GI Conditions Flashcards
How is constipation classified in children? (symptoms)
2 or fewer defecations a week
history of excessive stool retention, painful/hard bowel movement, large diameter stool, retentive posture
one episode/week of incontinence after acquisition of toileting skills
What is the step-wise treatment of functional constipation in children?
1) regular doses of stool softener or osmotic laxative
2) if 1 not work, use stimulant laxative
3) ineffective monotherapy, combination of laxatives
4) glyceryl suppositories
Name the stool softeners used to treat constipation (children)
Poloxamer = <6months, 6-18months, 18-36 months
Docusate = 3-6, 6-12 years old
liquid paraffin = 1-6 yrs, 7-12 yrs, <12 yrs
It is a first line treatment
Name the osmotic laxatives used to treat constipation (children)
lactulose = <1 yrs, 1-5 yrs, 6-12 yrs, >12 yrs
Macrogol +/- electrolyte = 1-12 yrs
Name the stimulant laxatives used to treat constipation (children)
Senna = 2-6 yrs, 7-12 yrs
Bisacodyl = >3 yrs, 6-months -2yrs
Sodium picosulfate drops = 4->10 years
All stimulant laxatives are given at night
What are some key points to consider when treating constipation in children?
regular doses of laxatives
gradual reduction of laxative meds = prevent further impaction
med treatment can be continued for several months
avoid prune juice/brown sugar water
Referral points for constipation in children
Faecal impaction
ineffective general treatment
chronic (>6 months duration)
pain
affecting child’s lifestyle
What is diarrhoea?
defined as at least three loose or liquid bowel movements, accompanied by increased freq and fluidity relative to normal stool
What is the main focus for diarrhoea treatment?
prevent dehydration and correct fluid loss & electrolyte loss
treat cause if possible
relieve symptoms
Referral points for diarrhoea
diarrhoea alternating constipation, intermittent
blood or mucus/both in stool, chronic med conditions, suspected laxative misuse, fam history of GI disease
symptoms >14 days, severe symptoms (8-10 motions/day)
severe abdominal pain, unintentional weight loss
pregnancy, infant <6 months, <1 year (Symptoms last >24 hrs)
recent overseas travel
What is the first line treatment for diarrhoea?
oral rehydration therapy, avoid sugar hydration products
What is second line treatment for diarrhoea?
Antimotility agents:
symptomatic relieve adults/children >12 yrs old
for mild/moderate acute diarrhoea
short term control for social inconvenience
What are some contraindications for antimotility/ anti-diarrhoeal agents?
Severe diarrhoea
possibility of invasive organism
severe irritable bowel syndrome
Acute management of infants and young children
What are the available anti-motility agents?
loperamide (+/- simethicone)
diphenoxylate (+atropine)
What schedules do loperamide belong to?
unscheduled= 8 pack or less
S2 = 20 pack or less
GastroStop has PBS listing = authority requirements
What schedules do diphenoxylate belong to?
S2 = 8 pack or less
S4 = 20 pack or more
PBS listing available
Briefly mention Giardiasis
parasitic infection of small intestine found in water contaminated by raw sewage or animal waste
Transmitted also person-person (poor hygiene)
Symptoms (come and go)= diarrhoea, stomach cramps, gas, nausea
What commonly treats giardiasis?
metronidazole, three times a day for 5 days
Discuss rotavirus
cause of acute viral gastroenteritis in children, most common cause of severe diarrhoea in children
resolves = 3-9 days
Transmission = rota virus shed in stool, spread via contaminated hands/objects
How is rota virus diarrhoea treated?
treated depending on severity of dehydration
Oral rehydration supplements
How is rota virus diarrhoea prevented?
Oral rotavirus vaccine
85-98% effective against severe rota virus after 3 doses (2, 4, and 8 months of age)
won’t prevent diarrhoea and vomiting caused by other organisms
What causes GORD?
weakened or impaired function of lower GI sphincter
Inc intra-abdominal pressure –> reduced oesophageal clearance –> impaired mucosal defence
reduction of salivary secretion can inc exposure to gastric acid
When is GORD classified?
heartburn/reflux symptoms occur more than 2+ days per week and become troublesome
What are some GORD symptoms/signs?
heartburn, excessive burping
regurgitation of food or acid, upper abdominal pain/discomfort
sore throat, waterbrash, difficulty swallowing, persistent dry cough, angina-like chest pain
What factors exacerbate GORD?
Diet, supine position post eating
medications
inc gastric pressure
Tobacco smoking, bending or straining, wearing tight clothing, stress
What medications worsen GORD?
Anticholinergics, sedating antihistamines
antidepressants, nitrates, CCB, nicotine, benzodiazepines, beta blockers, NSAIDs
When to refer a patient with GORD
Anaemia, weight loss, anorexia, dark stools, swallowing impairment (dysphagia, odynophagia)
nocturnal choking, persistent cough, vomiting red blood
radiating chest pain
What drugs are used to treat GORD?
Antacids = 1st line in preg, quick onset
Simethicone = used alone or with antacids
Alginates = used alone or with antacids
H2 antagonists = used in preg
PPIs = most potent
What H2 antagonists are used to treat GORD?
Famotidine
Nizatidine
Ranitidine (least drug interactions)
Begins to work in 1 hours, persist 6 - 12 hrs
Name the PPIs used in GORD
omeprazole, lansoprazole, rabeprazole, esomeprazole, pantoprazole
Pack of 7 = S2
Pack of 14 = S3
What is the PSA protocol for supply PPIs?
Asses = presenting signs and symptoms, symptoms freq, age (>18, <55), prior treatments, lifestyle, medical/fam history, current meds
Confirm recommendation appropriate = treatment option, C/I, preg/lactating, drug interaction
What are some PSA PPI counselling points?
take 30-60 mins before meal
acid liable, has enteric coating = do not crush or chew
slow onset of action, use antacids initially
well tolerated, can cause = headache, nausea, diarrhoea, constipation, flatulence
discuss lifestyle mods, alarm symptoms to look out for, referral advice
Outline the step down approach to PPIs in GORD
H2 antagonist is initial therapy = greater efficacy at standard dose
PPIs at standard dose (therapeutic trial 4-8 wks) = rapid symptoms relief and heal erosive diseases present
Review maintenance therapy regularly
Things to consider in well controlled GORD
Stopping treatment unless patient has severe oesophagitis or complicated disease
Intermittent use when symptoms are present
Step down to low dose therapy
What are some acute and chronic causes of vomiting/nausea?
Medicines (NSAIDs, opiods, chemo drugs)
GI disorders (GORD, IBS, GI obstruction)
Vertigo, motion sickness
Pregnancy
What is motion sickness?
Response to abnormal signals, brain difficulty processing conflicting signals
Common in children 2-12 years old
How do you prevent motion sickness?
Dry crackers, ventilation, look forward, look at horizon, dont read or focus on games in move vehicle
Name the pharmacological treatments for motion sickness
Promethazine
Dimenhydrinate + hyoscine, caffeine
Hyoscine hydrobromide
When should promethazine be taken?
Long trip = start the night before
Short trip = 1-2 hrs prior to travel
When should dimenhydrinate (travelcalm) be taken?
Commence 20-30 mins before trip
When should hyoscine hydrobromide be taken?
20-30 mins prior to travel
What are some non-pharm motion sickness treatments?
Acupressure = sea band, travel calm band. Target P6, pericardium acupuncture pressure point. Two to three fingers width down from wrist
Ginger =Take 3 days prior to travel, safe in pregnancy, 30 mins before travel and repeated every 4 hrs
What are some haemorrhoids symptoms?
Pain, irritation, swelling, burning, mucous discharge, bleeding (bright only, not mixed with stool)
What are some causes of haemorrhoids?
constipation = meds, lack of fibre, dehydration
Pregnancy = resolves after birth
straining = bowel motions, cough/sneeze, heavy lifting
obesity
long periods of sitting
What are non-pharm treatments of haemorrhoids?
Drink water, dont strain, high fibre diet, look at meds being taken, exercise if possible, eight loss
What general treatments are available for haemorrhoids?
Astringents
Local anaesthetics
corticosteroids
What astringents are available for haemorrhoids? What do?
Zinc = forms protective coating, soothing relief
What local anaesthetics are used to treat haemorrhoids?
Lignocaine, benzocaine, cinchocaine = freq application, pain relief
What corticosteroids are used for haemorrhoids?
hydrocortisone (cream), prednisolone (oral, S4) = reduce inflammation and itching
Caution = can only be used for 7 days max.
What combination products are available for haemorrhoids?
Proctosedyl ointment and suppositories (S2) = cinchocaine + hydrocortisone
Scheriproct (S4) = cinchocaine + prednisolone
What are referral points for haemorrhoids?
Pregnancy, known GI conditions associated with bleeding (Crohns, ulcerative colitis)
Not seen GP before, blood in stool, unexplained rectal bleeding, marked protrusion, fever, abdominal pain
Recent unusual change in bowel habit
What is an anal fissure?
slit-like tear or defect in anal canal lining, usually acute and will heal in 4-8 weeks (becomes chronic afterwards)
Localised trauma –> spasm of anal sphincter + inc resting anal sphincter pressure —> reduced blood flow & poor healing
What are the symptoms of anal fissure?
Pain (intense and last minutes/hrs after defecation)
bleeding (bright red)
mucous discharge
itching
What are the treatments for anal fissures?
Break cycle of anal sphincter spasm, inc fibre intake and/or laxatives
warm bath
topical ointments
What topical ointments and creams can treat anal fissures?
glyceryl trinitrate (topical) = 3-4x a day, 4-8 wks, limited healing effect
lignocaine = pain relief
hydrocortisone = anti-inflam
CCB (topical: diltiazem, nifedipine) = vasodilation
What are some considerations for glyceryl trinitrate use?
C/I = sildenafil, tadalafil, vardenafil (PDE-5 inhibitors)
ADRs = headache, light headed
stop use = severe headache, dizziness
Advice = avoid straining, inc fibre/fluid intake or use bulking agents
How are hookworms and rounworms treated?
Albendazole (S4)
Mebendazole, pyrantel (OTC)
What is the first line treatment for threadworms/pinworms?
mebendazole, pyrantel, albendazole
What are the treatments for tapeworms?
1) Praziquantel
2) niclosamide
What are the treatments for whipworm?
1) albendazole
2) mebendazole
What are the treatments for strongyloidiasis?
1) ivermectin
2) albendazole
True or false
albendazole is safe in pregnancy?
False
Is pyrantel safe in pregnancy?
Can be used, dosage determined by weight
repeat after 2 weeks
Is mebendazole safe in pregnancy?
Yes but avoid in trimester 1
Repeat after 2-4 weeks if unsuccessful
What is the community deworming program?
In communities with high rates of intestinal worm infections
treated with albendazole once a year
Deworming program improves nutrition and growth
target age = 6 months and 12 years
