GI Flashcards
1
Q
What is the treatment for dyspepsia?
A
PPI up to 4 weeks
If no response to PPI - test for H. pylori
2
Q
What should happen if a patient does not respond to a PPI for dyspepsia after 4 weeks?
A
Test for H. pylori
3
Q
What is the treatment for mild GORD?
A
Antacids and alginates
PPI
PPIs preferred over H2 antagonists
4
Q
PPI or H2 antagonist for GORD?
A
PPI is preferred over H2 antagonist
5
Q
What is the treatment for severe GORD?
A
Continued PPI - lower dose once symptoms are under control
6
Q
What is the treatment of GORD in pregnancy?
A
1) Lifestyle advice
2) Antacid
3) H2 antagonist (ranitidine)
4) Omeprazole - severe/complicated reflux disease
7
Q
Name 3 types of medicine that may worsen the symptoms of GORD
A
Calcium channel blockers
Anti-depressants
NSAIDs
8
Q
What times of day are antacids given?
A
After meals and at bedtime
9
Q
What are the effects of aluminium-containing and magnesium-containing antacids
A
Magnesium - laxative
Aluminium - constipation
Antacid containing both bases can avoid this problem
10
Q
What is the purpose of simeticone in antacids?
A
Relieve flatulence
11
Q
What is the purpose of alginates in antacids?
A
Relieve symptoms of GORD - forms raft
12
Q
How do antacids help to reduce the symptoms of GORD?
A
Neutralise gastric acid
Contain bases - aluminum, magnesium
13
Q
What should be considered when deciding on an antacid in renal impairment?
A
Avoid antacids that contain magnesium or large amounts of sodium
14
Q
What should be considered if a patient is using an antacid and is on other medication
A
Do not take antacid at the same time as other medicines
Leave 2-4 hours after taking antacid before taking other medicines
15
Q
What is Maalox?
A
Antacid
Low sodium
Aluminium only
16
Q
What do Gaviscon and Peptac contain?
A
Calcium carbonate (no Mg or Al)
Bicarbonate
Alginate
17
Q
What does Gaviscon Advance contain?
A
Potassium bicarbonate
Alginate
18
Q
What effect do anti-spasmodics have on the GIT?
A
Relax intestinal smooth muscle
Anti-muscarinics
19
Q
What kind of drug are anti-spasmodics?
A
Anti-muscarinics
20
Q
Name 2 conditions that antispasmodics are commonly used in
A
IBS
Diverticular disease - small bulges/sacs (diverticula) form in the wall of the colon
21
Q
Name 4 examples of antispasmodics
A
Atropine
Hyoscine butylbromide
^^Antimuscarinics
Peppermint oil
Mebeverine
22
Q
List 5 main side effects of antispasmodics
A
Typical of antimuscarinics: Constipation Bradycardia Urinary retention Dilated pupils Dry mouth
23
Q
Name an antispasmodic that should not be used in pregnancy
A
Hyoscine butylbromide - Buscopan
24
Q
Describe the legality surrounding the sale of Hyoscine Butylbromide (Buscopan)
A
POM
Can be sold for diagnosed IBS - 20mg up to QDS
25
Name a side effect of peppermint oil (IBS and diverticular disease)
Heartburn
26
Which antispasmodic can be used in pregnancy?
Peppermint oil capsules
27
How is H. pylori diagnosed?
```
Breath test
or
Stool sample
or
Blood test
```
28
Broadly, how is H. pylori eradicated?
Acid inhibition + antibacterial treatment
29
What must happen before H. pylori is treated?
Confirmation of H. pylori presence
Using breath test, stool sample or blood test
30
What is the treatment for H. pylori?
1 week triple therapy
- PPI
- Clarithromycin
- Amoxicillin / Metronidazole
If severe ulceration - continue PPI/H2 antagonist for another 3 weeks
31
What does H. pylori cause?
Duodenal and gastric ulcers
| Most of these ulcers are caused by H. pylori, if not by NSAIDs
32
For H. pylori - why is 1 week triple therapy preferred over a 2 week regimen?
Increased eradication rates
BUT
Adverse effects are common
Compliance rates are lower
So not worth the extra week
33
What are the 2 main causes of gastric or duodenal ulcers?
H. pylori
| NSAIDs
34
4 risk factors for NSAID-associated ulcers
1) Age - over 65
2) History of ulceration
3) Serious co-morbidity - CVD, diabetes, renal/hepatic impairment
4) Taking drug that increases risk of GI side effects
35
What should be done with the NSAID if it causes an ulcer?
Discontinue the NSAID
36
What can be used to prevent NSAID-associated ulcers?
PPI for non-selective NSAIDs
37
Name 2 non-selective NSAIDs
Diclofenac
| Naproxen
38
Name a group of selective NSAIDs (COX-2 selective)
The -Coxibs
39
What should be changed with meds if an NSAID-ulcer occurs and the NSAID cannot be stopped?
PPI
Switch to COX-2 selective inhibitor
Misoprostol good in elderly
40
List 2 side effects of misoprostol
| NSAID-associated ulcer
Colic
| Diarrhoea (severe)
41
What effect do H2 receptor antagonists have?
They reduce gastric acid secretion through H2 receptor blockade
To treat ulcers and relieve symptoms of GORD
42
2 main indications for H2 antagonists
Ulcers
| GORD
43
Name 2 H2 receptor antagonists
Ranitidine
| Cimetidine
44
3 side effect of H2 antagonists
Diarrhoea
Headache
Dizziness
45
What is important to consider regarding Cimetidine?
```
It is an enzyme inhibitor
Increases plasma concentration of:
- Carbamazepine
- Warfarin
- Phenytoin
- Sodium valproate
- Theophylline
```
46
What drugs does cimetidine affect?
```
Enzyme inhibitor -
Carbamazepine
Warfarin
Phenytoin
Sodium valproate
Theophylline
```
47
Which H2 antagonist has the least interactions?
Ranitidine
| Cimetidine has more interactions
48
What misoprostol?
Prostaglandin analogue
Anti-secretory and protective properties
Can prevent NSAID ulcers
Used in elderly patients who rely on NSAID continuing after ulcer formation
49
What is misoprostol used for?
Prevention of NSAID ulcers
| Elderly patients - when NSAID cannot be stopped after ulcer formation
50
Consideration for misoprostol in women?
Should not be used in women of child-bearing age unless pregnancy ruled out
Potent uterine stimulant
Teratogenic
Can be sued for abortions and to induce labour
51
How do PPIs work?
Block hydrogen-potassium proton pump
52
List 8 groups of patient which are at an increased risk of osteoporosis
Family history
Underweight
Alcoholics
Corticosteroids - long term
Post-menopausal women
Rheumatoid arthritis
Crohn's
Hyperthyroidism
53
How can those at risk of developing osteoporosis reduce their chances?
Maintain adequate intake of calcium + vitamin D
| Adcal D3
54
What extra precautions should be taken if at risk of osteoporosis and on PPI
Maintain adequate intake of calcium + vitamin D
| Adcal D3
55
Name 2 electrolytes which should be watched if on PPI
Magnesium
Sodium
PPIs can cause hypomagnaesia & hyponatraemia
56
Which electrolyte should be monitored if patient is on PPI + digoxin?
Magnesium
| = Hypomagnaesia
57
Which electrolyte can digoxin affect?
Magnesium
Hypomagnaesia
Especially if on other drugs which affect Mg - e.g. PPI
58
List 6 side effects of PPIs
```
Nausea
Vomiting
Abdominal pain
Flatulence
Diarrhoea or constipation
Headache
```
59
Name an adverse effect of using a PPI
Rebound acid hypersecretion
60
Which 2 PPIs should not be used in pregnancy or breastfeeding?
Lansoprazole + Pantoprazole
| Should not be used in PG/BF
61
Which PPI can be used in pregnancy and breastfeeding?
Omeprazole
| Can be used in PG + BF
62
When should PPIs be taken?
PPIs should be taken 30-60 minutes before food
63
What is the primary concern in acute diarrhoea?
Electrolyte depletion
64
Which group is anti motility drugs not recommended in for acute diarrhoea?
Young children
| Should not be given anti-motility drugs
65
What are most cases of diarrhoea due to?
Viruses
| Does not need antibiotics
66
Name the drug used for diarrhoea following ileal disease (Crohn's) or resection
Colestyramine
67
What is colestyramine used for?
Diarrhoea following ideal disease (Crohn's) or resection
68
What should be considered if patient taking colestyramine and other medicines?
Take other medicines an hour before or 4-6 hours after colestyramine
69
How do anti motility drugs work?
Anti-motility drugs work by:
| Binding to the opioid receptors in the GIT
70
Name 3 anti-motility drugs
Loperamide
Codeine
Morphine/kaolin
71
From what age can morphine/kaolin be used?
Over 12 years old
72
What is the minimum age for loperamide?
```
POM = 4 years old
OTC = 12 years old
```
73
How is inflammatory bowel disease treated?
Mild - oral aminosalicylate
Moderate - oral corticosteroid (prednisolone, budesonide)
Severe - immunosuppressant (ciclosporin, azathioprine, methotrexate)
No response - infliximab
74
How is mild inflammatory bowel disease treated?
Oral aminosalicylate alone
| sulfasalzine, mesalazine
75
How is moderate inflammatory bowel disease treated?
Oral corticosteroid - prednisolone, budesonide
76
Name 2 oral corticosteroids used in the treatment of moderate inflammatory bowel disease
Prednisolone
| Budesonide
77
How is severe inflammatory bowel disease treated?
Immunosuppressant:
- Azathioprine
- Ciclosporin
- Methotrexate
78
Name 3 immunosuppressants used in the treatment of severe inflammatory bowel disease
Azathioprine
Ciclosporin
Methotrexate
79
How do oral aminosalicylates work?
Compounds contain 5-ASA (API)
Interferes with body's response to inflammation
Sulfasalazine - 5-ASA bonded to sulfapyridine
Sulfapyridine delivers 5-ASA to intestine
80
Which 2 conditions does IBD cover?
Crohn's
| Ulcerative colitis
81
Why is sulfapyridine (in sulfasalazine) not an ideal compound?
Side effects of sulfapyridine:
Headache
Nausea
Rash
82
What are the 2 main compounds in sulfasalazine?
5-ASA (5-aminosalicylic acid)
| Sulfapyridine
83
Why may certain aminosalicylates be preferred to others? (IBD)
1) Tolerance (sulfapyridine side effects)
| 2) Formulation - area of 5-ASA delivery
84
What different formulations of aminosalicylate are available?
Enema - left-sided disease (colon)
Suppository - rectum to sigmoid colon
Delayed release/extended release - small intestine/ileum/colon
85
List 8 side effects of sulfasalzine
```
Headache
Nausea
Rash
Loss of appetite
Vomiting
Fever
Decreased WBC count
Decreased sperm production
```
86
Mesalazine and renal function
Caution in kidney disease/renal impairment
| Monitor eGFR annually
87
2 indications of mesalazine
Treatment of ulcerative colitis
| Maintenance of remission of ulcerative colitis
88
What symptoms should be reported when on aminosalicylates?
```
Unexplained bleeding/bruising
Sore throat
Fever
Malaise
Purpura - purple spots on skin caused by burst small blood vessels
```
^^ signs of blood dyscrasias
89
List 4 signs of possible blood dyscracias
Unexplained bruising/bleeding
Sore throat
Temperature
Malaise
90
What is important in the prescribing of mesalazine?
Brand-specific
Asacol
Octasa
Pentasa
91
What is used in IBD if patients do not respond to aminosalicylates/steroids/immunosuppressants?
Infliximab
92
Which drugs can be used for maintenance of remission in inflammatory bowel disease?
Aminosalicylates + immunosuppressants
| Can be used to maintain remission in IBD
93
Which drugs should not be used to maintain remission in inflammatory bowel disease?
Corticosteroids
Aminosalicylates and immunosuppressants for maintenance of remission in IBD
94
What should be used for constipation in inflammatory bowel disease?
Movicol
| For constipation in IBD
95
What should be used for diarrhoea in inflammatory bowel disease?
Colestyramine
| For diarrhoea in IBD
96
What should be used for constipation and diarrhoea in IBD?
Movicol - constipation
| Colestyramine - diarrhoea
97
Which drugs are used in the treatment of C. diff?
Vancomycin or metronidazole
98
What is a common cause of C. diff?
Antibiotic therapy:
- Fluoroquinolones
- Cephalosporins
- Penicillins
- Clindamycin
99
Response to diarrhoea following course of Clindamycin?
Immediate referral
Possible C. diff
Clindamycin is a common cause of C. diff
100
Which 4 drugs/classes are known to commonly cause C. diff?
Cephalosporins
Fluoroquinolones
Penicillins
Clindamycin
101
What is diverticular disease?
When small bulges/sacs (diverticula) form in the wall of the colon
102
What is the treatment of diverticular disease?
Ispaghula husk (Fybogel)
Antispasmodics (Buscopan)
Antibacterials - if infected
103
Which class of GI drug should not be used in diverticular disease?
Antimotility drugs should not be used diverticular disease:
- Loperamide
- Codeine
- Morphine/kaolin
104
How does irritable bowel syndrome usually present?
IBS usually presents as:
- Pain
- Constipation
- Diarrhoea
105
Why may antidepressants be useful in irritable bowel syndrome?
Aggravating psychological factors
106
Why may amitriptyline be useful in irritable bowel syndrome?
Reduce abdominal pain
107
Which tricyclic antidepressant may be used in irritable bowel syndrome?
Amitriptyline
| Reduces abdominal pain
108
List 4 drugs that may be used in IBS
Fybogel (husk)
Movicol
Loperamide
Buscopan (hyoscine butylbromide)
109
Which laxatives are recommended for irritable bowel syndrome (IBS)?
Fybogel (ispaghula husk)
| Movicol
110
Which anti motility drug is recommended for irritable bowel syndrome?
Loperamide
111
Which antispasmodic is recommended for use in irritable bowel syndrome?
Buscopan (hyoscine butylbromide)
112
When are laxatives most appropriate?
Drug-induced constipation
Straining issue - haemorrhoids, angina
Avoid in healthy individuals
113
How should constipation be treated in infants?
Prune juice
Lactulose
Movicol
Glycerol suppositories
114
How should constipation be treated in children?
```
Prune juice
Lactulose
Movicol
Glycerol suppositories
Stimulant laxative if no response (Senna, bisacodyl, sodium picosulphate)
```
115
List 6 stimulant laxatives
Senna
Bisacodyl
Sodium picosulphate
Docusate sodium (stimulant & faecal softener)
Glycerol suppositories (rectal stimulant & lubricant)
Co-danthramer - palliative use only
116
How do stimulant laxatives work?
Increase intestinal motility by stimulating nerves involved in peristalsis
117
What is a common side effect of stimulant laxatives?
Abdominal cramp
118
Why is co-danthramer limited to palliative care only?
Co-danthramer is:
- Carcinogenic
- Genotoxic
119
How do glycerol suppositories have their laxative effect?
Irritant action of glycerol
| Rectal stimulant and lubricant
120
List 3 bulk-forming laxatives
Ispaghula husk
Methylcellulose (also faecal softener)
Bran
121
When are bulk-forming laxatives particularly useful
Adults with small, hard stools where fibre cannot be increased
122
How long is the onset of action for bulk-forming laxatives?
72 hours
123
3 common side effects of bulk-forming laxatives
Flatulence
Bloating
Abdominal cramp
124
What must be ensured to avoid intestinal obstruction with bulk-forming laxatives
Adequate fluid intake
125
Main counselling point of bulk-forming laxatives
Adequate fluid intake to avoid intestinal obstruction
126
All info on bulk-forming laxatives
- Ispaghula husk, methylcellulose, bran
- Absorbs liquid in intestine = softer stool, peristalsis
- 72 hours for onset of action
- Good for adults with small hard stools where fibre cannot be increased
- Side effects: flatulence, bloating, abdominal pain
- Adequate fluid intake must be maintained - intestinal obstruction
127
How do bulk-forming laxatives work?
Absorb/retain liquid in intestine
= Softer stool - easier to pass
And stimulates peristalsis
128
All info on stimulant laxatives
- Senna, bisacodyl, sodium picosulfate, docusate sodium, glycerol suppositories, co-danthramer
- Most common side effect = abdominal cramp
- Avoid in intestinal obstruction
- Stimulate nerves involved in peristalsis
- Co-danthramer = carcinogenic & genotoxic
129
How do faecal softeners work?
Reduce surface tension of faecal mass and increasing fluid penetration into it
130
Name 5 drugs that act as faecal softeners
```
Docusate sodium
Glycerol suppositories
Arachis oil enema (nut oil)
Methylcellulose
Liquid paraffin
```
131
How do archis oil enemas work?
Lubricates and softens impacted to faeces and encourages bowel movements
132
What kind of laxative is docusate sodium?
Stimulant and faecal softener
133
What kind of laxative is glycerol suppositories?
Stimulant - rectal irritant
| Faecal softener
134
What kind of laxative is methyl cellulose?
Bulk-forming
| Faecal softener
135
Why should liquid paraffin be used with caution as a laxative/faecal softener?
Used as a lubricant
| Adverse effects - anal seepage, granulomatous disease
136
All info on faecal softeners
Reduce surface tension and increase fluid penetration of faecal mass
Docusate sodium, glycerol suppositories, methylcellulose, arachis oil, liquid paraffin
Arachis oil = nuts
Liquid paraffin - caution - seepage, granulomatous disease
137
How do osmotic laxatives work?
Increase water content of stool in the large bowel
| By drawing water from body into bowel or retaining water present
138
Name 3 osmotic laxatives
Lactulose
Macrogols
Polyethylene glycol
139
Why is lactulose useful in hepatic encephalopathy?
Not absorbed from GIT
Lowers faecal pH
Discourages proliferation of ammonia-producing bacteria
Ammonia worsens HE
140
What is a common side effect of macrogols? (osmotic)
Dehydration
| Can be reduced by giving with fluid
141
How can dehydration from use of macrogols be reduced?
Give with fluid
142
When should a bulk-forming laxative be used?
Short duration constipation
Where dietary measures are ineffective
If stools remain hard - add or switch to osmotic laxative
Ensure adequate fluid intake
143
Which type of laxative should be used for short-duration constipation?
Bulk-forming laxative for short-duration constipation
Where dietary measures are ineffective
If still hard stools - add or switch to osmotic laxative
Ensure adequate fluid intake
144
Which type of laxative for soft stool but difficult to pass?
Bulk-forming + Stimulant laxative
145
Which type of laxative for inadequate emptying?
Bulk-forming + Stimulant laxative
146
Which type of laxative in opioid-induced constipation?
Osmotic + stimulant laxative
Docusate sodium can be used in place of osmotic
For opioid induced constipation
147
Which type of laxative should be avoided in opioid induced constipation?
Bulk-forming laxatives
| Should be avoided for opioid-induced constipation
148
Which laxative should be used in opioid induced constipation if no response to 1st line approach?
Naloxegol
149
When should naloxegol be used?
Opioid induced constipation
| If no response to 1st line (osmotic/docusate + stimulant)
150
How should chronic constipation be treated?
1) Bulk-forming laxative
2) + or change to osmotic laxative (macrogol)
3) Lactulose - if macrogol ineffective/not tolerated
4) + stimulant
Dose adjusted to = 1-2 soft stools a day
151
When and how can laxatives be withdrawn in chronic constipation?
Slowly withdraw
When regular bowel movements occur without difficulty
If combination laxatives have been used - reduce and stop 1 at a time
Reduce stimulant laxative first
152
How should constipation in pregnancy be managed?
1) Dietary fibre, lifestyle changes
2) Fibre supplements - bran, wheat
3) Bulk-forming laxative - ispaghula
4) Lactulose
5) Senna, bisacodyl if stimulant effect necessary - but avoid near full term/history of unstable pregnancy
6) Docusate sodium, glycerol suppositories
Stimulant laxatives more effective than bulk-forming but more likely to cause side effects (diarrhoea, abdominal discomfort)
153
Why are bulk-forming laxatives preferred to stimulant laxatives in pregnancy?
Stimulant more effective than bulk-forming
| But more likely to cause side effects - diarrhoea, abdominal discomfort
154
How should constipation be managed during breastfeeding?
1) Dietary measures
2) Bulk-forming laxative
3) Lactulose or macrogol (osmotic)
4) Short course stimulant laxative - Senna/bisacodyl
155
How should constipation in children be managed?
1) Macrogol laxative + dietary modifications/behavioural interventions
- Fibre
- Fluids
- Exercise
Unprocessed bran is not recommended - bloating, flatulence, reduced micronutrient absorption
2) Add stimulant if inadequate, change to stimulant if not tolerated
3) If stools remain hard - add lactulose or softener (docusate)
156
What is 1st line for constipation in children?
Macrogol laxative + dietary modification/behavioural intervention
Dietary modification alone not enough for 1st line
157
Why is unprocessed bran not recommended for constipation in children?
Flatulence
Bloating
Micronutrients not absorbed
158
How should chronic constipation be managed in children?
Continue laxatives for several weeks after regular bowel habits return
Taper dose gradually over months
159
Which type of laxative can be used for diarrhoea in diverticular disease?
Fybogel - bulk forming
160
Which electrolyte may become imbalanced by excessive use of laxatives?
Potassium
| Hypokalaemia
161
5 red flags for constipation
Red flags for constipation:
- Over 50 years old
- Anaemia
- Abdominal pain
- Weight loss
- Blood in stool
162
Is lactulose suitable for diabetic patients
Yes
| Even though it is a synthetic sugar - not absorbed from GIT
163
What is the onset of action for lactulose?
48 hours
164
What is the main difference between Crohn's and Ulcerative Colitis?
UC = just colon
| Crohn's any part of GIT
165
Where does Crohn's affect?
Any part of GIT
166
Where does UC affect?
Limited to the colon
167
How do symptoms differ in dyspepsia vs GORD?
Dyspepsia:
- Upper abdominal pain
- Bloating
- Nausea
GORD:
- Heartburn
- Acid regurgitation
- Ulceration
168
What is ursodeoxycholic acid used for?
- Dissolution of gall stones
| - Primary biliary cirrhosis
169
What drug is used for the dissolution of gall stones?
Ursodeoxycholic acid
170
What is Terlipressin used for?
Oesophageal varices
Vasoconstrictor
Reduce portal hypertension
171
What is the BMI at above which a person is considered 'obese'?
Over 30 kg/m2
172
When is Orlistat used?
Obese patient - <30 kg/m2
| When diet, excercise and behaviour changes fail to reduce weight
173
What is the licensing of Orlistat in terms of BMI?
>30 kg/m2
or
>28 kg/m2 if also other risk factors
174
When should orlistat be discontinued?
Discontinue after 12 weeks if weight loss has not exceeded 5% of starting weight
175
Which laxative is recommended in haemorrhoids?
Bulk-forming laxatives for haemorrhoids
Osmotic as alternative
Focus on soft and easily passed stools
176
What should be used for haemorrhoids in pregnancy?
No licensed preparations
| Consider simple soothing solution
177
What are the indicators of exocrine pancreatic insufficiency?
Maldigestion
Malnnutrition
Low levels of micronutrients, fat soluble vitamins & lipoproteins
Also - diarrhoea, abdominal cramps, steatorrhoea (fat in faeces)
178
What is the main treatment for exocrine pancreatic insufficiency?
Pancreatic enzyme replacement therapy
179
When are pancreatic enzymes given?
With meals and snacks
180
What does pancreatin contain?
Amylases
Lipases
Proteases
Assists digestion of starch, fats, proteins
181
What should be considered regarding choice of food when taking pancreatin?
Its enzymes are denatured by heat + gastric acid
Avoid excessive heat
Best taken with food
