GI Tract

Question 1

What is a mouth ulcer? + what could the patient recall?

Answer 1

• Usually a single, irregularly-shaped ulcer
• Patient can often recall the cause
• Burn – hot/cold/chemical
• Biting lining of mouth
• Sharp surface of tooth/denture

Question 2

What is the most common type of mouth ulcer?

Answer 2

Recurrent aphthous stomatitis

Question 3

What are the types of aphthous stomatitis?

Answer 3

*aphthous minor (80% of cases)
*aphthous major (10% of cases)
*herpetiform (10% of cases)

Question 4

Summarise what are the symptoms of aphthous minor

Answer 4

• Often in groups of up to five
• Small ulcers (<1cm)
• “uncomfortable”
• Heal within 10-14 days

Question 5

Summarise what are the symptoms of aphthous major

Answer 5

Usually 1-3 ulcers
* Larger than 1cm
* Painful and may affect eating
* Can take weeks to heal

Question 6

Summarise what are the symptoms of aphthous herpetiform

Answer 6

• Groups of 10-50 small ulcers
• Very painful
• Heal within 10-14 days

Question 7

What could be the causes to mouth ulcers?

Answer 7

Iron deficiency anaemia
* Vegetarian/vegan diet often implicated
* Heavy menstrual loss
* Hypersensitivity
* Preservatives in food (benzoic acid/benzoates)
* Foods (chocolate, tomatoes)
* Sodium lauryl sulfate
* Psychological stress

Question 8

What are the treatment options for ulcers?

Answer 8

*saline solution
*antiseptic (chlorhexidine)
*anti-inflammatory benzydamine
*steroid hydrocortisone

Question 9

How is saline used to treat mouth ulcers?

Answer 9

• Half a teaspoon of salt in a glass of warm water
• Rinse frequently until ulcers subside
• Any age

Question 10

How is antiseptic chlorhexidine used to treat mouth ulcers?

Answer 10

• Rinse (or spray) twice a day
• Not within 30 minutes of toothpaste
• Can cause temporary yellow staining of teeth
• Can be used OTC from age 12

Question 11

How is benztdamine used to treat mouth ulcers?

Answer 11

Use every 1.5-3 hours
* Can be used OTC from age 6

Question 12

How is hydrocortisone used to treat mouth ulcers?

Answer 12

• One tablet dissolved on ulcer four times a day
• Can be used OTC from age12

Question 13

When should you refer a patient suffering with a mouth ulcer?

Answer 13

• Lasts longer than 3 weeks
• Keeps coming back
• Painless and persistent
• Grows bigger than usual
• At back of throat
• Bleeds or gets red and painful

Question 14

What is dyspepsia?

Answer 14

A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks

Question 15

What are the symptoms to dyspepsia?

Answer 15

• Severity varies from patient to patient (most: mild + intermittent)
• Upper abdominal pain or discomfort
• Burning sensation starting in stomach, passing upwards to behind the breastbone
• Gastric acid reflux
• Nausea or vomiting

Question 16

What are the common causes to dyspepsia?

Answer 16

• Gastro-oesophageal reflux disease (GORD)
• Peptic ulcer disease (gastric or duodenal ulcers)
• Functional dyspepsia
• Epigastric Pain Syndrome
• Post-prandial distress syndrome (fullness and early satiety)
• Barrett’s oesophagus
• A premalignant condition
• Upper GI malignancy

Question 17

What is GORD? + causes?

Answer 17

Gastric-oesophageal reflux disease (GORD)
1. Transient relaxation of lower oesophageal sphincter
2. Increased intra-gastric pressure
3. Delayed gastric emptying
4. Impaired oesophageal clearance of acid

Question 18

What are the trigger factors to GORD?

Answer 18

• Smoking
• Alcohol
• Coffee
• Chocolate
• Fatty foods
• Being overweight
• Stress
• Medicines (calcium channel blockers, nitrates, NSAIDs)
• Tight clothing
• Pregnancy

Question 19

What are the causes to peptic ulcers (stomach)?PUD

Answer 19

• Helicobacter pylori infection
• Medication, mainly NSAIDs (others can cause them)
• Zollinger-Ellison syndrome (rare condition causing high acid secretion)

Question 20

How can you confirm and treat a peptic ulcer?

Answer 20

• Can only confirm ulcers with endoscopy
• H. pylori infection managed with eradication therapy (2 antibiotics and a PPI)
• Therefore, wouldn’t be managed OTC
• However, patients frequently present asking for symptomatic relie

Question 21

What are the treatment options for dyspepsia?

Answer 21

• Non-pharmacological
• Antacids
• Alginates
• H2 receptor antagonists (block them)
• Proton pump inhibitors

Question 22

Dyspepsia - non pharmacological treatment options?

Answer 22

• Lose weight if overweight
• Eating small, frequent meals rather than large meals
• Eat several hours before bedtime
• Cut down on tea/coffee/cola/alcohol
• Avoid triggers, e.g. rich/spicy/fatty foods
• If symptoms worse when lying down, raise head of bed (do not prop
  up head with pillows)
• Avoid tight waistbands and belts, or tight clothing
• Stop smoking

Question 23

What is an antacid + alginate?

Answer 23

antacid = compounds that neutralise stomach acid
alginate = form a raft on top of stomach contents, creating a physical barrier to prevent reflux

Question 24

What are some examples of antacids + alginates?

Answer 24

antacid: pepto-bismol, Rennie
alginate: gaviscon advance
dual product: gaviscon dual action, peptac

Question 25

What do PPIs do? + example + side effects?

Answer 25

* PPIs block proton pumps in stomach wall to prevent gastric acid production * Takes 1-4 days to work fully, so may need to cover with antacids until it kicks in * Esomeprazole: * Common s/e: GI disturbances, headache, abdo pain * Can increase risk of GI infections such as Campylobacte

Question 26

When to refer a patient with dyspepsia?

Answer 26

* 55 years or over, especially with new onset * Dyspepsia hasn’t responded to treatment * Features including bleeding, dysphagia, recurrent vomiting or unintentional weight loss

Question 27

What are the associated symptoms with nausea and vomiting? + medication that can be used?

Answer 27

?diarrhoea – may be gastroenteritis, question about food intake, could be rotavirus in children * ?blood in vomit – differentiate fresh blood from that of gastric/duodenal origin * ?faecal smell – GI tract obstruction * Medication: opioids, NSAIDs/aspirin, antibiotics, oestrogens, steroids, digoxin, lithium, etc

Question 28

What are the symptoms of constipation?

Answer 28

* abdominal discomfort * cramping * bloating * nausea * straining

Question 29

When to refer someone with constipation?

Answer 29

* unexplained weight loss * rectal bleeding * family history of colon cancer or inflammatory bowel disease * signs of obstruction * co-existing diarrhoea * long-term laxative use * failed OTC > 1 week

Question 30

What medications can cause constipation?

Answer 30

Opioid analgesics * Antacids – aluminium * Antimuscarinics (anticholinergics) * Anti-epileptics * Anti-depressants * Anti-histamines * Anti-psychotics * Parkinson’s medication * Calcium-channel blockers * Calcium supplements * Diuretics * Iron * Laxatives

Question 31

What are the pharmacological + non pharmalogical treatment options for constipation?

Answer 31

non pharm: *increase fibre intake *increase fluid intake *increase exercise pharm: bulk forming, ispaghula + methylcellulose osmotic e.g lactulose, macrogols faecal softener stimulant e.g glycerin, Senna, bisacodyl

Question 32

Diarrhoea - causes + types?

Answer 32

90% of acute cases associated with viral or bacterial infection * norovirus and campylobacter most common in the community * may be parasites such as giardiasis following travel to certain areas * Acute: symptoms less than 14 days * Persistent: symptoms more than 14 days * Chronic: symptoms more than 4 weeks

Question 33

What are the symptoms to diarrhoea?

Answer 33

* Three or more lose, watery stools in 24 hours * Faecal urgency * Abdominal cramps * Abdominal pain * +/- nausea and vomiting

Question 34

What to treat diarrhoea with? + when to refer?

Answer 34

*oral rehydration therapy - dioralyte *loperamide *kaolin +/- morphine -refer when- * Duration longer than: * 1 day in < 1year old * 2 days in < 3 year old or in older adults * 3 days in older children and adults * Pregnancy * Severe vomiting * Fever * Blood or mucous in stools * Suspected reaction to prescribed medicine * Suspected outbreak of “food poisoning” * Recent foreign travel * Persistent diarrhoea following antibiotic treatmen

Question 35

What are haemorrhoids? + risk factors?

Answer 35

* Haemorrhoids are clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal * Constipation and poor diet * Increased incidence between ages 45-65yrs * Pregnancy * Heavy lifting * Chronic cough * Certain toilet behaviours, such as straining or spending more time on a seated toilet than on a squat toilet

Question 36

What are the two types of haemorrhoids + their symptoms?

Answer 36

* External haemorrhoids * lumps and bumps around the anus * itchy (irritation from faecal matter not being fully removed by wiping) * not usually painful unless severely swollen * Internal haemorrhoids * discomfort/pain * feeling of fullness in rectum * when prolapsed, itchy and irritating * not usually painful unless prolapsed and strangulated * Both may bleed (especially after passing stools)

Question 37

What are the treatment options for haemorrhoids?

Answer 37

* Usually self-limiting and heal within a week or so * Life-style measure in relation to diet and fluid intake * Analgesia as needed * Topical preparation may contain astringents, local anaesthetics, corticosteroids or a combination * Can be internal (creams, suppositories) or external (creams, gels, ointments)

Question 38

When to refer a haemorrhoids patient to the gp?

Answer 38

*patients can feel a mass *systemic symptoms *extreme pain on defecation *weight loss *persistent change in bowel habit *faecal incontinence *over 40 years old