Gastrointestinal Flashcards
1
Q
What is Crohn’s Disease
A
affect whole GI tract (mouth to rectum) but patchy - thickened wall, extending through all layers with deep ulceration
2
Q
Crohn’s complications
A
- intestinal strictures or fistulae
- anaemia and malnutrition
- colorectal and small bowel cancers
- growth failure
- delayed puberty in children
- extra-intestinal manifestation
- arthritis
- joints, eyes, liver and skin abnormalities
3
Q
Crohn’s acute treatment if 1st flare in 12 months
A
- monotherapy with either: pred, methylpred or IV hydrocortisone
- if distal ileal, ileocaecal or right sided disease: budesonide if normal tx doesn’t work
- aminosalicylates (sulfasalazine/mesalazine) can be used - reduced side effects but reduced effectiveness
4
Q
Crohn’s acute treatment if 2+ flares in 12 months
A
- azathioprine or mercaptopurine
- methotrexate if aza/merc contraindicated
- severe = monoclonal antibodies
5
Q
Crohn’s maintenance treatment
A
- stop smoking
- mono therapy of either azathioprine or mercaptopurine
- methotrexate in induction or if can’t tolerate aza/merc
- after surgery = azathioprine and metronidazole - aza alone if metro not tolerated
- diarrhoea associated = loperamide, codeine, colestyramine (can’t use loperamide & codeine in UC)
6
Q
What is fistulating Crohn’s disease
A
when fistula develops between intestines and perianal skin, bladder and vagina
7
Q
Fistulating Crohn’s disease treatment
A
- left alone if asymptomatic
- to improve symptoms (not heal) = metronidazole +/- ciprofloxacin - metro for 1 month - no longer due to peripheral neuropathy
- maintenance = aza/merc - infliximab if not responding - tx must last at least one year
8
Q
Name aminosalicylates
A
sulfasalazine, balsalazine, mesalazine, olsalazine
9
Q
Aminosalicylates side effects
A
- nephrotoxic - monitor before inititiation, at 3 months, then annually
- hepatotoxic - monitor monthly for first 3 months
- blood disorders - bloods monthly for first 3 months - stop if blood dyscrasias
- contraindicated in salicylate hypersensitivity
10
Q
Sulfasalazine specific side effect
A
stains contact lenses and bodily fluids orangey-yellow
11
Q
What is Ulcerative Colitis
A
- can affect region from rectum to whole colon = bloody diarrhoea, defecation urgency, abdominal pain (affects colon)
- common in ages 15 - 25
12
Q
Complications of ulcerative colitis
A
- colorectal cancer
- secondary osteoporosis
- VTE
- toxic megacolon
13
Q
Acute treatment of mild - mod ulcerative colitis summary
A
- distal = rectal preps (suppos/enemas) - foam preparations if can’t retain liquid enema
- extended = systemic medication
- diarrhoea = avoid loperamide and codeine = can cause toxic megacolon (big infection)
14
Q
Acute treatment of mild - mod proctitis UC
A
- topical aminosalicylate
- & oral aminosalicylate
- & topical or oral corticosteroid for 4 - 8 weeks
15
Q
When do you move to the next stage of acute treatment of UC
A
if no improvement after 4 weeks
16
Q
What is the difference between Crohn’s and UC
A
- UC = continuous
- Crohn’s = patchy
17
Q
What if people don’t want topical aminosalicylate for acute treatment of UC
A
- oral aminosalicylate 1st if preferred but not as effective as topical
- if aminosalicylates contraindicated then topical or oral corticosteroid for 4 - 8 weeks
18
Q
Acute treatment of mild - mod proctosigmoiditis and left-sided UC
A
- topical aminosalicylate
- & high dose oral aminosalicylate
2.1 OR switch to high dose oral aminosalicylate + 4-8 weeks topical corticosteroid
3. stop topicals and give oral aminosalicylate + 4-8 wks oral corticosteroids
19
Q
Acute treatment of mild - mod extensive UC
A
- topical + high dose oral aminosalicylate
- stop topical and give high dose oral aminosalicylate + 4-8 wks oral corticosteroid
20
Q
Acute treatment of severe UC
A
- life-threatening = medical emergency
- IV hydrocortisone or methylpred and assess need for surgery
- If IV steroids contraindicated - give IV ciclosporin or surgery
- symptoms not reducing within 72 hours = IV steroid + IV ciclosporin OR surgery
- infliximab if ciclosporin contraindicated
21
Q
Maintenance treatment of UC
A
- oral aminosalicylates - more effective as OD dose but more side effects
- not corticosteroids due to side effects
- proctitis/proctosigmoiditis = rectal +/- oral aminosalicylate (oral alone if rectal not worked)
- left-sided/extensive = low dose oral aminosalicylates
- 2+ flares in 12 months = oral azathioprine or mercaptopurine - monoclonal antibodies if no effect
22
Q
What is Coeliac disease
A
- in small intestine - associated with gluten, wheat, barley and rye = immune response in intestinal mucosa
- may cause malabsorption of nutrients
23
Q
Coeliac disease treatment aims
A
- manage symptoms - diarrhoea, bloating, abdo pain
- avoid malnutrition - give vitamin D, calcium, and other nutrients (under supervision)
- only effective option = avoid gluten
24
Q
What is diverticulosis
A
small pouches along intestinal tract but asymptomatic
25
What is diverticular disease
small pouches along intestinal tract but symptomatic - abdo pain, constipation, diarrhoea, rectal bleed
26
What is acute diverticulitis
when pouches inflames/infected = severe abdo pain, constipation, diarrhoea, rectal bleed, fever
27
What is complicated acute diverticulitis
- abscess
- perforation
- fistulas
- obstruction
- sepsis
- haemorrhage
28
Diverticular disease treatment
- fibre
- laxatives
- paracetamol
- if needed in earlier stages
29
What is irritable bowel syndrome
common, chronic, relapsing, life long - abdo pain, diarrhoea or constipation, urgency, incomplete defection, passing mucus
30
Who is IBS more common in
- women
- people aged 20 - 30
31
What is IBS exacerbated by
- coffee
- alcohol
- milk
- large meals
- fried foods
- stress
32
IBS non-drug treatment
- increased exercise
- eat regular meals
- reduce fresh fruit to 3 portions a day
- reduce insoluble fibres
- 8 cups of water daily
- reduce caffeine/alcohol/fizzy drinks
- avoid sorbitol if diarrhoea
- reduce stress
33
OTC drug treatment of IBS
- antispasmodics = alverine, mebeverine, peppermint oil
- laxatives = if constipated (not lactulose = bloating)
- loperamide if diarrhoea
- antimuscarinics = hyoscine butylbromide (avoid in cardiac disease)
34
IBS treatment if OTC treatment doesn't work
- low does TCA (amitriptyline)
- SSRI if TCA doesn't work = unlicensed use
35
What is short bowel syndrome
- shortened bowel due to large surgical resection
36
Short bowel syndrome treatment
- need to ensure adequate absorption of nutrients and fluid
- nutritional deficiencies: replace vitamin D, E, A, K, B12, essential fatty acids, zinc, selenium
- diarrhoea and high output stomas = loperamide and codeine to reduce intestinal motility
37
What is constipation
infrequent, difficult stools - common in women, elderly, pregnant
38
Constipation red flags
- blood in stool
- anaemia
- abdo pain
- weight loss
- new onset constipation over 50 years
39
Constipation non-drug treatment
- increase fibre
- adequate fluid intake
- exercise
- r/v meds e.g. opioids, aluminium, clozapine
40
Bulk-forming laxatives information
- methylcellulose, ispaghula husk, sterculia
- small hard stools - increases faecal mass, stimulating peristalsis
- takes 2-3 days to work
- take with water to prevent intestinal blockage
41
Stimulant laxatives information
- bisacodyl, sodium picosulfate, senna, docusate, glycerol
- stimulate colonic nerves = peristalsis
- takes 6-12 hours to work
- avoid in intestinal obstruction
- co-danthramer & co-danthrusate in terminal illness due to carcinogenity = red urine
42
Faecal softener laxatives information
- liquid paraffin, docusate, glycerol
- increases water penetration into stool
- quickest acting = docusate enema (15-20 minutes)
- liquid paraffin - avoided due to anal seepage, granulomatous disease of the GI tract, lipid pneumonia on aspiration
43
Osmotic laxatives
- lactulose, macrogol
- increases amount of fluid in large bowel = peristalsis
- 2-3 days to work
- also have faecal softening properties
44
Constipation short duration treatment
1. bulk-forming and good hydration
2. osmotic
45
Chronic constipation treatment
1. bulk-forming and good hydration
2. +/change to macrogol (or lactulose 2nd line)
3. no change after 6 months = prucalopride (women only)
- withdraw lactulose slowly when patient improves
46
Faecal impaction treatment
- hard stool = macrogol & stimulant once softened
- soft stool = stimulant
- rectal bisacodyl and/or glycerol if remain constipated
47
Opioid induced constipation treatment
- osmotic and stimulant
- naloxegol if no response to first line
- AVOID BULK FORMING - peristalsis already slow so can cause obstruction faecal impaction
48
Constipation in pregnancy and breastfeeeding
1. dietary & lifestyle - fibre supplements e.g. bran/wheat
2. bulk-forming - ispaghula
3. osmotic
4. bisacodyl or senna (not senna near term)
49
Constipation in children
1. dietary advice & macrogol (if no faecal impaction)
2. stimulant
- if stool hard = lactulose or docusate
50
Acute diarrhoea treatment
- usually settles w/o medical treatment
- can use oral rehydration therapy to prevent/correct dehydration
- severe dehydration/can't drink = hospital for IV fluids
51
Rapid control for diarrhoea/traveler's diarrhoea
- loperamide
- avoid in bloody or suspected inflammatory diarrhoea
52
Loperamide information
- 1st line for faecal incontinence
- OTC = 12 yrs +, prescribed = 4 yrs +
- 1-2 caps (2-4mg) initially, then 1 with every loose stool
- max = 8 caps (16mg)
- MHRA = serious cardiac reactions (QT prolongation) with high doses
- treat overdose with naloxone
53
What is dyspepsia
upper abdo pain, heart burn, gastric reflux, bloating, NV
54
Dyspepsia referral symptoms
- GI bleed
- Age 55 +
- Unexplained weight loss
- Dysphagia
GAUD
55
Dyspepsia drug treatment
- uninvestigated = PPI for 4 wks first, if doesn't work = test for H.pylori - tx if +ve
- functional dyspepsia (investigated but no cause present) = test for H. pylori - tx if +ve, no infected = 3 wksPPI or H2 receptor antagonist
56
H. pylori diagnostic test
- most common cause of peptic ulcers
- urea 13c breath test or stool helicobacter antigen test
- stop PPI 2 wks before test and abx 4 wks before test
57
H. pylori treatment
- Triple therapy
1. PPI - BD 7 days
2. Clarithromycin - 500mg BD 7 days
3. Amoxicillin - 1g BD 7 days (other 2 in pen allergy)
3. Metronidazole - 400mg BD 7 days
58
What is GORD caused by
- increased with: fatty foods, pregnancy, hiatus hernia, family Hx, stress, anxiety, obesity, smoking, alcohol
- drug side effects due to loosening sphincter e.g. a/b-blockers, CCBs, anticholinergics, benzos, bisphosphonates, corticosteroids, NSAIDs, nitrates, TCAs
59
GORD urgent referral criteria
GAUD
- GI bleed
- Age 55 +
- Unexplained weight loss
- Dysphagia
60
GORD lifestyle advice
- healthy eating
- weight loss
- avoid trigger foods
- smaller meals
- evening meals 3-4 hours before bed
- raised head of bed
- smoking cessation
- reduce alcohol
61
GORD treatment
- medicines review if taking a drug that exacerbates GORD
- uninvestigated GORD = PPI for 4 wks - test for H. pylori if doesn't work
- confirmed GORD = 4-8 wks PPI
- pregnancy = dietary/lifestyle advice -> antacid or an alginate -> omeprazole/famotidine
62
Antacids
- Mg containing = laxative effect
- Aluminium containing = constipating effect
- Ca containing = induces rebound acid secretion
- simeticone (antifoaming agent) added to antacid = relieves flactulence
- Alginates and antacids = increase in viscosity of stomach content = viscous gel 'raft' that floats on surface of stomach contents
63
Antacids interactions
- increased stomach pH = enteric coated damaged before reaching intestine
- check Na in antacid - don't take with lithium/in hypertension
- low Na = co-magaldrox
- antacids no with other drug due to impairing absorption - bisphosphonates, tetracyclines, ciprofloxacin
64
Name PPIs
omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole
65
PPIs MHRA Warning
low risk of subacute cutaneous lupus erythematosus
66
PPIs risks
- increased risk of fractures/osteoporosis - due to hypomagnesaemia
- increase risk of C. diff
- masks symptoms of gastric cancer
- can't use eso/omeprazole with clopidogrel - lansop instead
- increases concentration of methotrexate, warfarin, digoxin
67
Name H2 receptor antagonists
cimetidine, famotidine, nizatidine
68
H2 receptor antagonists risks
- masks symptoms of gastric cancer - rule out alarm features before tx
- side effects = diarrhoea, headache, dizziness, rash, tiredness
- interactions = reduced absorption of -azole antifungals
- cimetidine = CYP450 enzyme inhibitor
69
what is cholestasis
- impaired bile formation or flow = fatigue, pruritus, dark urine, pale, jaundice
70
cholestatic pruritus treatment
- relieved by cholestyramine, ursodexycholic acid, rifampicin
71
Intrahepatic cholestasis in pregnancy
- during late pregnancy = adverse foetal outcomes
- treatment of pruritus associated = ursodexycholic acid
72
What are gall stones
hard mineral or fatty deposits forming stones in gall bladder bile duct
73
Gall stones symptoms
- most patients - asymptomatic
- irritated/blocked gall bladder = pain, infection and inflammation
- untreated = complications = biliary colic, cholecystitis, cholangitis, pancreatitis
- symptoms develop = surgical removal
74
Gall stones drug treatment
- mild-mod pain = paracetamol/NSAID
- severe pain = IM diclofenac
- whilst waiting for surgery
75
What is an anal fissure
tear or ulcer in anal canal = bleeding and pain on defecation
76
anal fissures acute management
- help stool pass easily and pain management
- bulk-forming or osmotic laxatives
- short term topical with local anaesthetic (lidocaine) (not for preg) or analgesic
77
anal fissure chronic management
- 6 wks or longer = GTN rectal (high incidence of headache)
- topical/oral diltiazem or nifedipine (reduced adverse effects especially topical)
- specialist = bolinum toxin type A (botox type A)
- surgery effective when no drug response
78
What are haemorrhoids
- swelling of vascular mucosal anal cushions around anus (high risk during pregnancy)
- internal = painless
- external = itchy or painful
79
Haemorrhoids management
- maintain easy stools to minimise straining = increased fibre/fluid or bulk forming
- pain = paracetamol (opioids = constipation, NSAIDs = rectal bleeding)
- pain/itching = topicals (anaesthetics, corticosteroids, lubricant, antiseptics)
- topical anaesthetics (lidocaine) = use for a few days
- topical corticosteroids = no more than 7 days due to side effects
- pregnancy = bulk-forming laxatives - no topicals, only simple soothing prep if needed
80
What is pancreatic insufficiency
- reduced secretion of pancreatic enzymes into the duodenum
- can be due to pancreatitis, CF, pancreatic tumours, coeliac disease, GI resection
- can lead to maldigestion and malnutrition
81
Treatment of exocrine pancreatic insufficiency
- pancreatic enzyme replacement (pancreatin)
- levels of fat soluble vits (DEAK) and micronutrients monitored - give supplements when needed
82
What is in pancreatin
- lipase, amylase, protease, which digests fats, carbohydrates and proteins so it can be absorbed
- take with meals and snacks - prevent early breakdown
83
Pancreatin in cystic fibrosis
- fibrosing colonopathy at high dose pancreatin
- don't exceed 10000 units/kg/day of lipase
- report new abdominal symptoms
84
What is a stoma
artificial opening on abdomen to divert flow of faeces/urine to external pouch
85
Drug suitability with stomas
EC/MR capsules not suited - insufficient effect from drug - use quick acting forms e.g. liquids, caps, uncoated/soluble tabs
86
Stoma Care
- diarrhoea = sorbitol, Mg antacids, iron (ileostomy)
- constipation = opioids, aluminium and calcium antacids, iron (colostomy)
- GI irritation and bleed = aspirin and NSAIDs
- diuretics/laxatives = dehydration = hypokalaemia = use K+ sparing diuretics or K+ supplements. Liquid K+ preferred to MR forms.
- fluid and Na depletion = hypokalaemia = increased risk of digoxin toxicity
87
What are pesto-bismol and milk of magnesia used for
indigestion
88
Clarithromycin and ciclosporin interaction
clarithromycin increases concentration of ciclosporin
89
What is an astringent and give an example
- substance that draws water out of tissue and causes the tissue to shrink
- bismuth oxide
90
Classic symptom of colic in a baby and treatment
- baby pulls legs to chest and crying, red in the face
- OTC simethicone (infacol)
91
Colestyramine side effects
- constipation, diarrhoea, NV, GI discomfort
- increased tendency to bleed
- decreased absorption of DEAK = hypoprothrombinaemia due to low K
- hypertriclycerideaemia = aggravation
92
Colestyramine administration
1 hour before or 4 hours after other medication to reduce interference with absorption
93
Ranitidine OTC max supply
2 weeks
94
Antacids containing both magnesium and aluminium
- reduced colonic side effects
- insoluble in water so long-acting if retained in the stomach
95
PPIs and GI infections
PPIs increased risk of GI infections
96
Orlistat advice
take with vitamins and minerals if concerns about inadequate micronutrient intake
97
Misoprostol key information
- synthetic prostaglandin analogue
- has antisecretory and protective properties, promoting healing of gastric and duodenal ulcers
- used for termination in pregnancy following mifepristone
- common SE = NV, rash
- cautioned on effects on driving
