GI Flashcards
How long must a child have symptoms to diagnose him with functional constipation?
One month of at least 2 defining symptoms
What are some symptoms of functional constipation in children?
- 2 or fewer defecations per week
- history of excessive stool retention
- history of painful or hard bowel movements
- history of large diameter stools
- presence of a large faecal mass in the rectum
- at least one episode per week of incontinence after acquisition of toilet skills
- history of retentive posturing or excessive retention in toilet-trained children
What is the stepwise treatment approach for functional constipation?
- regular doses of a stool softener or osmotic laxative
- if step 1 fails, use stimulant
- if monotherapy is ineffective, use combination of laxatives
- glycerol suppositories
What stool softeners can be used in children and from what ages?
Poloxamer (from under 6 months)
Docusate (from 3 years)
Liquid paraffin (from 1 year) - not recommended
What osmotic laxatives can be used in children and from what age?
Lactulose (from under 1 year)
Macrogol +/- electrolytes (from 1 year)
What stimulant laxatives can be used in children and from what age?
Senna (from 2 years)
Bisacodyl (from 3 years)
Sodium picosulfate drops (from 4 years)
What suppositories can be used in children?
Glycerol suppositories from under 1 year (infant)
How long can a course of laxatives be used in children with functional constipation?
May be used for several months, medication should be gradually reduced
What treatments should be avoided in constipated children?
Prune juice, brown sugar in water
When to refer a constipated child?
Fecal impaction, ineffective treatment, lasting more than 6 months, pain, affecting child’s lifestyle
Define diarrhoea
> 3 loose or liquid bowel movements, usually accompanied by increased frequenecy and fluidity to normal bowel pattern
When to refer diarrhoea?
- alternating with constipation
- occurring intermittently
- blood or mucus in the stool
- > 14 days
- severe, more than 8-10 motions per day
- persistent fever and severe vomiting
- severe abdominal pain
- pregnancy
- weight loss
- recent travel overseas
- child <6 months or <1 year if >24h
- chronic medical conditions
- suspected laxative misuse
- family hx of GI disease
What are the diarrhoea treatment? (1st and 2nd line)
1 - oral rehydration therapy
2 - antimotility agents
When can antimotility (anti-diarrhoeal) agents be used?
In adults and children >12
Mild to moderate acute diarrhoea
Short term control for convenience
When should antimotility agents never be used?
- Severe diarrhoea, possibly caused by invasive organisms
- Severe IBD
- Children
What anti-diarrhoea agents are available?
Loperamide (+/- simethicone)
Diphenoxylate (+/- atropine)
What schedule is loperamide?
Unscheduled <8 pills, Schedule 2 <20 pills, PBS listing - authority required
What schedule is diphenoxylate?
Schedule 3 <8 pills, Schedule 4 >20 pills, PBS listing available
List 3 brand names for loperamide?
Imodium, Gastro-stop, Gastrex
List 2 brand names for diphenoxylate?
Lomotil, lofenoxal
What is giardiasis?
Parasitic infection of the small intestine caused by Giardia lamblia
How is giardia transmitted?
From contaminated water by raw sewage or animal waste, also human to human
What are some symptoms of giardiasis?
Diarrhoea (foul smelling)
Stomach cramps
Gas / flatulence
Nausea
What is the treatment for giardia infection?
Metronidazole, 3 times a day for 5 days (80-90% effective)
What is a common cause of viral gastroenteritis in children?
Rotavirus
How is rotavirus infection managed?
Prevention with the vaccine, oral rehydration solution, hospitalisation when severe
Define dyspepsia
Pain or discomfort in the upper abdomen
What is heartburn/reflux
Common symptom of dyspepsia causing a burning sensation that rises from the stomach to the chest
What is GORD
Prolonged exposure of the oesophageal lining to refluxed gastric contents leading to troublesome symptoms such as heartburn and reflux and mucosal damage
What causes GORD?
Weakened or impaired function of the lower esophageal sphincter; increased intra-abdominal pressure; reduced oesophageal clearance; impaired mucosal defences
What frequency of heartburn and reflux indicates possible GORD?
2 or more days per week and becoming troublesome
List signs and symptoms of GORD
Heartburn, excessive burping, regurgitation of food or acid, upper abdominal pain or discomfort, waterbrash, difficulty swallowing, sore throat, persistent dry cough, angina-like chest pain
What are some exacerbating factors for GORD?
Fatty and spicy food, supine position after eating, gastric pressure increased, smoking, bending or straining, tight clothes, stress, MEDICATIONS
What medications can make GORD worse?
Anticholinergics (sedating antihistamines), antidepressants, nitrates, CCBs, Nicotine, benzodiazepines, beta-blockers, alpha-blockers, opiates, oral corticosteroids, aspirin, NSAIDs, bisphosphonates, tetracyclines, quinine, Vit C, potassium chloride, iron
When do you refer a case of GORD?
Anaemia, weight loss, anorexia, recurrent or recent onset of symptoms, dark stools (blood), swallow impairment, nocturnal choking, persistent cough, vomiting blood, radiating chest pain.
What classes of drugs can be used for GORD?
Antacids (S2) - quick onset, last 3-6 h
+/- simethicone to reduce flatulence
+/- alginates to form a raft on top of the stomach contents
H2 Antagonists (S2, S3, S4 and unscheduled) , reduce gastric acid secretion, can be used in pregnancy
PPIs (S2, S3, S4) Reduce gastric acid secretion, most potent
Name 3 H2 antagonists
famotidine, nizatidine, ranitidine
How quickly do H2 antagonists work
Anti-secretory activity begins within 1 h and persist for 6 to 12 h
Name some PPIs
omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole
Name some AEs of PPIs
Common: headache, diarrhoea, GI upset, constipation, flatulence;
Infrequent: rash, itch, dry mouth, dizziness, fatigue
Rare: blurred vision, myalgia, myopathy, taste disturbance
Counselling for PPIs
Take 30 to 60 mins before meal; Do not crush or chew; slow onset of action, can use an antacid first;
What is the GORD Step-Down Approach
Start with H2 antagonist; PPIs are initiated at standard dose as trial for 4-8 weeks; maintenance therapy to be reviewed frequently; if symptoms are well controlled consider stopping treatment, intermittent use and step down to low-dose
List medicines for motion sickness
Promethazine, Dimenhydrinate, hyoscine hydrobromide
What are common effect of motion sickness tablets
Sedation, anticholinergic effects
Which motion sickness drug is the most long acting?
Promethazine, can be taken every 8h
What motion sickness drug can be used in children?
Promethazine >2 yo, Dimenhydrinate >4 yo, hyoscine >2 yo
What are some non-pharmacological treatments for motion sickness
Acupressure and ginger (safe in pregnancy)
What is Diphenoxylate?
Antimotility drug
Why is atropine added to diphenoxylate?
It discourages misuse at it triggers anticholinergic effects - causes dry mouth, blurred vision, urinary retention
What are some symptoms of haemorrhoids?
Pain, tag around anus, irritation, swelling, burning, discomfort, itching, bleeding
What are some causes of hamorrhoids?
Constipation, pregnancy, straining, obesity, sitting down a lot
What is a common S3 medication for haemorrhoids?
Proctodesyl - cinchocaine + hydrocortisone
What is an S4 medication for haemorrhoids?
Scheriproct - cinchocaine + prednisolone
How long does an acute anal fissure take to heal?
4 to 8 weeks
What treatments are used for anal fissure?
Increase fiber and laxatives, warm baths, topical ointments - glyceryl trinitrate, lignocaine, hydrocortisone, CCB (topical diltiazem and nifedipine)
What is the common ointment used for anal fissure?
Restogesic - glyceryl trinitrate
What are the counterindications for rectogesic?
PDE5 inhibitors - sildenafil, tadalafil, vardenafil
What medications can be used for threadworm?
Pyrantel (S2), mebendazole (S2), albendazole (S4)
Which anti-helminthic medicine is used in the aboriginal population under the PBS?
Albendazole
What tests can be done to diagnose Coeliac disease?
Serological - in px consuming gluten, but 5% of px with disease have negative serology; not reliable in children <5
Gastroscopy and biopsy - no need to stop gluten, shows damage to villi
Genotype - for px on gluten free diet, screen for Human Leukocyte antigen (HLA), >99% px with Coeliac test positive; 30-50% of population has gene, but only 10% have disease
What are some signs and symptoms of coeliac?
Can be asymptomatic, fatigue, weakness, lethargy, GI problems (bloating, flatulence, diarrhoea/constipation, abdominal pain, indigestion), weight loss or gain , nutritional deficiencies, anaemia, osteoporosis, infertility in women
How do you manage coeliac disease?
Gluten free diet - avoid wheat, barley, rye; use vitamin supplements, including calcium, temporarily restrict lactose if px becomes intolerant, refer to dietician
Who is at increased risk of bowel cancer?
> 50 yo
family hx
have had polyps
have IBD
smoking and drinking
overweight
poor diet - low fibre, high fat
What is the routine test done for bowel cancer screening?
FOBT (faecal occult blood test) - detects blood in stool
Which population is targeted in the bowel screening program?
All australians 50 to 74 yo, screened every 2 years
What interferes with the FOBT?
No food, no medication but:
- do not collect 3 days outside menstrual period
- if bleeding haemorrhoids
- after recent colonoscopy
- if visible blood present
What is the pharmacist’s role in bowel cancer prevention?
Educate px, facilitate screening for those ineligible fro the national program; Bowel Screen Australia - pharmacy based program
What are the advantages of Macrogol for colonoscopy preparation?
Less risk of dehydration and electrolyte imbalance; needs to be dissolved in 3 L water; reduced fluid shifts
What are some advantages and disadvantages of magnesium plus sodium picosulfate for colonoscopy prep?
Dissolved in less volume, easier to take; more likely to cause fluid shifts, electrolyte imbalances and dehydration; use with caution in >65, kidney or heart disease
What is an alternative (not 1st line) drug for colonoscopy preparation?
Sodium phosphate - higher risk of complications, avoid in elderly, kidney and heart problems, dehydration of hypercalcaemia , reduced renal function
