GI system Flashcards
1
Q
Where does ulcerative colitis affect
A
Mucosal inflammation and ulcers
restricted to colon and rectum
2
Q
Symptoms of UC
A
- bloody diarrhoea or rectal bleeding
- abdominal pain (cramps) and tenesmus)
- systemic features (severe); malaise and fever
3
Q
Symptoms of acute flare up of UC
A
Mouth ulcers
Arthritis
Sore skin
Weight loss
Fatigue
4
Q
What drugs are contraindicated in acute flare up of UC
A
Loperamide
Codeine phosphate
avoid anti-motility drug/antispasmodics: paralytic ileus = increased risk of toxic megacolon
5
Q
What is chrohns disease?
A
Chronic inflammation of the GI tract from mouth to anus
6
Q
What is fistulating Chrons disease (CD)
A
A complication that involves the formation of abnormal connection between two organs or vessels
7
Q
Link between smoking and CD
A
Smoking cessation reduces risk of relapse
8
Q
Drugs used in IBD
A
Aminosalicylates
Corticosteroids
Immunosuppressive
Biological drugs
Antibiotics
Surgery
9
Q
Examples of aminosalicylates
A
Masalazine
Sulfasalazine
10
Q
Examples of corticosteroids
A
Methyl prednisolone
Prednisolone
11
Q
Examples of immunosuppressive
A
Azathioprine
Mercaptopurine
12
Q
Example of biological drugs
A
Infliximab
13
Q
Antibiotics used in IBD
A
Ciclosporin - UC
Metronidazole / ciprofloxacin - CD
14
Q
What type of IBD may require surgery
A
Crohn’s disease
fistulae
15
Q
What pain killer can be given in IBD
what one is avoided
A
Paracetamol
Avoid NSAIDS - risk of bleeding
16
Q
What is giving to patient with UC and constipation?
A
Bulk forming laxative
Avoid all other types of laxative
17
Q
What laxative is beneficial in proximal proctitis
A
Macrogol- containing osmotic laxative
18
Q
What area of the bowel does proctitis affect?
Choice of drug form
A
Rectum
*Suppositories**
19
Q
What area of the bowel does left-sided colitis (distal) affect?
Choice of drug form
A
Descending colon
Enema
20
Q
What area of the bowel does proctosigmoiditis affect?
Choice of drug form
A
Rectum and sigmoid colon
Foam preparation
21
Q
What area of the bowel does extensive colitis (proximal) affect?
Choice of drug form
A
Most of ascending colon
Oral drug
22
Q
What is used in acute mild- moderate UC first line?
A
Pricititis / Proctosigmoiditis
Aminosalicylate (rectal or oral or both)
Alt: Rectal/oral corticosteroids
Extensive colitis / Left-sided colitis
High dose oral aminosalicylate
+rectal aminosalicylate or oral beclometasonse
Alt: oral prednisolone
23
Q
What is used in acute mild- moderate UC second line?
A
- Add oral prednisolone (after 4 weeks with aminosalicylate)
- Add oral tacrolimus (if no response after 2-4 weeks)
24
Q
What is used in acute moderate to severe UC first line?
A
Oral prednisolone
Alt: monoclonal antibodies
25
Treatment of acute sever UC
First line: **IV Corticosteroid** + assess need for surgery
- *Alt: IV Ciclosporin or surgery*
Second line: **IV Ciclosporin + IV Corticosteroids or Surgery**
- *Alt to Ciclosporin: infiximab*
26
Maintenance of remission in UC
Aminosalicylate
- *oral azathioprine/ mercaptopurine* - if 2+ acute flare-ups in 12 months that required systemic corticosteroids
- *Monoclonal antibodies* - continued if effective/tolerated during acute flare up
27
What needs to be monitored in UC
Bone health
28
Treatment of CD (monotherapy)
**Corticosteroid** - prednisolone, methyl prednisolone, IV hydrocortisone
*Alt: budesonide (1st) or aminosalicylate*
29
When to introduce add on treatment for CD
- If 2 or more inflammatory exacerbations in 12 months
- Corticosteroids dose cannot be reduced
30
What are the add on treatments for CD
1st: **Azathioprine / Mercaptopurine**
2nd: Methotrexate
31
What to be monitoring with CD treatment
Neutropenia
32
Maintaining remission in CD
1. **Azathioprine or Mercaptopurine**
2. Methotrexate, if worked previously
*Corticosteroids or budesonide should NOT be used*
33
Remission of CD post surgery
1st: Azathioprine or Mercaptopurine
If had >1 resection or complex/debilitating disease
2nd: Aminosalicylate
34
Side effects of aminosalicylate
- **Blood dyscrasia**
- Nephrotoxicity
- Agranulocytosis
- Renal impairment
- Salicylate hypersensitivity *(itching and hives)*
- **yellow/orange** bodily fluids with **sulfasalazine**
35
Counselling with aminosalicylate
- Avoid bright sunlight/ sun beds and use sun scream (SPF >15)
- Preps with granules should be placed under tongue and washed down without chewing
36
Interaction with mesalazine
Lactulose
*Prevents sufficient release of the active ingredient in E/C or M/R preparations*
37
Counselling with methotrexate
Give with folic acid
**OW on a different day of methotrexate**
Reduce toxicity
38
What can be used to decrease acid stimulation
H2 - antagonists
PPI
39
Examples of H2 - receptor antagonist
Cimetidine
Famotidine
Nizatidine
Ranitidine
40
Difference between UC and CD
**UC** - only in **colon and rectum**
*continuous inflammation*
**CD** - **anywhere from mouth to anus**
41
What is the mechanism of action of aminosalicylates
Decrease inflammation
42
Side effect of sulfasalazine
**Yellow/orange urine**
*Warning: soft contact lenses may be stained*
43
Why is given in a specific formulation
**E/C or M/R**
- so it’s not absorbed in the upper GIT
44
Antibiotics used in IBS
- Metronidazole
- Clarithromycin
- Ciprofloxacin
45
What are the classes of drugs used in IBS
- **Antispasmodic** *(GI spasms)*
- **Antimuscaranics** *(GI spasms)*
- **Laxatives** *(Constipation)*
- **Antimotility** *(Diarrhoea)*
- **Antidepressants** *(Second line for abdominal pain/ discomfort)*
46
Examples of antispasmodics
Alverine
Mebeverine
Peppermint oil
47
Examples of antimuscarincs
Hyoscine butylbromide
Atropine
Duct clover one
Propantheline bromide
48
What do you give to a patient with IBS who is unresponsive to different laxative classes and have had constipation for 12 months
Linoclotide
49
What laxative is not recommended in IBS
Lactulose - causes bloating
50
What is used first choice in IBS with diarrhoea
Loperamide
51
What antidepressants are used in IBS for second line abdominal pain/ discomfort
TCA
SSRI
52
Main symptom of short bowel disorders
**Malabsorption and Malnutrition**
*Deficiency of vitamin A, B12, D, E & K, Essentially fatty acids, Zinc, Selenium, Hypomagnesaemia - supplementation*
53
What drugs are impacted by short bowel syndrome
*Increase dose*
- **Warfarin**
- **Oral contraceptives**
- **Digoxin**
54
What triggers coeliac disease?
**Gluten**
- Wheat
- Barley
- Rye
- Pasta, cakes, cereals, bread
55
Symptoms of coeliac disease
‘**ABCD**’
- Abdominal pain
- Bloating
- Constipation
- Diarrhoea
56
Treatment of coeliac acid
- Supplementation with **calcium, vit D and folic acid**
- DO NOT self medicate with **OTC** supplements
- Treat **osteoporosis & bone disease**
- **Prednisolone** *(initial management while awaiting specialist advice)*
57
Can coeliac disease be treated OTC with supplements?
No
Refer for specialist advice with supplements
58
What causes Diverticulitis
Poor fibre diet
59
Difference between Diverticulosis and Diverticular disease/ diverticulitis
**Diverticulosis** - No symptoms
**Diverticulitis/ diverticular disease** - symptoms/ severe symptoms
60
What age is at high risk of diverticulosis
40+
61
What symptom does diverticular disease **NOT** cause?
Inflammation or infection
62
Main Symptoms of diverticulitis
- **Constant lower abdominal pain**
- Sudden **inflammation and infection**
63
Do you give antibiotics in diverticular disease
No
64
What type of pain killers are used in diverticulitis
Paracetamol
**NOT NSAIDS OR OPIOIDS**
65
Risk factors of IBD
- Stress
- Smoking
- Infection
- Air pollution
- Drugs
66
What is used in pt with Crohn’s disease experiencing diarrhoea
**Loperamide / Codeine phosphate**
Colestyramine
67
What is associated with long term steroid therapy
Increased risk of **shingles**
(*red blotchy rash, painful to touch*)
68
What is used to treat procitis
First line: **Topical aminosalicylate**
If remission not achieved within 4 weeks, **add on oral aminosalicylate**
If response remains inadequate **add topical or oral corticosteroid for 4-8 weeks**
69
Red flag symptoms of constipation
- New onset 50+
- Anaemia
- Abdominal pain
- Unexplained weight loss
- Blood in stool (could be cancer or GI bleed)
70
What are the different classes of laxatives
- Stimulants
- Opioid receptors antagonist
- Osmotic
- Bulk forming
- Stool softener
- Chloride-channel agonist
- Selective 5HT-4 agonist
71
What to use in short duration constipation
Bulk forming
Eg. Ispagula husk
72
What to use if stool remains hard after using bulk forming laxative
Switch to or add **osmotic laxative**
73
If stool is soft but difficult to pass or the person complains of inadequate emptying
Add a stimulant laxative
74
Side effect of laxative abuse
Hypokalaemia
75
Examples of bulk forming laxatives
- Isphagula husk
- Methylcellulose *(can be used in both constipation and diarrhoea)*
- Sterculia (fybogel)
76
bulk forming laxative onset of action
72 hours
Not ideal for patients who haven’t visited the toilet in a few days (consider stimulant)
77
When are bulk forming laxatives contraindicated
- faecal impaction
- intestinal obstruction
- reduced gut motility
78
Risk associated with bulk forming laxatives
Hypersensitivity
Risk of obstruction of GI - don’t take before going to bed
79
Examples of stimulant laxatives
- Bisacadoyl
- Docusate sodium
- Sodium picosulfate
- Senna
- Glycerol
- Co-danthromer / co-danthrusate
80
Which stimulant laxative is only used in palliative care
Co-danthromer
Co- danthrusate
*Colours urine red*
81
When to avoid stimulant laxative
Intestinal obstruction
- causes abdominal cramps
82
stimulant laxative onset of action
8-12 hours
*bedtime dose recommended*
Suppositories quicker - 20-60 minutes
83
Side effects of stimulant laxative
- abdominal cramps
- rash
- risk of abuse
- prolonged use; lazy bowel syndrome
84
Mechanism of glycerol suppositories
Lubricant
Rectal stimulants
85
Onset of action of Docusate sodium
1 to 2 days
Rectal: 20 minutes
**caution in pregnancy and breast feeding**
86
Properties of senna
- suitable in pregnancy and breastfeeding
- suitable for children above 1 month
- discolouration of urine
87
Counselling with bisacodyl
- suitable in pregnancy
- do not take indigestion remedies 2 hours before and after
88
Stimulant laxatives OTC
- Smaller packs available OTC for short-term ocassional constipation in **ADULTS ONLY** >12 years
- **20 standard tabs, 10 max strength and 100ml solutions**
- for children 12-17 years; supervision of a pharmacist
- **Bisacodyl** (5mg) may be used in children but higher doses not licensed
89
Examples of osmotic laxatives
- Lactulose
- Macrogol
- Magnesium hydroxide
- Sodium acid phosphate with sodium phosphate enema
90
Onset of action of osmotic laxatives
48-72 hours
91
Which acts faster between Macrogol and Lactulose
Macrogol
*Lactulose may take up to 2 days for max effect - not suitable for immediate relief*
92
Which osmotic laxatives are used to clear vowels quickly
- magnesium hydroxide
- sodium acid phosphate with sodium phosphate enema
93
Which laxative can be used in hepatic encephalopathy
Lactulose
*Not absorbed by GI tract and produces osmotic diarrhoea of low pH which discourages the proliferation of ammonia producing organisms*
94
Lactulose dose by mouth
• **1 - 11 months** : **2.5mL** BD
• **1 - 4 years** : **2.5-10mL** BD
• **5-17 years** : **5-20mL** BD
• **Adult** : initially **15mL** BD, adjusted according to response
95
Lactulose dose in hepatic encephalopathy
**30-50mL** TDS
96
MHRA warning with Macrogol
Potential interactive effect when mixed with starch based thickeners leading to increased risk of aspiration
Careful in elderly
