GI Flashcards
1
Q
What is coeliac disease?
A
An autoimmune condition associated with chronic inflammation of the small intestine unable to absrob nutrients
2
Q
What causes coeliac diasease?
A
Adverse reaction to gluten - dietary protein found in cereals, wheat, barley and rye
3
Q
Symptoms of coeliac disease?
A
Diarrhoea, abdominal pain and bloating
Causes higher risk of malabsorption of key nutrients (calcium and vit D)
4
Q
How to treat coeliac disease?
A
Strict life long gluten free diet
Assess for risk of osteoporosis and treat
Vit and mineral supplements following medical assessment
5
Q
What is diverticula?
A
Sac like pockets develop in the lining of the intestine causing intermittent lower abdominal pain in the abscense of inflammation/infecrion
6
Q
What is diverticulitis?
A
When the diverticula pockets become inflamed or infected
7
Q
How to manage diverticular disease?
A
High fibre diet
Bulk forming drugs
8
Q
How to manage uncomplicated diverticulitis?
A
Low fibre diet and bowel rest
9
Q
How to manage complicated diverticulitis?
A
IV antibacterial if infected and bowel rest
10
Q
Symptoms of UC? And position that it affects?
A
Mucosa inflamma and ulcers restricted to colon and rectum
Alternated between acute flare ups and remission Bloody diarrhoea (may contain mucus or pus) Abdominal pain Urgent need to defecate
Acute flare ups = mouth ulcers, arthritis, sore skins, weight loss, fatigue
11
Q
Long term complications of UC?
A
Colorectal cancer
Secondary osteoporosis (malabsorption and use of corticosteroid meds)
Venous thromboembolism
Toxic mega colon (esp if used loperamidr/codeine)
12
Q
Treatment for acute mild to moderate UC in proctitis and proctosugmoiditis?
A
1st line=rectal amino salicylate
2nd line = rectal corticosteroid or oral prednisolone
13
Q
Treatment for acute mild to moderate UC in extensive colitis and left sided colitis?
A
1st line= high dose oral aminosalicylate
2nd line=+rectal amino salicylate or oral beclometasone if necessary
Alternative to 1st line is oral prednisone alone
14
Q
Treatment for subacute moderate to severe UC?
A
Oral prednisolone
2nd line= monoclonal antibodies
15
Q
What to do in initial treatment failure in all extents of acute mild to moderate UC?
A
Add oral prednisolone (after 4wkd with aminosalicylate)
Add oral tacrolimus if no response after 2 to 4 wks
16
Q
Treatment for severe acute UC?
A
Immediate hospital admission as life threatening medical emergency
1st line = IV corticosteroid + assess need for surgery
Alternative is IV ciclosporin or surgert
2nd line = if symptoms don’t imptove/worsens in 72hrs
IV ciclosporin + IV corticosteroid or surgery
Alternative to ciclosporin is infliximab
17
Q
Maintaining remission in UC?
A
Generally aminosalicylate as corticosteroid has too many side effects
18
Q
Maintaining remission in UC proctitis and proctosigmoiditis
A
Rectal aminosalicylate alone or with oral aminosalicylate
can give oral alone if pts prefer not to use enemas/ suppositories but not as effective
19
Q
Maintaining remission in UC extensive colitis or left sided colitis
A
Low dose oral aminosalicylate
single daily dose more effective that multiple daily dose but has more side effects
20
Q
2nd line to maintaining UC?
A
Oral azathioprine or meraptopurone
(if 2+ flare ups in 12 months that required systemic corticosteroids, or if remission not maintained on aminosalicylate or after severe flare ups)
Monoclonal antibody can be continued if effective or tolerated during acute flare ups
21
Q
Bloody sttol is common in which disease? UC or crohns?
A
UC
22
Q
Malnutrition is more common in which disease? UC or Crohns?
A
Crohns
23
Q
Complications of crohns?
A
Intestinal strictures, abscess
Malnutrition, anaemia
Colorectal cancer, small bowel cancers
Growth failures and delayed puberty in childrrn
Arthritis, abnormalities of joints, liver, eyes and skin
Secondary osteoporosis
24
Q
Lifestyle advice on Crohns?
A
High fibre diet
Smoking cessation reduces risk of relapse
Loperamidr or codeine to treat diarrhoea but Not in UC
25
What to give to crohns pt who had 1 plus acute flare up in 12 months or first presentation?
Corticosteroid (pred, methyl or IV hydrocortisone)
Alternative is budesonidr or aminosalicylate in pts with distal ileal
Ileocaecal or right sided colonic disease
26
What to give to crohns pt who had 2 plus acute flare ups in 12 months? Or if corticosteroid dose cannot be reduced
Azathioprine or meraptopurone
Alternative is methotrexate
Alternative or last resort is monoclonal antibodies under specialist supervision in severe flare ups
27
How to maintain remission in chrons disease?
Azathioprine or meraptopurone
Alternative is methotrexate
28
How to maintain remission of crohns after surgery?
Azathioprine or meraptopurone or aminosalicylate
29
Side effects of aminosalicylate?
Blood dyscrasia - report unexplained bleeding, bruising, sore throat and fecer
Nephrotoxicity
Salicylate hypersensitivity
30
Pt advice on sulfasalazine?
Yellow orange bodily fluids with sulfasalazine
| Soft contact lenses may be stained
31
Interaction between lactulose and mesalazine?
Lactulose loerts stool oh in the intestine. Thai prevents sufficient release of the active ingredient in e/C or m/r preparations
32
What drugs is licensed for the relief of diarrhoea associated with CD?
Colestyramine
33
Symptoms of irritable bowel syndrome?
Common chronic relapsing and often life long cobdition
Abdominal pain
Blaoting
Alternating constipation and diarrhoea with urgency and incomplete evacuation
Aggravated by stress, depression and anxiety, lack of dietary fibre
Commonly affects young adult women 20 to 30
34
Name antispasmodic used for irritable bowel syndrome?
Mebeverine
Peppermint oil
Alverine
35
Side effects of Peppermint oil?
Heartburn, local irritation of mouth and oesophagus
36
Non drug treatment of irritable bowel syndrome?
Lifestyle changed, limiting fresh fruit consumption to no more than 3 portions a day
The sweetener Sorbitol should be avoided in pts with diarrhoea
37
Can you sell Peppermint oil?
All GSL 1 to 2 caps tds
38
Can mebeverine be sold?
Yes. provided that max. single dose is 135 mg and max. daily dose is 405 mg;
for uses other than symptomatic relief of irritable bowel syndrome provided that max. single dose is 100 mg and max. daily dose is 300 mg.
39
Antimuscarnics used for GI spasm?
Hyoscine butylbromidr
Atropine
Dicycloverine
Propantheline bromide
40
Can you sell hyoscine butylbromide?
Yes, to the public for medically confirmed irritable bowel syndrome, provided single dose does not exceed 20 mg, daily dose does not exceed 80 mg, and pack does not contain a total of more than 240 mg.
41
What laxatives can be used in irritable bowel syndrome?
As long as not lactulose as it can cause bloating
Linoclotide can be used if unresponsive to diff laxative classes and have had constipation for 12 months
42
What can be used 2nd line for abdominal pain and discomfort?
Antidepressants like low dose TCA or SSRI
43
When can carbon 13 urea breath test be performed after certain meds?
2wks after PPI treatment
| 4wks after antibacterial treatment
44
Characterisation of short bowel syndrome?
1. Malabsorption and malnutrition
= deficiency of vit A, B12, D, E and K, essential fatty acid, zinc, selenium, hyoomagnesaemua so need supplementation
2. Inadequate digestion leading to diarrhoea so need loperamide
3. Incomplete drug absorption
45
In short bowel syndrome, incomplete drug absorption occurs. How can you manage this?
Higher doses of warfarin, COC and digoxin required or give IV
EC/ M/R formulations not suitable
So use uncoated or soluble tabs or liquid
46
Red flag symptoms of constipation?
New onset constipation in over 50
| ARARM symptoms
47
How long does it take for bulk forming laxatives to work?
Works within 24hrs but takes 72hrs for full effect
48
How long does it take osmotic laxatives to work?
2-3 days
| 48hrs for lactulose
49
How can you reduce nausea caused by osmotic laxatives as a side effect?
Administering with water, fruit juice or meals
50
When to add stimulant laxatives?
Third line
Add if stools are soft but difficult to pass or incomplete emptying
For short term use up to 1wk
51
How long does it take for stimulant laxatives to work?
6-12hrs
Glycerol suppositories work in about 15-30mins
52
Side effects of stimulant laxatives?
Abdominal craps
Excessive used leads to Hypokalaemia, diarrhoea, lazy bowel
Senna colour urine yellow brown
53
Counselling points on senna?
Take at night to pass stool in the morning
| Moisten suppositories with water before use
54
What the gentoxic and carcinogenic stimulant laxative?
Co-danthramer
| Co-danthrusate
55
Side effects of Co-danthramer?
Carcinogenic so ussed only in terminally I'll pts
Red urine
Local irritation and excoriation so avoid prolonged contact with skin
56
Side effect of faecal softener?
```
Liquid paraffin has harsh side effects
Anal seepage
Lipoid pneumonia
Granulomatous
Malabsorption of fat soluble vitamins A, D E and K
```
57
Other laxatives with stool softening properties?
Mathylcellulose is a bulk forming
Docusate sodium is a weak stimulant
Glycerol is a rectal stimulant
58
When can you use lubiprostone or prucalopride?
If at least 2 laxatives if different classes have been tried at the highest tolerated recommended doses for at least 6 months
Consider prucalopride in women only
59
What laxative to use for opioid induce constipation?
Osmotic or Docusate with stimulant
Co-danthramer only in palliative
Methhlnaltrexone or naloxegol when response to laxatives are inadequate
60
Which laxatives need to be avoided in opioid induced constipation?
Bulk forming as it can lead to obstruction and painful colic
61
Chronic constipation management?
Same stepped approach as shirt
| Except macrogol is choice of osmotic
62
Management of constipation in children
Macrogol with diet/behaviour interventin
Add stimulant laxative if inadequate response
Add lactulose or faecal softener if stools remain hard
Docusate sodium or Glycerol suppositories
63
Senna and pregnancy
Avoid if near term as can stimulate uterine contractions
64
Management of constipation in BF?
Laxative
Osmotics
Alternatively: stimulant laxatives
65
Red flag symptoms of diarrhoea?
ALARM
Systemic illness
Received recent hospital treatment of antibiotics
Following foreign travel except Western Europe, Australia, North America or New Zealand
66
What's co-phenotrope?
Anti diarrhoeals
| Has antimuscarnic and opioid effect
67
Which bill forming laxative can be used to treat both constipation and diarrhoea?
Methyl cellulose
68
Loperamide dose?
Initially 4mg, then 2mg after each loose stool for up to 5 days
69
Max dose of loperamide?
16mg/day (8 tabs)
70
MHRA warning on loperamide?
Serious cardiac adverse reactions with high doses, misuse or abuse
QT prolongation, torsade de pointes, cardiac arrest and fatalities
71
How to manage loperamide overdose?
Naloxone
| And monitor for 48hrs for possible CNS depression
72
Common Side effects of loperamide?
Dizziness
Flatulence
Headache
Nausea
73
Contra indications of loperamide?
Active UC
Antibiotic associated colitis
When peristalsis is inhibitrd
Avoid in bloody diarrhoea or Inflammatory diarrhoea (fever, severe abdominal pain)
74
What's dyspepsia?
Group of upper abdominal symptoms
Upper abdominal pain
Fullness
Early satiety
75
How to manage uninvestigated Dyspepsia?
Antacids for symptoms relief
PPIs for 4 wks if symptoms persist.
H. PYLORI test if no response to PPI
76
How to manage investigated functional Dyspepsia?
Do a H. Pylori test first
If negative
PPIs or H2 antagonist for 4wks
77
How long does it take for antacids to work?
15-30mins
78
How do alginate work?
Forms viscous gel raft on top of stomach contents to prevent reflux
79
Disadvantage of calcium containing antacids?
Induce rebound acid secretion
80
Antacids with low sodium preparations?
Maalox
Mucogel (co-magaldrox)
Altacite plus (simeticone with hydrotalcite)
81
How to take antacids?
Take after each main meal and at bedtime PRN
82
Antacid interactions?
Impaired absorption go drugs so leave a 2hr gap
Esp with tetracycline, Quinolones, bisphosphonates, PPIs
Damages enteric coatings by increasing gastric pH
High sodium contain so cause fluid retention
Avoid in hypertention, heat, liver or kidney failure
Avoid in sodium restricted diet like lithium
83
How to take lansoprazole?
Take 30-60mins before food
84
Which PPI is safe in Preganancy?
Omeprazole
85
Side effects of PPIs?
Abdominal pain
Constioation
Diarrhoea
Nauea
86
MHRA warning on PPIs?
Very low risk of subacute cutaneous lupus eythematosus
87
Long term use of PPIs can lead to?
Hypomagnesium (predispose to digoxin. Toxicity)
Fractures
Rebound acid secretion
Protracted Dyspepsia after stopping
88
Important interactions of PPIs?
Omeprazole reduces clopidogrel Antiplatelet effect
Omeprazole decreases clearance of methotrexate
89
Which H2 antagonist is an enzyme inhibitor?
Cimetidine
90
Which H2 receptor antagonist is safe to use in pregnancy?
Ranitidine
91
Side effects of H2 antagonists?
```
Headaches
Rashes
Dizziness
Diarrhoea
Psychiatric reactions (confusion, depression, hallucinations in the elderly or very ill pts)
```
92
What's milk of magnesium used for?
Indigestion
93
What effect does PPI have on serum magnesium
Causes Hypomagnesium
| Which can occur 1yr after treatment
94
Non drug treatment of haemorrhoids?
Keep stools soft and easy to pass to minimise straining by increasing dietary fibre and fluid intake
95
Topical agents for haemorrhoids contain what drugs as a local anaesthetics? How long should they be used and why?
Lidocaine
Benzocaine
Cinchocaine
Pramocaine
Use only for few days as can cause sensitisation of the anal skin
96
How long can you use corticosteroid cream for haemorrhoids? What happens if you exceed that day?
No more than 7 days
Long term use can lead to ulceration or permanent damage due to thinning of the perianal skin
97
Haemorrhoids and pregnancy?
Bulk forming laxatives
No Topical haemorrhoidal preparations are licensed for use during preg so refer
If Topical required, soothing preparations can be considered
98
When to refer for haemorrhoids?
```
Suspected colorectal cancer for
Over 50 with rectal bleeding
Abdominal pain
Change in bowel habits
Weight loss
Iron deficient anaemia
```
99
Preparations containing mild astrigents or lubricants are good for haemorrhoids because?
Relieve local irritation and are less likely to cause skin sensitisation
100
Drugs that are considered as astrigents?
Zinc oxicde
Bismuth oxide
Hamamelis
Allantoin
101
Side effects of colestyramine?
```
Constipation
Increased tendency to bleed
Nausea and vomiting
Reduced absorption of vit A, D E And K
Diarrhoea
GI DISCOMFORT
aggregation of hypertriglyceridaemia
Hypoprothrombunaemia
```
102
What analgesic is not recommended in diverticular disease?
NSAIDs and opioid analgesic because may increase the risk of diverticular perforation
103
IBS affect what age group commonly?
20-30
Synptoms are usually relieved by defecation
Increase exercise
104
What drugs are used for gastric and duodenal ulceration?
PPI
H2 receptor antagonists
Misoprostol
Sucralfate
105
Side effect of Misoprostol?
Colic and diarrhoea are dose limiting side effect
| Diarrhoea is common and can occasionally be severe and require withdrawal
106
What is sucralfate and how to take them?
A chelate
| So causes bezor formation, take 1ht before meals and 1hr gap between enteral feeds
107
Treatment of NSAIDs induced ulcers?
Withdraw NSAIDs if possiblr
PPIs are first line
Alternative is H2 antagonist / misope
Test for H pylori on healing
If non selective NSAIDs are continued, continue PPI or Misoprostol
If history of upper GI bleeding, continue PPI and switch to COX2 inhibitor
108
Who needs prophylaxis for NSAIDs induced ulcers?
High risk pts like 65+, previous history, liver, kidney impairment, heart disease and diabetes
109
What prophylaxis is needed for NSAID induced ulcers at risk pt and for pts with 3 or more risk factors?
At risk pts = PPI. Alternatively H2 antagonist/Misoprostol
3 or more risk factors = PPI with Cox selective NSAIDs
110
Management of mild symptoms of GORD?
Antacids and alginates
| + H2 receptors/PPI
111
Management of severe symptoms of GORD?
PPI for 4-6wks
| Or H2 if intolerant
112
Management of GORD in preganant pts?
Antacids or alginate
Ranitidine if above is ineffective
Omeprazole is reserved for severe or complicated
113
Management of GORD in children?
It's quite common in infant and usually resolves age 12-18months old
If mild to moderate GORD, thickened feeds or alginate
114
What can be used for management of allergy when it's not anaphylaxis?
Sodium cromoglicate e. G. Eye drops
| Chloramphenicol is licensed for symptomatic control
115
What condition can cause GI smooth muscle spasm?
IBS
IBD
Bowel colic in palliative care
116
What antimuscarnics are used to manage GP spasm?
Hyoscine butylbromide
Atropine
117
Antimuscarnic side effects?
```
Can't see, pee, poo and spit
Blurred visition
Urinary retention
Constipation
Dry mouth
```
```
Tachycardia, pulpitation and arrhythmia
Pupil dilation
Reduced bronchial secretions
Glaucoma
Confusion esp in elderly
Drowsiness so impair driving
```
118
MHRA warning on hyoscine butylbromide injection?
Risk of serious adverse effects in pts with underlying cardiac diseasr
So contraindicated in tachycardia
119
MoA of antispasmodic?
Direct relaxants of intestinal smooth muscle
120
Drugs of antispasmodic?
Mebeverine
Alverine
Peppermint oil
121
Mebeverine and Alverine are contra indicated in?
Paralytic ileus
122
Side effects and pt advice on Peppermint oil?
Heartburn, local irritation of the mouth and oesophagus
Pt counselling says Swallow capsules whole
123
What's considered an acute anal fissures?
Less that 6wks
124
Management of acute anal fissures?
Ensure soft stools
So bulk forming laxatives
Alternative osmotics
If prolonged burning pain following defecation, short term Topical local anaesthetics applied before emptying bowel
125
What's considered as chronic anal fissures?
More than 6wks
126
Management of chronic anal fissures?
GTN rectal ointment (causes headache)
Alternative
Topical diltiazem or nifedipine
127
Lifestyle advice on haemorrhoids?
| Risk factors?
Increased fluid and fibre intake
Perianal hugiene
Constipation and constipation increase risk of developing haemorrhoids
128
What causes reduced secretions of pancreatic enzymes?
| What does it lead to?
Maldigestion, malnutrition and GI symptoms
Cystic fibrosis, chronic pancreatitis, coeliac disease, zollinger Ellison syndrome
129
Dietary advice on pancreatic insufficiency?
Distribute food intake between 3 main meals and 2-3 snacks
Avoid food that are difficult to digest like peas, beans and lentils and high fibre
Do not consume alcohol
Avoid reduced fat diets
130
What does pancreatin do?
Assist with the digestion of starch, fat and protein.
131
How to take pancreatin?
Take with meals/snacks or immediately before or after
Pancreatin is inactivated by gastric acid so use acid suppressor like PPIs if symptoms present despite high pancreatin dose
EC preps deliver a higher dose
Do not mix with excessively hot food or drinks as inactivated by heat
If mixed with food or liquids, drink within 1hr
132
Side effects of pancreatin?
GI side effects
Irritation in perioral skin and buccal mucosa
Excessive dose can lead to Hyperuricaemia, hyperuricosuria,
Skin irritation and hypersensitivity reactions when handling
Fibrosing colonopathy in cystic fibrosis with high dose
Risk increased with male children, more severe cystic fibrosis and laxative use
If new or changing abdominal symptoms exclude colonic damage
133
Contra indications of pancreatin?
Nuttizym and pancrease HL are contraindicated in children below 15 with cystic fibrosis as associated with colon strictures
134
Pt counselling on pancreatin?
Adequate hydration at all times with high strength preps
135
Stoma care?
Avoid EC and MR preps
Avoid Sorbitol containg preps as laxative effect
Vulnerable to GI side effects so iron given In IM, Opioids as well
Give PPI to reduce gastric acid secretion and stoma output
Vulnerable to water and electrolytes depletion so avoid laxatives by increasing fluid fibre intake or bulk forming
High doses of loperamide needed ot add codeine
