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
