Gastro-intestinal system Flashcards by Ann Awini

Can anti- diarrhoea’s be used in acute ulcerative colitis?

No- increased risk of toxic megacolon.

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How is an acute flare up of (non severe) ulcerative colitis treated?

1st line- oral/rectal aminosalicylate
2nd line- ADD oral beclometasone
3rd line- ADD oral prednisolone (if becometasone fails)
4th line ADD oral Tacrolimus
5th line- Monoclonal antibodies (e.g infliximab)

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How is an acute flare up of severe ulcerative colitis managed?

Medical emergency- immediate hospitalisation.

1st line- IV steroids
2nd line- IV cyclosporin or surgery
3rd line- monoclonal antibodies

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What is the maintenance treatment for ulcerative colitis?

1st line- oral or rectal aminosalicylates
2nd line- azathioprine or mercaptopurine
3rd line- monoclonals: infliximab, adalimumab and vedolizumab.

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What are some aminosalicylates?

When should treatment be discontinued?

Mesalasine, sulfasalazine

Can cause bone marrow suppression and blood disorders- STOP if sore throat, etc and do FBC.

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What side effect can monoclonal antibodies cause?

Increased susceptibility to opportunistic infections.

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What must be treated before starting a monoclonal antibody?

Screen for and treat latent TB.

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How is irritable bowel syndrome (IBS) treated?

1st line: antispasmodics to relax GI smooth muscle
2nd line: low dose TCA for abdominal pain/ SSRI

Use laxatives and antidiarrhoeals as needed.

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What is eluxadoline?

An antidiarrhoeal that can be used in IBS as a last resort if nothing else has worked.
Stop after 4 weeks if no benefit.
MHRA alert about risk of pancreatitis- avoid if liver disorders or cholecystectomy.

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What issues are present with short bowel syndrome?

Short bowel due to large surgical resection leading to inadequate absorption in the gut.

Many vitamins and minerals may need supplementation especially magnesium.
Some drugs may need higher doses than usual
MR/ GR drugs are unsuitable
Diarrhoea is common. Treat as appropriate

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What are some antispasmodics used in IBS?

alverine, mebeverine, peppermint oil.

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What are some bulk forming laxatives?

When are they used?

Ispaghula husk, sterculia, methylcellulose.

Small hard stools

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How long do bulk forming laxatives take to work?

72 hours.

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When should stimulant laxatives be avoided?

intestinal obstruction

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Which laxative is of benefit in hepatic encephalopathy and why?

Lactulose- discourages proliferation of ammonia producing organisms.

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What class of laxatives are macrogols?

osmotic laxatives

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What is linaclotide?

A laxative used for constipation in those with IBS

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What is the recommended treatment for opioid induced constipation?

1st line: osmotic laxative (lactulose) or docusate

2nd line: stimulant laxative (eg Senna)

3rd line: naloxegol, methylnaltrexone

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Which laxatives should be avoided in opioid induced constipation?

Bulk forming

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How is chronic constipation managed?

What about if pregnant or breastfeeding?

1st line: bulk forming (ispaghula husk)

2nd line: osmotic (macrogol first/ lactulose)

3rd line: stimulant (bisacodyl/ senna) or docusate.

Same pathway in pregnancy/breastfeeding

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What laxative can be used in WOMEN only when at least 2 other laxatives have failed at the maximum dose in the last 6 months.

Prucalopride (women only)

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Which laxative should be avoided in pregnant women near term?

Senna

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Should diet alone be used as first line management of constipation in children?

No - start laxatives immediately.

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What is the MHRA alert associated with loperamide?

Risk of serious cardiac events with large overdoses in misuse. Including QT prolongation, cardiac arrest, torsade de pointes.

Naloxone can be used as a reversal agent.

Which antibiotic can be used for prophylaxis of travellers diarrhoea (although it is not recommended)?

Ciprofloxacin

Which patients need urgent investigation if they have recent onset of dyspepsia not responding to treatment?

Patients over 55 - risk of cancer

What should be done if a patient has unexplained dyspepsia not responding to PPIs?

Test for H.pylori + treat if it is present

Why are bismuth containing antacids not recommended?

They are neurotoxic- can cause encepalopathy and are also constipating.

What is a common side effect of magnesium?

A laxative effect

What is a common side effect of aluminium?

Constipation

How do antacids work and what do they mostly contain?

Neutralise stomach acid. | Aluminium, magnesium, calcium

What do alginates do?

Increase viscosity of stomach contents and protect oesophageal mucosa from acid reflux.

What is simeticone? What is it used for?

An antifoaming agent. | Relieves flatulence and prevents hiccups in palliative care.

What medicines can be used for GORD in pregnancy?

1st line: antacids and alginates 2nd line: ranitidine 3rd line: omeprazole (if severe)

What are the 2 main causes of peptic (stomach) ulcers?

NSAIDS and h.pylori.

How is H.pylori infection treated?

1 week triple therapy of: 1 PPI + 2 of amox/ clarith/ metronidazole - Usual PPI doses: lansop 30mg BD omen 20mg BD - If a patient has used one of these antibiotics recently, exclude it from the regimen and use the other two. - Tinidazole can occasionally be used as an alternative to metronidazole

What can be used for h. pylori eradication failure?

2 weeks of: | PPI + tripotassium + tetracycline + metronidazole

What must be avoided before the test for h.pylori?

NO antibiotics 4 weeks before | NO anti secretory drugs (e.g PPIs) 2 weeks before

What is the MHRA alert regarding PPIs?

Very low risk of subacute cutaneous lupus erythematous. Skin lesions may develop in sun exposed areas- can be treated with steroids.

What are some side effects of PPIs?

Hyponatraemia, hypomagnesia, blood disorders Risk of oseteoporosis- maintain adequate calcium and vitamin D.

What is the difference between IBD and IBS?

IBD- inflammatory bowel diseases includes Crohn's and ulcerative colitis (UC) . IBS- irritable bowel disease- no inflammation and less damage to the bowel than IBD.

What is the difference between Crohn's and UC?

Crohn's can occur at any part of the GIT. | Ulcerative colitis only occurs at the colon.

How is an acute flare up of Crohn's managed?

1st line: Corticosteroids (only option if its severe) 2nd line: budesonide 3rd line: aminosalicylates You can add on azathioprine/mercaptopurine/ methotrexate to steroids if its recurrent flare ups. Monoclonals can also be added: infliximab/ adalimumab, vedolizumab.

What is the maintenance treatment for Crohn's?

1st line: azathioprine/ mercaptopurine | 2nd line: aminosalicylates

What is the MHRA alert associated with hyoscine injections?

Risk of serious cardiac side effects in patients with underlying cardiac disease (e.g tachycardia, hypotension, anaphylaxis). Have resus available.

What are acute antimuscarinic side effects?

Blind as a bat- blurred vision Dry as a bone- dry mouth Hot as hell- hyperthermia Mad as a hatter - confusion Red as a beet- tachycardia and vasodilation Full as a flask - urinary retention.

Which medicines can be used to treat pruritis associated with liver disorders?

- Colestyramine - reduces serum bile hence reduces itch - ursodeoxycholic acid - rifampicin

Which medicine can also be used to dissolve gallstones (although gall stones are usually asymptomatic)

ursodeoxycholic acid

When can orlistat be used for obesity?

BMI>30 or >28 and other risk factors

When should orlistat treatment be stopped and deemed ineffective?

Stop after 12 weeks if weight loss has not exceeded 5% (reduce this target in patients with T2DM)

When can bariatric surgery for obesity be considered?

BMI> 40 or | BMI>35 with significant disease (such as T2DM or hypertension)

What is the main counselling points to tell patients about orlistat?

Take with meals. Omit dose if a meal is being skipped. Impairs absorption of fat soluble vitamins (ADEK)- supplementation might be needed.

Whats the maximum duration for topical corticosteroids for haemorrhoids or piles?

7 days

What side effect can occur in patients with cystic fibrosis taking high doses of pancreatin?

Fibrosing colonopathy. | Doses shouldn't exceed 10,000 units/kg/day of lipase

What should be routinely assessed and supplemented if necessary in patients with pancreatic insufficiency?

Fat soluble vitamins (ADEK) | micronutrients (zinc and selenium)

What is a stoma?

An artificial opening on the abdomen to divert flow of faeces/ urine to an external pouch located outside the body- can be temporary or permanent.

What excipient should be avoided in patients with a stoma and why?

Sorbitol- laxative side effects

What can diuretics and digoxin commonly cause in patients with a stoma?

Hypokalaemia- potassium supplements may be needed

What can be used to reduce intestinal motility and decrease water and sodium losses from stoma?

Loperamide and codeine.