Gastro-intestinal system Flashcards
Coeliac is a chronic autoimmune condition associated with inflammation of which part of the gut?
The small intestine (think this is where most things are absorbed and can’t be because of the immune response in intestinal mucosa)
What causes the inflammation in coeliac?
Gluten
Where is coeliac found?
Wheat, barley, rye
What supplementation is/can be recommended for coeliac?
Calcium and vitamin D- assess osteoporosis and bone disease risk
How can you treat coeliac disease?
A gluten free diet, strict and lifelong. Although, prednisolone can be considered for initial management whilst waiting
What is diverticulosis?
An asymptomatic condition characterised by the presence of diverticula (small pouches protruding from walls of large intestine)
What is diverticular disease?
A condition where the diverticula cause intermittent lower abdominal pain in the absence of inflammation or infection.
What is acute diverticulitis?
Where the diverticula become inflamed or infected
How do you treat all of the above (diverticular disease/diverticulitis)?
Diet and lifestyle: healthy balanced diet including whole grains, fruit veg.
Increase fibre slowly to reduce constipation, fluid.
Exercise, weight loss, smoking cessation.
High fibre if tolerated should continue for life.
Drugs: antibiotics aren’t recommended but bulk forming laxatives when high fibre diet is unsuitable or persistent constipation or diarrhoea.
Simples analgesics ie paracetamol and antispasmodics.
NSAIDS NOT RECOMMENDED NOR OPIOIDS as increases risk of diverticular perforation.
Aminosalicylates also not recommended
What class of drug is Mesalazine?
Aminosalicylate
What is sulfasalazine combined with as well as 5-ASA?
5-ASA with Sulfapyridine (in the colon the enzymes break this bond)
What is the other indication sulfasalazine is used in?
Rheumatoid arthritis
List some more serious side effects of Aminosalicylates
Leucopoenia,
thrombocytopenia,
renal impairment,
oligospermia (reduced sperm count) and
hypersensitivity reaction.
What antiplatelet do we avoid with Aminosalicylates?
Aspirin as this is also a salicylate- overdose
MOA of methotrexate
Inhibits dihydrofolate reductase, which inhibits dihydrofolate convert to tetrahydrofolate which is required for DNA synthesis and protein synthesis. It also promotes inflammatory and immunosuppressive effects through IL6, IL8 and TNF alpha.
What medicine do we give to reduce methotrexate toxicity?
Folic acid 5mg once weekly
What medicines can you recommend treating diarrhoea in Crohns but not in colitis?
Loperamide or codeine
What do you recommend for the treatment for Crohns for the first presentation or if there has only been one acute flare up in the past year?
A corticosteroid (prednisolone, methylprednisolone, IV hydrocortisone).
Alternatives i.e., budesonide or Aminosalicylates but NOT TO USE THESE ALTERNATIVES IF SEVERE PRESENTATION
What do you recommend for addition to the monotherapy for treatment of Crohns if a patient has had two or more acute flare ups in 12 months?
Azathioprine or mercaptopurine. Alternate= methotrexate (added to corticosteroid or budesonide to induce remission)
What do we recommend for treatment in remission of Crohn?
Azathioprine or mercaptopurine (alt= methotrexate)
What do we recommend for maintenance of remission of Crohn after surgery?
Azathioprine, with three months of metronidazole [unlicensed].
What do we no longer recommend for maintenance of remission of Crohns after surgery?
Do not give aminosalicylates post-surgery as lack of efficacy in evidence. Also, do not give mercaptopurine generally as NICE do not deem this as cost effective
What is proctitis?
Chronic inflammation of the rectum (diffuse mucosal inflammation)
What is proctosigmoiditis?
Inflammation of the rectum and sigmoid colon
What is left sided colitis?
Colon distal to splenic flexure (end of left side just before transverse colon) and includes pan colitis where whole colon is involved (left part of colon is affected)
Why do we not give loperamide or codeine in acute UC for diarrhoea symptoms?
Increased risk of toxic megacolon
With treatment in UC with aminosalicylates. What is preferred, OD dosing or multiple daily dosing?
Single daily dosing
What formulation would you use in the different types of UC:
a) proctitis
b) proctosigmoiditis
c) left sided colitis
d) extensive colitis
A) suppositories
b) foam preparation
c) enemas
d) oral
How would you treat mild proctitis?
opical aminosalicylate if mild to moderate, if no remission in 4 weeks add an oral aminosalicylate. If still inadequate add topical/oral corticosteroids for 4-8 weeks.
How would you treat mild proctosigmoiditis?
Topical aminosalicylate for mild to moderate, if no remission in 4 weeks add a HIGH dose oral aminosalicylate and 4-8 weeks of topical steroid. If still inadequate, stop topical treatment and offer aminosalicylate and 4-8 weeks of oral steroid.
How would you treat mild left sided ulcerative colitis?
(the same as proctosigmoiditis) Topical aminosalicylate for mild to moderate, if no remission in 4 weeks add a HIGH dose oral aminosalicylate and 4-8 weeks of topical steroid. If still inadequate, stop topical treatment and offer aminosalicylate and 4-8 weeks of oral steroid.
How would you treat mild extensive ulcerative colitis?
Topical aminosalicylates AND high dose oral aminosalicylates. If no remission in 4 weeks, stop topical and offer high dose oral aminosalicylate AND 4-8 weeks of oral corticosteroid.
How would you treat moderate to severe ulcerative colitis?
Biologics i.e., adalimumab, golimumab, infliximab, vedolizumab etc but needs national funding
How would you treat ACUTE severe UC?
Immediate hospital admission, IV corticosteroids given to induce remission. Assess need for surgery, fluids
What can you do if a patient is contraindicated to corticosteroids in acute severe UC?
Give ciclosporin (NB: if ciclosporin not tolerated then use infliximab)
Why do we generally not give methotrexate in maintenance for UC?
No evidence to support it in inducing or maintaining remission
What do we give in maintenance for UC?
Proctitis= local 5ASA.
Extensive= aminosalicylates.
Can use mercaptopurine/azathioprine if has more than 2 flare ups a year
How often do you measure renal function with aminosalicylates?
At the start of treatment,
at three months,
then yearly
Why does/could lactulose interact with MR oral Mesalazine?
Mesalazine manufacturers suggest that anything that lowers the stool pH might affect/prevent the release of Mesalazine.
What colour can Mesalazine colour the urine/body secretions?
Yellow (NB sulfasalazine more than Mesalazine)
In IBS, how many portions of fruit should you limit the daily intake to?
3 portions of fruit a day
What should you recommend IBS patients do for fibre intake?
IBS patients should increase soluble fibre if needed, for example ispaghula or foods high in it (oats) and to reduce/discourage resistant starch or insoluble fibre i.e., bran as exacerbates IBS
What type of sugar should IBS patients avoid?
Sorbitol (found in sweetener)
How many cups of water should you have a day?
8 cups of water a day
If probiotics are initiated, how long should they be taken for to see if the effects work
4 weeks (at least)
What is the first line for IBS?
An antispasmodic i.e. alverine, mebeverine, peppermint oil. Second line = antimuscarinic- hyoscine butylbromide
What are the ages for IBS treatments?
alverine (12),
mebeverine 18,
peppermint 15.
Hyoscine butylbromide = 6
What laxative do we avoid in IBS?
Lactulose because it causes bloating
What do we use for constipation in IBS?
Bulk forming laxatives (ispaghula 6), if had for 12 months can use linaclotide
What do you use for diarrhoea in IBS?
Loperamide (12 OTC or IBS patients not under 18)
What is the MHRA alert with hyoscine butylbromide?
IJ can cause tachycardia, hypotension, anaphylaxis (especially in CHD) so should be used with caution in patients with CV disease and that they are monitored closely with resuscitation equipment available
What drug formulations can you not used in short bowel syndrome?
E/C and M/R not suitable. Ideally use liquid, uncoated tablets or soluble tablets are also fine.
What do you use first line for diarrhoea in short bowel syndrome?
Oral rehydration salts, it promotes adequate hydration
Colestyramine can be used in patients with an intact colon and less than …..cm of ileum resected. It is used for what in short bowel syndrome.
100cm. Used to bind unabsorbed bile salts and reduce diarrhoea
Anticholinergic side effects
Poor coordination, dementia, dry eyes, dry mouth, reduced mucus production, pupil dilation, double vision, increased HR, urinary retention
Alarm symptoms- new onset constipation in what age?
Over 50
Is abdominal pain an alarm symptom?
Yes
Laxatives cause which electrolyte abnormality?
Hypokalaemia
When do you refer children and adults with constipation?
Over 7 days in children and 14 days in adults
Onset for osmotic laxatives?
48-72 hours
Onset for bulk forming laxatives?
Up to 72 hours but can be 12-36 hours
Age for methylcellulose?
12
What is the onset for stimulant laxatives?
6-12 hours
Age for bisacodyl
4
Age for docusate sodium
6
What group of patients can co-danthromer and co-danthrusate be used in?
Palliative only
What laxatives are to be used in opioid induced constipation?
Opioid and osmotic
What laxative do we avoid in opioid induced constipation and why?
Bulk forming- faecal impaction
In women, if 2 different classes of laxatives has been trialled and not worked over 6 months what drug can be used?
Prucalopride (women only)
When would you refer diarrhoea?
<3 months in a child- immediate referral
3months-1 year >1 day refer
1 year to under 3 years: 2 days or more then refer
3 years and over: 3 days then refer
What are the red flags with diarrhoea?
Recent foreign travel, rectal bleeding, unexplained weight loss, persistent diarrhoea, systemic illness, received recently hospital treatment or antibiotic treatment
What is the first line for diarrhoea?
Oral rehydration salts first line but in severe cases hospital admission and urgent IV rehydration fluids.
Drugs: loperamide, (not recommended under 12, 18 in IBS)
What is chronic diarrhoea?
> 14 days
What is the dosing for loperamide?
Initially 4mg, then 2mg up to 5 days, take a dose after each stool. MAXIMUM 16MG A DAY
What is the normal antibiotic used in travellers’ diarrhoea?
Ciprofloxacin
What is the MHRA alert with loperamide?
Serious cardiac adverse reactions with high doses of loperamide associated with abuse or misuse. Naloxone is the antidote and monitor for 48 hours to detect possible CNS depression.
How long can you store oral rehydration therapy for in the fridge?
24 hours
What are the symptoms of dyspepsia?
Upper abdominal pain, discomfort, heartburn, gastric reflux, bloating, nausea and vomiting
What nondrug treatment would you advise for GORD?
Healthy eating, weight loss,
avoid trigger foods,
eat smaller meals,
eat evening meals 3-4 hours before bed,
raise head of bed,
smoking cessation and
reduce alcohol
What age would be a red flag for onset of GORD?
Over 55
What are red flags for GORD?
Dysphagia,
significant acute GI bleeding, age 55 and
over with new onset or unexplained weight loss
What is the initial management of dyspepsia?
PPI for 4 weeks, if ineffective test for H pylori and treat if positive. If symptoms persist, use for another 4 weeks (dose can be doubled) or a h2RA and can be used PRN. NB: alginates or antacids not supposed to be for long term treatment
What do you recommend for GORD in pregnancy?
Dietary and lifestyle advice first line. PPI for 1 month (omeprazole), or ranitidine [unlicensed]
What is the OTC age for antacids and alginates?
12 and over
Some OTC remedies can contain bismuth (i.e., Pepto-Bismol). Why should this occasionally be avoided?
Bismuth can be neurotoxic-> encephalopathy + constipating. (Licensed in 16+)
Which out of magnesium and aluminium is constipating?
Magnesium is a laxative and
aluminium is constipating
Why do we prefer sodium over calcium in antacids?
Calcium can induce rebound acid secretion and gives hypercalcaemia
Simeticone can be added to preparations for antifoaming properties. What else can it be used for?
Flatulence
How do you take lansoprazole?
30-60 mins before food
What is the MHRA alert with PPIs?
Very low risk of lupus (subacute cutaneous lupus erythematosus)
What electrolytes are monitored with PPIs?
Sodium and magnesium (lowered)
What is a risk with PPIs in long term use?
Risk of fractures and increased risk of GI infections, rebound acid secretion (rebound acid secretion upon discontinuation), masks symptoms of gastric cancer
Cautionary and advisory labels with PPIs (not lansop)?
Swallow whole
How long is H pylori treatment?
Normally 1 week
Do you give antisecretory treatment with H pylori?
No, only if ulcer is LARGE or complicated haemorrhage or perforation then PPI for 3 weeks
Dosing for H pylori treatment?
PPI, 2 antibiotics: proton pump inhibitor BD,
amox (normally 1g BD unless combo with omep and metronidazole then it is 500mg TDS),
clari 500mg BD with amox or clari 250mg BD with metronidazole is 400mg BD
When can H pylori testing not be done regarding recent antibacterials or antisecretory medicines?
It should not be done within 4 weeks of antibacterial or 2 weeks of an antisecretory
What medicines do you use in food allergy?
an use sodium cromoglicate as an adjunct to dietary avoidance.
Chlorphenamine for symptomatic control of food allergy and adrenaline/epinephrine for anaphylaxis
What are cautions with antimuscarinics?
Susceptibility to angle closure glaucoma, conditions causing tachycardia (i.e., hyperthyroidism), CV disease
Give examples of antispasmodics
Mebervine, peppermint oil, alverine (contraindicated in paralytic ileus)
How do you treat anal fissures?
Ensure soft stools: bulk forming laxatives (alternative-osmotic), and short term topical local anaesthetic, i.e., lidocaine. Apply before emptying bowel
What do you use to treat chronic anal fissures?
GTN rectal ointment
What is the treatment for haemorrhoids?
Bulk forming laxative, simple analgesics
(avoid NSAIDs in rectal bleeding, avoid codeine as constipating),
topical preparations such as lidocaine, corticosteroids. MAX USE = FEW DAYS, but for corticosteroids= 7 days max use
What is cholestasis?
Impairment in bile formation/flow
What are fat soluble vitamins?
Vitamin A D E K
What do you use in the treatment of cholestatic pruritis?
Colestyramine is the drug of choice (binds to bile acids and excretes them, it isn’t absorbed in the GI tract).
Second line- Ursodeoxycholic acid.
Third line= rifampicin [unlicensed]
How do you treat gallstones?
It doesn’t need treatment unless symptoms/pain develops, then surgical laparoscopic cholecystectomy. Can use analgesia for pain, paracetamol/NSAIDS for mild to moderate
What is the MHRA alert with Obeticholic acid (bile acid)?
Risk of severe liver injury in patients with pre-existing moderate or severe liver impairment, dose adjust
What is obesity classed as?
BMI 30 or over. Waist circumference men-94 women-80 or Asian men -90
Who can have orlistat?
Patients > 18 y/o with BMI of 28 or more with other risk factors
When do you discontinue orlistat?
After 12 weeks if weight loss has not exceeded 5%. Can only supply 6 months
When do you refer for orlistat?
If they are diabetic, if they have HTN, hypercholesteremia, taking amiodarone, levothyroxine, antiepileptics, using more than 6 months or no weight loss (5%) in 12 weeks/3 months
What enzymes are in pancreatin?
Amylase, lipase, protease
(all liver enzymes)
What is the dietary advice for exocrine pancreatic insufficiency?
Eat smaller meals (3),
do not consume alcohols, distribute snacks 2-3 a day ,
avoid reduced fat diets,
avoid foods that are difficult to digest i.e. legumes, and high fibre foods
How do you take pancreatin?
Take with meals/snacks or immediately after (do not mix with hot foods or drinks because inactivates enzymes)
What is the drug of choice for ascites?
High dose spironolactone
