Gastro-Intestinal System Part 1 Flashcards
What is Coeliac Disease
- Autoimmune condition with chronic inflammation of small intestine.
- Can’t absorb nutrients anymore
What are the Cause of Coeliac Disease
- Adverse Reaction to Gluten
Symptoms of Coeliac Disease
- Diarrhoea, abdominal pain and bloating
- High risk of malabsorption of key nutrients (vitamins and calcium)
Treatment of Ceoliac Disease
- Strict gluten free diet (life long)
- Assess risk of osteoporosis and treat if needed
- Vitamin and mineral supplements following blood tests
What is Diverticular Disease
- Small bulges/pockets (diverticula) develop in lining of intestine
What is Diverticulitis
Inflamed/infected diverticular
Symptoms of Diverticular Disease
- Lower abdominal pain, constipation, diarrhoea
Treatment of Diverticular Disease
- High fibre diet
- Treat diarrhoea or constipation
- Antibiotics if diverticulitis (infection)
What is Ulcerative Colitis
Inflammatory bowel disease
- Mucosal inflammation and ulcers (colon/rectum)
What is the Colon
Longest part of the large intestine
Symptoms of Ulcerative Colitis
Alternates between acute flare ups and remission
- acute flare up includes: mouth ulcers, arthritis, sore skin, weight loss, fatigue
- bloody diarrhoea (mucus or puss)
- abdominal pain (need a poo)
Complications of Ulcerative Colitis
- Colorectal cancer
- secondary osteoporosis (from corticosteroids or diet)
- Venous Thromboembolism (vein blood clot)
- toxic megacolon (swelling and inflammation in colon stopping it from working)
Contraindications during acute flare up in Ulcerative Colitis
- Anti-motility drugs (used to alleviate symptoms of diarrhoea)
—- Loperamide, Codeine - Antispasmodics/Antimuscarinics (muscles relaxants)
— Oxybutynin (relaxes muscle in bladder)
— Hyoscine butylbromide (relaxes smooth muscle) - Paralytic Ileus (physically impaired motor activity of bowel)
Ulcerative Colitis: Extensive Colitis (proximal)
Inflammation affecting most of ascending (proximal) colon
Ulcerative Colitis: Left-sided Colitis (Distal)
Inflammation up to descending colon (distal)
Ulcerative Colitis: Proctosigmoiditis
Inflmmation of rectum and sigmoid colon (last part of colon before the rectum)
Ulcerative Colitis: Proctitis
Inflammation of Rectum
Acute Mild-Moderate Ulcerative Colitis Treatment (Proctitis and Proctosigmoiditis)
First Line:
— Aminosalicylate (retal)
— Rectal corticosteroid (hydrocortisone)
Second Line (after no response within 4 weeks):
— Prednisolone 20-40mg daily until remission
— Oral Tacrolimus (granules for solution, dose based on weight)
Acute Mild-Moderate Ulcerative Colitis Treatment (Extensive Colitis and Left-Sided Colitis)
First Line:
— Hugh dose oral Aminosalicylate + (rectal Aminosalicylate) or (oral beclometasone)
Second Line (after no response within 4 weeks):
— Prednisolone 20-40mg daily until remission
— Oral Tacrolimus (granules for solution, dose based on weight)
Subacute Ulcerative Colitis (rapid onset recent) Treatment
Prednisolone 20-40mg daily till remission
Severe Ulcerative Colitis Treatment
Hospital Admission now
First Line:
— IV Corticosteroid
— IV Ciclosporin
— Removal of colon
Second Line (symptoms don’t improve within 72 hours):
— IV Corticosteroid and Ciclosporin/Infliximab
— Surgery
Ulcerative Colitis maintaining Remission
— Rectal/Oral Aminosalicylate (depending on where the colitis is)
If 2+ flare ups in 12 months then use:
— Oral Immunosuppressant (Azathioprine)
— Monoclonal Antibodies (only if tolerated)
What is Crohn’s Disease
inflammation of gasto-intestinal tract from mouth to anus
Symptoms of Crohn’s Disease
alternates between acute flare-ups and remission)
- abdominal pain
- diarrhoea and rectal bleeding
- weight loss, fever, fatigue
Complications of Crohn’s Disease
- Intestinal Strictures (intestinal narrowing)
- Abscesses (collection of puss)
- Fistulae (abnormal connection between two body parts)
- Anaemia (not enough healthy red blood cells)
- Colorectal/small bowel cancer
- Growth failure/delayed puberty in children
- Arthritis
Secondary Osteoporosis
Crohn’s Disease Lifestyle Advice
- High fibre diet
- smoking cessation
Crohn’s Disease: 1 flare up/first presentation treatment
— Corticosteroid (prednisolone 20-40mg until remission)
— Budesonide (9mg daily for 8 weeks)
Crohn’s Disease: 2+ flare ups in 12 months (or if corticosteroid failed) treatment
— Azathioprine 2-2.5mg/kg daily
(immunosuppressant)
— Methotrexate (25mg daily until remission, then 15mg daily)
— Monoclonal Antibodies
Remission maintenance in Crohn’s disease
— Azathioprine 2-2.5mg/kg daily or Methotrexate 15mg
After Surgery
— Azathioprine or Aminosalicylates
Drugs in Inflammatory Bowel Disease:(Aminosalicylates 5-ASA)
- Balsalazide, Mesalazine
- Olsalazine (5-ASA dimer)
- Sulfasalazine
Drugs in Inflammatory Bowel Disease: Corticosteroids
- Prednisolone
- Beclometasone (use with 5-ASA in ulcerative colitis)
- Hydrocortisone
Drugs in Inflammatory Bowel Disease: Immune System affecting drugs
- Azathioprine/Ciclosporin (immunosuppressants)
- Methotrexate (sows down immune system)
Aminosalicylates MoA
Reduces Cytokine and free radical formation and inhibits prostaglandin synthesis
Side Effects of Aminosalicylates
- Report anything unusal to do with blood (unexpected bleeding, bruising, sore throat, fever)
- Nephrotoxicity (monitor renal function)
- Allergy (itching and hives)
- Yellow/orange bodily fluid (soft contact lenses may be stained)
Aminosalicylates Interactions
- Lactulose and Mesalazine
(lactulose lowers stool pH in intestine, stopping production of sufficient active ingredient)
What is Irritable Bowel Syndrome
- Lower abdominal/colic pain
- Bloating
- Alternating constipation and diarrhoea
- Irregular bowel movements
What is irritable bowel syndrome aggravated by and common patient group
- stress, depression/anxiety, lack of fibre
- Adult women between 20 to 30 years
Irritable bowel syndrome: GI Spasm Treatment
Antispasmodics
- Mebeverine
- Alverine
- Peppermint oil
Antimuscarinics
- Hyoscine Butylbromide
- Dicyloverine
- Atropine
Irritable bowel syndrome: Constipation Treatment
First Line:
Laxatives
— Senna, Bisacodyl, Lactulose (not recommended as causes bloating)
If laxatives example fail
— Linoclotide
Irritable bowel syndrome: Diarrhoea Treatment
First Line:
Anti-motility Drugs
— Loperamid
Irritable bowel syndrome: Second Line for abdominal pain and discomfort
Antidepressant
- Tricyclic Antidepressant (Amitriptyline: 5-10mg daily, Max 30mg)
- SSRI (Citalopram)
What is Short Bowel Syndrome
Malabsorption following extensive resection of the small bowel
What is bowel cleansing
Nozzle inserted into rectum pumping water into bowels, cleans it form toxins, fluids and waste.
This is done a colonic surgery, colonoscopy, radiological examination.
What is constipation
- infrequent stools (less than 3 times a week)
- difficulty passing stools
- sensation of incomplete emptying
Constipation assosiative symptoms
- excessive straining
- lower abdominal pain/discomfort
- bloating
Constipation Red Flag Symptoms
- New onset in above 50
- anaemia
- abdominal pain
- unexplained weight loss
- Overt (seen)/ Occult blood (unseen) blood in stool
Constipation Laxative Classes
- Stimulant
- Chloride channel agonist
- Opioid receptor antagonist
- Osmotic
- Bulk forming
- Stool Softener
Stimlant laxative Exmaples
Senna, Docusate, Bisacodyl, Glycerol Supp, Sodium Picosulfate
Osmotic laxative Examples
Macrogol, Lactulose
Bulk Forming laxative Examples
Ispaghula Husk, Methylcellulose
Stool Softener laxative Examples
Liquid Parafin
Laxative: Bulk Forming: Mode of Action
- Swells in gut to increase faecal mass - - To stimulate peristalsis (muscle flexing in intestine)
- push faecal matter forward
- works in 24 hours (full effect 3 days)
Laxative: Osmotic: Mode of Action
- Increases water in colon from bodily or drank fluids
- 2-3 days
Laxative: Stimulant: Mode of Action
- increases intestinal motility by gut irritation
- 6 to 12 hours
- glycerol supp within 30 mins
Laxative: Faecal Softener: Mode of Action
- increases amount of water and fat stool absorbs
- softening stools
Bulk Forming Laxative
Examples
- Ispaghula Husk
- good for small hard stools, and fibre deficient diets
Side Effects
- bloating
- cramping
- flatulence
- gut obstruction
Counselling
- good fluid intake to avoid gut obstruction
- not before bed
Osmotic Laxatives
Second line:
Macrogol, Lactulose
Side Effects
- Discomfort, flatulence, cramps, nausea
reduce nausea by consumption with fluids or food
Stimulant Laxative
Third Line:
Glycerol Supp, senna
Side Effects
- Abdominal cramps, (senna colours urine yellow)
Excessive use:
- Lazy bowel, diarrhoea, hypokalaemia
Counselling:
- take at night
- wet suppositories before use
Co-Danthramer/Co-danthrusate: Stimulant Laxative
it is genotoxic and carcinogenic
Side Effects
- carcinogenic
- red rine
- local irritation (avoid prolonged contact with patient)
Faecal Softener Laxative
Liquid Parafin
Side Effects (Harsh)
- anal seepage
- lipid pneumonia (fat collection in lungs)
- granulomatous
- malabsorption of fat soluble vitamins
If 2 laxatives from different classes fail for 6 months, use…
Chloride Channel Agonsit
- Lubiprostone
Selective 5HT-4 Agonist
- Prucalopride (women only)
Opioid Induced Constipation Treatment
[Osmotic laxative or Docusate Sodium ] + [Stimulant Laxative]
Co-Danthramer/Danthrusate (palliative care only)
Methylnaltrexone/ Naloxegol
(avoid bulk forming= obstruction and painful colic)
Chronic Constipation Treatment
First Line:
Bulk Forming
Second Line:
Osmotic
Third Line:
Stimulant
Constipation in Children Treatment
First line:
Osmotic + diet change
Second Line:
+ stimulant laxative
Third Line:
+ lactulose
Constipation in Pregnancy Treatment
First Line:
Fibre Supplement
*Second Line: *
Bulk Forming
Third Line:
Osmotic
Fourth Line:
Senna, Bisacodyl, Docusate, Glyceral Supp
(avoid senna close to term)
Constipation in Breast feeding treatment
First Line:
Bulk Forming (if diet change fails)
Second Line:
Osmotic or Stimulant
What is diarrhoea
frequent loose, water stools
Associated symptoms of Diarrhoea
Cramps, Nausea and Dehydration
Red Flag symptoms of Diarrhoea
unexpected weight loss, rectal bleeding, persistent diarrhoea, systemic illness, recent hospital treatment, recent foreign travel
Diarrhoea Treatments
**First Line: **
Oral Rehydration Therapy
(replaces electrolytes and fluid depletion)
— Diarolyte
Second Line:
Anti-Diarrhoeals
— Codein (anti-motility)
— Loperamide (anti-motility)
— Rifamaxin (for travellers diarrhoea)
Loperamide Treatment for Diarrhoea
Antipropulsive
Prolongs the duration of intestinal transit by biding to opioid receptors in GI Tract
Loperamide Diarrhoea Use
Second Line only in over 12
**Dose: **4mg, then 2mg for up to 5 days
Maximum 16mg a day
Take after each loose stool
Loperamide Cautions and Monitoring
- Overdose can cause serious cardiac side effects
- Give Naloxone if overdose symptoms occur
- Patients. monitored for CNS depression for 48 hours after start
Loperamide side effects, contra-indications
Side Effects:
- dizziness, flatulence, headache, nausea
Contra-indications
- Ulcerative colitis
- antibiotic associated colitis
- conditions with impaired gut mobility
- Conditions with abdominal distention (swollen out abdomen)
- Bloody diarrhoea
- severe abdominal pain
What is Dyspepsia
Group of upper abdominal symptoms
(upper abdominal pain, fullness, early satiety, bloating, belching, nausea)
Causes of Dyspepsia
Indigestion, GORD (gasto-oesophegal reflux disease), gastritis (stomach lining inflammation), Gastric Ulcers
Dyspepsia Urgent Endoscopic Referral
Uninvestigated Dyspepsia Treatment
First Line:
Antacids (sodium bicarbonate, calcium carbonate, Gaviscon)
Second Line:
PPI (omeprazole, lansoprazole)
— for 4 week
*Third Line: *
H. Pylori Test
Investigated Dyspepsia
H. Pylori Test
PPI (omeprazole) or H2 Antagonist (Famotidine)
— for 4 weeks
Antacids Mode of Action
Neutralises stomach acid
Immediate relief within 30 mins
Liquid better than tablets
Alginates Mode of Action and examples
Forms viscous gel raft on top of stomach contents to prevent reflux
Alginic Acid
Sodium Alginate
Antacids Interactions
- impairs drug absorption (leave 2 hours when taking other drugs)
(tetracyclines, quinolones, Bisphosphonates) - Damages drug enteric coating due to high pH
- High sodium content, causing high sodium and water retention
(avoid in cardiac conditions, liver and kidney failure)
Proton Pump Inhibitors Mode of Action
Stops gastric acid secretion by blocking hydrogen-potassium ATPase (proton pump) of gastric parietal cell.
Best antisecretory drug
PPI Administration advice
Swallow whole, don’t chew
No indigestion remedies 2 hours before or after taking
PPI Cautions
- Masks symptoms of gastric cancer
- raises risk of fractures and risk of osteoporosis
- increased risk of GI infections (c. difficile)
PPI Dose and Side Effects
use lowest effective dose for shortest period
Side Effects:
- GI Upset (abdominal pain, constipation, diarrhoea, nausea
PPI Long term use and interactions
Long Term Use:
- Hypomagnesaemia
- fractures
- rebound acid secretion due to PPI withdraw
Interactions:
Omeprazole with…
- Clopidogrel (reduced anti-platelet effect)
- Methotrexate (reduced clearance of methotrexate)
H2 Receptor Antagonists Mode of Action
Reduces gastric acid secretion by blocking H2 receptors in gastric parietal cell
(antisecretory)
H2 Receptor Antagonist examples
Famotidine
Ranitidine (safe in pregnancy)
H2-R Antagonist Side Effects and Cautions
Side Effects:
Headaches, rashes, dizziness, diarrhoea
— Psychiatric reactions (confusion, depression)
Cautions:
- masks symptoms of gastric cancer
Where is the duodenum
cord connecting below the stomach
Gastric/Duodenal Ulceration Treatment
PPI (omeprazole)
H2R Antagonist (famotidine)
Gastric/Duodenal Ulceration Treatment Specific Drugs
**Misoprostol **
(synthetic prostaglandin analogue)
AVOID IN PREGNANCY
Colic (sever pain in abdomin)
Sucralfate
1 hour before meals/ 1 hour gap between enteral feeds (tube feeding)
H.Pylori Ulcers Treatment
1 week triple therapy
PPI (twice daily)
+
Amoxicilin / Metronidazole *( give if penicillin allergy or if recently treated with it) *
+
Clarithromycin (if using Macloides - any ‘YCIN’- use metronidazole)
NSAID-Induced Ulcers Treatment
- Stop NSAID if possible
- PPI / H2R Antagonsit
- Test for H.Pylori on healing (if positive, start H.Pylori Treatment)
If Non-selective NSAID continued, continue PPI
If history of upper GI bleeding, continue PPI + switch to COX-2 inhibitor
NSAID-Indced Ulcers: High Risk Patinets
- 65+
- Previous History
- Significant Co-morbidity (kidney liver heart disease or diabetes)
Gastro-Oesphaegal Reflux Disease Treatment: Mild
- Antacids + Alginates
- H2R Antagonist/PPI
maintain remission via intermisttant treatment
Gastro-Oesphaegal Reflux Disease Treatment: Severe
- PPI for 4 to 6 weeks
maintain remission with low dose PPI or intermittant PPI or using H2R Antagonist
Gastro-Oesphaegal Reflux Disease Treatment: Pregnancy
First Line:
Antacids / Alginates
Second Line:
Ranitidine
** Third Line:**
Omeprazole
Gastro-Oesphaegal Reflux Disease Treatment: Children
Self limiting after age 12-18 months
Thickened Feeds / Alginates
