GASTRO-INTESTINAL SYSTEM Flashcards
CROHN’S DISEASE- MAINTENANCE OF REMISSION TIPS
STOP SMOKING+NUTRITION KEY
DO NOT USE CORTICOSTEROIDS/BUDESONIDE FOR MAINTENANCE!
SULFASALAZINE/AMINOSALICYLATES
IMMEDIATE MEDICAL ATTENTION?
BLOOD DISORDERS? UNEXPLAINED BLEEDING/BRUISING PURPURA SORE THROAT FEVE
SULFALSAZINE/AMINOSALICYLATE SIDE-EFFECTS
Nausea Headache Rash Loss of appetite Raised temperature
STOMA CARE
LIQUID FORMS>MR FORMS, fluid/electrolyte loss
Na+Fluid depletion-> hypokalaemia, what risk?
DIGOXIN TOXICITY
STOMA CARE- ADVERSE EFFECT CAUSES
CAUSE OF DIARRHOEA?
CAUSE OF CONSTIPATION?
CAUSE OF GI irritation+bleed?
CAUSE OF DEHYDRATION->HYPOKALAEMIA?
CAUSE OF RAPID LOSS OF WATER/ELECTROLYTES?
DIARRHOEA? Sorbitol/Magnesium antacids/Iron (ileostomy)
CONSTIPATION? Opioids/Calcium antacids/Iron (colostomy)
GI irritation+bleed? Aspirin/NSAIDs
Dehydration->hypokalaemia? Diuretics-> Switch to K+ sparing diuretic
Rapid loss of water/electrolytes? Laxatives-> Switch to bulk-forming
STOMA CARE
EC/MR capsules unsuitable?
Better form?
EC/MR capsules unsuitable? Ineffective
Better form?
Quick action: liquids/uncoated/soluble tablets/capsules
STOMA CARE
What is it?
Artificial opening on abdomen, diverts flow of faeces/urine into external pouch
EXOCRINE PANCREATIC INSUFFICIENCY- MONITOR?
Levels of fat-soluble vitamins and micronutrients (zinc, selenium, etc)
EXOCRINE PANCREATIC INSUFFICIENCY
PATIENTS W/ CYSTIC FIBROSIS (CF)
High dose pancreatin issue?
Do not exceed?
Report any new?
PATIENTS W/ CYSTIC FIBROSIS (CF)
High dose pancreatin issue? Fibrosing colonopathy
Do not exceed? 10,000units/kg/day of lipase
Report any new? Abdominal symptoms
EXOCRINE PANCREATIC INSUFFICIENCY
WHAT DOES PANCREATIN CONTAIN?
COUNSELLING?
LIPASE+AMYLASE+PROTEASE
which digest
FATS+CARBS+PROTEINS
absorbed
COUNSELLING? Take w/ meal/snacks, prevent early breakdown
EXOCRINE PANCREATIC INSUFFICIENCY- TREATMENT?
Pancreatin- pancreatic enzyme replacemenet
PANCREATIC CANCER
What is it?
Reduced secretion of pancreatic enzymes into the duodenum due to pancreatitis/CF etc-> maldigestions/malnutrition
HAEMORRHOIDS- PREGNANCY?
BULK-FORMING LAXATIVE
Topical needed? Give a simple, soothing product
HAEMORRHOIDS- TREATMENT
PAIN/ITCHING?
TOPICAL PREPARATIONS
Lidocaine (anaesthetic)-> a few day use
Corticosteroids-> Max. 7 days use due to S-E
HAEMORRHOIDS
PAIN MANAGEMENT?
AVOID?
PAIN MANAGEMENT? PARACETAMOL
AVOID?
OPIOIDS-> constipation
NSAIDs-> exacerbate rectal bleeding
HAEMORRHOIDS
Constipated?
Bulk-forming laxative
HAEMORRHOIDS- NON-DRUG TREATMENT?
Increase dietary fibre+fluid intake
HAEMORRHOIDS
What is it?
Internal?
External?
What is it?
Swelling of vascular mucosal anal cushions around anus (high risk during prengnacy)
Internal?
Painless
External?
Itchy/painful
ANAL FISSURES- CHRONIC MANAGEMENT(>/6 weeks)
1st LINE?
2nd LINE?
Specialist?
Last resort?
1st LINE? Rectal GTN (headache common)
2nd LINE? Topical/oral diltiazem/nifedipine (less s-e w/ topical)
Specialist? botox
Last resort? SURGERY
ANAL FISSURES
ACUTE TREATMENT? (easy passage of stools+ease up pain)
-Prolonged burning?
ACUTE TREATMENT? (easy passage of stools+ease up pain)
Bulk-forming laxative–> Osmotic laxative
-Prolonged burning? Short-term topical containing
lidocaine (X pregnant women)
ANAL FISSURES
What is it?
Tear/ulcer in anal canal, causing bleeding+pain on defecation
GALLSTONES PAIN- TREATMENT
MILD-MORATE?
SEVERE?
MILD-MORATE? Paracetamol/NSAID
SEVERE? IM Diclofenac
GALLSTONES
DEFINITIVE TREATMENT (SYMPTOMATIC)?
SURGICAL REMOVAL
GALLSTONES
IRRITATED/BLOCKED GALLBLADDER?
Left untreated?
Can cause
pain/infection/inflammation
Left untreated? severe complications-> biliary colic, acute cholecystitis, cholangitis, pancreatitis, and obstructive jaundice
GALLSTONES
What is it?
Hard mineral/fatty deposits forming stones in the gallbladder bile duct
CHOLESTASIS- INTRAHEPATIC CHOLESTASIS IN PREGNANCY
When does it occur?
Treatment?
When does it occur? Late-> adverse fetal outcomes
Treatment? Ursodeoxycholic acid
CHOLESTASIS- CHOLESTATIC PRURITUS TREATMENT cur
1st LINE?
2nd LINE?
3rd LINE?
1st LINE? Cholestyramine
2nd LINE? Ursodeoxycholic Acid
3rd LINE? Rifampicin (unlicensed, careful in LD, hepato?)
LIVER DISORDERS- CHOLESTASIS
What is it?
Symptoms?
Impaired bile formation/flow-> fatigue, pruritus, dark urine, pale, jaundice
H2-RECEPTOR ANTAGONISTS- OTC sale FAMOTIDINE Age? Duration? Indication? Dose?
FAMOTIDINE Age? 16+ Duration? 2 weeks max Indication? Hearbturn/dyspepsia/prevention, sleep L, etc Dose? 10mg single, MAX. 20mg OD
H2-RECEPTOR ANTAGONISTS- INTERACTIONS?
Reduced absorption of -azole antifungals
Cimetidine- CYP450 enzyme inhibior
H2-RECEPTOR ANTAGONISTS- SIDE-EFFECTS?
DHDRT
Diarrhoea Headache Dizziness Rash Tiredness
H2-RECEPTOR ANTAGONISTS
Can mask symptoms of..?
Gastric cancer
H2-RECEPTOR ANTAGONISTS- EXAMPLES?
Famotidine
Ranitidine
Cimetidine
Nizatidine
PPIs- INTERACTIONS?
Clopidogrel+Omeprazole (Lansoprazole instead)
Methotrexate+Omeprazole (increased levels of methotrexate)-> PPI acts as enzyme inhibitor?
PPIs
Increased risk of..?
Can mask symptoms of?
Increased risk of..?
Fractures/Osteoporosis (hypomagnesaemia)
C. Difficile
Can mask symptoms of?
Gastric cancer
PPIs
MHRA Warning?
Low risk of subacute cutaneous lupus erythmeatosus, crazy
PPIs- EXAMPLES?
OMEPRAZOLE
ESOMEPRAZOLE
LANSOPRAZOLE
RABEPRAZOLE
ANTACIDS- INTERACTIONS
Increases stomach ph (»alkali) so enteric-coated capsules are…?
Impairs absorption of other drugs..?
High sodium content, don’t take with or in..?
Low-sodium antacid- example?
Increases stomach ph (»alkali) so enteric-coated capsules are…? Damaged before reaching intestine
Impairs absorption of other drugs..?
Bisphosphonates (risderonate, alendronate, zolendronic acid),
High sodium content, don’t take with or in..? Lithium/Hypertension
Low-sodium antacid- example? Co-magaldrox
ANTACIDS EFFECT
MAGNESIUM? (LM)
ALUMINIUM? (AC)
CALCIUM?
SIMETICONE?
ALGINATES+ANTACIDS?
MAGNESIUM? LAXATIVE effect
ALUMINIUM? CONSTIPATING effect
CALCIUM? Induces rebound acid secretion
SIMETICONE? relieves flatulence
ALGINATES+ANTACIDS? Increases viscosity of stomach content
-Forms a viscous gel (‘raft’) that floats on the surface of the stomach contents
GORD IN PREGNANCY
First, you gotta give diet+lifestyle advice
If that’s an L?
If above is also an L?
If that’s an L? antacid/alginate
If above is also an L? omeprazole/ranitidine
GORD TREATMENT
First, you gotta review the current medicines.
Uninvesigated GORD?
Confirmed GORD?
Uninvesigated GORD? 4 weeks of PPI (same as dyspepsia)
Confirmed GORD? 4-8 weeks of PPI
GORD
INITIAL LIFESTYLE ADVICE?
Healthy eating Weight loss (obese) Avoid trigger foods Smaller meals Evening meal 3-4hrs before bed Raise head of bed Smoking cessation Reduce alcohol consumption
GORD increases with…?
Consuming fatty foods Pregnancy Hiatus Hernia Family History Stress/anxiety Obesity Smoking Alcohol Some drugs: e.g. a/b-blockers, CCBs, benzos (use lowest effective dose OR STOP)
Nitrates- loosens up sphincter between windpipe/stomach, more acid? Mad
H. PYLORI TREATMENT?
3 COMBOS?
w/ Omeprazole? n maybe esomep
IF PENICILLIN ALLERGY?
H. PYLORI TREATMENT?
PPI+2 ANTIBIOTICS
PPI: BD (Omeprazole 20-40 | Lansoprazole 30)
Amoxicillin: 1000mg BD (other 2 in pen allergy)
Clarithromycin: 500mg BD
Metronidazole: 400mg BD
7 DAYS TREATMENT
3 COMBOS?
PAC OR PAM OR PCM
PPI+bismuthsubsalicylate+metronidazole+tetracycline
How do you test for H. pylori?
2 conditions?
How do you test for H. pylori? Urea (13C) breath test OR Stool Helicobacter Antigen Test (SAT)
2 conditions?
PPIs should’ve been stopped 2 weeks before test
&
Antibiotics should’ve been stopped 4 weeks before test
FUNCTIONAL DYSPEPSIA TREATMENT?
TEST FOR?
NOT INFECTED?
FUNCTIONAL DYSPEPSIA TREATMENT? Can’t identify underlying cause
TEST FOR? H. pylori- treat if +
NOT INFECTED? 4 weeks of PPI/H-2 receptor antagonist, e.g. cimetidine/famotidine, etc
UNINVENSTIGATED DYSPEPSIA TREATMENT?
TEST FOR?
UNINVENSTIGATED DYSPEPSIA TREATMENT?
PPI for 4 weeks
TEST FOR?
H. pylori if PPI didn’t work, treat if positive (PPI+ 2 antibacterials)
2 TYPES OF DYSPEPSIA?
UNINVENSTIGATED
&
FUNCTIONAL
Dyspepsia/GORD
Urgent Referral Symptoms?
GI bleeding
55 years+
Unexplained weight loss
Dysphagia
GASTRIC ACID DISORDERS & ULCERATION
Dyspepsia
What is it?
Upper abdominal pain/heartburn/gastric reflux/bloating/nausea/vomiting
LOPERAMIDE
OTC AGE? Diarrhoea w/ IBS? PRESCRIPTION AGE? HOW TO TAKE IT? MHRA WARNING? HOW TO TREAT OVERDOSE?
OTC AGE? 12 years+
Diarrhoea w/ IBS?- 18 years+
PRESCRIPTION AGE? 4 years+
HOW TO TAKE IT? 1-2 doses (2-4mg), then 1 w/ every loose stool, max. 8 doses (16mg) per day
MHRA WARNING? Serious cardiac reactions (QT prolongation) w/ high doses
HOW TO TREAT OVERDOSE? Naloxone
DIARRHOEA
1st LINE FAECAL INCONTINENCE? (can’t control bowels, just leaks)
Loperamide
DIARRHOEA
Rapid control needed/traveller’s diarrhoea?
BUT avoid in…
Use loperamide
BUT avoid in…
BLOODY/SUSPECTED inflammatory diarrhoea
DIARRHOEA
SEVERE/CAN’T DRINK?
Hospital-> IV fluids ASAP
ACUTE DIARRHOEA- usually settles itself but can use ORT to prevent/correct dehydration. Obvs
CONSTIPATION IN CHIDLREN
1st LINE? L?
STILL HARD STOOLS?
1st LINE? Dietary advice+macrogol (if no faecal impaction) L? Stimulant
STILL HARD STOOLS? Lactulose/Docusate
CONSTIPATION IN PREGNANCY/BREAST-FEEDING? 1st LINE? 2nd LINE? L? Still an L?
1st LINE? Diet+lifestyle, fibre key!
2nd LINE? Bulk-forming, e.g. ISPAGHULA HUSK.
L? Lactulose
Still an L? Bisacodyl/senna (don’t use senna near birrth)?
OPIOID-INDUCED CONSTIPATIENT TREATMENT
1st LINE?
L?
AVOID?
1st LINE? OSMOTIC+STIMULANT
L? NALOXEGOL
AVOID? BULK-FORMING (peristalsis already slow mate!)
FAECAL IMPACTION TREATMENT
HARD STOOLS? once softened?
L?
SOFT STOOLS?
L?
HARD STOOLS? Macrogol & once softened? Stimulant
L? Rectal glycerol ONLY OR glycerol+bisacodyl
SOFT STOOLS? Stimulant
L? Rectal bisacodyl
CHRONIC CONSTIPATION TREATMENT?
Still hard stools?
Still no change after 6 months?
Bulk-forming+good hydration
Still hard stools? Add/change to Macrogol/Lactulose
Still no change after 6 months? Prucalopride
Withdraw lactulose slowly when patient improves by the way!
SHORT-DURATION CONSTIPATION TREATMENT?
Bulk-forming+good hydration.
L? Osmotic
OSMOTIC LAXATIVES
Examples?
How does it work?
How long?
Examples? Lactulose, Macrogol
How does it work? Increases amount of fluid in the large bowel-> peristalsis
How long? 2-3 days
LIQUID PARAFFIN CAUTION DUE TO SIDE-EFFECTS..?
Anal seepage
Risks of:
Granulomatous disease of GI tract
Lipoid pneumonia on aspiration
LAXATIVES
FAECAL SOFTENERS
Examples?
How it works?
Quickest-acting?
Examples? Liquid paraffin, docusate, glycerol
How it works? Increases water penetration into stool
Quickest-acting? GLYCEROL SUPPOSITORY THE QUICKEST!
STIMULANT LAXATIVES USED IN TERMINALLY ILL PATIENTS?
CO-DANTHRAMER (red urine)
CO-DANTHRUSATE (orange urine)
limited use due to carcinogenicity..
STIMULANT LAXATIVES Examples? How it works? How long? Avoid in?
Examples? Senna, Sodium Picosulfate, Bisacodyl, docusate, glycerol
How it works? Stimulates intestinal motility
How long? Takes 6-12hrs to work
Avoid in? Intestinal obstruction
BULK-FORMING LAXATIVES Examples? How it works? How long? Advice?
Examples? Methylcellulose/Ispaghula Husk/Sterculia
How it works? Small, hard stools- increases faecal mass, stimulates peristalsis
How long? 2-3 days to work
Advice? Take w/ plenty of water to prevent intestinal blockage
LAXATIVES
4 TYPES? BSFSO
BULK
STIMULANT
FAECAL SOFTENERS
OSMOTIC
CONSTIPATION
NON-DRUG TREATMENT?
FIBRE WATER EXERCISE \+ Review possibly medications-causing? E.g. opioids, aluminium?, CLOZAPINE (BIG RED FLAG!) intestinal peristalsis?
CONSTIPATION- RED FLAG? BAAW>?
Blood in stool Anaemia Abdominal pain Weight loss New onset constipation> 50 years
CONSTIPATION
What is it?
Infrequent, difficult stools
SHORT BOWEL SYNDROME
DIARRHOEA/HIGH OUTPUT STOMAS TREATMENT?
LOPERAMIDE/CODEINE TO REDUCE INSTETINAL MOTILITY
SHORT BOWEL SYNDROME
NUTRITIONAL DEFICIENCIES?
Replace…
Vitamins A, B12, D, E, and K, essential fatty acids, zinc, and selenium
SHORT BOWEL SYNDROME
What is it?
Shortened bowel due to large surgical resection. Need to ensure adequate absorption of nutrients+fluid!
IBS TREATMENT- OTC an L for abdominal pain/discomfort
2nd LINE?
Alternative?
2nd LINE? TCA: Amitriptyline
Alternative? SSRIs
[UNLICENSED]
IBS TREATMENT
x4 OTC? LALA
LAXATIVES: if constipated (X lactulose, can cause bloating)
ANTISPASMODICS: alverine, mebeverine & peppermint oil
LOPERAMIDE: if experiencing diarrhoea
ANTIMUSCARINICS: hyoscine BUTYLbromide (avoid in cardiac disease)
hyscoine BUTYLbromide- IBS, your BUTT
hyoscine HYDRObromide- ship, water, motion sickness, HYDRO
IBS
NON-DRUG TREATMENT?
Exercise Regular meals Reduce fresh fruit-3/day Reduce insoluble fibre Drink >/= 8 cups of water Reduce caffeine/alcohol/fizzy drinks Avoid sorbitol if you have diarrhoea Reduce stress
IBS CAN BE EXACERBATED BY..?
COFFEE/ALCOHOL/MILK
LARGE MEALS
FRIED FOODS
STRESS
IRRITABLE BOWEL SYNDROME
What is it?
Common/chronic/relapsing/life-long-> abdomina pain/diarrhoea/constipation/urgency/incomplete defaecation/passing mucus
AMIONOSALICYLATES CONTRAINDINCATED IN..
SULFASLAZINE COLOURFUL SIDE-EFFECT?
AMIONOSALICYLATES CONTRAINDINCATED IN SALICYLATE HYPERSENSITIVITY. Obvs…
SULFASLAZINE COLOURFUL SIDE-EFFECT? Stains contact lenses orangey-yellow
AMINOSALICYLATES- SIDE-EFFECTS & MONITORING
NHB
NEPHROTOXIC? RENAL
HEPATOTOXIC?
BLOOD DISORDERS?
NEPHROTOXIC? Monitor before, at 3 months & /year
HEPATOTOXIC? Monitor at monthly intervals for first 3 months
BLOOD DISORDERS? Monitor at monthly intervals for first 3 months
Perform blood count+stop drug ASAP if signs of blood dyscrasia
ULCERATIVE COLITIS- MAINTENANCE TREATMENT
PROCTITIS/PROCTOSIGMOIDITIS?
LEFT-SIDED/EXTENSIVE?
2+ FLARES IN 12 MONTHS?
PROCTITIS/PROCTOSIGMOIDITIS?
RECTAL AND/OR ORAL AMINOSALICYLATE
LEFT-SIDED/EXTENSIVE?
LOW-DOSE ORAL AMINOSALICYLATE
2+ FLARES IN 12 MONTHS?
ORAL AZATHIOPRINE/MERCAPTOPURINE (Give monoclonal antibodies if no effect)
ULCERATIVE COLITIS- MAINTENANCE TREATMENT
WHY DO WE AVOID CORTICOSTEROIDS?
Cos of side-effects
AMINOSALICYLATES>CORTICOSTEROIDS
ULCERATIVE COLITIS- ACUTE SEVERE TREATMENT
1st LINE?
2nd LINE?
Symptoms not helped within 72hrs?
Alternative to Ciclosporin?
1st LINE? IV hydrocortisone/methylprednisolone-> need for surgery?
2nd LINE? IV cyclosporin/surgery
Symptoms not helped within 72hrs? IV steroid+IV ciclosporin OR surgery
Alternative to Ciclosporin? Infliximab
ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT
EXTENSIVE ULCERATIVE COLITIS
1st LINE?
2nd LINE?
1st LINE? TOPICAL AMINOSALICYLATE+HIGH-DOSE ORAL AMINOSALICYLATE
2nd LINE? NO CHANGE AFTER 4 WEEKS?
STOP TOPICAL AMINOSALICYLATE, GIVE:
HIGH-DOSE ORAL AMINOSALICYLATE+4-8 WEEKS ORAL CORTICOSTEROID
NOTE: Aminosalicylates contraindicated? Consider ORAL (ONLY) corticosteroid 4-8 weeks.
ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT
PROCTOSIGMOIDTIS/LEFT-SIDED ULCERATIVE COLITIS
1st LINE?
2nd LINE?
3rd LINE?
1st LINE?
TOPICAL AMINOSALICYLATE
2nd LINE?
ADD-ON HIGH-DOSE ORAL AMINOSALICYLATE if no improvement after 4 weeks
OR
SWITCH TO HIGH-DOSE ORAL AMINOSALICYLATE+4-8 WEEKS OF TOPICAL CORTICOSTEROIDS
3rd LINE?
STOP TOPICAL TREATMENT, GIVE:
ORAL AMINOSALICYATE+4-8 WEEKS OF ORAL CORTICOSTEROIDS
NOTE: Aminosalicylates contraindicated? Consider topical/oral corticosteroid 4-8 weeks.
ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT
PROCTITIS
1st LINE?
2nd LINE?
3rd LINE?
1st LINE? Topical aminosalicylate (sulfasalazine, mesalazine…)
2nd LINE? Oral aminosalicylate (if no improvement after 4 weeks)
3rd LINE? Topical/oral corticosteroid for 4-8 weeks
NOTE: Aminosalicylates contraindicated? Consider topical/oral corticosteroid 4-8 weeks.
DIARRHOEA IN ULCERATIVE COLITIS?
AVOID LOPERAMIDE/CODEINE-> can cause toxic megacolon (as gastric emptying is slowed down, build-up)
Only use on advice of a specialist!^
DIARRHOEA IN ULCERATIVE COLITIS?
AVOID LOPERAMIDE/CODEINE-> can cause toxic megacolon (as gastric emptying is slowed down, build-up)
Only use on advice of a specialist!^
ULCERATIVE COLITIS- ACUTE MILD-MODERATE TREATMENT
DISTAL-RECTAL?
EXTENDED?
DISTAL-RECTAL? Suppositories/Enemas-> foam preps used if patient has difficulty retaining liquid enema
EXTENDED? Systemic medication
ULCERATIVE COLITIS
INCREASING SEVERITY?
- Proctitis
- Proctosigmoiditis
- Left-sided
- Extensive colitis
- Pancolitis
UC has a continuous pattern, CD is patchy
ULCERATIVE COLITIS
MOST COMMON AGE?
COMPLICATIONS?
MOST COMMON AGE? 15-25years
COMPLICATIONS? Colorectal cancer Secondary osteoporosis Venous thromboembolism Toxic megacolon
ULCERATIVE COLITIS
What is it?
Can affect region from rectum-whole colon- blood diarrhoea/defecation urgency/abdominal pain
FISTULATING CROHN’S DISEASE
ASYMPTOMATIC?
TO IMPROVE SYMPTOMS?
MAINTENANCE?
ASYMPTOMATIC? Let it be
TO IMPROVE SYMPTOMS?
Metronidazole AND/OR Ciprofloxacin
(Metronidazole- ~1 month, NOT >3 months due to peripheral neuropathy)
MAINTENANCE?
Azathioprine OR Mercaptopurine (Infliximab if response L)
Treatment >/= 1 year by the way
FISTULATING CROHN’S DISEASE
WHAT IS IT?
When a fistula develops between intestine & perianal skin/bladder/vagina
CROHN’S DISEASE- DIARRHOEA TREATMENT?
LOPERAMIDE
CoDeine (CD) UC, you can’t by the way!
COLESTYRAMINE
CROHN’S DISEASE- MAINTENANCE OF REMISSION
STOP SMOKING+NUTRITION KEY
DO NOT USE CORTICOSTEROIDS/BUDESONIDE FOR MAINTENANCE!
MONOTHERAPY?
-Alternative?
POST-SURGERY?
STOP SMOKING+NUTRITION KEY
MONOTHERAPY? Azathioprine OR Mercaptopurine
-Alternative? Methotrexate
POST-SURGERY?
Azathioprine+Metronidazole (3 months)
OR
Aazathioprine alone
CROHN’S DISEASE- ACUTE
2+ FLARE UPs in 12 MONTH PERIOD
Add-on 1st LINE?
2nd LINE?
SEVERE?
Add-on 1st LINE? Azathioprine OR Mercaptopurine
2nd LINE? Above an L-> add-in Methotrexate
SEVERE? Monoclonal antibodies
CROHN’S DISEASE TREATMENT- ACUTE
1 FLARE-UP IN 12 MONTH PERIOD
1st LINE?
Patient has distal ilea/ileocaecal/right-sided disease?
-Alternative?
1st LINE? Prednisolone/methylprednisolone/IV hydrocortisone (monotherapy)
Patient has distal ilea/ileocaecal/right-sided disease? Budesonide
-Alternative? Aminosalicylates (sulfasalazine/mesalazine)-> less side-effects, less effective
CROHN’S DISEASE
Can lead to complications such as…?
INTESTINAL FISTULAE
ANAEMIA/MALNUTRITION
COLORECTAL/SMALL BOWEL CANCER
GROWTH FAILURE/DELAYED PUBERTY IN CHILDREN
EXTRA-INTESTINAL MANIFESTATION: arthritis/joints/eyes/liver/skin abnormalities
CROHN’S DISEASE
What is it?
Affects whole GI-tract- thickened wall, all layers, deep ulceration
TREATMENT
DIVERTICULAR DISEASE/ACUTE DIVERTICULITIS? mynaaa
COMPLICATED?
DIVERTICULAR DISEASE/ACUTE DIVERTICULITIS?
Paracetamol- ongoing abdominal pain
Bulk-forming laxatives- constipation
COMPLICATED? SURGERY ASAP
AVOID NSAIDs by the way-> higher risk of diverticular perforation
DIVERTICULAR DISEASE & DIVERTICULITIS
DIVERTICULOSIS?
DIVERTICULAR DISEASE?
ACUTE DIVERTICULITIS?
COMPLICATED ACUTE DIVERTICULITIS?
DIVERTICULOSIS? small pouches but asymptomatic (no treatment needed)
DIVERTICULAR DISEASE? small pouches but symptomatic- abdominal pain, constipation, diarrhoea, rectal bleeding
ACUTE DIVERTICULITIS? when pouches become inflamed/infected- severe abdominal pain, fever, significant rectal bleeding
COMPLICATED ACUTE DIVERTICULITIS? abscess, perforation, fistula, obstruction, sepsis, haemorrhage
COELIAC DISEASE- AIMS
MANAGE SYMPTOMS?
AVOID MALNUTRITION?
MANAGE SYMPTOMS? diarrhoea/bloating/abdominal pain
AVOID MALNUTRITION? give vitamin D, calcium+other nutrients (supervised)
COELIAC DISEASE
Occurs in..?
Asscoiated w/..?
May cause malabsorption of..?
Occurs in small intestine
Asscoiated w/ gluten/wheat/barley/rye
-Causes immune response in intestinal mucosa (JUST AVOID GLUTEN)
May cause malabsorption of nutrients
CHRONIC BOWEL DISORDERS
3 TYPES???????
COELIAC DISEASE
CROHN’S
ULCERATIVE COLITIS
H PYLORI- GASTRIC ULCER- TREATMENT!
ATENOLOL DYSPEPSIA? IT DOESN’T HAPPEN
MEBEVERIN ALTERNATIVE?
HYOSCINE
PREGNANT, DIET, LIFESTYLE, CONSTIPATED?
START BULK FORMING
SULFASALAZINE, SORE THROAT?
GP BRUH
BLOOD DISORDER/DYSCRASIA
STOMA CARE, LOPERAMIDE CODEINE?
The antidiarrhoeal drugs, loperamide hydrochloride and codeine phosphate, reduce intestinal motility and decrease water and sodium output from an ileostomy. Loperamide hydrochloride circulates through the enterohepatic circulation, which is disrupted in patients with a short bowel.
CROHN’S SEVERE?
Aminosalicylates and budesonide are not appropriate for severe presentations or exacerbations.
PPI LONG-TERM L?
B12 absorption lacking
Ms. B comes into the pharmacy asking to speak to the pharmacist. She tells you her stools
have been hard and pellet like. You can see that she may be pregnant and on questioning,
you confirm that she is 7 months pregnant. She has tried to change her diet and drink more
water but this has been ineffective. She has no other medical condition and on no other
medication
Recommend the use of Lactulose – Ms B is suffering from constipation so she needs
a laxative if dietary measures have been ineffective.
PeptoBismol & Milk of Magnesia -for indigestion;
Astringent?
Bismuth oxide
H. Pylori eradication treatment must be given to all patients with gastric ulcers – The
test must be done before giving treatmen
Mr T has been diagnosed with a blocked bile duct and has been prescribed the drug
colestyramine in an attempt to control the itching he is experiencing. He enquires about the
potential side effects of the drug.
Which one of the following adverse effects is not normally associated with
colestyramine?
Myalgia
Other side-effects?
Diarrhoea, GI discomfort, hypertriglyceridaemie (aggravation),
hypoprothrombinaemia associated with Vit K deficiency, vomiting
A patient has been taking clindamycin for the past three days and has developed nausea
and diarrhoea. They ask for your advice about what to do. They have been taking
Clindamycin as prescribed: 450mg QDS. They still have four more days of treatment to go.
What is the most appropriate advice to give the patient?
They should stop taking the Clindamycin immediately and go and get an urgent
appointment with their doctor
METHOTREXATE SIDE-EFFECTS? (D)USSBM
DARK URINE/ABDOMINAL DISCOMFORT SOB SORE THROAT BRUISING MOUTH ULCERS
Coeliac disease test?
IBD TEST FOR UC/CROHN’S?
FAECAL CALPROTECTIN,
normal in IBS, raised in IBD
addison’s disease, raised cholesterol, weight gain, cold, test?
Thyroid test
test for DVT?
D-dimer
VTE test?
D-dimer
Patient, abdominal pain, bloating, diarrhoea, lactose intolerant. Test?
Hydrogen breath test- detects intestinal bacterial overgrowth or lactose/fructose intolerance
vitamin deficiency, scurvy, gum disease?
Vitamin C is key!
WHAT IS VITAMIN B9?
folic acid (give with methotrexate, separate day, etc)
+ inotrope n - chronotropic drug?
digoxin
- inotrope and - chronotrope drug?
diltiazem
drug affected by alcohol, give by brand, 10-20 target?
theophylline!
sulfasalazine, diarrhoea does occur but?
it does not need to be reported
carbon 13 urea test?
h pylori
crp test for?
inflammation, infection/arthritis/ lupus?
ANAL FISSURE
