GI+HG

Question 1

What is the function of the GI tract

Answer 1

• Mastication (mouth)
• Ingestion (mouth)
• Propulsion (Waves of peristalsis from cardiac sphincter to pylorus about 3 times a minute)
• Mechanical and chemical digestion (begins in stomach completed in small intestine)
• Absorption (some in stomach rest in small intestine)
• Elimination of non-usable residues as faeces (large intestine)

Question 2

What are the different GI disorders?

Answer 2

• Nausea, vomiting, hyperemesis gravidarum
• Coeliac disease
• Constipation
• Irritable bowel syndrome
• Inflammatory bowel disease
  o Crohn’s disease
  o Ulcerative colitis

Question 3

Problems involving the small intestines

What is coeliac disease?

Answer 3

• Coeliac disease is not an allergy or an intolerance like some people believe, but a lifelong autoimmune disease where the body’s immune system damages the lining of the small bowel when gluten, a protein found in wheat, barley and rye, is eaten.
• More common in those with other autoimmune disorders
• Inflammatory condition of the small bowel (duodenum, jejunum, ileum) caused by an inability to digest GLUTEN (wheat protein)
• Gluten = mixture of 2 proteins (gliadin, glutenin)
• Lining of small intestine damaged on exposure to gluten; gut villi become inflamed and flattened, eventually undergoing atrophy
• Results in malabsorption, malnutrition, systemic illness
• Aetiology unknown but is related to a combination of genetic predisposition and environmental factors- the amount of gluten ingested, stress of a pregnancy or a GI infection.

Question 4

What are the signs and symptoms of coeliac disease?

Answer 4

• (Adults) General lassitude; diarrhoea; iron/folate deficiency; vitamin D/vitamin K deficiency; weight loss
• Adults may experience less acute symptoms than children
• (Children) Usually present at age 9 months to 3 years when cereals introduced into diet: Pale, bulky and foul-smelling stools; steatorrhoea- fat in the stools; malabsorption and failure to thrive; weight loss; abdominal distension; diarrhoea

Question 5

Investigations and management of coeliac disease

Answer 5

• Blood tests to detect auto-antibodies
• Stool sample, to exclude infection
• FBC (exclude anaemia; check WBC); CRP-inflammatory marker
• Small bowel biopsy (via endoscopy)
• Serological tests
• Women first presenting in pregnancy – need to consider the desirability, practicability and safety of the more invasive investigations
• Health education/advice; help with accessing information about Coeliac Disease; support breastfeeding; delay weaning in the infant

Question 6

What are the complications of coeliac disease?

Answer 6

• Anaemia
• Osteoporosis
• Short statures
• Reproductive problems
• Malignant disease

Question 7

What are the pregnancy issues related to coeliac disease?

Answer 7

• Can experience an aggravated response during pregnancy
• Haematological disorders: iron-deficiency anaemia
• Some studies have showed that if left untreated can increase risk of miscarriage, fetal growth restrictions and LBW.
• Further vitamins and mineral supplementations need to be given- folic acid.

Question 8

What is constipation?

Answer 8

• Definitions of constipation vary:
  o fewer than 2 bowel motions per week
  o feeling of incomplete defecation
  o hard, lumpy stools
  o straining to move bowels
  o less frequent bowel motions than is customary
  o nausea; bloated feeling
• Related to fluid intake, dietary fibre content, activity levels, effectiveness of gastro-colic reflex, psychological factors, hormone levels
• Nausea & vomiting may cause reduced food/fluid intake
• Pregnancy: progesterone and prostaglandins slow GI tract motility; gravid uterus exerts pressure on the sigmoid colon and rectum –> constipation
• May have GI upset with iron supplementation
• May be exacerbated by presence of haemorrhoids or anal fissure, or increase the risk of developing them
• Impact: physical, emotional, behavioural effects; abdominal pain/discomfort; rectal bleeding; depression

Question 9

What are the interventions for constipation?

Answer 9

• Dietary advice: adequate fluid intake (at least 2 litres/day); increased fibre content - aim for gradual increase in fibre, to avoid bloating/discomfort
• Reduce caffeine – diuretic effects will increase water loss
• Consider temporarily stopping or changing iron tablets
• Increased physical activity/exercise will promote gut peristalsis
• Retraining the bowel – relaxation exercises; modify environment to facilitate comfort/privacy
• Laxatives, stool softeners, suppositories, enema, bulking agents; should be a last resort, short-term measure only
• Professional awareness of possibility of enforced immobility and changed environment (bed-rest, hospital in-patient stay) on normal bowel function

Question 10

What is IBS

Answer 10

• Functional disorder of the intestines
• Appears to be the results of motor disturbances in the intestine that respond to certain stimuli.
• Similar symptoms to other bowel functional disorders
• Recurrent abdominal pain, discomfort, distension, bloating (relieved on defecation); more frequent, looser stools; passage of mucus per rectum; feeling of incomplete evacuation of bowel; bouts of constipation
• May be linked with hormonal cycles (esp female); stress, genetic predisposition, food allergies and sensitivities, bacterial overgrowth in the intestines
• Symptoms exacerbated by certain antibiotics and non-steroidal anti-inflammatory drugs (noxious stimuli to gut)
• Symptoms may be exacerbated by pregnancy (especially if already experiencing constipation)

Question 11

Management of IBS

Answer 11

• Aetiology is unknown
• Thorough assessment of progress and impact of the condition; nature, timing and severity of symptoms
• Dietary review – reduce caffeine; avoid triggers; eliminate fructose and sorbitol sources; modify fibre content; avoid foods that ferment in the gut
• Assess and aim to reduce emotional stressors
• Provide environment that promotes relaxation, privacy, hygiene (may be difficult in hospital wards)
• Pharmacological treatments – symptom relief
• No evidence of malabsorption of nutrients

Question 12

Drug treatment in IBS

Answer 12

• Anticholinergic drugs (antispasmodics)
  o Smooth muscle relaxants; clients with IBS have increased gut motility after eating, resulting in cramps, bloating and diarrhoea; e.g. hyoscine (Buscopan), dicyclomine (Merbentyl)
• Peppermint oil
• Opioid derivatives (anti-diarrhoeal effect)
  o Slow gut peristalsis; long-term use may worsen constipation
• Antidepressants (including SSRIs)
  o Have been used in clients unresponsive to conventional treatment; can reduce bowel’s response to distension/stimulation
• Antibiotics and probiotics
  o May help if there is overgrowth of gut bacteria

Question 13

Inflammatory Bowel Disease

Chron’s disease

Answer 13

• Chronic inflammatory disease affecting ANY part of GI tract
• Get granulomatous changes through whole thickness of bowel wall
• Unknown cause but thought to be some genetic predisposition. It is considered that the condition is in response to environmental triggers, such as infection and drugs.
• Less common than U.C: affects up to 5:10,000 people
• More common in smokers (compared with non-smokers); both sexes are equally affected
• Can lead to bowel perforation; stricture formation; fistulae; abscess formation

Question 14

Complications of chron’s disease

Answer 14

• Poor self esteem
• Fissures in the anal canal
• Abscesses in the pelvis
• Arthritis

Question 15

What is Ulcerative colitis?

Answer 15

• Inflammatory disorder affecting large bowel mucosa
• May involve rectum only, or part/whole of colon.
• Never involves the small intestine
• Unknown aetiology, but some evidence for genetic susceptibility
• Twice as common in non-smokers
• Affects women more frequently than men
• Can result in colonic dilatation; malignancy

Question 16

Signs and symptoms of IBD

Answer 16

• Watery diarrhoea (with blood & mucus)
• Lower abdominal pain/cramps
• Change in frequency of bowel motions; urgency
• Weight loss/malnutrition
• Abdominal tenderness
• Perianal abscesses, fistulae, skin tags (in C.D.)
• Anal/rectal strictures (in C.D.)
• R.I.F. mass (in C.D.)
• Fever
• Malaise
• Anorexia
• Tachycardia
• Ulcers in mouth
• Clubbing of fingers (proliferation of soft tissue)
• Arthritis symptoms
• Liver and kidney impairment

Question 17

Investigations of IBD

Answer 17

• Thorough history-taking, examination, record-keeping and referral to appropriate specialists
• Care should be offered by gastroenterologist who specialises in IBD.
• Bloods: FBC, ESR, CRP, U&Es, LFTs, blood cultures, serum iron, B12, red cell folate
• Stool sample for infection screening
• Abdominal X-ray (?during pregnancy)
• Colonoscopy; biopsy (rectum or colon)
• Barium enema (not during pregnancy or during an acute attack)

Question 18

Management of IBD in pregnancy

Answer 18

• Pregnancy does not usually affect the course of IBD; symptoms generally remain stable
• Most symptom changes occur in early pregnancy or postnatally
• Pregnancy outcome not affected by ‘quiescent’ IBD but may be adverse effects if active disease present
• Women may already have a stoma (ileostomy, colostomy), with or without a stoma bag (some may have a conduit for administration of medication only)
• Investigations: FBC, stool culture, serum albumin, sigmoidoscopy/proctoscopy
• LSCS only for obstetric indications, or if have severe perianal Crohn’s disease
• Anti-inflammatory drugs, such as sulfasalazine or mesalazine are safe to use during pregnancy and when breastfeeding
  o Sulfasalazine interferes with folate metabolism, so these women should be advised to take folic acid supplements (high dose)
  o Oral/rectal steroids safe to use in pregnancy
  o Avoid immunosuppressive agents such as 6-mercaptopurine; azathioprine (use the latter with caution)
  o Avoid NSAID’s as they may cause inflammations and bleeding in the small intestines.

Question 19

What is hyperemesis gravidarum?

Answer 19

• Very severe NVP
• May begin very early, even before a positive test
• Symptoms peak at 9-13 weeks, improve around 16-24 weeks but may continue throughout the pregnancy
• Weight loss is severe and rapid and dehydration is common
• If not managed appropriately complications can ensue
• Medical treatment is necessary
• Psychological support is beneficial

Question 20

Impacts of HG?

Answer 20

• Physical complications and risks for mum
  o Hypokaleamia and hypocalcaemia
  o Wernicke’s encephalopathy: brain condition
  o Re-feeding syndrome
  o Death
  o Also: Oesophageal damage, ongoing gastrointestinal problems, burst blood vessels, torn stomach muscles, VTE, pressure sores.
• Risks and complications for baby if poorly managed:
• Termination! IUGR, miscarriage, placental abruption, pre-term labour, intrauterine death. Malnutrition in early pregnancy linked with cardiometabolic disorders behavioural and development problems in childhood.
• Psychological complications
  o Peri-natal depression, PTSD, flashbacks, PND
  o Caused by hyperemesis not a cause of it!!
  o Loss of hope of “normal pregnancy”

- Social impact
o Unable to work and maintain household, loss of identity 
o Isolation
o Financial hardship
o Relationship difficulties
o Concerns over care of other children

Question 21

HG is more likely in?

Answer 21

• Young primips
• Non-smokers
• Non-caucasian
• Multiple pregnancy
• Previous history of HG (risk of admission 29 times higher)
• Current or previous molar pregnancy
• Pre-existing diabetes
• Depression or psychiatric illness
• Hyperthyroid disorder
• Peptic ulceration or other gastrointestinal disorders
• Asthma

Question 22

Aetiology of HG

Answer 22

• Not entirely known, likely multifactorial
• Genetic factor – 86% recurrence in subsequent pregnancy vs 0.7% for non-sufferers. 30-35% risk if mother/sister suffered.
• Reduced risk of recurrence with a different partner – difficult to explain without genetics of foetus being involved!
• Various theories around thyroid function, H.Pylori- bug in the stomach, oestrogen and hCG, Prostaglandin E2: None stand up in robust studies
• New theories emerging around the hCG molecule, Growth and Differentiation Factor 15 (GDF15) and intracellular calcium release channel (RYR2) [1,2]

Question 23

Clinical indicators of HG

Answer 23

• Constant nausea and/or vomiting >5 x a day for >5 days
  o or more severe but for less time? >10 times a day for 2-3 days is surely HG?
  o Nausea so constant and severe that she can’t eat/drink for 3+ days?
• Weight loss >5% pre-pregnancy weight
• Dehydration and malnutrition
• Metabolic disturbances
• Psychosocial morbidity, QoL affected – often the nausea is more impacting
• Ptyalism – excessive salivation
• Heightened/warped sense of smell
• Acid reflux (in addition to vomiting)
• Oesophagitis
• Lethargy and fatigue (symptom of hypocalcaemia)
• Headaches
• Sensitivity to sensory stimulation, lights/noise/movement etc
• Depression, effect not cause!
• Constipation
• Hair loss
• Loss of bladder control

Question 24

Diagnosing HG

Answer 24

-	Differential diagnosis
o Gastrointestinal
o Neurological
o UTI
o ENT disease
o Drugs
o Metabolic and endocrine disorders
o Psychological disorders ie. Eating disorders

Assessing symptoms

• History
• Severity of symptoms
• Impact of symptoms, physical/emotional/social/financial, be holistic
• Treatment to date

Question 25

Treatments of HG

Answer 25

Principles of treatment

• Rehydrate
• Sort out the electrolytes/vitamins
• Maintain with anti-emetics
• Give realistic goals, it’s about managing rather than curing in the short term
• None of the treatments are miracle cures and some have unpleasant side effects – be honest
• Aim to work as a team with the patient to manage their condition

IV therapy
- Rehydration
o Rapid IV Fluid replacement
o Get 2 litres in them over 4 hours
o ie. 1 litre Hartman’s over 2 hours then 1 litre Normal Saline over 2 hours (with 20mmol potassium)
- Longer regimes never achieve full rehydration and they spiral down on discharge
- Avoid dextrose containing IV Fluids

• Vitamins Electrolytes

o Vitamin B1
 Oral Thimine or IV Pabrinex
 Risk of Wernike’s encephalophathy
 Educate to need for tablet on discharge if vomiting is severe

o Potassium
 10mmol KCL over 1 hour
 Give in second bag of fluid

Question 26

Types of HG

Answer 26

Spectrum within a spectrum

• “Mild HG” managed with cyclizine and perhaps second-line antiemetic, may need a round of rehydration. Symptoms improve significantly during second trimester
• “Moderate HG” managed with ondansetron or steroids. Rehydration required at least once. Symptoms likely to last for most of pregnancy but hopefully improvement in second trimester
• “Severe HG” is unresponsive to antiemetic therapy. Requires regular rehydration, possibly via a PICC line. Symptoms usually last until birth and complications can be ongoing for years. TOP may be necessary.