Gastrointestinal system Flashcards
What is coeliac disease?
An autoimmune condition associated with chronic inflammation of small intestine triggered by dietary protein (gluten)
List examples of food that contain gluten
Wheat, barley, rye, cakes etc
Gluten activates an abnormal immune response in the intestine that leads to malabsorption of what kind of essential vitamins?
Folic acid, vit D, Ca and Fe
Symptoms of celiac disease
ABCD
Abdominal pain
Bloating
Constipation
Diarrhoea
What is the only effective tx for coeliac disease
A strict life long gluten free diet
Drug tx of coeliac disease
Supplementation with ca, folic acid and vit D
Osteoporosis tx
What is diverticulosis
Asymptomatic condition
Presence of diverticula
Age dependent usually 40+
Difference between diverticulitis and diverticular disease
Diverticular disease is a condition where diverticulitis are present and cause symptoms such as abdominal tenderness, constipation and diarrhoea, rectal bleeds and Intermittent lower abdominal pain WITHOUT inflammation or infection
Whereas Diverticulitis causes inflammation and Infection
Signs and symptoms of acute diverticular disease
Constant lower abdominal pain
Fever
Significant rectal bleeding
Sudden change in bowel habit
Abdominal tenderness
Abdominal mass
State when to refer patients with diverticulitis
Pts with complications such as
Abscess
Bowel perforation
Intestinal obstruction
Sepsis
Non drug tx for Diverculitis
Diet ,lifestyle changes
Eat healthy, balanced diet ,increase fibre
Weight loss, smoking cessation
Exercise
State what to give patient with diverticulosis suffering from constipation
Bulk foaming laxative
Tx for acute diverticulitis
Simple analgesia
Refer pts with Complications
No antibacterial prescribing
What is IBD
A term to define to conditions Crohn’s disease and Ulcerative colitis
Causes of IBD
Genes
Environment
Smoking
Alcohol
Difference between Crohn’s disease and Ulcerative colitis
Crohn’s disease is an inflammation of the whole GI tract whereas UC is the inflammation of the colon
Drug tx of IBD
Aminosalicylates
Medicine affecting the immune system
Biologic therapy
Corticosteroids
Abx
Other medication for Diarrhoea and constipation
Mnemonic for medication used to tx IBD
IBD ACTS BAD
Aminosalicylates
C- corticosteroids
T- Thiopurine
B- Biological agents
A- Antibiotics
D- Diarrhoea, constipation and other drugs
Antidiarrhoal drug is contraindicated in acute UC. True or False?
True
Facts about Ulcerative colitis
Chronic inflammatory condition associated with significant morbidity and life long disease
Common in ages 15 and 25
What’s the tx for mild to moderate Ulcerative colitis ( Procitis)
Ist line line tx- Give topical aminosalicylates
No improvement, give oral aminosalicylates
No improvement, give oral or topical corticosteroids for 4-8weeks
Tx for Proctosigmoidisis and left sided UC
First line- Topical aminosalicylates
Tx for Extensive Ulcerative colitis
First line- Topical amonosalicylates and high dose of oral aminosalicylates
Tx of acute severe UC(life threatening)
I.V corticosteroids and Infiximab
What drug is used to maintain remission in mild, moderate or severe Ulcerative colitis
Use aminosalicylates
AVOID corticosteroids because of side effects
State when to use Oral Azathioprine or mercaptopurine?
It is used when two or more inflammatory exacerbations in a 12month period that required a systemic corticosteroids
Complications of Ulcerative colitis
Colorectal cancer
Secondary osteoporosis
Venous thromboembolism
Toxic megacolon ( widening of colon ,rare but life threatening
Facts about Sulfasalazine
Older aminosalicylates
With more side effects eg stains contact lenses
List eg of newer aminosalicylates with less side effects
Mesalalzine
Balsalazide
Olsalazine
State the most Important side effect of aminosalicylates
Bone marrow suppression
Blood dyscaria( perform blood count and stop drug immediately if blood dyscaria suspected)
What are the signs and symptoms of blood disorder
Unexplained bleeding
Bruising purpura
Sore throat
Fever or malaise
Monitoring requirements with Aminoglycoside
Renal function before starting, at 3months of tx and then annually
Does sulfasalazine stain bodily fluids?
Yes, orange/yellow
Is aminosalicylates nephrotoxic?
Yes
What is IBS( irritable bowel syndrome)
A long term condition of the bowel
Mainly affect s people BTW 20-30yrs
More common in women
What are the causes of IBS
Alcohol, stress, caffeine, certain spicy/fatty food
Symptoms of IBS
ABCD
Abdominal pain
Bloating
Constipation
Diarrhea
Symptoms worsen by eating and relieved by defecating
Flatulence
Passing mucus from bottom
Lethargy
Bowel incontinence
Non drug tx of IBS
Soluble fibre eg fybogel, oat, sterculia
Increase water intake( 8cups/day)
Diet and lifestyle changes
Increase physical activity
Eat regularly without missing meals
Limit fresh fruit consumption
Reduce alcohol, alcohol and fizzy drinks
Drug tx of IBS
Diarrhoea- loperamide
Bloating- peppermint oil
Constipation- increase fibre, avoiding lactose as can cause Bloating
Antispasmodic/ Antimuscarinic- abdominal pain( mebeverine, hyoscine butybromide and peppermint oil)
CBT- depression
Antidepressants
Drug used in moderate to severe IBS associated with constipation
Linaclotide
It’s shown to reduce pain , Bloating and constipation
Causes of constipation
Inadequate fibre
Inadequate fluid intake
Certain medication eg codeine, morphine, some antacids aluminium and some Antidepressants and Iron tablets
Medical condition such as IBS, underactive thyroid
Pregnancy due to hormonal changed slowing bowel movements and baby growing
Red flag symptoms for constipation
New onset constipation 50+
Anaemia
Abdominal pain
Unexplained weight loss
Blood in the stool( black and mixed in stool)
Cancer or G.I bleed
Different types of laxative
BOSS
Bulk
Osmotic
Stimulant
Softeners
Give an example of Bulk laxative
Bran, isphaghula husk, sterculia, methyl cellulose
Give example of Osmotic laxative
Macrogols eg Laxido , lactulose
Give an example of stimulant laxative
Bisacodyl, senna
Give example of Softener laxative
Liquid paraffin
List examples of other laxative used in constipation
Linaclotide and pricalopride
Facts about bulk forming laxative
Onset of action = 72hrs
It’s also a fecal softener eg methylcellouse
MOA: increase bulk in the stool like fibre
Maintain adequate fluid intake to prevent intestinal obstruction
Can cause symptoms of Bloating, flatulence and cramp occasionally
State other conditions Bulk forming laxatives are used in
Colostomy, ileostomy, haemorrhoids, anal fissure, IBS , diverticular disease and UC
List examples of stimulant laxative
Bisacodyl, sodium picosulfate , senna, glycerol and co- danthramer
A stimulant laxative that also acts as a fecal softener is called
DOCUSATE SODIUM
A stimulant laxative that is reserved for terminally ill patients due to carcinogenicity and colours urine RED is called
Co-danthramer and Co-danthrusate
State how Stimulant laxative work
They increase intestinal motility therefore causing abdominal cramps
Onset of action 8-12 hrs
Suppositories-20-60mins
Bed time dose recommended
Stimulant laxative is contraindicated in
Intestinal obstruction and undiagnosed abdominal pain
Side effects of stimulant laxative
Abdominal cramps
Abuse risk which can cause hypokaelamia
MHRA update on stimulant laxative
Following a national safety review and concerns over misuse and abuse, the MHRA has introduced new pack size restrictions, revised recommended ages for use, and new safety warnings for over-the-counter stimulant laxatives (administered orally and rectally). Patients should be advised that dietary and lifestyle measures should be used first-line for relieving short-term occasional constipation, and that stimulant laxatives should only be used if these measures and other laxatives (bulk-forming and osmotic) are ineffective.
Smaller packs will remain available for general sale for the treatment of short-term, occasional constipation in adults only, and will be limited to a pack size of two short treatment courses. Stimulant laxatives should not be used in children under 12 years of age without advice from a prescriber; in children aged 12 to 17 years, products can be supplied under the supervision of a pharmacist.
Facts about faecal softener
Decrease surface tension and increase penetrative of liquid into faecal mass. Softens and wet faeces
Facts about liquid paraffin as a faecal softener
Can cause malabsorption of fat soluble vitamins ADEK
Avoid- can cause anal seepage with prolonged use
Facts about docusate sodium as a fecal softener
Most commonly used softener
Facts about Peanut( arachis) as a fecal softener
Enemas soften and lubricate faeces
List the two types of osmotic laxative
Lactulose
Macrogols
MOA of osmotic laxative
Increase amount of water in large bowel either by drawing fluid from the body into bowel maintaining fluid in the bowel
Onset of action of lactulose to tx constipation
Can take up to 2days for max effect
Not suitable for immediate relief
Macrogols acts faster
Side effect of lactulose
Abdominal pain and Bloating
Electrolyte imbalance
Lactulose is also use to treat
Hepatic encephalopathy
Which drug cause constipation
Verapamil
Opiates
Antimuscarinics
Antihistamines
Antiepileptic
Antispasmodic
Antipsychotics
Antidepressants
Antacids (Aluminium)
Mnemonic of drugs that cause constipation
Very Old Aunties get Constipation
Pt and carer advice for those on bulk forming laxative
Preparation that swell in contact with liquid should be carefully swallowed with water and should not be taken immediately before going to bed. Full effect may take a few days to develop
List the two types of diarrhoea
Acute Diarrhoea < 14days
Chronic Diarrhoea > 14days
What are the causes of diarrhoea
Infection
Gastroenteritis
Side effects of drug
Symptoms of GI disorder
Mnemonic of drug that cause Diarrhoea
CALM diarrhoea
Colchicine
Abx
Laxatives
Magnesium (antacids)
Digoxin
Aim of tx diarrhoea
To prevent dehydration and fluid/electrolytes depletion esp in children and elderly
Signs of dehydration
Tiredness
Headaches
Light headedness
Muscular cramps
Sunken eyes
Dry mouth and tongue
Weakness, confusion, reduced urine output
What is dyspepsia
Umbrella term for upper G.I tract symptoms which typically present for 4 or more weeks
Upper abdominal pain or discomfort
Heartburn
Acid reflux
N and V
When to refer a pt with diarrhoea
Unexplored weight loss
Rectal bleeding
Persistent diarrhoea
Systemic illness
Has received recent hospital or abx tx
Recent foreign travel ( other than western Europe, North America, Australia and New Zealand)
How to tx diarrhoea
Hydration
ORS
Loperamide
Kaoline with morphine
Ciprofloxacin ( occasional prophylaxis for travellers diarrhoea, routine use not recommended)
Symptoms of dyspepsia for 4wks and more
Upper abdominal pain
Heartburn
Gastric reflux
Early satiety
Bloating
N and V
Red flags for dyspepsia
Bleeding
Dysphagia
Recurrent vomiting
Weight loss
55+( unexplained recent onset not responded to tx)
Lifestyle advice for dyspepsia
Lifestyle measures
Eat 3-4hrs before going to bed
Avoid smoking and etoh
Raising the head of the bed
Assess patient for stress, anxiety or depression as these may Exacerbate symptoms
State when urgent endoscopy is required in dyspepsia
Patients with dysphagia, significant acute GI bleed, age 55 and over with unexplained Weight Loss and symptoms of Upper abdominal pain reflux or dysphagia
Causes of dyspepsia
Too much acid( GORD, peptic uler Gastroesophageal malignancy, side effect from drugs , lifestyle)
List the two types of dyspepsia
Functional and Uninvestigated dyspepsia
Explain functional dyspepsia
Dyspepsia symptoms but no underlying cause. Normal endoscopic findings
What is uninvestigated dyspepsia
Symptoms in patients who have not had an endoscopy
Drugs that cause dyspepsia
Nsaids, theophylline, alpha blockers, aspirin, benzodiazepine, beta blockers, bisphosphonates, CCB, nitrate, TCA
Antacids can be used for short term control
How to tx dyspepsia
Antacids/ Alginate short term
Initial management of Dyspepsia ( uninvestigated )
Offer PPI for 4 weeks
Test for H.plyroi
Offer H2 receptor antagonist if inadequate response to
PPI
Initial management for functional dyspepsia
Lifestyle advice
Test for H.pylori and tx if positive
Leave a 2week wash put period after PPI use before testing for H.pylori
If no H.pylori tx with PPI or histamine receptor antagonist for 4weeks
State what to do in pts with uninvestigated dyspepsia unable to stop NSAIDs
Reduce NSAID dose and use long term gastro protection with acid suppression therapy
Switch to alternate to NSAID eg PCM or COX 2 inhibitors ( risk of CV event)
Pt on aspirin unable to stop- switch to an alternative Antiplatelet
What are symptoms of GORD
Heart burn
Acid regurgitation
Chest pain
Hoarseness
Cough
Wheezing
Asthma
Causes of GORD
Fatty food, pregnancy, hiatus hernia, family hx of GORD, stress , anxiety, obesity, smoking,
Drug used to tx GORD
Alginate
Antacids
H2 receptor antagonist
PPI
Drug tx in pregnancy
First line- diet and lifestyle
Antacids or alginate
Omeprazole ( for severe symptoms)
Or Ranitidine (discontinued due to cancer stuff)
How is GORD managed in children?
Change frequency and volume of feed
Use feed thickener
Older children- tx like adults( gaviscon sachet)
Counselling and Pt advice with dyspepsia
Avoid ppt factors such as spicy food, coffee, alcohol and smoking
Eat small.meals ,slowly and avoid eating at bed time .
Sleep with head raised, lose weight
Key points on antacids
See photo fav.
Memory trick for Antacid Ingredients
SCAM
Sodium bicarbonate
Calcium bicarbonate
Aluminium Hydroxide
Magnesium Hydroxide
Affect absorption of certain drugs eg tetracycline take 1-2hrs b or after
Antacids duration of action
Don’t last long
Provide quick symptoms relief in 15-30mins
What is the definition of low sodium content
< 1mmol/tablet or 10ml dose
Which antacids has a low sodium content
MAM
Co- magaldrox = Mg and Al( MAALOX and MUCOGel
2. Co- simalcite eg Altacite plus simeticone
Example of antacids with high sodium
Magnesium carbonate
Magnesium Trisilicate
Sodium alginate with Potassium bicarbonate eg Gaviscon advance contains double Sodium compared to gaviscon original
High Sodium antacids should be avoided in
Liver, kidney failure, htn, sodium restricted diet and CVD
Eg of PPI
Pantoprazole
Omeprazole
Lansoprazole
Esomeprazole
Rabeprazole
Indication of PPI
Gastric Ulcer
Duodenal Ulcer
H.pylori
Dyspepsia
Gord
Nsaid associated Ulcerative
Zollinger - Ellison syndrome
Monitoring requirements for PPI
Measure serum Magnesium conc. Especially when used with other drugs that cause hypomagnesemia or with digoxin( toxicity if low)
MHRA warning for PPI
Lupus
Cautions with PPI
Risk of fracture
Risk of G.I infection
Mask symptoms of gastric cancer
Risk of osteoporosis
Mnemonic for PPI caution
MC GOLF
Osteoporosis ( give VIT D and Ca)
What are the signs of Hypomagnesaemia
Convulsions, muscle pain and weakness
MHRA advice with PPIs
Low risk of subacute cutaneous lupus erythematous (SCLE)
Lesions appear on skin when exposed to the sun, advice patients to avoid exposing the skin
Discontinue meds if possible
Most cases resolved when PPI is stopped
PPI safe in pregnancy
Omeprazole
Important Omeprazole interaction
Avoid CLOE
Omeprazole and esomeprazole decrease efficacy of clopidogrel.
Methotrexate: Omeprazole decreases the clearance of Methotrexate
High dose( use with caution)
Monitor Magnesium with Digoxin
PPI and Breastfeeding
Use with caution
Drug tx for H plyori
PPI
Clarithromycin
Amoxicillin/Metronidazole
Tetracycline and levofloxacin( unlicensed)
Bismuth subsalicylate
Rifabutan/
Memory trick for Triple therapy for H.pylori
PCM
PAM
PAC
PAT/PAL
First line tx for H.pylori in pen. Allergy
PPI + clarithromycin + Metronidazole
2nd line tx for H.pylori in pen allergy pt
PPI plus Metronidazole and Levofloxacin
Alternative first line tx in pt previously tx with clarithromycin
PPI plus bismuth plus Metronidazole plus tetracycline
What test do you use to confirm H.pylori
Urea(13) breath test
SAT
Public England advice for H.pylori test
See photo fav
Gastroprotective complexes
See photo fav
Sucrafate
Causes bezoar formation in pt in ITU
Facts about Sucralfate
Take it ONE hr before you eat
Take late( at bed time)
Take 1 hrs before meals or enteral feeds and at bed time
H2 receptor antagonist
See photo
What is misoprostol
Synthetic prostaglandin analogue
Promote healing of gastric and duodenal Ulcer
Conception and contraception with misoprostol
Do not use in women of child bearing age
Use effective contraception during treatment
What’s a difference between food allergy and intolerance
Food allergy is immunological while food intolerance is not
Most common allergen
Cow’s milk
Hen’s egg
Soy
Wheat
Peanuts
Fish
Shell fish
Management of food allergy
Strict avoidance of causal food
Drug tx
Educate people about the allergens
Drug tx for food allergy
Sodium cromoglicate given as adjunct to dietary avoidance
What drug is licensed for the symptomatic control of food allergy
Chlorphenamine maleate
State what to offer for food induced anaphylaxis
Adrenaline. Check bnf for dose
State drugs used in gastro intestinal smooth muscle spasms
Antimuscarinic and other antispasmodic drugs used to relax intestinal smooth muscle and reduce intestinal motility
Examples of antimuscarinic drugs used
Hyoscine butylbromide
Dicycloverine HCL
List examples of antispasmodic drugs
Alverine, mebeverine
Side effect of antimuscarinic side effects
Can’t see- blurry vision
Can’t pee- urinary retention
Can’t shit-constipation
Can’t speak- Dry mouth
What is Obesity
BMI > or= 30kgm/m2
Obesity classification
See pic
State when to tx obesity with drugs
If BMI is greater than 30 in whom atleast 3months of diet, exercise fail to achieve a reduction in weight
Or if BMI is greater than 28 with associated risk factors eg T2D , HTN and hypercholeterolaemia
Drug for obesity
Orlistat
Vit D supplementation if concerned about deficiency of fat soluble vitamins
Patient with type 2 diabetes lose weight slower true or false?
True
State when an obesed patient should stop taking Orlistat
If when loss since start of tx does not exceed 5% within 3months
State when Bariatric surgery is suitable for obesed patient?
BMI greater than or equal to 40kg/m2( Class 111 Obesity) or between 35-39kg/m2 with a significant disease or high bp
State other drugs used as adjunct in weight management with diet and exercise
Saxenda( Liraglutide)
GLP receptor agonist
Used in pt With BMI >or = 30kg/m2 or 28kg/m2 with associated risk factors
What’s the max daily dose of Saxenda?
3mg
State when to avoid Saxenda in obesed patient
If CrCL is < 30ml/min
Nice recommends Saxenda should be used with…
Caution
What is Anal fissure?
A tear or ulcer in the lining of the anal canal
Symptoms of anal fissure
Bleeding
Persistent pain on defecation
Linear split in the anal mucosa
Aim of tx
To relieve pain and promote healing of fissure
Drug tx for Acute Anal fissure
Present <6weeks
Bulk forming laxative
Osmotic laxative
Short term use of topical preparation containing local anaesthetic eg lidocaine
Simple analgesic - for prolonged burning following defecation
Drug tx for chronic anal fissure
> 6weeks
GTN rectal ointment (s/e: headache)
Alternatively,
Oral or topical diltiezem or nifidipine
Non drug tx for anal fissure
Increase dietary fibre
Increase fluid intake
Good personal hygiene
What’s Haemorrhoid
Abnormal Swellings of vascular mucosal around anus
What is Internal Haemorrhoids
Painless unless they become stragulated
Facts about External Haemorrhoids
Itchy or painful
Haemorrhoid is common in pregnancy . T/F
True
Drug Tx
Bulk forming laxative ( for constipation)
Simple analgesic ( pcm)
Avoid opoids because they cause constipation and avoid NSAID if rectal bleeding present.
Topical Prep. Containing local anaesthetics, corticosteroids, astringent, lubricants and antiseptic ( to reduce pain and itching)
Lidocaine, benzocaine, cinhocaine, pramocaine- should only be used for a few days as they may cause sensitization of the Anal skin.
Duration of tx for hemorrhoids
Short term use for 7days( steroids)
Long term use can cause UC.
Continous use of steroids can cause adrenal suppression
Tx of haemorrhoids in pregnancy
Bulk forming laxativeuse simple soothing products if a tx with topical Prep is required
Symptoms of reduced exocrine secretion
Maldigestion and malnutrition
Diarrhoea
Abnormal cramps
Steartorrhea- fatty stool
Causes of exocrine insufficiency
Chronic pancreatitis
Cystic fibrosis
Ceoliac disease
Zollinger Ellison syndrome
Pancreatic tumors
G.I enzyme
Drug tx for Exocrine Insufficiency
Pancreatin eg Creon, pancrex v and nutrizym22
Take with food( inactivated by gastric enzyme)and avoid heat
Two types of stoma
Colostomy
Ileostomy
Prescribing for pts with stoma
Avoid enteric coated tablet and MR pre due to insufficient release of active ingredients
Avoid preparation that contains Sorbitol as an excipients ( laxative effect)
Painkillers for pts with stoma
Paracetamol most suitable
Opioid may cause constipation in colostomy pts and aspirin, NSAID gastric irritation and bleeding
