of polycyclic hydrocarbons have mutagenic potential
- banned for use in food
- MOH no longer recommends
How is constipation managed in infants?
-on midwife or GP advice, may use extra fluid particularly breast milk or water if infant is less than 12 weeks of age
How is constipation managed in children? (4 points)
- often increasing diet fibre will work
- can use half a glycerine suppository (only available in adult strength so use half.)
- only use glycerine suppository if constipation is recent with no other symptoms
- would normally refer to doctor
How is constipation managed in pregnancy? (3 points)
- may be caused by hormones or iron supplementation
- ensure adequate fibre and fluid intake
- avoid stimulants. Bulk laxatives are preferred but may be uncomfortable
How is constipation managed in the elderly? (3 points)
- common due to decreased exercise, inadequate fibre and fluid in diet, medications,
- false teeth can make fibrous foods hard to chew as granules can get caught in dentures
- manage with bulk laxatives and plenty of fluids (preferred) but lactulose may be an option
