GI System Flashcards by Vera Arabi

What is coeliac disease, including symptoms and treatment?

It is a chronic inflammatory disease involving the small intestine due to an adverse reaction to gluten.

Symptoms: bloating, abdominal pain, diarrhoea.

Treatment: strict gluten-free diet

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What is diverculitis?

Small pouches developing in the lining of the stomach.

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What is the treatment for diverticulitis?

High fibre diet if constipated
Antibiotics if signs of infection or immunocompromised
Anti-spasmodics e.g. mebeverine, propantheline, peppermint oil, hyoscine

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What 2 conditions ar einvolved in inflammatory bowel disease?

Crohns disease
Ulcerative colitis

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What is ulcerative colitis?

Mucosal inflammation/ulcers present in the descending colon and near the rectum

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Which drugs are contraindicated in ulcerative colitis, and what can they cause?

Anti-motility drugs, anti-spasmodics, loperamide and codeine
These can cause toxic megacolon and should be AVOIDED

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What is proctitis and which form of drug is better used to treat it?

It is inflammation of the rectum, and suppositories are best used.

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What is the 1s, 2nd and 3rd line treatment for acute mild-moderate ulcerative colitis?

1st: Topical aminosalicylate for 4 weeks.
2nd line: Add oral aminosalicylate if no benefit
3rd line: high dose aminosalicylate + topical steroid

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What is the 1st and 2nd line treatment for moderate-severe ulcerative colitis?

1st: Oral steroid
2nd: monoclonal antibodies

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What is the initial treatment in acute severe ulcerative colitis?

IV steroid (hydrocortisone/methylprednisolone)
Alternatively can use IV ciclosporin but this is unlicensed

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How is remission maintained in UC?

Rectal aminosalicylate alone, or with oral form

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Which 2 drugs are unlicensed for use in a patient with 2+ acute flare ups of UC in 12 months?

Azathioprine and mercaptopurine

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What is crohns disease?

Flare up involving lesions all throughout the GI tract

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What complications can arise from crohns disease?

Fistulas
Malnutrition, anaemia
Colorectal cancer, small bowel cancers
Growth failure
Arthritis
Osteoporosis

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Which 2 drugs can help with diarrhoea in crohns (not ulcerative colitis)?

Codeine, or loperamide

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What is fistulating crohns disease?

Complication involving formation of fistulas between the intestine and adjacent structures

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What is the treatment for a first time acute flare up in crohns disease?

IV steroid (hydrocortisone, methylprednisolone, prednisolone)

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What are the alternative treatment options for an acute flare up of crohns disease/first presentation?

Budesonide
Aminosalicylate
They also have fewer side effects than steroids

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What is the add on treatment if a patient has had more than 1 flare up in a year?

Azathioprine (unlicensed)
Mercaptopurine (unlicensed)
Methotrexate

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Which drugs are given to maintain remission in crohns disease?

Azathioprine, or mercaptopurine (not licensed)

After surgery: As above, or aminosalicylate

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What are some examples of aminosalicylates?

Mesalazine (Pentasa, Asacol, Octasa, Salofalk)
Sulfasalazine (Salazopyrin)

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Why should patients report any signs of unexpected bleeding/bruising/sore throat/fever with aminosalicylates?

Because they can cause blood disorders and blood dyscrasias

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When do blood disorders usually start with aminosalicylates?

Within 3-6 months of treatment

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What colour can sulfasalazine cause bodily fluids to change into (including soft contact lenses)?

Yellow-orange

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How often should renal function be monitored with aminosalicylates?

Before starting treatment, at 3 months, then annually thereafter

Which osmotic laxative interacts with mesalazine, and why?

Lactulose because it lowers the pH of the stool in the intestines which can effect the release of the active ingredient from E/R preps

What is irritable bowel syndrome and who is most affected?

A common, chronic relapsing condition affecting 20-30year olds, commonly in women.

What can aggravate IBS?

Stress Depression Lack of fibres Lack of sleep Anxiety

Which types of fibre are recommended in IBS related constipation?

Soluble fibres, e.g. isphagula husk, oats, bran

Which type of sugar should be avoided in diarrhoea related IBS?

Sorbitol

What is the usual dose of mebeverine?

135-150mg TDS before 20min meals

Why isnt lactulose recommended in IBS?

Because it can cause bloating

What are some examples of antispasmodics used in IBS?

Mebeverine Peppermint oil

What are examples of some antimuscurinics used in IBS?

Hyoscine butylbromide Atropine Propantheline Dicycloverine

When is linaclotide used in IBS?

When different laxatives have not worked and constipation has been present for 12 months

Which class of drug is unlicensed for use in abdominal pain/discomfort in IBS?

TCAs

Why are ER/MR preparations not suitable for patients with short bowel syndrome? What is suitable instead?

Because no sufficient drug release would be present. Uncoated, soluble tablets are preferred.

When do you refer a patient who presents with constipation?

New onset in >50 years Anaemic Abdominal pain present Unexplained weight loss Blood present in stool

How do stimulant laxatives work?

They stimulate the muscles lining the gut, aiding in defecation

What are some examples of stimulants?

Senna Bisacodyl Glycerol suppositories Co-danthramer Sodium picosulfate

When are stimulants taken during the day?

Usually at night

How long should stimulants max. be used?

1 week

Which stimulant laxative is only used in terminally ill patients, and why ?

Dantron (co-danthramer), because it is genotoxic and carcinogenic

Which stimulant laxative has the quickest onset of action?

Glycerol suppositories (within 15-20mins)

What are some examples of stool-softners?

Liquid paraffin Docusate (can also be classed as a stimulant)

Why is liquid paraffin not recommended anymore as a laxative?

Because it can cause side effects like anal seepage, malabsorption of fat soluble vitamins, and lipoid pneumonia

How do osmotic laxatives work, and what are some examples of it?

They increase the water content of stools making them easier to pass Can include: lactulose, macragol

Can osmotics be used in pregnancy?

Yes

What is the onset of action for osmotics?

2-3 days

What is the mechanism of action of bulk-forming laxatives?

They work by increasing faecal mass to stimulate peristalsis

Can bulk-forming laxatives be used in pregnancy?

Yes

What is the duration of action of bulk-forming laxatives?

2-3 days for full effect

Why should patients taking bulk-forming laxatives be told to drink plenty of water?

To avoid gut obstruction

What are some examples of bulk-forming laxatives?

Isphagula husk (fybogel) Methylcellulose Sterculia

Which laxative is only given to women if >2 laxatives have not worked?

Prucalopride, or lubiprostone

Which laxatives are given for opioid-induced constipation?

Stimulant + osmotic

What is the 1st and 2nd line options for constipation in children?

1st line: osmotics (macragol) 2nd line: add simulant, or faecal softener

What are the 1st and 2nd line laxative options for constipation in pregnancy/breastfeeding?

1st: bulk-forming 2nd line: osmotics REMEMBER TO AVOID STIMULANTS IN PREGNANCY

What are the red flag symptoms involved with diarrhoea?

Unexplained weight loss Rectal bleeding Persistent diarrhoea

What is the 1st line treatment option for diarrhoea?

ORT (dioralyte) Must maintain good hydration with it

What are other treatment options used for diarrhoea?

Loperamide Codeine

How does loperamide work?

Binds to opioid receptors in the GIT to prolong duration of intestinal transit

At what age should loperamide not be used?

<12 years old

What is the max. number of loperamide capsules that can be taken in a day?

8 capsules

What complications can arise if someone abuses/overdoses on loperamide?

QT prolongation Cardiac arrest

Which drug is given to reverse opioid induced toxicity?

Naloxone

Which conditions can cause dyspepsia?

Indigestion GORD Gastritis Gastric/duodenal ulcers

How do antacids and alginates work?

Antacids: neutralise pH of acid in stomach Alginates: form a viscous gel on top of stomach to prevent reflux

Which antacids have low sodium preparations?

Mucogel (co-magaldrox) Altacite Plus

What are some examples of drugs that can interact with antacids, and hence should be taken 2h apart?

Tetracylines Quinolones Bisphosphonates Levothyroxine Rifampicin Gabapentin

How do PPIs work?

They block the hydrogen-potassium ATPase pump of the gastric parietal cell

Which PPI is the safest in pregnancy?

Omeprazole

What are some long-term complications that can arise with PPIs?

Increased risk of osteoporosis Increased risk of C.difficile Vitamin B12 deficiency Rare cases of lupus

What can occur if PPIs have been used for >1 year?

Hypomagnasaemia

Which 2 drugs must always be avoided with omeprazole?

Clopidogrel and methotrexate

What are some examples of H2RA antagonists?

Cimetidine Famotidine Ranitidine

Which H2RA antagonist is safest in pregnancy?

Ranitidine

What are some common causes of peptic ulcer disease?

NSAIDs SSRIs Steroids H.Pylori Poor lifestyle

What are the different diagnostic tests used to diagnose H.Pylori?

Urea 13c breath test Stool helicobacter antigen test (SAT) laboratory based serology

What is the treatment for H.pylori?

ALWAYS TRIPLE THERAPY PAC, PAM, OR PMC 1. Amoxicillin 1g BD 7/7 2. Clarithromycin 500mg BD 7/7 3. Lansoprazole 30mg BD 7/7 4. Metronidazole 400mg BD 7/7

How can NSAID-induced ulcers be treated?

Withdraw NSAID, or gradually lower dose Switch to COX-2 inhibitor Add PPI/H2RA antagonist/misoprostol

What is the treatment for confirmed GORD?

1. Antacids/alginates 2. PPI for 4-6 weeks, or H2RA antagonist

When should the urea 13C breath test NOT be done for H.pylori?

Within 2 weeks of starting PPI, or 4 weeks within antibacterial treatment This can lead to a false negative

What are some examples of antimuscurinic side effects?

Dry mouth Constipation Blurred vision Tachycardia Urinary retention Angular-closure glaucoma Confusion in elderly

Are antimuscurinics used in urinary retention or incontinence?

They are used in urinary incontinence

Why should peppermint oil capsules be swallowed whole?

To avoid side effects e.g. local irritation of mouth/oesophagus

What is cholestasis?

Impaired or disrupted bile formation/flow

What are the symptoms of liver disorders?

Fatigue Dark urine Pale stools Itchy skin Signs of fat-soluble decifiency

What is the treatment of cholestasis?

Colestyramine for itchy skin Ursodeoxycholic acid used as alternative Rifampicin (unlicensed)

Which biomarker is not specific to the liver, but can also indicate cholesasis/tumour in the liver?

ALP

What can cause high GGT levels in the liver?

Alcohol Enzyme inducing drugs

What can high AST/ALT levels indicate?

Acute liver damage

What is ascites and how is it treated?

It is high sodium/water retention and hepatic portal hypertension. Treatment: b-blockers, spironolactone, furosemide, lower sodium/water intake

How is hepatic encephalopathy treated?

Lactulose + neomycin 4g OD

What is given to correct any vitamin B/C deficiency?

Pabrinex

What should a patients BMI be to consider giving orlistat?

>30kg/m squared, or >28kg/m squared + risk factors

When should orlistat be discontinued?

If patient has not lost >5% of body weight in 12 weeks

What are the fat-soluble vitamins which orlistat can deplete?

A, D, E and K

Which GLP-1 agonists are also used for aid in weight loss?

Semaglutide (victoza) Liraglutide (ozempic, wegovy)

What are anal fissures?

A tear or ulcer in the lining of the anal canal, leading to bright red blood in stool

What is the treatment for acute anal fissures?

Bulk-forming or osmotic laxatives Topical use of lidocaine Analgesics

What is given for chronic anal fissures?

GTN rectal ointment (unlicensed)

What are haemorrhoids?

Swelling of anal mucosa found inside or outside of anus which can be itchy and painful

What is the treatment of haemorrhoids?

As anal fissures, PLUS (max. 7 days): Xyloproct: lidocaine + hydrocortisone Proctosedyl: cinchocaine + hydrocortisone

Which enzymes are included in pancreatin?

Lipase Amylase Protease

How are pancreatin capsules (creon) taken?

With meals/snacks Granules can be mixed with slightly acidic liquid or food (e.g. apple juice)