GI OTC Flashcards
What are red flags for chest symptoms?
- Chest pain
- Shortness of breath
- Wheezing
- Swollen ankles
- Blood in sputum
- Palpitations
- Persistent cough
- Whooping cough
- Croup
- Sputum mucoid, coloured??
What are red flags for your gut?
- Difficulty swallowing
- Blood in vomit
- Bloody diarrhoea
- Vomiting with constipation
- Weight loss
- Sustained alteration of
bowel habit
What are red flags for your eye?
- Painful red eye
- Loss of vision
- Double vision
What are red flags for your ear?
- Pain
- Discharge
- Deafness
- Irritation
- Tinnitus
- Vertigo
what are genitourinary red flags?
- Difficulty in passing urine
- Blood in urine
- Abdominal/loin/back pain with cystitis
- Urethral discharge
- Vaginal discharge
- Vaginal bleeding in pregnancy
what are other general red flag symptoms?
- Neck stiffness/ rigidity with temperature
- Vomiting (persistent)
what things do you consider when selling someone a product OTC?
- Interactions= with prescribed, non prescribed
and herbal medications - Contraindications= with conditions already
present - Age of patient!!!!
- License restrictions
- Legal issues
- Confidentiality
what questions would you ask around abdominal pain?
– Where is the pain?
– When did it start?
– Is it constant or intermittent?
– Has it moved and/or spread?
– Have you had it before?
– Is the area tender?
– Have you taken anything which helps?
when would you refer abdominal pain?
– continuous severe pain lasting more than 1 hour
– mild/moderate lasting on/off for 7 days
– swelling – associated with hernias
– Over 45ys v 55yrs and suffering persistent dyspepsia (NICE)
– recent unexplained weight loss
– vomiting/constipation/diarrhoea + persistent abdominal pain
– blood in vomit or stools (red or coffee grounds)
– abdominal pain + chronic back pain
– babies – projectile vomiting, constipation, diarrhoea – Gastro-enteritis
what medications could cause abdominal pain?
– gastric pain – NSAID’s,
– constipation – opioids, tricyclic
antidepressants, iron
– oesophageal ulceration – potassium
chloride, alendronic acid, doxycycline
what is the cause of oral thrush? where does it exist?
Candida infection
Exists normally in the mouth, GIT and vagina.
what are some factors which can cause an increase in the number of organisms for oral thrush?
Antibiotic therapy
Immunocompromised.
Diabetes.
Ill-fitting dentures.
Pregnancy.
Inhaled corticosteroids.
what are the symptoms of oral thrush?
- White raised patches on oral mucosa
- Tendency to bleed
- Can be painful
– baby may be refusing feeds
– sometimes associated with nappy rash
what is the treatment for oral thrush?
miconazole 20mg/g- daktarin oral gel
what advice would you give when using daktarin?
– treatment of choice from 4 months
– Dose is age related
* Maintain good oral hygiene
* Apply after food
* Continue treatment for 7 days after symptoms
have gone (SmPC advice)
* People with dentures
* Inhaler technique
* Application to babies
what is miconazole? what is it contraindicated with?
it is an enzyme inhibitor
c/i with warfarin, sulphonylureas, phenytoin
when would you refer someone with oral thrush?
when patient is pregnant/ breast feeding
what can cause mouth ulcers?
- Sometimes unknown
- Deficiency? Vit B, Folic Acid?
- Stress?
- Physical illness….Crohn’s, IBD
- Nutrition
- Trauma
- Carcinoma
what are the symptoms of mouth ulcers?
- Shallow yellow/white ulcers on tongue, cheek
and lip mucosa - Painful, can look swollen
- Single or in clusters
- Can be recurrent
- Relatively common complaint
how would you treat mouth ulcers?
- Topical local anaesthetics/analgesics eg bonjela
or/and
Antiseptic mouth washes
e.g Chlorhexidine (Corsodyl Mouthwash)
what advice would you give surrounding bonjela treatment?
– limited use
– short duration of action
– should not take before a meal
what is the benefits of antiseptic mouth washes for mouth ulcers?
- reduces incidence of secondary infection
- accelerates healing process
how can you use difflam oral rince- benzydamide HCl to treat mouth ulcers?
Can use every 1.5 to 3 hrs prn, max 7 days.
* Rinse not to be used on children under 13 yrs
what tablets are available to treat mouth ulcers? how are they used?
Hydrocortisone 2.5 mg Muco-Adhesive Buccal
Tablets
Over 12 years - keep in the mouth and allow
to dissolve slowly in close proximity to the
ulcers QDS
when should you refer a patient with mouth ulcers?
- Recurrent ulcers
- If ulcer more than 3 wks old
- If patient is:
– pregnant, breast feeding, diabetic, or ulcers due
infection – refer
what would be symptoms of oral cancer?
· A white patch and/or red patch on the gums,
tongue, or lining of the mouth
· A small sore that looks like a common mouth
ulcer that fails to heal
· A lump or mass that can be felt on the lip or in the mouth or throat
what is other terms used to describe dyspepsia?
Indigestion, heartburn, trapped wind
what are some of the causes of dyspepsia?
Hurried meals
* Overindulgence (food and drink)
* Spicy food
* Smoking
* Overweight
* Pregnancy
* Medication (NSAID’s, digoxin, iron)
* Heart failure
* H. pylori
what are the symptoms of dyspepsia?
- Epigastric discomfort shortly after
eating/drinking - Feeling of fullness
- Heartburn
- Trapped wind
- Nausea/vomiting
what are the antacids that treat indigestion?
– Magnesium salts (Milk of Magnesia)
* can cause diarrhoea
– Aluminium salts (now only in combination products)
* can cause constipation
– Bismuth salts (Pepto-Bismol)
* avoid if aspirin sensitive
* avoid if pregnant
* Not suitable under 16 years
– Combination preparations
* Kolanticon Gel
* Co-magaldrox
what is activated simeticone?
it is an antifoaming agent used to treat indigestion
it reduces surface tension of gas bubbles
ie wind settlers
how do alginates work?
useful to treat acid reflux
make a raft
usually in combination with antacids
eg gaviscon
what interactions do you have to be cautious of when using antacids?
– digoxin
– enteric coated tablets
– Lithium…serum levels reduced by Sodium Bicarb
– tetracycline
– warfarin
– Iron
– Alendronic acid
what advice should you give to someone whos on an interacting medication with antacids?
Avoid concomitant administration 2-4 hours either
side of dose *Note SmPC’s differ
how are h2 receptor antagonists useful in indigestion treatment?
– OTC license for short term symptomatic relief of
excess acid, dyspepsia and heartburn
who can use h2 receptor antagonists?
adults and children over 16
not for use in pregnancy
not for long term use- refer
when would PPIs otc be appropiate for indigestion treatment?
for recurrent heartburn
when should you refer indigestion with PPI use?
No improvement after 2 weeks - refer
what should be considered when using PPI otc>
use the lowest effective dose
what counselling would you give for indigestion?
- Small regular meals
- Avoid meals late at night
- Avoid highly spiced food
- Avoid bending/stooping
- Don’t wear tight clothing
- Raise the head of the bed
- Take antacids about 1 hour after food
when would you refer for indigestion?
Caution: GP Referral??
- 1st time dyspepsia age 45 yrs +
* Refer: Endoscopy???
– over 55yrs and with alarm signs or persistent
unexplained symptoms
* Persistent vomiting
* loss of appetite
* difficulty swallowing
* feeling of lump in throat
* Gastrointestinal bleeding
what is common triggers of IBS?
- Emotion/stress?
- Food intolerances?
what are the common symptoms of IBS?
– Bloating
– alternating bouts of constipation/diarrhoea
– abdominal pain
* Rectal fullness, incomplete evacuation
* Non-colonic symptoms: nausea, back pain,
urinary frequency/urgency
when can you offer IBS treatment OTC?
Should only offer IBS treatment OTC if the
condition has been previously diagnosed by
a Dr
what should treatment of IBS be based on?
based on the major presenting symptom
what are the usual major symptoms of IBS?
abdominal bloating, diarrhoea or constipation
what is an anti-spasmodic, when and what is it used for?
Intestinal smooth muscle relaxants
– Hyoscine butylbromide (Buscopan IBS)
when is anti-spasmodics c/i?
in paralytic ileus
what antidiarrhoeal can be used to treat IBS?
Loperamide- imodium
bulking agent- may improve constipation and diarrhoea- ispaghula husk
what counselling would you give for IBS?
Food diary – identify triggers
* Ask if taking any other medicines
* Try not to rush meals
* Eat balanced diet and plenty fluids
* Take regular exercise
* Relaxation
when would you refer for IBS?
f symptoms persist for more than 2wks despite
treatment, or if symptoms have changed
– blood in stool
– not had IBS diagnosed by Dr
– fever
– Unexplained weight loss
what are the common causes of constipation?
- Change in lifestyle
- Change in eating habit
- Reduced fluid intake
- Lack of exercise
- Medication
- Depression
- IBS
- Anal fissures
- Haemorrhoids
- Pregnancy
- Refusal to obey urge to pass stool
what are the main symptoms of constipation?
Decrease in frequency of bowel movement.
Hard stools. Straining.
what is the first line treatment for constipation?
alter diet and lifestyle and increase fluids….however patients are likely to want/need a quick fix!!
what are bulk forming laxatives and how do they work?
closest to the natural process
– e.g ispaghula husk
– slow action (24 to 72 hours)
– take with plenty of water
– not to be taken at bedtime
– not for the frail elderly
– can alter absorption of medication
how long do stimulant laxatives take to work?
– stimulate the nerve endings in the bowel
wall
– Anthraquinones: senna (Senokot, Ex-lax)
* act within 8 to 12 hours
what are the restrictions around stimulant laxatives?
GSL – 18 years +
P – 12 years +
what advice should you give for a stimulant laxative about overuse/ inappropiate use?
short term occasional relief only.
how do osmotic laxatives work?
retain fluid in the bowel so stimulating peristalsis and forming a loose stool
more powerful than bulk
eg lactulose/macrogol
longer action up to 72 hours of regular dosing
when should you be cautious for use of osmotic laxatives?
c/i in use in patients lactose/ glucose intolerant
caution for use in diabetes
how quick do glycerol suppositories work?
within 1-2 hours
how do faecal softners help constipation? how long does it take?
– Docusate sodium (Dioctyl caps)
– little if any straining required
– effect within 1 - 3 days
what are some counselling points for constipation?
Improve diet, exercise, increase fluids
* Do not take laxatives regularly
* Do not take bulk laxatives at bedtime
what constipation treatment should be given to someone who is pregnant?
– Osmotic/bulk forming safe
– stimulant laxatives – C/I
can you use stimulant laxatives while breast feeding?
no- c/i
what advice would you give for a baby who is constipated?
breast-fed: may need extra water from a bottle
– bottle-fed: are they making feed with sufficient water?
what advice would you give to an elderly patient who is breast feeding?
– increase fluids–possible dehydration
– bulk laxatives - care in bed bound or inactive
patients
when should you refer constipation?
– illness and unable to work
– children/babies who exhibit ill symptoms
– blood in the stool
– continuous severe pain lasting more than 2 days
– weight loss
– diarrhoea
– self medication not effective after 4-5 days
– fever/night sweats
– nausea/vomiting
what are haemorrhoids?
Piles) - varicose dilatations of the veins in the lower part of the
large intestine and/or anus. Become engorged with blood.
what are some of the causes of haemorrhoids?
- Anal infections – scratching/STI
- Sports eg cycling
- Sitting/standing for long periods
- Pregnancy
- Constipation
- Lesions of pelvic area
- Abuse of laxatives
what are the symptoms of haemorrhoids?
- Itching in perianal area
- Not always but can be painful
- Can be sharp pain on defaecation
- Bright red blood on stool and toilet paper
what are the contribution factors for haemorrhoids?
- Increase in intra-abdominal pressure
- Old age
- Dehydration
- Inadequate fibre in diet
- Medication
what are some of the haemorrhoid treatments made up from?
Astringents Emollients
Local anaesthetics Antiseptics
Antipruritics
Heparinoids
what is an example of a haemorrhoid treatment?
annusol
what is the best way to treat haemorrhoids?
Will produce the best results!!
– use for no more than 7 days
– not to be used in pregnancy/BF
– for adults > 18yrs
– not to be used if broken skin or infection
what counselling would you give for haemorrhoids?
- Hygiene
- Diet
- Try not to scratch area
- Try to avoid straining
- Increase activity
- Laxative (Faecal
softener)
when would you refer haemorrrhoids?
– Duration > 3 wks
– Internal anal pain
– rectal bleeding
– Suspected drug
induced constipation
– recurrent piles
(regular recurrence)
what can cause nausea and vomiting?
- Viral/Bacteria/Bacterial toxins
- Inner ear disorders
- Migraine
- Motion sickness
- Meningitis
- Medication – digoxin, theophylline, nsaids
- Pregnancy
what counselling would you give for nausea and vomiting?
- Ensure patient does not become
dehydrated/Offer electrolyte replacement - Sip water/little and often
- Avoid dairy products + greasy foods for 24 hrs.
- Pregnancy - morning sickness
– frequent small meals
– ginger
– sea-bands - Re-introduce light diet when hungry
when should you refer nausea and vomiting?
– projectile vomiting – babies and adults
– vomit stained with blood
– vomiting with associated weight loss
Reference sources for referral timelines differ…..2
days often a cut off but look at the overall health
/presentation of the patient!!!!!
– babies <12mths and symptoms for 24hrs
– children <3 yrs and elderly and symptoms for
48hrs
– people with diabetes (if persistent)
what are some of the causes of diarrhoea?
- Bacterial/Viral
- Diet changes /overindulgence
- Medication
- Food allergies
- Secondary to a medical condition
– e.g diabetes; hyperthyroidism; IBS - Stress
what advice/ treatment can you give for diarrhoea?
Usually resolves itself!!
* Must maintain fluid intake
– oral rehydration sachets (Dioralyte)
– mix with recommended amount of water
– will keep for 1hr or 24 hrs if in fridge
– sip little and often
how does loperamide work?
it is an anti-diarrhoea
it decreases bowel motility
over 12’s
when is pepto-bismol (bismuth salicylate) contra indicated?
C/I if allergic to aspirin
what advice would you give to babies with diarrhoea?
ensure bottles are properly sterilised and making the feeds properly
– Refer*……text book recommendations….
* if <12mths and symptoms more than 24hrs
* if <3 years and elderly and symptoms more than 48hrs
* Older adults and children more than 72 hours
when would you refer patients with diarrhoea?
Elderly
– if symptoms persist for 48hrs – refer
* Refer if
– chronic diarrhoea
– recurrent diarrhoea
– with fatigue/pain lasting more than 2 days
* Refer all patients if
– weight loss
– blood in stool
– persistent mucous in stool
– symptoms change/worsen
– alternating diarrhoea/constipation
