GI

Question 1

What is dyspepsia

Answer 1

Dyspepsia is a term used to describe a collection of symptoms rather than a disease
These symptoms include:
* Upper abdominal discomfort or pain
* Heartburn
* Nausea and vomiting related to eating
Acid reflux with or without bloating

Question 2

common causes of dyspepsia

Answer 2

The most common causes of dyspepsia are GORD, peptic ulcer disease and non ulcer dyspepsia

Question 3

ALARM features

Answer 3

ALARM features suggest a more serious underlying pathology:
* GI bleeding
* Dysphagia
* Progressive unintentional weight loss
* Persistent vomiting
* People over 55 yrs of age with persistent or unexplained recent onset dyspepsia
* Also iron deficiency anaemia, an epigastric mass or suspicious barium meal, all of which may be identified by a GP examination
* Abdominal swelling
Anyone describing the ALARM features listed above should be referred to the GP for further investigation

Question 4

Dyspepsia practical advice

Answer 4

NICE1 recommends that people should be offered simple lifestyle advice, including advice on healthy eating, weight reduction and smoking cessation. They should also be advised to avoid known precipitants they associate with their dyspepsia, where possible. These include smoking, alcohol, coffee, chocolate, fatty foods and being overweight1. Raising the head of the bed and avoiding meals close to bed-time may help some people1. Possible stress or anxiety should also be considered as these may worsen symptoms and relaxation strategies encouraged if needed

Question 5

dyspepsia treatment

Answer 5

Simple antacids - there is limited evidence on the efficacy of antacids in the management of dyspepsia3; however, symptomatic relief is often reported with the use of an antacid or alginate. Patients should be advised that antacids only relieve symptoms in the short-term rather than preventing them3. They may be used for immediate relief of symptoms if the person finds this helpful but advice should be offered that long-term, frequent and continuous use of antacids is inappropriate3. The BNF4 states ‘antacids should preferably not be taken at the same time as other drugs as they may impair absorption’.
Liquid preparations may be more effective than tablet preparations
The acid-neutralising capacity, solubility and side-effect profile of the metal salts used as antacids differs and hence the onset and duration of action and patient tolerability of marketed products varies. Antacids containing sodium bicarbonate should be avoided in people on salt-restricted diets4.
There are a number of factors to be considered when supplying antacids to patients. These will include combination of ingredients to avoid side-effects of diarrhoea or constipation, patient acceptability of taste and texture of the product, and the need for it to be portable (e.g. a bulky glass bottle of liquid will not be the ideal treatment to carry in a handbag).
Other types of treatment are:
* Alginates - see information later under GORD
* PPI - see information later under GORD
* Histamine H2-receptor antagonists - such as ranitidine, suppress acid secretion as a result of histamine H2-receptor blockade.
Domperidone is no longer available OTC. It is associated with a small increased risk of serious cardiac side-effects and following a Europe-wide review, the UK commission on Human Medicines concluded that products containing domperidone meet the requirements for prescription-only supply

Question 5

what is GORD

Answer 5

Gastro-oesophageal reflux disease (GORD) describes the reflux of gastric contents into the oesophagus, causing such symptoms as heartburn and acid regurgitation6.
Heartburn is an unpleasant burning feeling felt behind the breastbone, often accompanied by a sour or bitter taste in the throat.
GORD is thought to be caused by a combination of mechanisms, such as transient relaxation (reduced tone) of the lower oesophageal sphincter, increased intra-gastric pressure (e.g. straining and coughing), delayed gastric emptying and impaired oesophageal clearance of acid6.
If heartburn is experienced regularly, investigation by endoscopy may reveal oesophagitis. This may lead to complications such as oesophageal stricture or Barrett’s oesophagus where the normal cube-shaped cells that line the gullet become replaced by elongated cells as a result of damage from the stomach acid.
Long-standing and untreated Barrett’s oesophagus may lead to ulcer and a higher tendency to undergo malignant change. A number of sufferers have endoscopy-negative reflux disease, where reflux is the predominant symptom but a normal endoscope result is seen

Question 6

Dyspepsia red flags

Answer 6

Dysphagia, unexplained weight loss or any other ALARM features (see earlier) should be routinely referred to the person’s GP as these may suggest oesophageal or gastric carcinoma

Question 7

GORD treatment

Answer 7

Proton pump inhibitors (PPIs) inhibit gastric acid secretion by blocking the hydrogen-potassium adenosine triphosphatase enzyme system (the proton pump) of the gastric parietal cell4. A Cochrane review concluded that PPIs are more effective than histamine H2-receptor antagonists in relieving heartburn in patients with GORD8. PPI side-effects include GI disturbances (nausea, vomiting, abdominal pain, flatulence, diarrhoea, constipation) and headache4.
Omeprazole 10 mg, pantoprazole 20 mg and esomeprazole 20 mg tablets are available OTC for the short-term relief of reflux-like symptoms in adults over 18. It may be necessary to take the tablets for 2-3 consecutive days to achieve improvement of symptoms. The treatment duration is up to 2 weeks. After symptom relief, treatment should be discontinued. If no symptom relief within 2 weeks of continuous treatment, the patient should consult their GP.
Histamine H2-receptor antagonists improve symptoms of GORD more than antacids or alginates.
Alginates form a ‘raft’ on the stomach contents to reduce reflux and protect the oesophageal mucosa, e.g. Gaviscon® suspension.
Antacids may provide symptomatic relief in GORD

Question 8

Special considerations- GORD in children

Answer 8

Gastro-Oesophageal Reflux (GOR) is a common physiological event which can happen at all ages from infancy to old age9. It occurs more frequently after feeds/meals9. It usually begins before the infant is 8 weeks old and resolves in 90% of infants before they are one year old9. It occurs in both formula-fed and breast-fed infants9. GORD should be suspected in any infant or child if they present with regurgitation and 1 or more of the following:
* distressed behaviour shown, e.g. by crying while feeding
* hoarseness and/or chronic cough
* a single episode of pneumonia
* unexplained feeding difficulties, e.g. refusing to feed
* faltering growth10.
Children over 1 year of age may present with heartburn, retrosternal pain and epigastric pain10. Symptoms are due to the passive transfer of gastric contents into the oesophagus due to transient or chronic relaxation of the lower oesophageal sphincter10. The family of an infant or child with GORD should be reassured, educated and supported9. Referral is recommended, especially if there are any feeding difficulties or failure to thrive is suspected. Treatments, e.g. thickened feeds, should only be used under medical supervision

Question 9

What is colic?

Answer 9

Inconsolable crying with limb flexure in an otherwise healthy, thriving infant, which lasts for more than 3 hours per day, occurs on 3 or more days per week, has persisted for more than 3 weeks starting in the first weeks of life and ceasing around 3 to 4 months of age

The crying most often occurs in the late afternoon or evening and the baby typically draws its knees up to its abdomen or arches its back when crying11.
The exact underlying cause of infantile colic is not known and some commentators suggest it may reflect part of the normal distribution of infant crying11. Other possible causes include abnormal gastrointestinal motility, inadequate amounts of lactobacilli and psychosocial factors, e.g. family tension; parental anxiety; inadequate parent-infant interaction; overstimulation of child or misinterpretation of crying

Question 10

Colic danger symptoms

Answer 10

• failure to thrive
• post-natal depression – colic is often associated with anxiety of the parents
• those infants whose parents feel unable to cope despite advice and reassurance9
  be aware of the following “WARNING SIGNALS”- pointing to alternative more serious possible diagnoses: bile-stained vomiting, forceful vomiting, vomiting onset after 6 months of age, faltering growth, abdominal tenderness/distension, fever, lethargy, enlarged spleen and/or liver, bulging anterior fontanelle, small or enlarged head circumference, seizures, significantly disturbed stool pattern, sudden onset inconsolable crying, documented or suspected genetic/metabolic syndrome

Question 11

Colic practical advice

Answer 11

The most useful intervention is advice and support for parents and reassurance that infantile colic will resolve11. Reassure the parents that their baby is well; they are not doing something wrong, the baby is not rejecting them and that colic is a common phase that will pass within a few months11. Holding the baby through the crying episode may be helpful11.
However, if there are times when the crying feels intolerable, it is best to put the baby down somewhere safe (such as their cot) and take a few minutes time-out11. Burping post-feeds, gentle motion (pushing pram or ride in the car), ‘white noise’ (vacuum cleaner, hairdryer etc.) and bathing in a warm bath may help9.
Parents should also be encouraged to look after their own well-being, e.g. by asking family and friends for support and resting when the baby is asleep.
* CRY-SIS is a support group for families with excessively crying, sleepless and demanding children11.
The parents, or carers, of a baby with colic could also be provided with the HSCB leaflet: Parents/Carers Information Leaflet for the Management of Babies with Colic.

Question 12

Constipation causes

Answer 12

Secondary causes of constipation include drugs. Some examples are12:
* aluminium-containing antacids, iron or calcium supplements
* analgesics, such as opiates and nonsteroidal anti-inflammatory drugs (NSAIDs)
* antimuscarinics, such as procyclidine and oxybutynin
* antidepressants, such as tricyclic antidepressants
* antipsychotics, such as amisulpride, clozapine or quetiapine
* antiepileptic drugs, such as carbamazepine, gabapentin, oxcarbazepine, pregabalin or phenytoin
* antihistamines, such as hydroxyzine
* antispasmodics, such as dicycloverine or hyoscine
* calcium-channel blockers, such as verapamil
diuretics, such as furosemide.

Question 13

Constipation practical advice

Answer 13

A person with constipation should be offered education and advice to support them with their symptoms which includes eating a healthy, balanced diet and having regular meals12. The person’s diet should contain whole grains, fruits (and their juices) high in sorbitol and vegetables12. Fibre intake should be increased gradually (to minimise flatulence and bloating). An adequate fluid intake is required, especially if there is a risk of dehydration12. Activity and exercise levels should be increased, if needed

Question 14

Guidance on toileting routines

Answer 14

• advise on a regular, unhurried toilet routine, giving time to complete defecation
• advise on responding immediately to the sensation of needing to defecate
• ensure that people with limited mobility have appropriate help to access the toilet and adequate privacy
• ensure the person has access to supported seating if they are unsteady on the toilet12.
  If these lifestyle measures are ineffective or symptoms do not respond adequately, offer treatment with oral laxatives using a stepped approach

Question 15

Constipation treatment

Answer 15

Offer a bulk-forming laxative first-line, such as ispaghula12, 14. If stools remain hard or difficult to pass, add or switch to an osmotic laxative, such as a macrogol12, 14. If a macrogol is ineffective or not tolerated, offer treatment with lactulose second-line. If stools are soft but difficult to pass or there is a sensation of inadequate emptying, add a stimulant laxative 12, 14.
Bulk-forming laxatives should not be used if the person has opioid-induced constipation12, 14. An osmotic laxative and a stimulant laxative are recommended, involvement of prescriber is also recommended 12, 14.
Advise the person to gradually reduce and stop laxatives once the person is producing soft, formed stools without straining at least three times per week

Question 16

constipation danger symptoms

Answer 16

New onset constipation, especially in patients over 50 years of age or accompanying symptoms such as anaemia, abdominal pain, weight loss or overt or occult blood in the stool should provoke urgent investigation because of the risk of malignancy or other serious bowel disorder4. In those patients with secondary constipation caused by a drug, the drug should be reviewed4. Constipation with greater than 14 days duration with no identifiable cause needs to be referred for fuller investigation as there may be an underlying cause13. A physical examination is required for all children and young adults under 18 years with constipation, referral is therefore required14. Signs of inflammatory bowel disease also need to be referred for investigation, these include tenesmus and mucus in the stool. Diarrhoea that co-exists with constipation should be investigated further as should, treatment failure.

Question 17

bulk forming

Answer 17

Act by retaining water in the gut and increasing faecal mass, therefore stimulating peristalsis.

Question 18

osmotic laxatives

Answer 18

Act by increasing the amount of water in the large bowel

Question 19

stimulant laxatives

Answer 19

Increase intestinal motility. Onset of action depends on product used

Question 20

stool softeners

Answer 20

Act by reducing surface tension and increasing penetration of intestinal fluids into the faeces

Question 21

Constipation in children and young people

Answer 21

Constipation is common in childhood14. It is prevalent in around 5–30% of the child population, depending on the criteria used for diagnosis14. Symptoms become chronic in more than one-third of patients18. The signs and symptoms of childhood idiopathic constipation include: infrequent bowel activity, foul smelling wind and stools, excessive flatulence, irregular stool texture, passing occasional enormous stools or frequent small pellets, withholding or straining to stop passage of stools, soiling or overflow, abdominal pain, distension or discomfort, poor appetite, lack of energy, an unhappy, angry or irritable mood and general malaise18. Management of constipation in children and young people should be undertaken by a healthcare professional experienced in the management of constipation in children4,18. Referral to the GP is therefore necessary for all children and young adults under 18 years of age. Changes in diet and lifestyle and behavioural modifications should occur alongside the early use of laxatives18. Advice to keep the bowels healthy such as eating foods high in fibre, drinking adequate fluids and remaining physically active will all be important18. Preferred first-line drug treatment is polyethylene glycol 3350 plus electrolytes

Question 22

treating constipation in pregnancy and breastfeeding

Answer 22

When managing constipation during pregnancy and while breastfeeding, advice should be offered on lifestyle measures, such as increasing dietary fibre, fluid intake and activity levels, as appropriate12. If these measures are ineffective or symptoms do not respond adequately, offer short-term treatment with oral laxatives12. Adjust the dose, choice and combination of laxatives used, depending on the woman’s symptoms, the desired speed of symptom relief, the response to treatment and their personal preference12. Offer a bulk-forming laxative first-line, such as ispaghula12. If stools remain hard, add or switch to an osmotic laxative, such as lactulose12. A short course of a stimulant laxative, e.g. senna could then be considered however, care is required. Simulant laxatives are best avoided in pregnancy due to their stimulant effect on uterine contractions

Question 23

laxative dependence

Answer 23

Some people take laxatives in the false belief that they need to empty their bowels daily4. Dieters are also known to abuse laxatives to aid weight loss13. Hypokalaemia is a risk as is malabsorption due to the effects of the laxatives on the small intestine4. Pharmacists should be alert to any inappropriate use of laxatives and refer to other healthcare professionals as necessary.

Question 24

what is diarrhoea

Answer 24

Diarrhoea is the abnormal passing of loose or liquid stools, with increased frequency and/or increased volume19. Acute diarrhoea lasts less than 14 days19.
Viruses, especially norovirus, are the most common infectious cause in the community19. Bacterial causes include infection with Salmonella species, Campylobacter jejuni, Shigella species and Escherichia coli19. Other causes of diarrhoea include protozoal infections, drugs, e.g. antibiotics and anxiety19.
In developed countries, acute diarrhoea is usually self-limiting and resolves without complications, although dehydration can occur if symptoms are severe, particularly in infants, children and elderly persons19,20. Many people with symptoms of acute diarrhoea will improve within 2–4 days

Question 25

diarrhoea red flag symptoms

Answer 25

People presenting with diarrhoea should be asked about the presence of ‘red flag’ symptoms19:
* blood in the stool
* recent hospital treatment or antibiotic treatment
* weight loss
* evidence of dehydration
* nocturnal symptoms.
Urgent referral is appropriate for people with any of these ‘red flag’ symptoms.
Symptoms of moderate to severe dehydration warrant urgent referral. These include drowsiness or confusion, passing little urine, dry mouth & tongue, sunken eyes, weakness, cool hands or feet19. Referral is necessary if an adult has features suggesting infection19.
Patients should be referred to their doctor if symptoms of dehydration develop or if symptoms do not resolve as expected (over 16s with a duration longer than 1 week). Pregnant patients should also be referred for assessment.

Question 26

diarrhoea differential diagnosis

Answer 26

Some gastro-intestinal disorders give rise to diarrhoea, e.g. inflammatory bowel conditions or irritable bowel syndrome13. If suspected, patients should be appropriately managed for these conditions and referral to the GP would be generally recommended13.
Other factors that require careful consideration when an adult presents with diarrhoea are19 (use clinical judgment for referral):
* older age (people 60 years of age or older are more at risk of complications)
* home circumstances and level of support
* fever
* bloody diarrhoea
* abdominal pain and tenderness
* increased risk of poor outcome, for example:
* coexisting medical conditions — immunodeficiency, lack of stomach acid, inflammatory bowel disease, valvular heart disease, diabetes mellitus, renal impairment, rheumatoid disease, systemic lupus erythematosus
* drugs — immunosuppressants or systemic steroids, proton pump inhibitors, angiotensin-converting enzyme inhibitors, diuretics

Question 27

diarrhoea practical advice

Answer 27

The priority in acute diarrhoea is the prevention or reversal of fluid and electrolyte depletion and resulting dehydration16. This is particularly important in infants and in frail and elderly patients16.
NHS21 suggests the following advice for people with diarrhoeal symptoms:
* in adults and children diarrhoea usually stops within 5 to 7 days
* drink lots of fluids, such as water or squash – small sips if they feel sick; fruit juice and fizzy drinks should be avoided as they can make diarrhoea worse
* eat when feel able to – there is no need to eat or avoid any specific foods
* always wash your hands thoroughly with soap and warm water after going to the toilet and before eating or preparing food. The toilet, including the handle and seat, should be cleaned with disinfectant after each bout of diarrhoea. Referral is required for those whose job involves handling food
* avoid returning to work or school until at least 48 hours after the last episode of diarrhoea.

Question 28

diarrhoea treatment

Answer 28

Oral rehydration solution (ORS)
This is used for the prevention of dehydration, especially in the very young and frail older people, and is suitable for treating mild dehydration. Two types of ORS are available: polymer-based ORS (i.e. prepared using rice or wheat, e.g. Dioralyte® Relief) and glucose ORS, e.g. Dioralyte®)4.
A Cochrane review has concluded that polymer-based ORS show some advantages compared to glucose ORS for treating all-cause diarrhoea and in diarrhoea caused by cholera22.
In either type of ORS, proprietary preparations should be used. These are available in different flavours. One of these sachets should be reconstituted with 200 mL of water, freshly boiled and cooled water for infants4. The reconstituted sachets should be taken after each loose stool in adults and children, in addition to other fluids throughout the day. The volume for infants should be adjusted according to their normal feed volume and use should be under medical supervision. After reconstitution any unused solution should be discarded no later than 1 hour after preparation unless stored in the fridge where it may be kept for up to 24 hours
Treatment
The World Health Organisation (WHO) ORS formulation contains too much sodium for the needs of people in the UK who do not tend to lose as much sodium4. Diabetes UK advises that a patient with diabetes must check their blood sugar more often when they are ill – at least every four hours, including during the night.
Anti-motility drugs, e.g. loperamide, relieve the symptoms of acute diarrhoea4. Loperamide is a useful adjunct in reducing the number of bowel movements but should be reserved for those patients who will find it inconvenient to have to go to the toilet13. OTC loperamide is licensed for the treatment of acute diarrhoea in adults and children aged 12 years and over. OTC loperamide can also be used for the symptomatic treatment of acute episodes of diarrhoea associated with irritable bowel syndrome in adults aged 18 years and over following initial diagnosis by a doctor. The maximum strength of capsule or tablet is 2 mg with a maximum dose of 4 mg. The maximum daily intake varies between products but most now state 12 mg. Patients should be advised to maintain an increased fluid intake while using loperamide.
Kaolin and morphine preparations are not recommended for diarrhoea symptoms because of lack of clinical efficacy
Special circumstances- travellers diarrhoea
Travellers’ diarrhoea is defined as passing three or more unformed stools in a 24 hour period with at least one additional symptom, such as abdominal pain or cramps, nausea, vomiting, fever, or blood in the stools23. It occurs during, or within 10 days of, a trip abroad23. It most commonly affects people travelling from areas of high standards of hygiene and sanitation to less developed destinations23. It is thought that travellers’ diarrhoea occurs in 20–90% of people travelling for up to two weeks in low- or middle-income countries23.
High-risk areas include Africa, Latin America, the Middle East and most parts of Asia23. Diarrhoea following recent travel to tropical or subtropical climates should be referred13. Travellers should take preventative measures against travellers’ diarrhoea, e.g. avoiding fruit and vegetables with damaged skins, avoiding ice unless made from safe water and ensuring all food is cooked thoroughly23.
Oral rehydration treatment is recommended and loperamide may help symptoms23. Bismuth subsalicylate can improve symptoms but is not as effective as loperamide and is associated with side-effects such as blackened tongue and stools

Question 29

Avoiding dehydration

Answer 29

Babies and children who have no detectable signs of dehydration should continue to be fed as usual, including breast or other milk feeds. They should be encouraged to drink plenty of fluids and discouraged from drinking fruit juices and carbonated drinks20.
If the baby or child has or is at risk of developing dehydration, they should be given ORS20.
Children who are being treated for rehydration should not be given solid food or other oral fluids, unless advised but breastfeeding should continue

Question 30

preventing spread

Answer 30

The following advice should be offered to prevent the primary spread of diarrhoea20:
* washing hands with soap (liquid if possible) in warm running water and careful drying is the most important factor in preventing the spread of gastroenteritis
* hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food
* towels used by infected children should not be shared
* children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis
* children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting
children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea

Question 31

diarrhoea referral

Answer 31

The following children are at an increased risk of dehydration and therefore, should be referred20:
* children younger than 1 year
* infants who were of low birth weight
* children who have passed more than five diarrhoeal stools in the previous 24 hours
* children who have vomited more than twice in the previous 24 hours
* children who have not been offered or have not been able to tolerate supplementary fluids before presentation
* infants who have stopped breastfeeding during the illness
children with signs of malnutrition

Question 32

red flag symptoms in children

Answer 32

• appears to be unwell or deteriorating
• altered responsiveness (for example, irritable, lethargic)
• sunken eyes
• tachycardia
• tachypnoea
  reduced skin turgor.

Question 33

what is IBS

Answer 33

Irritable bowel syndrome is a chronic, relapsing and often lifelong, disorder of gastro-intestinal function with no discernible structural or biochemical cause
Typical clinical features are abdominal pain:
* associated with a change in stool form and/or frequency
which may be related to defaecation, and there may be associated bloating

Question 34

IBS practical advice

Answer 34

People with IBS should be given information that explains the importance of self-help in effectively managing their IBS25. This should include information on:
* general lifestyle
* physical activity
* diet25.
People with low activity levels should be given brief advice and counselling to encourage them to increase their activity levels

Question 35

IBS danger symptoms

Answer 35

Rectal bleeding associated with a change in bowel habit should be referred24. This will allow investigation to exclude GI carcinoma and inflammatory bowel diseases, which are associated with a change in bowel habit.
If the rectal bleeding is severe or associated with any systemic symptoms, then urgent referral is needed

Question 36

IBS differential diagnosis

Answer 36

Other conditions that may present with similar symptoms are diverticulitis, anxiety, premenstrual syndrome and endometriosis24. If there are large amounts of diarrhoea passed, there may be an infective or inflammatory cause. If the person has not had IBS officially diagnosed by the GP, they should be referred for a routine appointment

Question 37

Dietary advice

Answer 37

People with IBS should be given information that explains the importance of self help in effectively managing their IBS. This should include information on general lifestyle, physical activity, diet and symptom targeted medication. Healthcare professionals should encourage people with IBS to identify and make the most of their available leisure time and to create relaxation time.
Healthcare professionals should review the fibre intake of people with IBS, adjusting (usually reducing) it while monitoring the effect on symptoms. People with IBS should be discouraged from eating insoluble fibre (for example, bran). If an increase in dietary fibre is advised, it should be soluble fibre such as ispaghula powder or foods high in soluble fibre (for example, oats).
The use of aloe vera in the treatment of IBS should be discouraged.

Question 38

IBS treatment

Answer 38

Reassurance and diagnosis often is the only treatment required for IBS sufferers. However, the nature of the condition is that it may ‘flare up’ now and again and sufferers may seek treatment. The treatment should be based on the presenting symptoms.
A laxative should be considered for people with constipation25. Bulk-forming laxatives are preferred, e.g. ispaghula husk24. For people who cannot tolerate a bulk-forming laxative or who need an additional laxative, a macrogol or a stimulant laxative, e.g. senna, (for short-term use only) should be used24. Lactulose is not recommended25.
An antimotility agent, e.g. loperamide should be the first choice for diarrhoea in people with IBS25.
Antispasmodic agents, e.g. mebeverine or peppermint oil, should be considered on a when required basis for all people with IBS and in particular those with pain occurring as spasm, alongside dietary and lifestyle advice24,25. CKS recommends mebeverine, alverine citrate and therapeutic peppermint oil as first-line treatments for the management of irritable bowel syndrome. The OTC licensing of these agents needs to be considered for supply within the pharmacy setting.
Colofac® IBS (mebeverine 135 mg) tablets are only for those over 18 years of age who have had their symptoms diagnosed by their doctor; they are not to be used while breastfeeding and are not recommended for use in pregnancy26. Colpermin® IBS relief capsules (peppermint oil 0.2 mL) are for those over 15 years of age who have had their condition diagnosed by their doctor; they are not to be used during pregnancy or by those with a peanut allergy27.

Question 39

Haemorrhoids

Answer 39

Haemorrhoids are abnormally swollen vascular mucosal cushions that are present in the anal canal28 and are a common medical condition29. Painless bright red bleeding is the commonest symptom of internal haemorrhoids and often occurs with defecation28. The bleeding can vary from streaks on the toilet paper to blood dripping into the toilet28. Other symptoms include anal itch, irritation & soiling28. A feeling of rectal fullness, discomfort or of incomplete evacuation of bowel movements may be present if prolapse occurs with straining and in people with large haemorrhoids28. Pain is not usually reported28.
Haemorrhoids are classed as internal or external, depending on their position28.
* Internal haemorrhoids are usually painless unless they become strangulated28.
* External haemorrhoids can be itchy or painful28.
People can have internal and external haemorrhoids at the same time28. The causes of internal haemorrhoids are uncertain but may include straining while trying to pass stools, ageing and raised intra-abdominal pressure due to pregnancy28. A difficult bowel movement and straining, prolonged sitting or travel, heavy lifting, or labour and delivery may precipitate external haemorrhoids28.

Question 40

Haemorrhoids practical advice

Answer 40

Provide lifestyle advice to minimise constipation and straining by advising patients to:
* increase daily fibre (aim for 25–30 g of insoluble fibre)
* increase fluid intake; consume 6–8 glasses of fluid daily
* avoid excessive caffeine intake
to promote soft, bulky, regular stools.
This can help to relieve constipation and reduce straining28.
Patients should also be advised to:
* discourage straining during defecation, which can exacerbate symptoms of haemorrhoids28
keep the anal area clean and free of irritant faecal matter, e.g. by using moist toilet wipes28

Question 41

Haemorrhoids danger symptoms

Answer 41

Other causes of rectal bleeding need to be ruled out. The following conditions might give rise to rectal bleeding.
1. Colorectal malignancy: refer those aged 40 years or over if there is rectal bleeding and change in bowel habit persisting longer than six weeks. In patients aged 60 years and over, rectal bleeding or change in bowel habit presenting for longer than six weeks requires referral28.
2. Inflammatory bowel disease.
3. Diverticular disease.
4. Ulcer: refer if any suspected internal bleeding - the blood would be darker in appearance and would appear to be mixed in with the stool.
5. Anal fissure: rectal bleeding also occurs with anal fissure but there would be acute localised pain whilst the motion is passed.
It is appropriate to refer those with the following symptoms:
* a change in bowel habit
* abdominal pain
* rectal mucus
* night-time diarrhoea for several nights
* unexplained weight loss
rectal bleeding

Question 42

topical haemorrhoid preparations

Answer 42

Topical haemorrhoidal preparations may be used to provide short-term relief. Advise that they only provide symptomatic relief and do not cure haemorrhoids. There are a range of proprietary products available including cream, ointment and suppository formulations.
There is no evidence that any topical haemorrhoidal preparation is more effective than another28.. The choice of preparation should therefore be based on the risk of adverse effects and the person’s symptoms and preference28.
Soothing preparations
Soothing preparations containing mild astringents such as bismuth subgallate, zinc oxide and hamamelis may give symptomatic relief in haemorrhoids4. Preparations containing mild astringents or lubricants relieve local irritation and are less likely to cause skin sensitisation

Local anaesthetics
Local anaesthetics are used to relieve pain associated with haemorrhoids4. They may cause sensitisation of the peri-anal skin, therefore they should be used for short periods only4. Lidocaine is the preferred topical anaesthetic because others, including tetracaine, cinchocaine (dibucaine) and pramocaine (pramoxine) are more irritant

Topical corticosteroids
Topical corticosteroids, e.g. hydrocortisone, are combined with local anaesthetics and soothing agents in some proprietary preparations4. They are limited to seven days’ use only30,31. Anusol® Plus HC ointment and suppositories are not recommended for use in patients under 18 years of age.