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4TH YEAR - CPTP > Liver Disease/Dyspepsia/Altered Bowel Habit > Flashcards

Liver Disease/Dyspepsia/Altered Bowel Habit Flashcards

1
Q

What are the main problems in prescribing with liver impairment?

A
  1. Hypoproteinemia
  2. Impaired drug metabolism
  3. Reduced clotting
  4. Hepatic encephalopathy
  5. Fluid overload
  6. Hepatotoxic drugs
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2
Q

What is the resulted of hypoproteinaemia secondary to liver disease?

A

Low albumin is associated with reduced protein binding and increased toxicity of drugs which are highly protein bound
eg. phenytoin, prednisolone

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3
Q

Which drugs undergo the majority of their 1st pass metabolism in the liver? Why is this relevant?

A

Aspirin, Lidocaine, GTN, levodopa, morphine, salbutamol

If the liver is severely damaged, drug metabolism of these will be impaired

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4
Q

Which drugs precipitate hepatic encephatlopathy?

A

Sedatives, opiods, diuretics, drugs that cause constipation

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5
Q

Which drugs cause fluid retention?

A

NSAIDs, steroids

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6
Q

Which drugs are hepatotoxic?

A

Paracetamol, isoniazid, statins, methotrexate, phenytoin, aspirin, alcohol, COCP, abx

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7
Q

What is hepatic drug clearance? What 4 variables does it take into account?

A

The volume of blood perfusing the liver that is cleared of the drug per unit time.
Takes into account
Q - blood flow
F - fraction of free drug
Clint - intrinsic ability of liver to metabolise drug
Extraction ratio - % of drug removed from blood in the liver

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8
Q

What is a high extraction ratio?

A

> 0.7 - high first pass effect, most of the drug removed in the liver

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9
Q

If a patient with known liver disease is given a drug, how should the dose be adjusted?

What is the equation?

A

LOWER DOSE as the liver will no longer be able to metabolise drug so more will go into systemic circulation

New dose = (normal dose x (1-ER))/100

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10
Q

What is the pathophysiology of dyspepsia?

A

INCREASED ACID PRODUCTION (gastrin, pepsin, H. pylori, histamine)
DECREAED MUCOSAL PROTECTION (mucin, Cox, H. yplori)

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11
Q

What is the main cause of dyspepsia?

A

H. pylori infection

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12
Q

What else can cause dyspepsia?

A 
NSAIDS
Steroids (if not given alongside PPI)
Alcohol
Smoking
Stress
Hypersecretory states (Zollinger-Ellison)
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13
Q

How should an <55yo with dyspepsia be investigated?

A

Test for H.pylori with faecal antigen, C13 urea breath test

Prescribe 4 wk PPI in the mean time

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14
Q

How should an >55yo with dyspepsia be investigated?

A 
Urgent endoscopy (DONT PRESCRIBE PPI!)
and CLO test by biopsy
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15
Q

How should ulcer secondary to H.pylori infection be treated?

A

Triple therapy for 1/2 weeks

PPI + amoxicilllin + clarithromycin/metronidazole

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16
Q

Following triple therapy to eradicate h.pylori, how can peptic ulcer disease be further managed?

A

Antacids (aluminium, magnesium)
H2 receptor antagonist (cimetidine) and PPI for 8 weeks
Stop NSAID use

If gastric ulcer, repeat endoscopy at 8 weeks

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17
Q

In which cases is surgery indicated for PUD?

A

Failed management of upper GI bleed

Complications of PUD

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18
Q

How does PPI work?

A

Irreversible inhibition of H/K ATPase to stop H+ secretion from parietal cells

19
Q

How do H2RAs work?

A

Block action of histamine on parietal cells

20
Q

How do antacids work?

A

Raise stomach pH, bind to an inactivate pepsin

21
Q

What are the symptoms of upper GI bleed?

A

Malaena - sticky black stools
N&V
Upper abdo pain
Coffee ground vomit

22
Q

What is the Blatchford score for?

A

Evaluation of need for intervention after UGI bleed

Score > 0 indicates need for transfusion, endoscopy, surgery

23
Q

What is the Rockall score for? What factors does it take into account?

A

Measures risk of mortality and re-bleed following an endoscopy

Looks at age, shock, comorbidities, endoscopic signs, diagnosis

24
Q

How is an acute UGI bleed managed? (conservative, medical, surgical)

A
  1. IV fluids
  2. Assess haemodynamic status
  3. Calculate blatchord score
  4. Offer endoscopy (severe = now, non-severe = in 24h)
  5. Endoscopic therapy (clips, adrenaline, probe)
  6. Monitor and calculate Rockall score
  7. STAT omeprazole then IV for 72 hrs
25
Q

Following discharge from hospital, how should an UGI bleed be managed?

A
  • High dose PPI for 2 months
  • Stop NSAIDS
  • Repeat endoscopy at 6-8 weeks
26
Q

In patients with CVS risk factors, should COX2 inhibitors or NSAIDS be used?

A

NSAIDS - cox2 are prothrombotic

27
Q

In patients with GI disease, should COX2 inhibitors or NSAIDS be used?

A

COX2 - these are selective so less likely to damage the gut

28
Q

What can cause acute diarrhoea?

A 
Gastroenteritis
C. diff
IBD
IBS
Pancreatitis
Colitis
Alcoholic gastritis
29
Q

What special tests can be done in the setting of acute diarrhoea?

A

Flexi sig, serum amylase, faecal calprotectin (sign of inflammation), elastase, CT

30
Q

What drug is used for diarrhoea, and when is it contraindicated?

A

Loperamide (anti motility agent)

Contra: severe UC, toxic megacolon, bloody stool

31
Q

What can cause constipation?

A

Primary: Hirschprungs, rectocoele

Secondary: medication, neurological, low fibre, mechanical, metabolic, endocrine (hypothyroid, diabetes)

32
Q

Which meds cause constipation?

A

Opiates, CCBs, iron

33
Q

In what case does constipation require investigation?

A

> 40yrs, recent change in bowel habit and associated symptoms

34
Q

What investigations can be done for constipation?

A

BLOODS: FBC, U&E, LFT, TFTs, bone, PSA, haematinics
IMAGING: AXR, CT
SPECIAL: OGD/colonoscopy

35
Q

What are the 4 types of laxatives? Give examples

A
  1. BULK FORMING
  2. STIMULANT
  3. OSMOTIC
  4. STOOL SOFTENERS
36
Q

Give an example of a bulk forming laxative

A

Bran

Isphagula husk

37
Q

Give an example of a stimulant laxative

A

Senna

Bisacodyl

38
Q

Give an example of an osmotic laxative

A

Macrogol
Movicol
Lactulose

39
Q

Give an example of a stool softener

A

Liquid paraffin

Docusate sodium

40
Q

A patient has constipation related to poor diet and needs long term laxatives. What is the best choice?

A

Bulk forming (bran, ispaguhla husk)

41
Q

A patient has renal failure. Which laxatives should not be used?

A

Osmotic (macrogol, lactulose)

42
Q

A patient on morphine has constipation. What laxative should be used and why do you use with care?

A

Stimulnat (senna, bisacodyl) - risk of cathartic colon as they are very strong

43
Q

A patient has had recent surgery but is not yet constipated. What should be used to prevent constipation?

A

Stool softeners (docusate sodium, liquid paraffin)

4TH YEAR - CPTP (19 decks)

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