GI

Question 1

Coeliac disease

Answer 1

Autoimmune condition associated with chronic inflammation of small intestines
Immune response triggered by gluten
Leads to malabsorption of nutrients (calcium and vitamin D =osteoporosis)
Diagnose with igA tissue glutaminase test

Question 2

Coeliac disease symptoms

Answer 2

Abdominal pain
Bloating
Complications from nutrient malabsorption (e.g calcium and vitamin D) =osteoporosis / bone disease
Diarrhoea

Question 3

Non-drug treatment for coeliac disease

Answer 3

Strict life long gluten free diet
Assess risk osteoporosis
Vitamin and mineral supplement

Question 4

Drugs used in coeliac disease

Answer 4

Supplementation with calcium and vitamin D
Osteoporosis and bone disease treatment e.g biphosponates
Prednisolone (initial management while awaiting specialist advice)

Question 5

Diverticular disease

Answer 5

Condition where diverticula causes intermittent lower abdominal pains without inflammation or infection
Prevalence; increases with age, mainly patients over 50 years +

Question 6

Diverticulitis

Answer 6

Infected and inflammed diverticula
Symptoms; fever, general malaise, fistula, large rectal bleeds, constipation, abdominal pain

Question 7

Drug treatment for diverticulitis

Answer 7

High fibre diet
Bran supplements
Bulk forming drugs (treat constipation or diarrhoea)
Antispasmodics (relieve colic)
Antibiotics (infection)
Elective surgery
AVOID; anti-motility drugs as they can exacerbate symptoms; make you constipated e.g codeine

Question 8

Irritable bowel disease

Answer 8

Autoimmune no triggers
Umbrella term to define Crohn’s disease (mouth to anus) and ulcerative colitis (inflammation of gut)

Question 9

Crohn’s disease exacerbation treatment

Answer 9

Mouth to anus
For acute exacerbation; corticosteroid for single exacerbation in last 12 months or aminosalyclates
When 2/+ exacerbation in 12 months; add th iPrint or methotrexate to corticosteroid
Severe or unresponsive to conventional therapy use biological therapy

Question 10

Crohn’s disease maintenance of remission treatment

Answer 10

Thioprine or methotrexate
Not to use corticosteroids for remission due to s.e

Question 11

Ulcerative colitis acute exacerbations treatment

Answer 11

Acute mild-mod; topical amino salicylates alone or adding oral. (Alternative corticosteroid)
Left sided and extensive UC; high dose oral aminosalicylate; consider adding of topical as well or oral corticosteroid
Acute Mod-severe; biological therapy
Acute severe; IV corticosteroids (+/- ciclosorpin +/or tacrolimus)

Question 12

Maintenance of remission for ulcerative colitis

Answer 12

1st line aminosalicylates - topical +/or oral (depending on severity)
If 2 or more exacerbations in 12 months or uncontrolled with aminosalicylates ADD thioprine or methotrexate (2nd line)
If severe or unresponsive to conventional therapy consider biological therapy (infliximab , adalimumab etc under specialist supervision)

Question 13

Symptoms of IBD

Answer 13

Vary between patients and severity
Abdominal pain
Rectal bleeding
Diarrhoea; can be bloody or mucus
Fever
Weight loss
Anal fissures
Ulcers, anaemia and mouth ulcers
Skin rashes, liver inflammation, middle layer eye inflammation, joints

Question 14

IBD complications

Answer 14

Stricture; narrowing of GIT; difficulty passing food = vomiting and sickness
Perforation holes in the GIT, infection or abscess in abdomen
Fistula
Cancer (higher risk colon cancer)

Question 15

Non drug treatment for IBD

Answer 15

Diet change
Stop smoking
Stress management

Question 16

Ulcerative colitis CI

Answer 16

Loperamide or codeine is CI
Avoid anti motility drug or antispasmodics
Paralytic ileus increase risk of toxic mega colon
(Can use to treat crohns diarrhoea though)

Question 17

Aminosalicylates mechanism of action and examples.

Answer 17

Sulfasalazine and mesalazine
Exerting immunomodulatory effects, antibacterial effects, effects on the arachidonic acid cascade and alteration of activity of certain enzyme

Question 18

Patient and carer advice for aminosalicylates

Answer 18

Report; bleeding, bruising, purpura, sore throat, fever or malaise = signs blood dyscrasia
Swallow tablets whole and ensure adequate fluid intake
Stain contacts or bodily fluids yellow/orange
Monitor salicylate hypersensitivity - itching or hives

Question 19

Monitoring requirements for aminosalicylates

Answer 19

Monitor renal function before starting treatment, 3 months and annually thereafter

Question 20

Aminosalicylate interactions

Answer 20

Drugs that increase hepatotoxicity (alcohol, statin, flucloxacilin, carbamezapine) - not severe advise patients to motion signs of hepatotoxicity
LACTULOSE; and MR/GR of the drug; prevent breakdown of mesalazine in lower pH levels as lactulose lowers pH

Question 21

Adverse effects of aminosalicylates

Answer 21

Arthralgia (joint stiffness)
Cough
Diarrhoea
Fever
GI discomfort
Headache
Leukopenia
Nause and vomitingg

Question 22

Contraindications and caution with aminosalicylates

Answer 22

Acute porphyria’s
G6PD deficiency
Hx allergy
Hx of asthma
Risk haematological toxicity
Risk hepatic toxicity
Slow acetylator status

Question 23

What is irritable bowel syndrome?

Answer 23

Long term chronic condition of the bowel
Mainly affecting ages 20-30 years
More common in women
Disturbance in brain triggers it
Managed by Food and mood

Question 24

Symptoms of IBS

Answer 24

Abdominal pain
Bloating
Either diarrhoea or constipation

Question 25

Non-drug treatment of IBS?

Answer 25

Diet and lifestyle changes; aggregated by stress, depression, anxiety or lack dietary fibre etc Increase physical activity 3 fruit a day not 5 If fibre is required use soluble (oats, ispaghula) as insoluble (bran) can cause exacerbation Increase water intake Reduce caffeine, alcohol and fizzy drinks

Question 26

Drug treatment for IBS?

Answer 26

Depends on severity Antispasmodics; mebeverine, hyoscine and peppermint oil Constipation; increase fibre, laxative (AVOID LACTULOSE = bloating) Linaciotide; used if other laxatives infective and lasts for 12 months; to reduce bloating, pain constipation Diarrhoea; loperamide Bloating; peppermint oil Antidepressants are last line for abdominal discomfort; TCAs and SSRIs CBT Antimuscarinics

Question 27

Constipation

Answer 27

Passage of hard stool less frequently than the patients normal pattern

Question 28

Symptoms of constipation

Answer 28

Hard difficult and painful stools to pass Change from usual bowel habit Can be accompanied by abdominal pain, bloating and sickness (if severe)

Question 29

Causes of constipation

Answer 29

Inadequate fibre intake Inadequate fluid intake Medications; codeine, morphine, aluminium (antacids), iron, some antidepressants Medical conditions; IBS, bowel disorders, under active thyroid Pregnancy; bowels are slowed, baby growing bigger

Question 30

Red flags in constipation

Answer 30

New onset of constipation in patients over 50 years Anaemia Abdominal pain Unexplained weight loss Blood in stool

Question 31

4 types of laxatives?

Answer 31

Bulk forming Stimulants Osmotic Faecal softners

Question 32

What are the line of treatments for laxatives?

Answer 32

Bulk forming Osmotic laxatives Stimulants Then high dose of macrogol osmotic

Question 33

Bulk forming laxatives

Answer 33

E.g bran, ispaghula, methylcellulose (also a softener), sterculia - increase bulk of stool - 72 hour onset Can cause bloating, flatulence and cramping

Question 34

Stimulant laxatives

Answer 34

E.g bisacodyl, sodium picosulphate , senna, glycerol (suppositories work within 30 mins), co-danthramer (terminally ill patients) Increase intestinal motility Onset 8-12 hours so best to use at night and go in the morning Can cause abdominal pain and cramping

Question 35

Osmotic laxatives

Answer 35

Lactulose, macrogols (laxido), phosphate enemas and magnesium salts Lactulose works within 2 days and can cause pain and bloating Increases water drawing in fluid from the body into the bowel or main thing fluid in bowl Hypokalaemia

Question 36

Faecal softeners

Answer 36

Liquid paraffin; avoid as it can cause anal seeping in prolong use Docusate sodium; weak stimulant activity Peanut; softener/lubricant Decreases surface tension and increases penetration of liquid into faecal mass, softens and wets poo

Question 37

Opioid induced constipation

Answer 37

Avoid bulk forming as it can cause obstruction, painful colic Use only osmotic or stimulant Co-danthramer or co-danthrusate in palliative care only Naloxegel or methylnarexate; used for peripheral Ovid-receptor antagonist when response to laxative is inadequate

Question 38

Pregnancy and constipation

Answer 38

Dietary and lifestyle advice first; fibre supplement such as bran or wheat 1st line is bulk forming if above fails 2nd line osmotic e.g lactulose Stimulants avoided can cause abdominal pain and diarrhoea, not to use senna near term time or history of unstable pregnancy as it can stimulate uterine contractions

Question 39

Constipation in children

Answer 39

Use laxatives and dietary advice as first line treatment (lifestyle advice alone is not recommended) Macrogols are first line e.g laxido paeds Second line is stimulants Lactulose if above fails and stool remains hard

Question 40

Patient and carer advice with bulk forming laxatives

Answer 40

Preparations that swell in contact with liquids should always be carefully swallowed with water and shouldn’t be taken immediately before going to bed Full effect may take a few days to develop

Question 41

Diarrhoea

Answer 41

Abnormal passing of loose or liquid stools with increased frequency, increased volume or both Acute diarrhoea lasts for <14 days and symptoms improve between 2-4 days OR Chronic diarrhoea >14 days

Question 42

Causes of diarrhoea

Answer 42

Infection (salmonella, noro virus, e.coli C.diff) Gastroenteritis Side effects of drug Gastrointestinal disorder symptom

Question 43

Aims of diarrhoea treatment

Answer 43

Prevent dehydration and fluid electrolyte depletion

Question 44

Dehydration symptoms

Answer 44

Tiredness Headaches or light headless Sunken eyes Dry mouth and roundup Weakness Confusion Decreased urine output

Question 45

Red flags of diarrhoea

Answer 45

Unexplained weight loss Rectal bleeding Systemic illness Travel abroad Recent hospital treatment

Question 46

Treatment of diarrhoea

Answer 46

Drink plenty to avoid dehydration Eat as normal Self-limiting Oral rehydration satches; 1st line, IV only in severe Loperamide; for rapid control used travellers diarrhoea Ciprofloxacin; occasional prophylaxis for travellers diarrhoea Other drugs used methycellulose, colesyramine, ispaghula husk if associated with diverticular diease

Question 47

Loperamide

Answer 47

12 + MHRA; cardiac reaction with high doses e.g abuse or overdose S/e dizziness, flatulance and nausea CI; UC, antibiotic associated colitis, avoid bloody or inflamed diarrhoea

Question 48

Dyspepsia

Answer 48

Disorder of gastric acid and ulceration Pain or discomfort in the upper abdomen Can occur from gastric, duodenal ulcers, medication related or gastric cancer

Question 49

Symptoms of dyspepsia

Answer 49

Epigastric pain Fullness or bloating Nausea Flatulence Early satiety

Question 50

Red flags with dyspepsia

Answer 50

Bleeding Dysphagia Recurrent vomiting Weight loss >55 years Not responded to treatment

Question 51

Advice for dyspepsia

Answer 51

Lifestyle changes avoid excess alcohol and foods Weight loss advice Smoking cessation advice Raise head of bed Stop any medication that may cause dyspepsia e.g NSAIDs, steroids, etc

Question 52

Referral for dyspepsia

Answer 52

Chronic GI bleeding Progressive dysphasia Persistent vomiting Iron deficiency anemia Epigastric mass Pts over 55 with unexplained and persistent onset of dyspepsia - refer urgent endoscopy

Question 53

Treatment of dyspepsia

Answer 53

Antacids If symptoms persist in uninvestigated dyspepsia then PPI given for 4 weeks If uninvestiagted and not responded well to PPI test for H.pylori If there is population where H.pylori is common treat straight away whilst testing If symptoms persist, PPI or H2 receptor antagonist for 4 weeks

Question 54

Antacids

Answer 54

Contain magnesium or aluminium compounds Take after each meal and at bedtime prn Used to relive symptoms of ulcer dyspepsia, non-erosive GORD, symptoms present Liquid more effective than tablets

Question 55

Aluminium and magnesium containing antacids

Answer 55

Magnesium; tend to be laxatives Al; tends to be constipating

Question 56

Bismuth containing antacids

Answer 56

Pesto-bismol 16 plus Not recommended as bismuth can be constipating neurotoxic and cause encalopathy

Question 57

Calcium contains antacids

Answer 57

Causes rebound acid secretion High doses can cause hypercalcaemia Can precipitate the milk alkali syndrome interaction

Question 58

Simeticone containing antacids

Answer 58

Acts as anti forming agents to relieve flatulence Useful for relive of hiccups in palliative care Antifoaming drug E.g detinex and infacol Simeticone (Activated dimeticone)

Question 59

Alginate containing antacids

Answer 59

Increases viscosity of stomach content and can protect oesophageal mucosa from acid reflux Sodium varies in different antacid perpetrations; avoid hypertension, fluid retention, heart, liver, kidney or those with restricted sodium diets (e.g lithium patients) Gaviscon has mg and Na Gaviscon advance K and Na Not interchangable

Question 60

Peptic ulceration

Answer 60

Involves stomach, duodenum and lower oeseophagus Nearly all duodenal ulcers and most gastric ulcers not associated with NSAIDs are caused by H.pylori

Question 61

H.pylori infection

Answer 61

Diagnose with urea breath test kit (carbon 12 urea test) Initial treatment 1 week triple therapy PPI + clarithromycin + (amoxicillin OR metronidazole) If pt has been treated with metronidazole for other infections use amoxicillin, if pt allergic to amoxicillin use metronidazole

Question 62

NSAID associated ulcer

Answer 62

NSAID can cause GI bleeding and ulcers Withdraw if ulcer occurs High risk; 65+, hx of peptic ulcer disease or serious GI complication, taking other medication that increase ulcer risk, serious co-morbidities e.g CVD, DM, renal/hepatic impairment

Question 63

NAID associated ulcer risk protection

Answer 63

Give PPI Ranitidine or misoprostol Misoprostol is more appropriate for old or frail who NSAIDs can’t be stopped can cause colic and diarrhoea

Question 64

Gastro-protective complexes and chelators

Answer 64

Chelators; e.g sucralfate protect the mucosa from acid-pepsin attack in gastric and duodenal ulcers Complex of aluminium hydroxide and sulphate sucrose Has minimal antacid properties Given one hour before meals Caution bezose formation

Question 65

H2 receptor antagonoits

Answer 65

Famotidine, ranitidine and cimetidine Heal gastric and duodenal ulcers Relives GORD symptoms S/e; rash, dizziness, psychiatric reactions Can masks signs of gastric ulcers Not used for Zollinger-Ellison syndrome as PPI is more effective

Question 66

Prostaglandin gastroprotection

Answer 66

Misoprostol; synthetic prostaglandin analogue Teratogenic Heal gastric and duodenal ulcers Avoid women in childbearing age as it induces undermine contractions, associated with abortion and birth defects S/e diziness and can impair driving or skills tasks

Question 67

PPI

Answer 67

Effective in short term treatment for gastric and duodenal ulcers Lowest effective dose at shortest time Use with abx eradication of H.pylori, treat dyspepsia, GORD, NSAID associated ulcers

Question 68

PPI caution

Answer 68

Can masks signs of gastric cancers Increase risk of osteoporosis Increase GI infection risk

Question 69

PPI side effects

Answer 69

Long term HPYOmagnesia - predisposes digoxin toxicity Fractures Rebound secretion

Question 70

PPI interactions

Answer 70

Omeprazole Reduced clopidogrel antiplatlet effect Decrease clearance of methotrexate

Question 71

GORD symptoms

Answer 71

Heart burn Acid regurgitation May also cause in extreme cases; dysphagia, oesophagitis, ulceration, stricture formation

Question 72

GORD management

Answer 72

Drug treatment Lifetyle advice - avoid excess alcohol, aggravating food, weight loss, raising head of bed Surgery Treatment based on severity of symptoms

Question 73

Mild symptom of GORD treatment

Answer 73

Antacids and alienates H2 receptor antagonists PPI PPI for 4-6 weeks then reassess

Question 74

Pregnancy and GORD

Answer 74

Dietary and lifestyle advice first Antacid or alginate Ranitide Omeprazole

Question 75

Children and GORD

Answer 75

Most resolve without treatment For infants change volume and frequency of feed; more thickeners (thinner it is =more likely to come back up) Can use alginate in older children similar to adults

Question 76

Food allergy

Answer 76

Adverse immune response to food Immunological while food intolerance is not Most common; cow milk, hen eggs, soy, wheat, fish, peanuts,

Question 77

Management of food allergies

Answer 77

Strict avoidance of food Sodium cromoglicate given as adjuvant Educate patients on allergies

Question 78

Drug treatment for food allergies

Answer 78

Chlorphenamine maleate for symptomatic control of food allergy Adrenaline in anaphylaxis

Question 79

Gastroenteritis intestinal and smooth muscle spasm

Answer 79

Antimuscarinic; to relax intestinal smooth muscle; hysocine butylbromide (buscopan for 6+ in diangnosed IBS or buscopan relief in 12+) Antispasmodics reduce intestinal motility e.g mebeverine and alverine

Question 80

Obesity

Answer 80

Increases risk many health problems BMI over or greater 30 is obese 25 to 30 is overweight Assess any underlying issues and encourage lifestyle changes

Question 81

Drug treatment in obesity

Answer 81

Never drug treatment alone use weight management plan Anti-obesity drugs considered in over or greater than 30 BMI and have had least 3 months of diet and exercise or behavioural changes and failed to achieve a realistic weight reduction OR BMI over or greater 28 of they have associated risk factors

Question 82

Orlistat

Answer 82

Obesity treatment Reduces absorption of dietary fat Licensed over or greater 30 BMI or 28 if have other associated risk factors Discontinue after 12 weeks if no weight loss of 5% from start of treatment Vitamin D supplementation if concerns of loss

Question 83

Surgery for obesity

Answer 83

Bariatric surgery BMI over or greater than 40 or between 25-39.9 if they have significant risk factors

Question 84

Anal fissure

Answer 84

Tear or ulcer in the lining of anal canal Symptoms; bleeding, persistent pain on defecation and linear split in anal mucosa

Question 85

Treatment of anal fissure

Answer 85

Acute anal fissue <6 weeks; bulk forming laxatives or osmotic laxatives (constipation can aggravate condition), short term use topical local anaesthetic (lidocaine) or simple analgesia Chronic fissure >6 weeks; glyceryl trininitrate rectal great (rectogesic)

Question 86

Haemorrhoids

Answer 86

Swelling of vascular mucosal around the anus Internal haemorrhoids; painless unless they become strangulated External haemorrhoids; itchy or painful Common in pregnancy Aimee reduce symptoms, promote healing and prevent recurrence

Question 87

Non-drug treatment for haemorrhoids

Answer 87

Increase dietary fibre Increase fluid intake Good perinatal hygiene

Question 88

Drug treatment for haemorrhoids

Answer 88

Bulk forming laxatives Simple analgesia Local topical; anaesthetics, corticosteroids lubricants, antiseptics to reduce pain and itchiness Topical corticosteroids are suitable for occasional short term use; no more than 7 days; long term can cause ulcerations or permanent damage due to thinning of skin and continuous use = adrenal suppression

Question 89

Pregnancy and haemorrhoids

Answer 89

Bulk forming laxatives are safe to use Only use simple soothing products if a treatment with topical haemorrhoids preparations is required; avoid any local anaesthetic or corticosteroid.

Question 90

Specialist treatment for haemorrhoids

Answer 90

Rubber band ligation Injection sclerotherapy (using phenol in oil) Infrared coagulation Haemorrhoidectomy

Question 91

Reduced exocrine secretions

Answer 91

Reduced secretion pancreases Exocrine pancreatic insufficiency reduced secretion of pancreatic enzymes into the duodenum Symptoms; maldigestion and malnutrition , diarrhoea, abdominal cramps steatorrhoea Causes; exocrine pancreatic insufficiency can be caused by; chronic pancreatitis, cystic fibrosis, coeliac disease, Zollverein-Ellison syndrome, pancreatic tumour GI surgery Aims of treatment; to relieve GI symptoms and to achieve normal nutritional status

Question 92

Reduced exocrine secretions; drug treatment

Answer 92

Main treatment is pancreatic replacement therapy with pancreatic (crean, pancrx V, and nutrizum 22) Inactivated by gastric enzyme (take with food so it doesn’t get broken down by gastric enzyme) and avoid heat Pancreatic contains 3 groups of enzymes (lipase, amylase and protease)which assists in the digestion of fats, carbohydrates and protein.

Question 93

Non-drug management with reduced exocrine secretions

Answer 93

Dietry advice Distribute food intake between 3 main meals a day and 2 or 3 snacks Avoid hard to digest foods such as legumes (peas beans lentils and high fibre foods) Reduced fat diets not recommended Avoid alcohol completely Ensure adequate hydration for patients on high strength pancreatin

Question 94

Stoma

Answer 94

Stoma is an artificial opening opening on the abdomen to divert flow of faeces or urine into an external pouch located outside the body 2 most common forms; Colostomy Ileostomy

Question 95

What to AVOID in stoma

Answer 95

Avoid E/C and MR medicine = medicine unsuitable especially for ileostomy due to insufficient release of active ingredients Avoid sorbitol due to its laxative effects Soluble tablets, liquids, caps and uncharted tablets suitable due to quicker absorbtion

Question 96

Stoma drugs

Answer 96

Analgesics; paracetamol most suitable, opioids may cause constipation and NSAIDS gastric irritation and bleeding in colostomy patients Antacids; risk diarrhoea from Mg and constipation from Al salts increased in pts with stoma Antisecretory drugs; gastric acid secretion increases output (PPI used to reduce risk) Antidiarhoeal drugs; loperamide, codeine and co-phenotype are effective Digoxin susceptible to hypokalaemia esp when on digoxin due to fluid and sodium depletion. Should be given potassium supplements or pottasoum sparing diuretics Diuretics; caution with ileostomy; risk dehydration and K depletion Oral iron may cause loose stools IM preffered Avoid enemas as their stronger can cause rapid and severe loss of water and electrolyte. Advice colostomy pts to increase fluid intake and fibre intake to prevent constipation can use bulk forming and senna Pottasoum supplements; liq preparation preferable to MR ones, daily doses to split to avoid osmotic diarrhoea

Question 97

What test is used to differentiate IBS and IBD?

Answer 97

Faecal calprotectin test IBS; doesn’t produce signs of disease of colonoscopy or other tests IBD is inflammatory so can be detected

Question 98

How would you test for colon cancer?

Answer 98

Flexible sigmoidoscopy

Question 99

How would you test for lactose intolerance or bacterial growth?

Answer 99

Hydrogen breath test

Question 100

NSAIDs and alcohol

Answer 100

Alcohol increases the risk of GI haemorrhage associated with NSAIDs Some cases of AKI in excessive use

Question 101

Risk of NSAIDs

Answer 101

Highest risk; piroxicam, ketoprofen and ketorolac trometamol Intermediate risk; indometacin, diclofenac and naproxen Lowest risk; ibuprofen (higher does = intermediate) Start lowest recommended dose and use one NSAID at a time

Question 102

Cardiovascular events and NSAIDs

Answer 102

NSAIDs can increase small irks of thrombotic events Greatest risk is higher doses for long term use Diclofenac 150 mg and ibuprofen 2.4 g daily is associated with increase thromobotic event risk

Question 103

Peptic ulcer

Answer 103

Dark brown red tarry bleed Duodenal ulcer symptoms are relived after eating whereas pain from gastric ulcer is exacerbated after eating

Question 104

Cirrhosis

Answer 104

Damage to the liver Nodules become surrounded by fibrosis which overall affects the livers ability to function Can progress further into liver failure

Question 105

Compensated vs decompensated cirrhosis

Answer 105

Decompensated cirrhosis; liver damaged to the point it cant function Compensated; damage but the liver can still function few or no clinical symptoms

Question 106

Major complications with decompensated cirrhosis

Answer 106

Ascites Hepatic encephalopathy Haemorrhage Infection Jaundice

Question 107

What drugs to avoid in hepatic encephalopathy?

Answer 107

Drugs can further impair cerebral function Sedative drugs, opioid analgesics diuretics that cause hypokalaemia and drugs that cause constipation