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Pharmacy Practice 1 > Gastrointestinal tract > Flashcards

Gastrointestinal tract Flashcards

1
Q

what is the function of the GI tract

A

Breaks down food
Food digested to the point where nutrients can be absorbed
Peristalsis and enzymes all the way!
Reabsorption of fluids/electrolytes in large intestine
The GI tract is a large structure comprising of many components
Lot of things can go wrong
Some major and some minor but symptoms can be very similar

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2
Q

what are common minor ailments that affect the mouth:

A

Mouth ulcers
Oral candidiasis
Dental problems
Dental pain
Xerostomia
Gingivitis

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3
Q

Types of ulcer

A

Aphthous ulcer i.e. common mouth ulcer
Aetiology and epidemiology poorly understood
Minor aphthous
2-5mm lasting < 14 days
Common and affect 10-40 year olds
Major aphthous
>1cm lasting 1-2 months
Linked to stress, trauma, sensitivities, deficiencies and infection
Herpetiform ulcers
Clumps of pin size ulcers covered in a yellow layer
Affect gingiva/hardpalate towards rear of mouth

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4
Q

What features of a mouth ulcer do we need to look at when deciding whether to treat/refer?
NUMBER

A

Number: Single/small number aphthous ulcers
Larger number likely to be other forms
Refer if 5 or more

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5
Q

What features of a mouth ulcer do we need to look at when deciding whether to treat/refer?
LOCATION

A

Inside of cheeks/lips and tongue aphthous ulcers
Other location likely to be other forms so refer

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6
Q

What features of a mouth ulcer do we need to look at when deciding whether to treat/refer?
SIZE AND SHAPE

A

Irregular is trauma or insidious so unless known trauma refer
Very large/small unlikely to be aphthous ulcers

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7
Q

What features of a mouth ulcer do we need to look at when deciding whether to treat/refer?
ASSOCIATED PAIN

A

Uncomplicated aphthous ulcers are painful, more likely to be insidious if not so refer

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8
Q

What features of a mouth ulcer do we need to look at when deciding whether to treat/refer?
AGE OF PATIENT

A

Uncomplicated aphthous ulcers occur commonly in 10-40 year olds, refer if outside of this
Mouth ulcer can be a sign of herpes infections in children <10, immediate referal

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9
Q

What features of a mouth ulcer do we need to look at when deciding whether to treat/refer?
OTHER MEDICATION

A

Drugs such as gold, carbimazole, carbamazepine can cause dangerous blood dyscrasias – mouth ulcers can be an early warning sign of this

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10
Q

Mouth ulcers: when should we refer urgently?

A

Children under 10
Signs of anaemia (common differential diagnosis)
Duration > 14 days
Painless ulcer / irregular shape
Concurrent systemic illness (e.g. fever)
> 1cm diameter Major or Candida
Crops of 5 or more

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11
Q

What treatment options are there for mouth ulcers?

A

Choline salicylate (16+)
Local anaesthetic gel/liquid
Hydrocortisone pellet (12+)
Antibacterial/analgesic mouthwash

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12
Q

Oral Candidiasis

A

Oral infection of fungus Candida albicans
Part of natural flora and fauna for 40% people but proliferation can occur due to environment changes in mouth cavity
Diagnosis
Creamy white soft elevated patches that can be wiped off
Erythematous mucosa i.e. red and sore
Common in infants and elderly patients so occurs in adults due to underlying pathology:
1. Diabetes 4. Antibiotic use
2. Immunosuppression 5. Inhaled corticosteroids
3. Xerostomia 6. Ill fitting dentures

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13
Q

What features of oral candidiasis do we need to look at when deciding whether to treat/refer?
SIZE AND SHAPE

A

Patches are different sizes/irregular shapes d.d. mouth ulcers

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14
Q

What features of oral candidiasis do we need to look at when deciding whether to treat/refer?
ASSOCIATED PAIN

A

Normally sore/painful otherwise refer

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15
Q

What features of oral candidiasis do we need to look at when deciding whether to treat/refer?
LOCATION

A

Normally tongue/cheek but can be pharynx with inhaled corticosteroids

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16
Q

What features of oral candidiasis do we need to look at when deciding whether to treat/refer?
MEDICATION

A

Antibiotic use, inhaler corticosteroids, anti-diabetic medication (highlights diabetes), immunosuppresants

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17
Q

What features of oral candidiasis do we need to look at when deciding whether to treat/refer?
DRY MOUTH/DENTURES

A

Referral to manage underlying cause or recurrence

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18
Q

Oral candidiasis: when to refer urgently

A

Diabetes: adherence issues or under-managed?
>3 weeks
Immunocompromised patients
Painless lesions
Patches do not wipe off (could be leukoplakia)

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19
Q

What treatment options are there for oral candidiasis?

A

Daktarin oral gel is only licensed OTC product
Evidence suggests more effective than POM nystatin
Drug interactions (statins/warfarin)
Licensed dose varies with age – check pack/SPC

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20
Q

What dental problems are commonly encountered in pharmacy?

A

Dental pain
Xerostomia
Gingivitis

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21
Q

What dental problems are commonly encountered in pharmacy?

A

Dental pain
Pharmacy can only sell painkillers – referral to treat underlying cause
Xerostomia
Often iatrogenic – anti-muscarinic (anti-cholinergic) side-effect…
Gingivitis
Due to toxin release by bacteria in calcified plaques (tartar)

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22
Q

What subjects might you broach to better identify the cause of dental problems?

A

Tooth-brushing habits
Bleeding gums
Dental appointments
Smoking
Duration of problem
Medication

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23
Q

What subjects might you broach to better identify the cause of dental problems?
TOOTH BRUSHING

A

Dental problems can obviously be caused by poor dental hygiene BUT
Overzealous brushing can cause bleeding gums and receding gum-line too

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24
Q

What subjects might you broach to better identify the cause of dental problems?
BLEEDING GUMS

A

If due to gingivitis then bleed due to mild trauma (including brushing) BUT
Refer gums that bleed spontaneously

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25
Q

What subjects might you broach to better identify the cause of dental problems?
DENTAL APPOINTMENTS

A

Regular check-ups indicator of good dental hygiene BUT
Are they seeing their dentist due to an ongoing dental health issue?

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26
Q

What subjects might you broach to better identify the cause of dental problems?
SMOKING

A

Leads to poor dental hygiene and could be used as a factor to encourage cessation BUT
BUT NOTHING

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27
Q

What subjects might you broach to better identify the cause of dental problems?
DURATION OF PROBLEM

A

Gingivitis is a chronic condition
Acute symptoms with oral fetor/swollen lymph glands in the neck suggests a clinical infection

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28
Q

What subjects might you broach to better identify the cause of dental problems?
MEDICATION

A

Anticoagulants can lead to bleeding gums – Does acuteness or change in severity suggest over-anticoagulation requiring urgent referral?
Iatrogenic gingival overgrowth e.g. phenytoin, ciclosporin
Dental problems with medication that cause blood dyscrasias requires urgent referral i.e. agranulocytosis due to carbimazole, carbamazepine, NSAIDs, DMARDs.

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29
Q

Dental problems: when to refer urgently

A

Spontaneous gum bleeding

Systemic symptoms

Foul taste with acute bleeding

Medication could be implicated

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30
Q

Treating dental problems

A

Toothbrush, toothpaste and dental floss!
Chlorhexidine mouthwash

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31
Q

Dyspepsia

A

Dyspepsia is an umbrella term covering several conditions often referred to indiscriminately by the public as either heartburn or indigestion

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32
Q

What clinical conditions does this term cover?

A

Over 90% of cases with presenting symptoms of dyspepsia are diagnosed as:
Gastro-oesophageal Reflux Disease (GORD)
Gastritis (Non-ulcer dyspepsia)
Duodenal ulcers
Gastric ulcers

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33
Q

Gastro-oesophageal Reflux Disease (GORD)

A

Stomach contents reflux past oesophageal sphincter
Smoking relaxes sphincter
Pregnancy alters size and shape of stomach forcing contents past sphincter

34
Q

Gastritis (Non-ulcer dyspepsia)

A

Increased acid production results in gastritis (inflammation of stomach lining)
Helicobacter Pylori (H. Pylori) increases gastritis and acid secretion – it is the most common cause of both gastric and duodenal ulcers if left untreated
NSAIDs and alcohol are other common causes of gastritis and ulceration

35
Q

What symptoms might a patient present with suggesting dyspepsia?

A

Nausea
Heartburn (acid regurgitation/’burning’ localised behind sternum)
Epigastric pain
Generalised abdominal discomfort
Bloating/feeling of fullness
Flatulence

36
Q

What information do you need to ascertain before deciding to treat or refer?

A

Age
Location
Nature of pain
Severity
Associated symptoms
Aggravation/relief by eating
Lifestyle
Medication

37
Q

treating and referring
DYSPEPSIA
AGE

A

Dyspepsia is rare in children and should be referred
Middle age patients and older should be referred where there is no history of dyspepsia or where dyspepsia is regular and uncontrolled

38
Q

treating and referring
DYSPEPSIA
LOCATION

A

Epigastric pain (above belly button) is gastritis dyspepsia
‘Burning’ behind sternum is (breast bone) is reflux (heartburn)
Pain/burning elsewhere is likely to be something else

39
Q

treating and referring
DYSPEPSIA
NATURE OF PAIN

A

Pain described as burning, aching or discomfort fits with dyspepsia
Pain described as gnawing, sharp or stabbing pain is unlikely to be dyspepsia
Pain that radiates is unlikely to be dyspepsia i.e. differential diagnosis of cardiovascular disease – undiagnosed angina may present as ‘heartburn’ which radiates down the left arm

40
Q

treating and referring
SEVERITY
DYSPEPSIA

A

If the symptoms are severe and debilitating then refer urgently e.g. look at your patient – are they pale and sweating?

41
Q

treating and referring
DYSPEPSIA
ASSOCIATED SYMPTOMS

A

Persistent vomiting is suggestive of ulceration
Vomiting with blood or black and tarry stools suggests damaged/perforated ulcer

42
Q

treating and referring
DYSPEPSIA
AGGRAVATION/RELIEF BY EATING

A

Pain/discomfort aggravated by food suggests gastric ulcer
Pain/discomfort relieved by food suggests duodenal ulcer

43
Q

treating and referring
DYSPEPSIA
LIFESTYLE

A

Smoking, alcohol consumption, poor diet, obesity and stress are all linked to dyspepsia

44
Q

treating and referring
DYSPEPSIA
MEDICATION

A

Many drugs including aspirin, NSAIDs, SSRIs, iron and macrolide antibiotics can cause dyspepsia
Regular use of NSAIDs and aspirin can cause iatrogenic ulceration
Effects are additive with risk of severe dyspepsia and ulceration enhanced when such drugs are used concurrently.

45
Q

Dyspepsia: when to refer urgently

A

Black/tarry stools
Persistent vomiting/blood in vomit
Change in bowel habits
Severe/debilitating pain/discomfort
Radiating pain
Feeling of food sticking in throat
Treatment fails to help manage symptoms
Unexplained weight loss

46
Q

What treatment options are there for dyspepsia?

A

Antacids
Alginates
H2 antagonists
PPIs
Lifestyle advice

47
Q

What treatment options are there for dyspepsia?
ANTACIDS

A

Na/K salts quicker acting
Mg salts cause diarrhoea Al salts cause constipation so newer antacids that use these combine both
Ca salts
Take after food to slow GI transit so work longer
Care needed due to interactions and systemic absorption
Liquids quicker acting but less convenient

48
Q

What treatment options are there for dyspepsia?
ALIGNATES

A

‘raft-forming’
Better than antacids for reflux
Liquids quicker acting but less convenient
Safe and effective in pregnancy

49
Q

What treatment options are there for dyspepsia?
H2 ANTAGONISTS

A

Ranitidine 75mg OTC
Comparable effect to antacids but lasts 12 hours
Only licensed for short-term use: can mask more serious pathology

50
Q

What treatment options are there for dyspepsia?
PPIs

A

Esomeprazole (Nexium Control®) and omeprazole OTC
Only licensed OTC for reflux in patients aged 18+
Care needed: interactions and contraindications
Only licensed OTC for short-term use: can mask more serious pathology
Slower acting: may need to take for 1-2 days before effective

51
Q

What treatment options are there for dyspepsia?
LIFESTYLE ADVICE

A

Eat little and often
Avoid rich/spicy food and alcohol
Smoking cessation
Weight loss for overweight patients
Nocturnal reflux: Alginate at bedtime, raise head of the bed/extra pillow(s)

52
Q

Constipation: ‘Bowel habits’

A

As a rule the general public tend to be very interested in their own bowel habits!
Older patients start to eat less and be less active but still expect to open their bowels in the same way that they always have
Mothers tend to focus on their children’s bowel habits and too many consider laxatives before reflecting on their child’s diet and lifestyle

53
Q

Empty bowel less often than normal

A

Empty bowel less often than normal
Difficulty passing hard stools
Incomplete emptying of bowels
Most common in the elderly….
2-3x more common in women
40% of pregnant women in later stages become constipated

54
Q

What causes constipation?
LIFESTYLE

A

Less active (sedentary)
Poor fluid intake
Eating less
Poor diet low in:
Fibre
Fruit and vegetables
Ignoring ‘nature’s call’
Toilet training

55
Q

WHAT CAUSES CONSTIPATION:
Medical

A

MS
Parkinson’s disease
Any condition that renders the patient less active/motile including depression and acute anxiety/stress
Haemorrhoids (vicious circle)
Pregnancy

56
Q

WHAT CAUSES CONSTIPATION?
Iatrogenic

A

Opioids
Iron
Any drug with anti-muscarinic/anti- cholinergic properties
Indirectly diuretics

57
Q

What information do you need to ascertain before deciding to treat or refer?
LIFESTYLE CHANGES

A

Eating less, drinking less, less active…
Aging patient who is less active and eats less will open their bowels less
Patient’s who are ‘on a diet’/
Lots of exercise (not enough rehydration)

58
Q

What information do you need to ascertain before deciding to treat or refer?
pain on passing stools

A

Further reluctance to defecate
Haemorrhoids
Generally refer

59
Q

What information do you need to ascertain before deciding to treat or refer?
BLOOD

A

Always refer but how urgently?
Bright red specks on toilet paper suggest haemorrhoids/fissure
Black/tarry stools is GI bleed – urgent referral

60
Q

What information do you need to ascertain before deciding to treat or refer?
DURATION

A

14 days with no obvious cause and have not seen GP about it then refer
Can help treat chronic diagnosed constipation/common explainable cause

61
Q

What information do you need to ascertain before deciding to treat or refer?
MEDICATION

A

As before medication that can cause constipation
As before medication that suggests condition that can cause constipation
Medication for cardiovascular disease – forcing the bowels to open increases heart rate and fluctuates blood pressure – MI, arrhythmia, stroke

62
Q

Constipation: when to refer urgently

A

Blood in the stool
>14 days with no obvious cause
Pain when opening bowels
>40 years old with sudden and significant change in bowel habits (especially with associated weight loss) – colorectal cancer (possible not in early stages)
Tiredness
Anaemia or upper GI bleed
Or hypothyroidism if also associated with weight gain and feeling cold

63
Q

Treating constipation: What treatment options are there for constipation?
LIFESTYLE CHANGES

A

Lifestyle changes should always be recommended first line
Where laxatives are used lifestyle advice should always be given at the same time

64
Q

Treating constipation: What treatment options are there for constipation?
LAXATIVES

A

Bulk forming
Stimulant
Osmotic
Stool softeners

65
Q

What are bulk forming laxatives?

A

Principally ispaghula husk
Contain or mimic fibre
Binds water to increase size of faecal matter
Stretches gut wall stimulating peristalsis
Normally work in 12-36 hours but can take up to 72 hours
Adequate fluid intake is essential otherwise can worsen constipation

66
Q

What are stimulant laxatives?

A

Senna, bisacodyl, sodium picosulphate, glycerin/glycerol (suppositories), sodium docusate (also has stool softening properties)
Directly stimulate increased secretions and peristalsis
Should not be used long-term for chronic constipation as can lead to atonic bowel
Quick acting: 8-12 per oral or 20-60 minutes per rectum (suppositories)

67
Q

What are osmotic laxatives?

A

By far the most common are lactulose and macrogols (Movicol® and Laxido®)
Draw fluid into the gut and/or retain it in the gut preventing absorption
Lactulose is slow acting (48 hours) and response is therefore titrated according to response every 48 hours, it is very sweet and sickly and contains a lot of sugar
Macrogols are particularly effective in managing chronic constipation, particularly opioid induced constipation
Magnesium salts in products like Epsom salts and Milk of Magnesia® are traditional treatments not recommended in practice anymore but may be requested by older patients

68
Q

What are stool softeners?

A

Sodium docusate is a stimulant laxative with stool softening properties, but other stool softeners are seldom used in practice
Pure stool softeners like liquid paraffin are oils that lubricate and soften gut contents, they were traditionally used in constipation but bind fat soluble vitamins so can cause deficiencies with long term use, and can also cause rectal seepage

69
Q

What is diarrhoea? Who gets it? What causes it?

A

Increased frequency of bowel movements
Watery/ill-formed stools
Classified as acute (<7 days), persistent (7-28 days) and chronic if longer
Diarrhoea is always the symptom of an underlying cause/condition
UK cases most commonly viral
Traveller’s diarrhoea often bacterial, usually E. Coli
Iatrogenic causes are antibiotics (changes to natural flora/fauna), PPIs (gut less acidic so bacteria proliferate), and orlistat (fat in stools soften and lubricate)
Chronic diarrhoea often due to ulcerative colitis or IBS

70
Q

What information do you need to ascertain before deciding to treat or refer?

A

Blood
Recurrence
Duration
Onset
Timing
Dietary changes
Signs of dehydration
Medication

71
Q

What information do you need to ascertain before deciding to treat or refer?
BLOOD

A

Refer patients with blood in their stools – could be colon cancer or inflammatory bowel disease

72
Q

What information do you need to ascertain before deciding to treat or refer?
RECURRENCE

A

Recurring diarrhoea suggests an underlying pathology so refer

73
Q

What information do you need to ascertain before deciding to treat or refer?
DURATION

A

Could be due to IBS, ulcerative colitis, Crohn’s disease or colon cancer - refer

74
Q

What information do you need to ascertain before deciding to treat or refer?
ONSET

A

Is there a genuine pattern to the onset in relation to a ‘dodgy meal?’ from several hours to a few days before? Has anyone else who had this meal also affected? Refer suspected food poisoning

75
Q

What information do you need to ascertain before deciding to treat or refer?
TIMING

A

Diarrhoea every morning then okay the rest of the day? IBD/IBS

76
Q

What information do you need to ascertain before deciding to treat or refer?
DIETARY CHANGES

A

Significant dietary changes may be involved
Been on holiday? Traveller’s diarrhoea

77
Q

What information do you need to ascertain before deciding to treat or refer?
SIGNS OF DEHYDRATION

A

Irritability, tiredness
Sometimes confusion
Sunken eyes
Cold extremities
Not passing urine for 8 hours
Weak pulse and rapid heart rate
Dry skin that returns slowly back to position when pinched
May require referral depending on severity of symptoms and if associated with vomiting and severe diarrhoea

78
Q

What information do you need to ascertain before deciding to treat or refer?
MEDICATION

A

As before, refer with antibiotics and PPIs
Counselling with orlistat – 15g fat/meal max

79
Q

Diarrhoea: when to refer urgently

A

Chronic diarrhoea
Persistent change in bowel habits in >50s due to risk of underlying pathology
Refer if recently been to a tropical area especially if very watery diarrhoea
Diarrhoea for longer than 3 days in children and elderly – dehydration risk
Unable to drink fluids – dehydration risk
Blood in stools
Severe abdominal pain – suggestive of more serious pathology like diverticulitis

80
Q

What treatment options are there for diarrhoea?

A

The goal is to prevent dehydration!
Oral Rehydration Solutions (ORS) i.e. Dioralyte®
As dehydration prevention is main goal ORS is primary treatment
Suitable for all ages
Loperamide (12+)
Kaolin (consider in children under 12)
Kaolin and morphine, and codeine linctus, are not longer recommended OTC for diarrhoea as they are inferior to loperamide but have the risk of addiction/abuse

81
Q

Other considerations:
treating diahorrea

A

Acute viral/bacterial causes i.e. gastroenteritis/traveller’s diarrhoea associated sometimes with vomiting
No licensed treatment in UK to prevent vomiting
Again ORS to reduce risk of dehydration
Pre-emptive sales particularly of ORS for those who will be at risk of traveller’s diarrhoea

82
Q

Example exam question

A

A. Corsodyl®
B. Dulcoease®
C. Imodium®
D. Movicol®
E. Peptac®
Which of the above proprietary medications can be used to manage aphthous lesions?
Which of the above proprietary medications can be used long-term for constipation caused by opioid painkillers?
Which of the above proprietary medications would be useful to sell for a whole family with children over 12 who are going abroad on holiday?
Which of the above proprietary medications would be useful for a patient with a burning sensation behind their sternum after eating fatty or spicy food?
Which of the above proprietary medications is safer than traditional remedies like liquid paraffin, but has a similar effect on the contents of the colon?

Pharmacy Practice 1 (15 decks)

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