GI Flashcards
What is the treatment for diverticular disease?
Bulk-forming laxatives if fibre diet not suitable or patients with persistent diarrhoea or constipation
Simple analgesia
Antispasmodics if abdominal cramping
What are the symptoms of diverticular disease?
Abdominal tenderness and/or
Intermittent lower abdominal pain
Constipation
Diarrhoea
Occasional large rectal bleeds
Which drugs should you avoid if you have diverticular disease?
NSAIDs and opioids as this may increase risk of diverticular perforation
What is the treatment of H.pylori in patient who DO NOT have a penicillin allergy?
1st line for 7 days: (APC)
PPI + amoxicillin + clarithromycin/metronidazole
(Lansoprazole 30mg capsules B.D, Amoxicillin 1g capsules twice daily and Clarithromycin 500mg tablets twice daily)
2rd line for 7 days:
PPI + amoxicillin + tetracycline/levofloxacin
What is the treatment of H.pylori in patients who HAVE a penicillin allergy?
1st line for 7 days:
PPI + clarithromycin + metronidazole
or
PPI + bismuth + metronidazole + tetracycline
2nd line for 7 days:
PPI + metronidazole + levofloxacin
What are the symptoms of crohns disease?
Abdominal pain
Diarrhoea
Fever
Weight loss
Rectal bleeding
What is the monotherapy treatment for acute Crohn’s disease?
Induce remission in first presentation or single inflammatory exacerbation in 12-month periods
- corticosteroid (prednisolone or methylprednisolone or iv hydrocortisone)
Patients with distal ileal, ileocaecal or right-sided colonic disease, consider:
- budesonide (less effective but causes less side effects)
- alternative: aminosalicylates (sulfasalazine and mesalazine)
Budesonide and aminosalicylates NOT suitable in severe presentations or exacerbations
When is add-on treatment considered for acute Crohn’s disease?
If there are TWO or more exacerbations in 12 month period or the corticosteroid dose cannot be reduced
What is the add-on treatment for acute Crohn’s disease?
Azathioprine or mercaptopurine (unlicensed) - added to corticosteroids or budesonide to induce remission
In those who cannot tolerate azathioprine or mercaptopurine or in whom thiopurine methyltransferase (TPMT) activity deficient
- methotrexate can be added to corticosteroids
What is the treatment for severe active Crohn’s disease who have not tolerated conventional therapies?
Adalimumab and infliximab following inadequate response to conventional treatments
Unsuccessful - Vedolizumab or Ustekinumab
How do you maintain remission in Crohn’s disease?
Azathioprine or Mercaptopurine - can be used as monotherapy to maintain remission when previously needed to induce remission with a corticosteroid
- may also be used in patients who have not previously used drugs
Methotrexate can ONLY be used in patients who required it to induce remission
Corticosteroids and budesonide should not be used
How do you maintain remission of Crohn’s disease after surgery?
Azathioprine in combination with up to 3 months’ post-op metronidazole should be considered in patients with ileocolonic Crohn’s disease who have had complete macroscopic resection within previous 3 months
How do you manage diarrhoea associated with Crohn’s disease?
Diarrhoea associated with Crohn’s disease but do NOT have colitis
Loperamide
Codeine phosphate
How is severity of ulcerative colitis determined?
Truelove and Witt’s Severity Index
Why are loperamide and codeine contraindicated in diarrhoea in acute ulcerative colitis?
Increase the risk of toxic megacolon
What kind of laxative is recommended in proximal faecal loading in proctitis (inflammation of rectum) in ulcerative colitis?
Macrogol-containing osmotic laxative
e.g. 3350 with potassium chloride, sodium bicarbonate and sodium chloride
e.g. Laxido and Movicol and Cosmocol
How do you treat acute mild-moderate ulcerative colitis proctitis?
1st line: topical aminosalicylate
If remission not achieved after 4 weeks:
- add oral aminosalicylate
If response still inadequate:
- add topical or oral corticosteroid for 4-8 weeks
How do you treat acute mild-moderate ulcerative colitis proctosigmoiditis and left-sided ulcerative colitis?
1st line: topical aminosalicylate
Remission not achieved within 4 weeks:
- add high dose oral aminosalicylate OR
- switch to a high-dose oral aminosalicylate and 4-8 weeks of a topical aminosalicylate
If response still inadequate:
- stop topical aminosalicylate
- offer oral aminosalicylate + 4-8 weeks of oral corticosteroid
How do you treat extensive ulcerative colitis?
1st line: topical aminosalicylate and high-dose oral aminosalicylate
If remission not achieved within 4 weeks:
- stop topical aminosalicylate
- offer high dose oral aminosalicylate and 4-8 weeks of oral corticosteroid
How do you treat acute severe ulcerative colitis?
Regarded as medical emergency
1st line:
- IV corticosteroid (hydrocortisone or methylprednisolone) given to induce remission
if contraindicated or not tolerated:
- IV ciclosporin or surgery
2nd line: when little or no improvement in 72 hours
- IV ciclosporin + IV corticosteroid
or surgery
If ciclosporin contraindicated/ clinically inapparopate - use infliximab
How do you maintain remission in ulcerative colitis?
After mild-moderate exacerbation of proctitis or proctosigmoiditis:
- rectal aminosalicylate alone OR in combination with oral aminosalicylate daily or as part of intermittent regimen (twice/three weekly or first 7 days of each month)
- oral aminosalicylate can be used alone also but not as effective
left-sided or extensive ulcerative colitis:
- low-dose oral aminosalicylate (single daily doses more effective than multiple daily doses but may experience more side effects)
When would you consider azathioprine or mercatopurine in remission maintenance therapy?
Azathioprine or mercaptopurine can be considered to maintain remission if there has been two or more inflammatory exacerbations in 12 month period that required treatment with systemic corticosteroid, if remission not maintained by aminosalicylate or following a single acute sevre epsidoes
What are some common side effects of sulfasalazine?
Insomnia
Stomatitis
Taste altered
Tinnitus
Urine abnormalities
Blood disorders: haematological abnormalities usually occur within first 3-6 months of treatment - discontinue if occur
What are some common side effects of budesonide?
Dry mouth
Muscle complaints
Oedema
Oral disorders
What are the symptoms of IBS?
Abdominal pain or discomfort
Disordered defaecation (either diarrhoea or constipation with straining, urgency and incomplete evacuation)
Passage of mucus
Bloating
What is the dietary advise for IBS?
- limit fresh fruit consumption to 3 portions a day
- if increased fibre intake required: soluble fibre e.g. ispaghula husk (fybogel) or foods such as oats are recommended
- intake on insoluble fibre should be discouraged e.g. bran and ‘resistant-starch’
- fluid intake should be increased to at least 8 glasses
- intake of caffeine, alcohol and fizzy drinks should be limited
- artificial sweetener sorbitol should be avoided in patients with diarrhoea
What are the treatment options for IBS?
Antispasmodics (alverine, mebeverine and peppermint oil) with lifestyle changes
- 2nd line: low-dose TCA e.g. amitriptyline (if antispasmodics, anti-motility drugs or laxatives do not work)
- 3rd line: SSRI
Constipation: laxative
- if do not response to laxative from different classes and had constipation for at least 12 months: treat with linaclotide
Diarrhoea: loperamide
Why should lactulose be avoided in IBS?
Can cause bloating
What is a common electrolyte imbalance in short bowel syndrome?
Deficiency of magnesium
- oral or IV magnesium (oral may cause diarrhoea)
Intestinal motility
- loperamide or codeine (loperamide preferred)
How do you treat intestinal motility in short bowel synrome?
loperamide or codeine (loperamide preferred)
High doses of loperamide in patients:
- with short bowel due to disrupted enterohepatic circulation
- with rapid gastrointestinal transit time
Occasionally used:
- Co-phenotrope to help decrease faecal output but crosses BBB = CNS side effects (=limited use)
–> also has potential for dependence and anticholinergic effects
When is colestyramine used in short bowel syndrome?
In patient with intact colon and less than 100cm of ileum resected
- used to bind unabsorbed bile salts and reduce diarrhoea
Important to monitor evidence of fat malabsorption or fat-solube vitamin deficiencies if used
Give examples of drugs that need to be prescribed in higher doses in short bowel syndrome?
Some drugs are incompletely absorbed in patients with short bowel syndrome = need higher doses or given IV
e.g.
- levothryoxine
- warfarin
- oral contraceptives
- digoxin
What type of formulations in unsuitable in patients with short-bowel syndrome?
Enteric coated
MR
= may not be sufficient release of active drug
What is a consequence of laxative abuse?
Hypokalaemia
When are bulk-forming laxatives used?
When adults have small hard stools if fibre cannot be increased in diet
Adequate fluid intake must be maintained to avoid intestinal obstruction
e.g. ispaghula husk
Methylcellulose (also used as faecal softener)
sterculia (6 years +)
What is the onset of action of bulk-forming laxatives?
72 hours
What symptoms do bulk-forming laxatives exacerbate?
Flatulence
Bloating
Cramping
When should stimulant laxatives be avoided?
Intestinal obstruction
What are examples of stimulant laxatives?
Bisacodyl
Sodium picosulfate
Co-danthramer
Co-danthrusate
Limited use of co-danthramer co-danthrusate in patients terminally ill because of potential carcinogenicity
Sodium docusate acts as stimulant and softener
Glycerol acts as lubricant and stimulant
What are examples of osmotic laxatives?
Lactulose
Macrogols e.g. 3350 with potassium chloride, sodium bicarbonate and sodium chloride
What is licensed for iBS associated constipation?
Linaclotide (if have tried 2 laxatives and have been constipated for at least 12 months)
What is used for chronic constipation when other laxatives have failed?
Prucalopride
What is the management for short-duration constipation?
1st line: bulk-forming laxatives + fluids
2nd line: add or switch to osmotic
3rd line: if stools soft but difficult to pass or inadequate emptying ADD stimulant laxative
How do you treat opioid-induced constipation?
1st line: osmotic laxative (or sodium docusate) + stimulant laxative
If no response:
- naloxegol recommended
Which laxatives should you avoid in opioid-induced constipation?
Bulk-forming laxatives
How do you treat hard stools in faecal impaction?
High-dose oral macrogol
How do you treat soft or hard stools stools in faecal impaction after trying macrogols?
After a few days, start or add stimulant
If response to oral laxatives inadequate
- for soft stools rectal bisacodyl
- for hard stools glycerol alone or glycerol + bisacodyl OR enema of docusate sodium or sodium citrate may be used
How do you treat chronic constipation?
1st line: bulk-forming laxative
2nd line: add or change to osmotic laxative (if macrogols ineffective, use lactulose)
3rd line: adjust dose to produce one or two soft stools per day
4th line: if 2 laxatives of different classes tried for 6 months and not adequate = treat with prucalopride (in women only)
How do you treat constipation in pregnancy and breast-feeding?
1st line: fibre supplements in form of bran or wheat
2nd line: bulk-forming laxatives
3rd line: osmotic laxative - lactulose
Can you use senna in pregnancy?
Bisacodyl and senna may be suitable if a stimulant effect is necessary but use of senna should be avoided near term or if there is a history of unstable pregnancy
How do you treat constipation in children?
If no foecal impactation:
1st line: macrogol + dietary changes
2nd line: add or change to stimulant laxative
3rd line: add softening effects laxative e.g. docusate sodium or lactulose
How do you treat faecal impaction in children?
1st line: macrogol - to establish and maintain soft well-formed stools
2nd line: add stimulant
3rd line: stimulant + osmotic laxative (e.g. lactulose)
What are the red flag symptoms of diarrhoea?
Unexplained weight loss
Rectal bleeding
Persistent diarrhoea
Systemic illness
Recent hospital or antibiotic treatment
Following foreign travel (other than Western Europe, North America, Australia or New Zealand
How do you treat acute diarrhoea?
Oral rehydration therapy
- disodium hydrogen citrate with glucose
- potassium chloride and sodium chloride
- potassium chloride with rice powder
- sodium chloride and sodium citrate
What is first line for faecal incontinence?
Loperamide once underlying cause established
What is the MHRA warning for loperamide?
Reports of serious cardiac adverse reactions (e.g. QT prolongation, torsades de pointes and cardiac arrest) with high doses of loperamide associated with abuse or misuse
What are the three main groups of digestive enzymes pancreatin contains?
Lipase, amylase, and protease
What is the treatment for exocrine pancreatic insufficiency?
Pancreatin - with meals and snacks
What can be given in conjunction with adequate nutritional intake in patients with food allergies?
Sodium cromoglicate
Peanut allergy - peanut protein in peanut allergy in childhood
What drug is licensed for symptomatic control of food allergy?
Chlorphenamine maleate
What is used first line for food allergies?
Adrenaline/ epinephrine
Which drugs can cause dyspepsia?
Alpha blockers
Antimuscarinic
Aspirin
Benzodiazepines
BB
Bisphosphonates
CCB
Corticosteroids
Nitrates
NSAIDs
Theophyllines
TCAs
What is the initial management of uninvestigated dyspepsia and functional dyspepsia?
PPI for 4 weeks
What should always be tested for before initiating medication of dyspepsia?
H.pylori
What is the follow-up management of uninvestigated and functional dyspepsia?
Symptoms persistent or recur:
- PPI or Histamine H2-receptor antagonists at lowest dose needed, can be used on an ‘as needed’ basis
If on NSAID
- reduce dose if unable to stop drug
- use long-term gastro-protection with acid suppression therapy or switching NSAID to alternative
What drugs can induce peptic ulceration?
NSAIDs
Aspirin
Bisphosphonates
Immunosuppressive agents (e.g. corticosteroids)
Potassium chloride
SSRIs
Recreational drugs e.g. crack cocaine
How do you treat a peptic ulcer associated with an NSAID?
PPI or Histamine H2-receptor antagonists for 8 weeks
Followed by H.pylori infection eradication if patient has tested positive
How do you treat a peptic ulcer not associated with NSAID or H.pylori?
PPI or Histamine H2-receptor antagonists for 4-8 weeks
What is the MHRA warning for PPIs?
Low risk of subacute cutaneous lupus erythematosus (SCLE)
Which vitamin can PPIs reduce?
Reduced absorption of B12
Why do you need to be cautious of using PPIs in elderly patients?
Risk of osteoporosis - maintain adequate intake of calcium and vitamin d
What is the initial treatment of GORD?
Patients with uninvestigated symptoms which suggest GORD should be managed as uninvestigated dyspepsia
Confirmed GORD:
- 1st line: PPI for 4-8 weeks
- 2nd line: Histamine H2-receptor antagonists
Severe oesopahitis:
- PPI for 8 weeks
What drugs cause or exacerbate the symptoms of GORD?
Alpha blockers
Anticholinergics
Benzodiazepines
BB
Bisphonates
CCB
Corticosteroids
NSAIDs
Nitrates
Theophyllines
TCAs
What is the follow-up management of GORD?
Option 1:
- additional 1 month course of PPI
Option 2:
- double initial PPI dose for 1 month
Option 3:
- addition of Histamine H2-receptor antagonists at bedtime for nocturnal symptoms or short-term use
What should be given for GORD in pregnancy?
Antacid or alginate
Severe symptoms:
- omeprazole or ranitidine
What is the treatment for cholestatic pruritus?
Colestyramine
Alternative: rifampicin (caution in patients with pre-existing liver disease due to risk of hepatotoxicity
Ursodeoxycholic acid - small but valuable impact of cholestatic pruritus
How do you treat intrahepatic cholestasis in pregnancy?
(usually occurs in late pregnancy)
Ursodeoxycholic acid
How do you treat gallstone pain?
Mild-moderate:
- paracetamol or NSAID
Severe:
- IM diclofenac sodium OR
- IM opioid e.g. morphine or pethidine
When should waist-to-height ratio be measured?
BMI below 35kg/m2
When might Orlistat be considered?
Individuals with BMI of equal to or >30kg/m2 in whom diet, exercise and behavioural changes fail
Who might bariatric surgery be considered for?
Patients with BMI equal to or >40kg/m2 or between 35-39.9kg/m2 and a significant disease can be improved with weight loss and if all appropriate non-surgical measures have been tried
May be considered for patients with bMI of 30-34.9 who have recent-onset T2DM
What is the treatment for acute anal fissure (present for less than 6 weeks)?
Focus on ensuring soft and easily passed stools:
- Bulk-forming laxative (ispaghuka husk)
- alternative: osmotic laxative (lactulose)
Short-term use of topical preparation containing local anaesthetic
- e.g. lidocaine
OR simple analgesic e.g. ibuprofen or paracetamol
How do you treat chronic anal fissures (present for longer than 6 weeks)?
Glyceryl trinitrate rectal ointment 0.4% or 0.2% (associated with headache as adverse effect)
Alternative: topical diltiazem or nifedipine 0.2-0.5% which have lower incidence of adverse drug reactions than glyceryl trinitrate
Oral diltiazem or nifedipine may be as effective but are associated with higher risk of adverse effects
What type of drug formulations are unsuitable in patients with a stoma?
Enteric-coated
MR
What is the contraindication of azathioprine?
Absent thiopurine methyltransferase (TPMT) activity; very low thiopurine methyltransferase (TPMT) activity - risk of myelosuppression is increased
Which laxative can be used in hepatic encephalopathy?
Lactulose
Which drug colours urine yelow/orange?
sulfasalazine
What are the contraindications of loperamide?
Active ulcerative colitis
Antibiotic-associated colitis
How should cholestyramine be taken>
Cholestyramine should be taken at least 1 hour before, or 4–6 hours after other medications.
How long does lactulose take to work?
Up to 48 hours
What are the electrolyte imbalances of PPIs?
Hyponatraemia
Hypomagnesiaemia
What is misoprostol used for, how do you take it and what are the adverse effects?
Used for peptic ulcers, including enzyme-induced peptic ulcer
400 mcgs twice daily with breakfast and at bedtime
Uterine contractions
Diarrhoea may occasionally be severe and require withdrawal, reduced by giving single doses not exceeding 200mcgs and by avoiding magnesium-containing antacids.
What are the adverse effects of H2 receptor antagonists
Constipation, diarrhoea, dizziness, fatigue, headache, myalgia, skin
reactions
Erectile dysfunction, gynaecomastia (especially cimetidine), hallucination, hepatic disorders, tachycardia
How should lansoprazole be taken?
30 minutes before food
Do not take indigestion remedies two hours before or after dose
Orodispersible - place on tongue and suck
What are the adverse effects of aminosalicylates?
Blood dyscrasias- report unexplained bleeding, bruising, sore throat, fever and malaise
Nephrotoxicity
Salicylate hypersensitivity
Yellow/orange bodily fluids with sulfasalazine- soft contact lenses may be stained
What colour does senna turn urine?
Yellow/brown
How do you take stimulant laxatives?
At night to open bowel in the morning
Onset of action: 6-12 hours
Moisten suppositories with water before use
What is the urgent referral for dyspepsa?
ALARM
Anaemia (sign of GI bleed)
Loss of weight (sign of malignancy)
Anorexia
Recurrent/recent changes, unresponsive to treatment, new in over 55 years old
Malaena (blood in stool), dysphagia, haematemesis, recurrent vomiting
What is the antidote for loperamide?
Naloxone
Loperamide has a longer duration of action than naloxone so treatment with naloxone may need to be repeated
Monitor for at least 48 hours to look out for signs of CNS depression
What colour can co-danthramer make urine?
Red
How is H.pylori tested for?
Carbon urea breath test
Which NSAID has the highest association of GI side effects?
Piroxicam - also long acting
What are patients with coeliac disease at risk of?
Malabsorption of calcium and vitaminD
Osteoporosis
What is the initial treatment for coeliac disease when waiting for specialist advise?
Prednisolone
How do you treat haemorrhoids in pregnancy?
Bulk-forming laxatives - everything else is unlicensed
How do you treat haemorrhoids?
Constipation reported - bulk-forming laxatives
Pain relief: simple analgesic (avoid NSAIDs if rectal bleeding)
Topical preparations containing local aesthetic only for a few days
Topical corticosteroids - maximum of 7 days treatment after exclusion of infection
