Gastroenterology Flashcards
Difference between Crohn’s and Colitis?
Crohn’s: Can affect anywhere in GIT, inflammation can appear as patchy (skip lesions)
Colitis: Usually starts from rectum and progresses as continuous inflammation through large bowel
Types of colitis? (4)
Proctitis
Proctosigmoiditis
Left-sided (distal) colitis
Pancolitis
Which formulation would you use for each type of colitis?
Suppository - Proctitis
Foam Enema - Proctosigmoiditis
Liquid Enema - Distal colitis
Oral + Topical - Pan colitis
What would you use to induce remission for first presentation or single exacerbation (in 12 month period) of Crohn’s?
High dose corticosteroids - Prednisolone, methylprednisolone, hydrocortisone
Budesonide (if other corticosteroids are not tolerated)
Consider aminosalicylates if both the above unavailable (minimal evidence for efficacy)
What could be used as adjunct therapy to induce remission in Crohn’s? (3)
What are the clinical requirements for starting these?
Azathioprine or mercaptopurine
Methotrexate (if thiopurines not tolerated)
Experiencing 2 or more exacerbations per year or unable to taper corticosteroid dose
What should be checked prior to starting thiopurines?
How does this affect dosing?
TPMT activity
If below normal, consider lowering dose
If deficient, do not offer thiopurines
What should be excluded when a patient presents with an IBD flare up?
What tests should be carried out? (2)
Infectious cause of diarrhoea
Faecal calprotectin - Sign of active inflammation
Stool cultures
What would be last line treatment for severe active Crohn’s disease and when would this be appropriate?
Biologics - Infliximab, Adalimumab, Ustekinumab, Vedolizumab
If patient has not responded to conventional treatment (corticosteroids, immunosuppressants) and there is clear diagnosis of active disease
What should be checked 6-weeks after commencing treatment with thiopurines?
6-TGN levels (active metabolite of azathioprine/mercaptopurine)
What could be used if thiopurine metabolite levels are subtherapeutic?
What adjustments should be made?
Concomitant allopurinol
One-quarter of the usual dose of azathioprine/mercaptopurine should be used
What would you use to induce remission of proctitis?
Topical aminosalicylate
Oral add-on if no response in 4 weeks or monotherapy for patients who decline topical treatment
Oral or topical corticosteroids if still no response or aminosalicylates not tolerated
What would you use to induce remission of proctosigmoiditis?
Topical aminosalicylate
High dose oral add-on if no response in 4 weeks or switch to high dose oral preparation and use short course of topical aminosalicylate
High dose oral aminosalicylate if topical preparation declined
Oral or topical corticosteroids if still no response or aminosalicylates not tolerated/declined
What would you use to induce remission of pancolitis?
High dose oral aminosalicylate and topical preparation
If no response in 4 weeks, stop topical preparation and use short-term course of oral corticosteroids with HD oral aminosalicylate
What are the Truelove and Witts’ severity index for acute severe colitis? (6)
6+ bowel movements a day with systemic upset (*)
Visible blood in stools
- Pyrexia (37.8+)
- HR >90bpm
- Anaemia
- Erythrocyte sedimentation rate >30mm/hour
What is the first step in treatment of acute severe colitis?
IV corticosteroids
When would IV ciclosporin be considered as an adjunct in acute severe colitis? (2)
If little to no response to IV corticosteroids within 72 hours of starting treatment
If symptoms worsen whilst on IV corticosteroids
What can be used as an alternative to ciclosporin in acute severe colitis?
What is the criteria for this?
Infliximab
If ciclosporin is contraindicated or clinically inappropriate
How is remission maintained in each type of ulcerative colitis?
Proctitis/Proctosigmoiditis - Topical aminosalicylate (daily or intermittent) +/- oral aminosalicylate (daily or intermittent)
Distal/Pancolitis - Low maintenance dose oral aminosalicylate
When would a thiopurine be considered in maintaining remission of ulcerative colitis? (3)
2 or more exacerbations in 12 months requiring treatment with systemic corticosteroids
Remission not maintained with aminosalicylates
After a single episode of acute severe colitis
What is used to maintain remission in Crohn’s disease? (3)
Azathioprine
Mercaptopurine
Methotrexate
When would methotrexate be used to maintain remission in Crohn’s disease? (3)
If used to induce remission
If thiopurines not tolerated
If thiopurines contraindicated (e.g. TPMT deficiency)
What is the standard dose of azathioprine for maintenance of remission of Crohn’s/UC?
2-2.5mg/kg daily
What is the standard dose of mercaptopurine for maintenance of remission of Crohn’s/UC?
1-1.5mg/kg daily
What is the standard dose and regimen for Infliximab in active Crohn’s disease?
5mg/kg initially, then in week 2, 6 and 14 and then every 8 weeks
What is the standard dose and regimen for Adalimumab in active Crohn’s disease?
80mg initially, then 40mg every 2 weeks. If necessary increase to 40mg once weekly
Why is budesonide used if conventional corticosteroids are not tolerated?
There is less systemic absorption, minimising the side effects of corticosteroids
What is hepatic encephalopathy?
Confusion or altered consciousness caused by nitrates crossing the blood-brain barrier. This is a result of a build up of ammonia due to impaired liver function
What is the laxative of choice to treat hepatic encephalopathy and what is the dose?
Lactulose
30-50ml TDS
What is the treatment aim when using laxatives to treat hepatic encephalopathy?
Aim for 2-3 soft stools a day
What can be used in combination with laxatives to reduce the recurrence of hepatic encephalopathy?
What dose?
Rifaximin 550mg twice a day
What should be prescribed when performing an ascitic drain and how much?
Albumin 20%
100ml should be used to replace every 2L of fluid drained
What can be used to treat the symptoms of alcohol withdrawal?
What determines the dose?
Chlordiazepoxide
The dose should be determined by a patient’s CIWA score
Monitoring for thiopurines? (2)
Full blood count every week for first 4 weeks, then every 3 months
LFTs
Side effects of glucocorticoids? (6)
High blood sugars Osteoporosis Peptic ulcers Immunosuppression Adrenal suppression Psychiatric reactions (insomnia, behavioural disturbances,)
Side effects of mineralocorticoids? (5)
Hypertension Hypernatraemia Water retention Hypocalcaemia Hypokalaemia
What medications may you see prescribed alongside glucocorticoids? (2)
Colecalciferol+calcium
PPI (omeprazole, lansoprazole etc.)
Monitoring for methotrexate?
Full blood count and kidney and liver function tests every 1-2 weeks until stabilised, then every 2-3 months
How would you treat suspected or established Wernicke’s encephalopathy?
IV Pabrinex (vitamin B1) 2-3 pairs three times a day for 3-5 days, then 1 pair a day for 3-5 days
What would you use to prevent Wernicke’s encephalopathy in alcoholic liver disease?
Pabrinex (vitamin B1) 1 pair daily for 5-7 days
What should oral follow up should be used after a patient is treated with Pabrinex?
Thiamine, 50mg four times a day
What is the dose and treatment regime for alcohol withdrawal symptoms in moderate dependence?
10-30mg chlordiazepoxide four times a day, reducing over 5-7 days (titration depends on local guidelines)
What is the dose and treatment regime for alcohol withdrawal symptoms in severe dependence?
What is the maximum dose?
10-50mg chlordiazepoxide four times a day PLUS 10-40mg when required for first two days, reduce dose gradually over 7-10 days
Max 250mg a day
First line treatment for H.pylori?
7 day treatment
PPI twice a day (omeprazole 20-40mg, lansoprazole 30mg etc)
Amoxicillin 1g three times a day
Clarithromycin 500mg/metronidazole 400mg twice a day
If penicillin allergic metronidazole 400mg twice a day instead of amoxicillin
