GI Flashcards
What does H. Pylori infection cause
Peptic ulcer disease (responsible for more than70%), acute/chronic gastritis, gastric cancer, MALT lymphoma
What has an additive effect with H. pylori
NSAIDS
When to test for H pylori`
- Those with dyspepsia that are unresponsive to lifestyle changes, antacids and following a one month treatment of PPI,
- those at high risk (north African, high risk areas, older people - can be tested in parallel with PPI course,
- history of peptic ulcers/bleeds,
- before initiating NSAIDS in those with history of peptic ulcers/bleeds,
- unexplained iron deficiency anaemia after malignancy(and other causes) excluded via endoscopy
H pylori tests
- The urea (13C) breath test,
- Stool Helicobacter Antigen Test (SAT),
- or laboratory-based serology where its performance has been locally validated
When/what h pylori tests should not be done in certain circumstances
Urea/SAT within 2 weeks of PPI or 4 weeks of Abx due to false negatives
When should h pylori retesting be done
Retesting should be performed at least 4 weeks (ideally 8 weeks) after treatment.
What instances require a H pylori retest
Severe persistent treatment not consistent with GORD, taking aspirin without PPI, peptic ulcer/MALT/resection of gastric carcinoma, high local resistance rates, if first test was done incorrectly like within 2 weeks of PPI etc.
H pylori treatment
Triple therapy, one PPI Two Abx
What Abx courses increase risks of resistance
Clarithromycin, metronidazole, or quinolone
What bacteria is associated with diarrhoea
C diff
First/second line treatment if no penicillin allergy h pylori
PPI+ amoxicillin + clari/metro (second line = same but use which ever one of clari/metro not used) all for 7 days
Alternative second line if no penicillin allergy h pylori
PPI+ amoxicillin + tetracycline/levofloxacin (used if clari and metro used)
h pylori Third line if no penicillin allergy
PPI+bismuth + 2 other unused Abx or rifabutin or furazolidone
Pen allergy first/alt first line h pylori treatment
PPI+Clari+metro, alt= PPI+ bismuth+ metro + tetracycline (if clari used first line)
Penicilin allergy second line h pylori
7 days of PPI+ metro+levofloxacin or PPI+ Bismuth+metro+tetra
H pylori Third line penicillin allergy
PPI+ bismuth+rifabutin/furazolidone
Two main types of antispasmodics
Antimuscarinics and smooth muscle relaxants
Examples of antimuscarinics
Atropine, dicycloverine, propantheline, hyoscine
Examples of smooth muscle relaxants
Alverine citrate, mebeverine, peppermint oil
Antimuscarinic GI MOA
Reduce intestinal motility and are used for GI smooth muscle spasm
What antimuscarinics are less likely to cross the BBB
Quaternary ammonium compounds = propantheline, hyoscine butylbromide meaning less CNS side effects
What antimuscarinics are less well absorbed from GI tract
Quaternary ammonium compounds = propantheline, hyoscine butylbromide
Constipation is
Infrequent stools, difficult stool passage, or seemingly incomplete defaecation.
When is urgent investigation needed for constipation
New onset constipation in over 50s / accompanying symptoms like anaemia, abdominal pain, weight loss, overt/occult blood in stool due to risk of malignancy/serious bowl disorder
Lifestyle advice for constipation
Increase dietary fibre, adequate fluid intake and exercise advised,, balanced diet, fruits/juice high in sorbitol
Why and how should fibre be given
Fibre intake should be increased gradually (to minimise flatulence and bloating). Effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks.
Key downside to laxative
Hypokalaemia
Types of laxative
Bulk forming
Stimulant
Faecal softeners
osmotic
Other drugs used in constipation
Linaclotide, prucalopride
Bulk forming examples
Methylcellulose, ispaghula husk and sterculia Methylcellulose also acts as a faecal softener.
Bulk forming side effects
Exacerbation of flatulence, bloating , cramping
When is it best to use bulk forming
Small hard stools if fibre cannot be increased in the diet
Onset of bulk forming
72 hours
Stimulant laxatives
Bisacodyl, sodium picosulfate, and senna, co-danthramer and co-danthrusate, docusate a stimulant and softener, glycerol a stimulant and lubricant
Stimulant laxative MOA
Increase intestinal motility
Stimulant side effects
Abdominal cramp
When to avoid stimulant
Intestinal obstruction
What stimulants are only limited to terminally ill
Co-danthramer, co-fanthrusate
Faecal softeners
Docusate, glycerol, arachis oil
Faecal softener mechanism of action
Decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass
Arachis oil use and ingredients
Ground nut and peanut oil, lubricant, softener and promoter of bowel movement
Liquid paraffin use and downfall
Lubricant but caution as it can result in anal seepage and granulomatous disease of GI tract. Liquid pneumonia on aspiration
Osmotic laxatives
Lactulose macrogol
Osmotic MOA
Increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.
What else can lactulose be used for
Hepatic encephalopathy
How to reduce dehydrating effect of osmotic
Fluids
Linaclotide indication
IBS associated with constipation
Prucalopride indication
Chronic constipation when other options fail
Short duration treatment
Bulk forming, ensure adequate fluid then add/switch to osmotic if needed because of hard stools, switch to stimulant if stool soft but hard to pass/ inadequate emptying
What to do in opioid induced constipation
Osmotic laxative/docusate and stimulant or naloxegol if other laxatives not effective, methylnaltrexone can also be used
What laxative should be avoided in opioid induced constipation
Bulk forming
What to do if unresponsive to faecal impaction treatment
Arachis oil or sodium acid phosphate with sodium phosphate sodium, may need to be repeated several times
Treating chronic constipation
- Bulk forming+ water
- If still hard add/change to osmotic laxative( macrogol then lactulose)
- If ineffective add stimulant
Aim of chronic constipation treatment
Adjust until producing one/two soft stools a day
When to use prucalopride in chronic constipation
Only in women that have tried at least two laxatives at highest tolerable dose for at least six months, re-examine if not effective after 4 weeks
First choice laxative in breast feeding
Bulk forming if diet changes fail osmotic used or short course stimulant
What laxative should not be used in pregnancy
Senna
General pregnancy constipation advise
Lifestyle, fibre supplements (bran/wheat), they have no side effects on mother or fetus
Treating constipation in pregnancy
Bulk forming first line then osmotic if necessary then bisacodyl senna should definitely be avoided near term and if unstable pregnancy (stimulants more likely to cause side effects. Docusate/glycerol suppositories can be used
First line constipation treatment in children
Laxative and diet modification (diet modification alone is not recommended as first line)
What dietary suggestions is not recommended for children
Unprocessed bran may cause bloating and flatulence and reduces absorption of micronutrients
First line pharmacological treatment of constipation in children
Macrogol if inadequate/not tolerated then stimulant
What to do if stools remain hard after treatment in children for constipation
Lactulose or a softener like docusate
How to stop constipation treatment in children
Continue several weeks after regular pattern then taper gradually over months based on response
In adults what laxative should be stopped first
Stimulant but may need to adapt osmotic dose
How to stop laxative in adults
Wait till regular without difficulty then reduce and stop one laxative at a time
Treating faecal impaction in > 1 yo in children
Macrogol if disimpaction does not occur after 2 weeks then stimulant added but if stools hard used in combination with an osmotic laxative .
Who is cholera vaccine licensed for
Adults and children from 2YO travelling to endemic/epidemic areas
When should cholera vaccine be given
At least one week before potential exposure
Aim of short bowel syndrome management
Ensuring adequate nutrition and drug absorption reducing risk of complications
What deficiencies may arise due to short bowel
Deficiencies in vitamins A, B12, D, E, and K, essential fatty acids, zinc, and selenium - hypomagnesaemia
Hypomagnasaemia treatment
Oral/iv magnesium supplementation but may cause diarrhoea
Treating diarrhoea/high output stoma
Oral rehydration salts Antimotility drugs like loperamide at high unlicensed doses, co-phenotrope Colestyramine Antisecretory drugs(PPI/Octreotide) Growth factors
Colestyramine action
Bind unabsorbed bile salts and reduce diarrhoea
What do you monitor when giving colestyramine
Fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies
Octreotide is/does
Antisecretory drug, reduces
ileostomy diarrhoea and large volume jejunostomy output by inhibiting multiple pro-secretory substances.
Most important part of intestine for drug absorption and why
Small intestine, its large surface area and high blood flow
What preparations can’t be used in short bowel
Enteric/ modified release especially in ileostomy
What preparations are preferred in short bowel
Soluble tablets for quick dissolution, uncoated tablets, liquid formulations
What alters absorption in SBS
Length of intestine left and which section removed
What to consider before prescribing liquids in SBS
Osmolarity, excipient content and volume required as Hyperosmolar liquids and some excipients (such as sorbitol) can result in fluid loss.
What is coeliac
Autoimmune condition which is associated with chronic inflammation of the small intestine
Gluten role
A dietary protein found in wheat barley rye activate abnormal immune response leafing to malabsorption of nutrients
Aim of coeliac management
Eliminate symptoms and reduce risk of complications like malabsorption
Coeliac symptoms
Diarrhoea, bloating and abdominal pain
Coeliac treatment
Strict, life-long, gluten-free diet
Stoma is
Artificial opening on the abdomen to divert flow of faeces or urine into an external pouch located outside of the body
What preparations are unsuitable with stomas
Modified, enteric, sorbitol excipient (laxative side effects)
What to look for when NSAID used with stoma
Gastric irritation and bleeding; faecal output should be monitored for traces of blood
Considerations of antacids with stoma
Magnesium can cause diarrhoea, aluminium/calcium = increased constipation
Antacid ingredients and GI
Magnesium can cause diarrhoea, aluminium/calcium = increased constipation
Role of gastric secretion in stoma
Gastric secretion increases stoma output so antisecretory drugs like octreotide/lareotide used to reduce risk
Loperamide/codeine role in stoma
Reduce intestinal motility and decrease water and sodium output from an ileostomy
Loperamide effective mechanism of action
Circulates through the enterohepatic circulation, which is disrupted in patients with a short bowel;
Digoxin and stoma
Susceptible to hypokalaemia due to fluid and sodium depletion, can consider potassium supplement and potassium sparing diuretic
Laxatives and stoma
Ideally should not be used use bulk firming if needed if not then low dose stimulant, try diet and fluid intake first
What is sucralfate
A complex of aluminium hydroxide and sulfated sucrose but has minimal antacid properties
Role of sucralfate
Protecting the mucosa from acid-pepsin attack in gastric and duodenal ulcers.
Sucralfate indication
Benign gastric ulceration, Benign duodenal ulceration, Chronic gastritis, Prophylaxis of stress ulceration,
What is crohn’s
Chronic, inflammatory bowel disease that mainly affects the gastro-intestinal tract.
Crohn’s characterisation
Thickened areas of the GI wall, inflammation, deep ulceration/fissuring of mucosa, granulomas in any part of GI tract
Crohn’s symptoms
Adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in childrens
Crohn’s complications
Adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in children
Aim of Crohn’s treatment
Induce/maintain remission
Non drug crohn’s treatment
Smoking cessation, nutrition, surgery , closing fistula
Treating acute crohns
Corticosteroid (pred/methylpred/IV hydro) to induce remission, budesonide if not then aminosalicylates (sulfasalazine/mesalazine) which have fewer side effects but is less effective than budesonide
Add on crohn’s treatment
Azathioprine/mercaptopurine if ineffective the methotrexate
When can’t you use azathioprine/mercaptopurine
Thiopurine methyltransferase TPMT activity deficient
What can’t be used for maintaining remission
Corticosteroids and budesonide
What do you use in severe crohn’s
TNF alpha inhibitors, adalimumab, infliximab if not the vedoluzumab/ustkinumab
What happens if no maintenance treatment on remission
Unintended weight loss, abdominal pain, diarrhoea and general ill-health
What is used to maintain remission
Azathiprine/mercaptopurine or methotrexate onlu in those who used it to induce remission
Maintaining remission following surgery
Azathioprine in combination with up to 3 months postop metronidazole (ileocolonic crohn’s disease in those with macroscopic resection)
Treating diarrhoea in crohns
Loperamide/codeine in those without colitis and colestyramine
Why can’t metonidazole be given for more than 3 months
Peripheral neuropathy
Treating fistulae
Metronidazole(less than 3 months)/cipro combined or alone if not infliximab
Azathioprine, mercaptopurine, or infliximab should be continued as maintenance treatment for at least one year
What is ulcerative colitis
Chronic inflammatory condition
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
Diffuse mucosal inflammation, relapsing-remitting pattern
What is ulcerative colitis characterised by
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
When does ulcerative colitis commonly present
15-25 years
://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
What is inflammation of the rectum
Proctitis
What is inflammation of the rectum and sigmoid colon
Proctosigmoiditis
Common symptoms of active disease of UC
Bloody diarrhoea, urgent need to defecate, abdominal pain
Complications due to UC
Increased colorectal cancer, secondary osteoporosis, VTE, toxic megacolon
How is severity of UC classified
Truelove and Witts’ Severity Index to assess bowel movements, heart rate, erythrocyte sedimentation rate and the presence of pyrexia, melaena or anaemia
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
Preparation used to treat distal inflammation
Rectal but systemic if inflammation is extended
UC treatment aims
Managing symptoms, inducing and maintaining remission
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
Types of rectal preparations
Enemas, suppositories
What anti-diarrhoeal drugs are contraindicated in UC and why
Loperamide and codeine as they increase risk of toxic megacolon
Treating proximal faecal loading in proctitis
Macrogol containing osmotic laxative
Pros and cons of single daily dose of aminosaliciylates
Can be more effective than multiple but may result in more side effects
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
Duration of corticosteroid course in UC
4-8 weeks , depends on corticosteroid used
Proctitis treatment mild-moderate
Topical aminosalicylate first-line treatment, if remission is not achieved within 4 weeks, adding an oral aminosalicylate. If response remains inadequate, consider topical or an oral corticosteroid for 4 to 8 weeks.
Proctosigmoiditis/left sided UC mild-moderate
Topical aminosalicylate first-line treatment, if remission is not achieved within 4 weeks, adding a high dose oral aminosalicylate.
Switching to a high-dose oral aminosalicylate and 4 to 8 weeks of a topical corticosteroid. If response remains inadequate, stop topical and offer an oral corticosteroid for 4 to 8 weeks
Extensive UC treatment - mild-moderate
A topical aminosalicylate and a high-dose oral aminosalicylate are recommended as first-line treatment for patients. If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
Treating moderate-severe UC
Treating adalimumab, golimumab, infliximab, vedolizumab
Treating acute severe UC
IV corticosteroids, if not then ciclosporin
Second line acute severe UC treatment
IV corticosteroid + ciclosporin or surgery if ineffective within 72 hours of IV corticosteroids, infliximab used if ciclosporin not possible
Maintaining remission
Aminosalicylate, but azathioprine and mercaptopurine can be considered, no evidence for MTC but often used
PPI indications
Short treatment for gastric and duodenal ulcers, prevention/treatment NSAID-associated ulcers, following peptic bleed, reduce bleeding (IV)
Why is PPI used in CF
Reduces degradation of enzyme supplements in patients with CF
https://bnf.nice.org.uk/treatment-summary/proton-pump-inhibitors.html
What is primary biliary cholangitis/cirrhosis
Chronic cholestatic disease which develops due to progressive destruction of small and intermediate bile ducts within the liver, subsequently evolving to fibrosis and cirrhosis.
Treating primary biliary cholangitis
Ursodeoxycholic acid
Where does dyspepsia occur
Upper GI
How long do dyspepsia symptoms last
4/more weeks
Dyspepsia symptoms
Upper abdominal pain or discomfort, heartburn, gastric reflux, bloating, nausea and/or vomiting
Underlying cause of dyspepsia symptoms
GORD/ peptic ulcer disease
Cause of dyspepsia in pregnant women
Most often GORD
Aim of dyspepsia treatment
Manage symptoms and treat underlying cause if possible
Lifestyle dyspepsia tips
Healthy eating, weight loss (if obese), avoiding any trigger foods, eating smaller meals, eating the evening meal 3–4 hours before going to bed, raising the head of the bed, stop smoking and reducing alcohol consumption
What conditions exacerbate dyspepsia
Stress anxiety depression
When is urgent endoscopy needed for dyspepsia
Acute GI bleeding/ in over 55s with unexplained weight loss, upper abdominal pain, reflux or dyspepsia
Drugs that cause dyspepsia
Alpha blocker, antimuscarinics, aspirin, benzodiazepines, beta blockers, bisphosphonates, CCB , corticosteroids, nitrates, NSAIDS, theophylline, TCA
Short term control of dyspepsia
Alpha blocker, antimuscarinics, aspirin, benzodiazepines, beta blockers, bisphosphonates, CCB , corticosteroids, nitrates, NSAIDS, theophylline, TCA
TREATING uninvestigated dyspepsia
PPI for 4 weeks
Short term control of dyspepsia
Antacids and/or alginates (not long term)
Treating functional dyspepsia
If no h pylori PPI/ Histamine2 receptor antagonist for 4 weeks
Dyspepsia and h pylori
Test for h pylori
Diverticulosis
Asymptomatic condition with holes in walls of intestine
Who is most likely to have diverticulosis
Aged 40 and over
Diverticular disease
When diverticula (holes) are present with symptoms
Diverticular symptoms
Abdominal tenderness and/or mild, intermittent lower abdominal pain with constipation, diarrhoea, or occasional large rectal bleeds
Acute diverticulitis
Diverticula become inflamed
Acute diverticulitis symptoms
Fever, sudden change in bowel habits, significant rectal bleeding, palpable abdominal mass, constant lower abdominal pain
Diverticular lifestyle tips
Balanced diet, constipation advice - gradually increase fibre
Diverticular disease treatment
Management of diarrhoea/constipation (high fibre diet/bulk forming), paracetamol for pain, opioid and NSAID not recommended
Why aren’t opioids and NSAIDS used in diverticula treatment
May exacerbate diverticular perforation
Acute diverticulitis treatment
Paracetamol
What is acute diarrhoea
Abnormal passing of loose/liquid stools with increase frequency, volume / both for less than 14 days
Cause of diarrhoea
Infection, side effect, GI disorder like IBD/IBS
Aim of diarrhoea treatment
Reversal of fluid/electrolyte depletion
Antibacterial drugs for acute diarrhoea
Ciprofloxacin prophylactically against travellers diarrhoea
Sorting severe acute diarrhoea
IV rehydration fluid
How to treat faecal incontinence
Loperamide
Traveller’s diarrhoea treatment
Loperamide
When can’t you use loperamide
Significant abdominal pain (suggests inflammatory diarrhoea), bloody
Treating acute diarrhoea
Oral rehydration therapy
Cause of exocrine pancreatic insufficiency
Chronic pancreatitis, cystic fibrosis, constructive pancreatic tumours, coeliac
Clinical effect of exocrine pancreatic insufficiency
Maldigestion, malnutrition, low levels of micronutrients, fat soluble vitamins, lipoproteins
Exocrine pancreatic insufficiency treatment
Pancreatin
Physical manifestations of exocrine pancreatic insufficiency
Diarrhoea, abdominal cramps, Steatorrhoea
What food to avoid in exocrine pancreatic insufficiency
Legumes (peas, beans, lentils) and high-fibre foods. Alcohol should be avoided completely. Reduced fat diets are not recommended
What are haemorrhoids/piles
Abnormal swellings of the vascular mucosal anal cushions around the anus
Who is particularly predisposed to piles
Pregnant women
Lifestyle piles treatment
Soft stools by increasing dietary fibre/fluid intake
General piles pain treatment
Paracetamol not opioid
What do topical piles treatment typically contain
Local anaesthetics, corticosteroids, lubricants, antiseptics, astringents
What to avoid with topical local anaesthetics and why
Excessive application as it can cause irritation
Local topical anaesthetics
Lidocaine, benzocaine, cinchocaine, pramocaine
How long should topical corticosteroid be used for piles and why
7 days due to thinning of perianal skin and ulceration
Treating food induced anaphylaxis
Bulk forming laxative
Treating symptoms of food allergy
Chlorphenamine
Diet avoidance adjunct
Sodium cromoglicate - anti-allergic medicine which is prescribed to help prevent allergic reactions from occurring
H2 receptor antagonist indication /moa
gastric and duodenal ulcers by reducing gastric acid output as a result of histamine H2-receptor blockade; they are also used to relieve symptoms of GORD
Obese waist sizes
94cm men, 80cm women
Drugs that cause weight gain
Atypical antipsychotics, beta-adrenoceptor blocking drugs, insulin (when used in the treatment of type 2 diabetes), lithium carbonate, lithium citrate, sodium valproate, sulphonylureas, thiazolidinediones, and tricyclic antidepressants
When should drugs be considered for obesity
> 30 BMI, >28 BMI is risk factors
What drug is used for obesity
Orlistat
When is bariatric surgery considered
> 40 BMI
Gallstone drug treatment
Paracetamol/ NSAID for pain can give opioid if needed
Gallstone treatment
Leave if asymptomatic, or surgical removal
Result of excessive laxative use
Hypokalaemia
Cholethiases is
Gallstone other name
Drugs for GORD in pregnancy
Antacids/alginate if not then omeprazole/ranitidine
First line GORD treatment in pregnancy
Diet lifestyle
Refractory GORD treatment
Further PPI dose for a month, double PPI dose for a month or add H2 for nocturnal symptoms
Severe oesophagitis treatment
PPI 8 weeks
What to offer in confirmed GORD
4-8 weeks PPI if not then H2 receptor antagonist
What drugs exacerbate GORD
Alpha-blockers, anticholinergics, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), nitrates, theophyllines, and tricyclic antidepressants should be reviewed and lowest dose used
When to have urgent endoscopic investigation
Dysphagia and acute GI bleed or if over 55 and unexplained weight loss/upper abdominal symptoms, reflux or dyspepsia
GORD symptoms
Chest pain hoarseness cough wheezing genital erosions but more commonly heartburn and acid regurgitation
GORD is
Reflux of gastric contents back into the oesophagus
Treating IBS
Antispasmodic , laxative if constipation, linaclotide if persistent and loperamide if diarrhoea, A TCA like amitriptyline can be used for abdo pain second line if antispasmodics don’t work as can SSRIs
Lifestyle tips for IBS
Regular eating no long gaps, physical activity, less than 3 portions of fresh fruit a day, potentially increase dietary fibre via oats or isapaghula husk , increase water less caffeine/alcohol, fizzy, monitor probiotic use to see effectiveness
When are IBS symptoms relieved
On defecating
IBS symptoms
abdominal pain or discomfort, disordered defaecation (either diarrhoea, or constipation with straining, urgency, and incomplete evacuation), passage of mucus, and bloating
Who is IBS more common in
20-30, women
IBS is
Common, chronic, relapsing, and often life-long condition
Inborn errors of primary bile acid synthesis treatment
Cholic acid, chenodeoxycholic acid, ursodeoxycholic acid
