Gastrointestinal Flashcards
What is Crohn’s Disease
affect whole GI tract (mouth to rectum) but patchy - thickened wall, extending through all layers with deep ulceration
Crohn’s complications
- 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
Crohn’s acute treatment if 1st flare in 12 months
- 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
Crohn’s acute treatment if 2+ flares in 12 months
- azathioprine or mercaptopurine
- methotrexate if aza/merc contraindicated
- severe = monoclonal antibodies
Crohn’s maintenance treatment
- 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)
What is fistulating Crohn’s disease
when fistula develops between intestines and perianal skin, bladder and vagina
Fistulating Crohn’s disease treatment
- 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
Name aminosalicylates
sulfasalazine, balsalazine, mesalazine, olsalazine
Aminosalicylates side effects
- 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
Sulfasalazine specific side effect
stains contact lenses and bodily fluids orangey-yellow
What is Ulcerative Colitis
- can affect region from rectum to whole colon = bloody diarrhoea, defecation urgency, abdominal pain (affects colon)
- common in ages 15 - 25
Complications of ulcerative colitis
- colorectal cancer
- secondary osteoporosis
- VTE
- toxic megacolon
Acute treatment of mild - mod ulcerative colitis summary
- 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)
Acute treatment of mild - mod proctitis UC
- topical aminosalicylate
- & oral aminosalicylate
- & topical or oral corticosteroid for 4 - 8 weeks
When do you move to the next stage of acute treatment of UC
if no improvement after 4 weeks
What is the difference between Crohn’s and UC
- UC = continuous
- Crohn’s = patchy
What if people don’t want topical aminosalicylate for acute treatment of UC
- oral aminosalicylate 1st if preferred but not as effective as topical
- if aminosalicylates contraindicated then topical or oral corticosteroid for 4 - 8 weeks
Acute treatment of mild - mod proctosigmoiditis and left-sided UC
- 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
Acute treatment of mild - mod extensive UC
- topical + high dose oral aminosalicylate
- stop topical and give high dose oral aminosalicylate + 4-8 wks oral corticosteroid
Acute treatment of severe UC
- 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
Maintenance treatment of UC
- 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
What is Coeliac disease
- in small intestine - associated with gluten, wheat, barley and rye = immune response in intestinal mucosa
- may cause malabsorption of nutrients
Coeliac disease treatment aims
- manage symptoms - diarrhoea, bloating, abdo pain
- avoid malnutrition - give vitamin D, calcium, and other nutrients (under supervision)
- only effective option = avoid gluten
What is diverticulosis
small pouches along intestinal tract but asymptomatic
What is diverticular disease
small pouches along intestinal tract but symptomatic - abdo pain, constipation, diarrhoea, rectal bleed
What is acute diverticulitis
when pouches inflames/infected = severe abdo pain, constipation, diarrhoea, rectal bleed, fever
What is complicated acute diverticulitis
- abscess
- perforation
- fistulas
- obstruction
- sepsis
- haemorrhage
Diverticular disease treatment
- fibre
- laxatives
- paracetamol
- if needed in earlier stages
What is irritable bowel syndrome
common, chronic, relapsing, life long - abdo pain, diarrhoea or constipation, urgency, incomplete defection, passing mucus
Who is IBS more common in
- women
- people aged 20 - 30
What is IBS exacerbated by
- coffee
- alcohol
- milk
- large meals
- fried foods
- stress
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
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)
IBS treatment if OTC treatment doesn’t work
- low does TCA (amitriptyline)
- SSRI if TCA doesn’t work = unlicensed use
What is short bowel syndrome
- shortened bowel due to large surgical resection
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
What is constipation
infrequent, difficult stools - common in women, elderly, pregnant
Constipation red flags
- blood in stool
- anaemia
- abdo pain
- weight loss
- new onset constipation over 50 years
Constipation non-drug treatment
- increase fibre
- adequate fluid intake
- exercise
- r/v meds e.g. opioids, aluminium, clozapine
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
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
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
Osmotic laxatives
- lactulose, macrogol
- increases amount of fluid in large bowel = peristalsis
- 2-3 days to work
- also have faecal softening properties
Constipation short duration treatment
- bulk-forming and good hydration
- osmotic
Chronic constipation treatment
- bulk-forming and good hydration
- +/change to macrogol (or lactulose 2nd line)
- no change after 6 months = prucalopride (women only)
- withdraw lactulose slowly when patient improves
Faecal impaction treatment
- hard stool = macrogol & stimulant once softened
- soft stool = stimulant
- rectal bisacodyl and/or glycerol if remain constipated
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
Constipation in pregnancy and breastfeeeding
- dietary & lifestyle - fibre supplements e.g. bran/wheat
- bulk-forming - ispaghula
- osmotic
- bisacodyl or senna (not senna near term)
Constipation in children
- dietary advice & macrogol (if no faecal impaction)
- stimulant
- if stool hard = lactulose or docusate
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
Rapid control for diarrhoea/traveler’s diarrhoea
- loperamide
- avoid in bloody or suspected inflammatory diarrhoea
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
What is dyspepsia
upper abdo pain, heart burn, gastric reflux, bloating, NV
Dyspepsia referral symptoms
- GI bleed
- Age 55 +
- Unexplained weight loss
- Dysphagia
GAUD
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
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
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
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
GORD urgent referral criteria
GAUD
- GI bleed
- Age 55 +
- Unexplained weight loss
- Dysphagia
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
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
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
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
Name PPIs
omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole
PPIs MHRA Warning
low risk of subacute cutaneous lupus erythematosus
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
Name H2 receptor antagonists
cimetidine, famotidine, nizatidine
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
what is cholestasis
- impaired bile formation or flow = fatigue, pruritus, dark urine, pale, jaundice
cholestatic pruritus treatment
- relieved by cholestyramine, ursodexycholic acid, rifampicin
Intrahepatic cholestasis in pregnancy
- during late pregnancy = adverse foetal outcomes
- treatment of pruritus associated = ursodexycholic acid
What are gall stones
hard mineral or fatty deposits forming stones in gall bladder bile duct
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
Gall stones drug treatment
- mild-mod pain = paracetamol/NSAID
- severe pain = IM diclofenac
- whilst waiting for surgery
What is an anal fissure
tear or ulcer in anal canal = bleeding and pain on defecation
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
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
What are haemorrhoids
- swelling of vascular mucosal anal cushions around anus (high risk during pregnancy)
- internal = painless
- external = itchy or painful
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
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
Treatment of exocrine pancreatic insufficiency
- pancreatic enzyme replacement (pancreatin)
- levels of fat soluble vits (DEAK) and micronutrients monitored - give supplements when needed
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
Pancreatin in cystic fibrosis
- fibrosing colonopathy at high dose pancreatin
- don’t exceed 10000 units/kg/day of lipase
- report new abdominal symptoms
What is a stoma
artificial opening on abdomen to divert flow of faeces/urine to external pouch
Drug suitability with stomas
EC/MR capsules not suited - insufficient effect from drug - use quick acting forms e.g. liquids, caps, uncoated/soluble tabs
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
What are pesto-bismol and milk of magnesia used for
indigestion
Clarithromycin and ciclosporin interaction
clarithromycin increases concentration of ciclosporin
What is an astringent and give an example
- substance that draws water out of tissue and causes the tissue to shrink
- bismuth oxide
Classic symptom of colic in a baby and treatment
- baby pulls legs to chest and crying, red in the face
- OTC simethicone (infacol)
Colestyramine side effects
- constipation, diarrhoea, NV, GI discomfort
- increased tendency to bleed
- decreased absorption of DEAK = hypoprothrombinaemia due to low K
- hypertriclycerideaemia = aggravation
Colestyramine administration
1 hour before or 4 hours after other medication to reduce interference with absorption
Ranitidine OTC max supply
2 weeks
Antacids containing both magnesium and aluminium
- reduced colonic side effects
- insoluble in water so long-acting if retained in the stomach
PPIs and GI infections
PPIs increased risk of GI infections
Orlistat advice
take with vitamins and minerals if concerns about inadequate micronutrient intake
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
