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Pre-Reg (Trainee) Pharmacy > MID WEIGHTING - Gastrointestinal System > Flashcards

MID WEIGHTING - Gastrointestinal System Flashcards

1
Q

Gastric Acid Disorders & Ulceration

What is the most common cause of peptic ulcers?

A

H pylori

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2
Q

Gastric Acid Disorders & Ulceration

How is H Pylori diagnosed?

A

(1) Urea (13C) breath test

(2) Stool Helicobacter Antigen Test (SAT)

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3
Q

Gastric Acid Disorders & Ulceration

What requirements are there before taking a test for H Pylori?

A

(1) PPIs should be stopped 2 weeks before test

(2) Antibiotics should be stopped 4 weeks before test

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4
Q

Gastric Acid Disorders & Ulceration

What is the treatment for H Pylori?

A

Triple Therapy for 7 days

(1) PPI - BD

(2)
- Amoxicillin 1g BD
- Clarithromycin 500mg BD
- Metronidazole 400mg BD

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5
Q

Gastric Acid Disorders & Ulceration

What is the duration of treatment for H Pylori infections?

A

7 days

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6
Q

Gastric Acid Disorders & Ulceration

Give the acronyms for three different H Pylori treatment regimes.

A

(1) PAC

(2) PMC

(3) PAM

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7
Q

Exocrine Pancreatic Insufficiency

What is the effect of a pancreatic insufficiency?

A

Reduces secretion of pancreatic enzymes into the duodenum.

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8
Q

Exocrine Pancreatic Insufficiency

Name some common causes of pancreatic insufficiency.

A
  • Pancreatitis
  • Cystic Fibrosis
  • Pancreatic Tumours
  • GI resection (can lead to maldigestion + malnutrition)
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9
Q

Exocrine Pancreatic Insufficiency

How can GI resection lead to pancreatic insufficieny?

A

Maldigestion -> Malnutrition

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10
Q

Exocrine Pancreatic Insufficiency

What is the treatment for exocrine pancreatic insufficiency?

A

Pancreatic enzyme replacement (Pancreatin)

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11
Q

Exocrine Pancreatic Insufficiency

What is the name for pancreatic replacement enzyme?

A

Pancreatin

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12
Q

Exocrine Pancreatic Insufficiency

What is Pancreatin?

A

Pancreatic enzyme replacement

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13
Q

Exocrine Pancreatic Insufficiency

What is the contents of Pancreatin?

A

Lipase, amylase, protease

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14
Q

Exocrine Pancreatic Insufficiency

(1) What instructions should be given for Pancreatin? (2) Why?

A

(1) Take with meals and snacks

(2) Can be broken down very quickly without a meal

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15
Q

Exocrine Pancreatic Insufficiency

What limit is there for lipase in cystic fibrosis patients?

A

10,000units/kg/day

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16
Q

Exocrine Pancreatic Insufficiency

What should cystic fibrosis patients report if initiated on Pancreatin?

A

Any new abdominal symptoms

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17
Q

Exocrine Pancreatic Insufficiency

What monitoring requirements are there for patients taking Pancreatin?c

A

Levels of fat soluble vitamins & micronutrients
- Supplements should be given if needed

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18
Q

Gastric Acid Disorders & Ulceration

What does the term ‘dyspepsia’ refer to?

A

Describes a range of upper GI symptoms

Typically presenting for 4 or more weeks

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19
Q

Gastric Acid Disorders & Ulceration

Name some symptoms of dyspepsia.

A
  • Upper abdominal pain/ discomfort
  • Heartburn
  • Gastric reflux
  • Bloating
  • Nausea/ vomiting
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20
Q

Gastric Acid Disorders & Ulceration

What is the most common cause of dyspepsia?

A

Functional dyspepsia
- No known cause

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21
Q

Gastric Acid Disorders & Ulceration

What are dyspepsia symptoms in pregnancy often due to?

A

GORD

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22
Q

Gastric Acid Disorders & Ulceration

What are the aims of treatment for dyspepsia?

A

(1) Manage symptoms

(2) Treat underlying cause (where possible)

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23
Q

Gastric Acid Disorders & Ulceration

Which non-drug treatments may help reduce dyspepsia?

A
  • Healthy eating
  • Weight loss (if obese)
  • Eating smaller meals
  • Eating (minimum) 3-4 hours before bed
  • Avoiding trigger foods
  • Raising the head of the bed
  • Smoking cessation
  • Reducing alcohol consumption
  • Assessment and resolution of anxiety/ depression/ stress
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24
Q

Gastric Acid Disorders & Ulceration

For which patients is urgent endoscopy required for?

A

Those experiencing:
- Dysphagia
- Significant acute GI bleeding
- Aged >55yrs with unexplained weight loss + symptoms of upper abdominal pain/ reflux/ dyspepsia

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25
Q

Gastric Acid Disorders & Ulceration

Which drugs may cause dyspepsia?

A
  • Alpha-blockers
  • Antimuscarinics
  • Aspirin
  • Benzodiazepines
  • Beta-blockers
  • Bisphosphonates
  • Calcium channel blockers
  • Corticosteroids
  • Nitrates
  • NSAIDs
  • Theophyllines
  • TCAs
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26
Q

Gastric Acid Disorders & Ulceration

When are antacids/ alginates indicated in dyspepsia?

A

Short-term symptom control only

Continuous use is not recommended

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27
Q

Gastric Acid Disorders & Ulceration

What is the initial management for uninvestigated dyspepsia?

A

PPI for 4 weeks

Tested for H. pylori (treated if positive)

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28
Q

Gastric Acid Disorders & Ulceration

What test should be run, alongside treatment, for initial management of uninvestigated dyspepsia?

A

H. pylori test

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29
Q

Gastric Acid Disorders & Ulceration

What is Public Health England’s recommendation regarding initial management of uninvestigated dyspepsia?

A

H. pylori test should be undertaken first/ in parallel with PPI treatment

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30
Q

Gastric Acid Disorders & Ulceration

What is the initial management for function dyspepsia?

A

H. pylori infection test (treated if positive)

(If negative)
- PPI/ H2-receptor antagonist for 4 weeks

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31
Q

Gastric Acid Disorders & Ulceration

If symptoms persist/ recur following initial management of dyspepsia, how should the patient be treated?

A

PPI/ H2-receptor antagonist at lowest dose that controls symptoms

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32
Q

Gastric Acid Disorders & Ulceration

If a patient with refractory dyspepsia is on an NSAID and initial treatment was unsuccessful, how should they be managed?

A

Stop NSAID if possible

If not possible, switch to non-NSAID, e.g. paracetamol/ COX-2 inhibitor

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33
Q

Gastric Acid Disorders & Ulceration

(1) How often should patients with dyspepsia be reviewed? (2) What should be encouraged at these reviews?

A

(1) Annual review to reassess symptoms and treatment

(2) Step-down approach/ stopping treatment
- If possible AND clinically appropriate

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34
Q

Gastric Acid Disorders & Ulceration

When should a patient be referred to a specialist?

A

Gastro-oesophageal symptoms:
- Unexplained
- Non-responsive to treatment
- H. pylori infection non-responsive to second-line eradication therapy

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35
Q

Gastric Acid Disorders & Ulceration

What is peptic ulcer disease?

A

Gastric/ duodenal ulceration

Breach of epithelium of mucosa

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36
Q

Gastric Acid Disorders & Ulceration

What is the main symptom of a peptic ulcer?

A

Upper abdominal pain

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37
Q

Gastric Acid Disorders & Ulceration

What are some less common symptoms of a peptic ulcer?

A
  • Nausea
  • Indigestion
  • Heartburn
  • Loss of appetite
  • Weight loss
  • Bloated feeling
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38
Q

Gastric Acid Disorders & Ulceration

What are the most common causes of peptic ulcers?

A

(1) NSAIDs

(2) H. pylori infection

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39
Q

Gastric Acid Disorders & Ulceration

Which factors may contribute to developing peptic ulcer disease?

A
  • Smoking
  • Alcohol consumption
  • Stress
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40
Q

Gastric Acid Disorders & Ulceration

What are some complications of peptic ulcer disease?

A
  • Gastric outlet obstruction
  • Potentially life-threatening GI perforation & haemorrhage
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41
Q

Gastric Acid Disorders & Ulceration

Which patients are at high risk of developing GI complications with an NSAID?

A
  • Hx of complicated peptic ulcer OR
  • Those with ≥2 of the following:
    o >65yrs
    o High dose NSAIDs
    o Drugs that increase risk of GI side-effects
    o Serious co-morbidity
    o Heavy smoker
    o Excessive alcohol consumption
    o Previous ADR to NSAIDs
    o Prolonged requirement for NSAIDs
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42
Q

Gastric Acid Disorders & Ulceration

What are the aims of treatment for peptic ulcer disease?

A

Promote ulcer healing

Manage symptoms

Treat H. pylori infection (if positive)

Reduce risk of ulcer complications + recurrence

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43
Q

Gastric Acid Disorders & Ulceration

Describe the non-drug treatment of peptic ulcer disease.

A
  • Healthy eating
  • Weight loss (if obese)
  • Avoiding trigger foods
  • Eating smaller meals
  • Eat 3-4hours (minimum) before going to bed
  • Raise head of bed
  • Smoking cessation
  • Reduction in alcohol consumption
  • Assessment & resolution of anxiety/ depression/ stress
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44
Q

Gastric Acid Disorders & Ulceration

Describe the initial management of peptic ulcer disease.

A
  • Review/ stop drugs that induce peptic ulcers, if clinically appropriate
  • Antacids/ alginates may be used for short-term symptom control
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45
Q

Gastric Acid Disorders & Ulceration

When are antacids/ alginates recommended?

A

Short-term symptom control

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46
Q

Gastric Acid Disorders & Ulceration

What does the treatment strategy for peptic ulcer disease depend on?

A

(1) Presence of H. pylori infection

(2) Recently taken NSAIDs

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47
Q

Gastric Acid Disorders & Ulceration

What test should be taken for patients presenting with peptic ulcer disease?

A

H. pylori test

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48
Q

Gastric Acid Disorders & Ulceration

What is the management of a patient with peptic ulcer disease who has a positive H. pylori infection test result and have no history of NSAID use?

A

H. pylori infection should be eradicated

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49
Q

Gastric Acid Disorders & Ulceration

What is the management of a patient with peptic ulcer disease who has a positive H. pylori that is associated with NSAID use?

A

(1) PPI/ H2-receptor antagonist for 8 weeks

(2) Followed by H. pylori eradication treatment

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50
Q

Gastric Acid Disorders & Ulceration

What is the the management of a patient with peptic ulcer disease who has a negative H. pylori that is not associated with NSAID use?

A

PPI/ H2-receptor antagonist for 4-8 weeks

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51
Q

Gastric Acid Disorders & Ulceration

(1) When should patients with peptic ulcers who have tested positive for H. pylori be reviewed? (2) What can this depend on?

A

(1) 6-8 weeks after starting eradication treatment

(2) Re-tested depending on size of lesion

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52
Q

Gastric Acid Disorders & Ulceration

(1) When should patients with peptic ulcers who have tested positive for H. pylori have a repeat endoscopy? (2) For which patients does this apply?

A

(1) 6-8 weeks after treatment

(2) Gastric ulcers ONLY

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53
Q

Gastric Acid Disorders & Ulceration

For patients on long-term NSAID use with peptic ulcer disease, how often should NSAID treatment be reviewed?

A

At least every 6 months

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54
Q

Gastric Acid Disorders & Ulceration

For patients on long-term NSAID use with peptic ulcer disease, what should be assessed in their NSAID reviews?

A
  • Consider dose reduction
  • NSAID substitution with paracetamol
  • Use of alternative analgesic/ low-dose ibuprofen
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55
Q

Gastric Acid Disorders & Ulceration

When should a COX-2 inhibitor be considered for patients with peptic ulcer disease?

A

Previous ulceration for whom:
- NSAID continuation is necessary
- High risk of GI side-effects

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56
Q

Gastric Acid Disorders & Ulceration

(1) What is the preferred choice for gastro-protection with acid suppression therapy? (2) What are some alternative options of acid suppression therapy?

A

(1) PPI

(2) H2-receptor antagonist/ misoprostol

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57
Q

Gastric Acid Disorders & Ulceration

What limits the use of misoprostol as acid suppression therapy?

A

Side-effects limit its use

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58
Q

Gastric Acid Disorders & Ulceration

When should acid suppression therapy for gastro-protection be prescribed in patients with peptic ulcer disease?

A

Always

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59
Q

Gastric Acid Disorders & Ulceration

In patients with peptic ulcer disease, how should the patient be managed if symptoms recur after initial treatment?

A

PPI at lowest possible dose to control symptoms

Treatment used on as-needed basis
- Managed by patient

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60
Q

Gastric Acid Disorders & Ulceration

What differentials can be considered if a patient has persistent symptoms of peptic ulcer disease or an unhealed ulcer following initial treatment?

A
  • Malignancy
  • Failure to detect H. pylori
  • Inadvertent NSAID use
  • Other ulcer-inducing medication
  • Zollinger-Ellison syndrome
  • Crohn’s disease
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61
Q

Gastric Acid Disorders & Ulceration

If response to a PPI is inadequate, as acid suppression therapy, what is the alternative?

A

H2-receptor antagonist

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62
Q

Gastric Acid Disorders & Ulceration

How often should patients on long-term treatment for peptic ulcer disease be reviewed and what should be assessed in this review?

A

Annual review of symptoms of treatment

Step-down approach/ stopping treatment
- If possible + clinically appropriate

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63
Q

Gastric Acid Disorders & Ulceration

What is GORD?

A

Gastro-oesophageal Reflux Disease

Reflux of gastric contents (acid, bile, pepsin)

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64
Q

Gastric Acid Disorders & Ulceration

What are some common symptoms of GORD?

A
  • Heartburn
  • Acid regurgitation
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65
Q

Gastric Acid Disorders & Ulceration

What are some less common symptoms of GORD?

A
  • Chest pain
  • Hoarseness
  • Cough
  • Wheezing
  • Asthma
  • Dental erosions
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66
Q

Gastric Acid Disorders & Ulceration

What is required for GORD to be classified as non-erosive?

A

Symptoms of GORD with normal endoscopy

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67
Q

Gastric Acid Disorders & Ulceration

What is required for GORD to be classified as erosive oesophagitis?

A

Oesophageal inflammation AND mucosal erosions are seen on endoscopy

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68
Q

Gastric Acid Disorders & Ulceration

What are the risk factors for GORD?

A
  • Consumption of trigger foods
  • Consumption of fatty foods
  • Pregnancy
  • Hiatus hernia
  • FHx of GORD
  • Increased intra-gastric pressure from straining and coughing
  • Stress
  • Anxiety
  • Obesity
  • Drug side-effects
  • Smoking and alcohol consumption
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69
Q

Gastric Acid Disorders & Ulceration

Name some complications of GORD.

A
  • Oesophageal inflammation (oesophagitis)
  • Ulceration
  • Haemorrhage
  • Stricture formation
  • Anaemia due to chronic blood loss
  • Aspiration pneumonia
  • Barrett’s oesophagus
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70
Q

Gastric Acid Disorders & Ulceration

What are the aims of treatment of GORD?

A

Manage symptoms of GORD

Reduce risk of recurrence & complications associated with the disease

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71
Q

Chronic Bowel Disorders

Where does Coeliac disease occur?

A

Small intestine

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72
Q

Chronic Bowel Disorders

What is Coeliac disease?

A

Intolerance to gluten

-> Causes an immune response in intestinal mucosa

(Wheat, barley, rye)

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73
Q

Chronic Bowel Disorders

What can an immune response in the intestinal mucosa lead to?

A

Malabsorption of nutrients

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74
Q

Chronic Bowel Disorders

What are the aims of treatment of Coeliac disease?

A

(1) Manage symptoms

(2) Avoid malnutrition

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75
Q

Chronic Bowel Disorders

What are some symptoms of Coeliac disease?

A
  • Diarrhoea
  • Bloating
  • Abdominal pain
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76
Q

Chronic Bowel Disorders

What is done to help avoid malnutrition in Coeliac disease?

A

Supplement:
- Vitamin D
- Calcium

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77
Q

Chronic Bowel Disorders

What is currently the only effective treatment option for Coeliac disease?

A

AVOID gluten

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78
Q

Chronic Bowel Disorders

What is the difference between diverticular disease and diverticulitis?

A

Diverticulitis = Small pouches (asymptomatic)

Diverticular disease = Small pouches (symptomatic)

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79
Q

Chronic Bowel Disorders

What are some symptoms of diverticular disease?

A
  • Abdominal pain
  • Constipation
  • Diarrhoea
  • Rectal bleed
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80
Q

Chronic Bowel Disorders

What is the treatment for diverticular disease?

A
  • Fibre
  • Bulk-forming laxatives
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81
Q

Chronic Bowel Disorders

What is acute diverticulitis?

A

When pouches become inflamed or infected

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82
Q

Chronic Bowel Disorders

What are some symptoms of acute diverticulitis?

A
  • Severe abdominal pain
  • Fever
  • Significant rectal bleeding
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83
Q

Chronic Bowel Disorders

What is complicated acute diverticulitis?

A

Abscess, perforation, fistula, obstruction, sepsis, haemorrhage

In presence of acute diverticulitis (severe abdominal pain/ fever/ significant rectal bleeding)

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84
Q

Chronic Bowel Disorders

Where does Crohn’s disease occur?

A

Whole GI tract (mouth to rectum)

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85
Q

Chronic Bowel Disorders

Describe the pathophysiology of Crohn’s disease?

A

Associated with thickened wall (extending through all layers)

Deep ulceration

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86
Q

Chronic Bowel Disorders

What does the treatment of acute Crohn’s disease depend on?

A

Number of flare ups in 12 month period

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87
Q

Chronic Bowel Disorders

What complications can Crohn’s disease lead to?

A
  • Intestinal strictures/ fistulae
  • Anaemia/ malnutrition (unable to absorb nutrients)
  • Colorectal/ small bowel cancers
  • Growth failure/ delayed puberty in children
  • Extra-intestinal manifestation
    ø Arthritis of joints/ eyes/ liver/ skin abnormalities
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88
Q

Chronic Bowel Disorders

What is the treatment of acute Crohn’s disease for the first flare-up in a 12 month period?

A

MONOTHERAPY:
- Prednisolone/ methylprednisolone/ IV hydrocortisone

OR

Aminosalicylates (sulfasalazine/ mesalazine)

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89
Q

Chronic Bowel Disorders

How does the use of aminosalicylates compare to that of steroids for treatment of acute Crohn’s disease?

A

Fewer side effects, but less effective

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90
Q

Chronic Bowel Disorders

What is the treatment for the first flare-up of acute Crohn’s with distal ileal/ ileocaecal/ right-sided disease?

A

Usual steroid monotherapy

Use budesonide if normal treatment does not work

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91
Q

Chronic Bowel Disorders

What is the treatment for acute Crohn’s disease with 2+ flare-ups in a 12 month period?

A

Prednisolone/ methylprednisolone/ IV hydrocortisone

ADD azathioprine/ mercaptopurine

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92
Q

Chronic Bowel Disorders

What should be measured before initiating treatment of Crohn’s disease with mercaptopurine?

A

TMPT

Thiopurine methyltransferase

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93
Q

Chronic Bowel Disorders

What should be measured before initiating treatment of Crohn’s disease with azathioprine?

A

TMPT

Thiopurine methyltransferase

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94
Q

Chronic Bowel Disorders

Why are TMPT levels measured before initiating azathioprine/ mercaptopurine?

A

TMPT enzyme is needed for metabolising these drugs

Deficiency can lead to inadequate metabolism and risk of immunosuppression

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95
Q

Chronic Bowel Disorders

When should methotrexate be considered for treatment of Crohn’s disease?

A

2+ flare ups in 12 month period

When azathioprine/ mercaptopurine are contraindicated

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96
Q

Chronic Bowel Disorders

What is the treatment for severe Crohn’s disease?

A

Monoclonal Antibodies

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97
Q

Chronic Bowel Disorders

What is fistulating Crohn’s disease?

A

Development of a fistula between intestine and perianal skin, bladder, vagina

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98
Q

Chronic Bowel Disorders

What can be used to improve symptoms of fistulating Crohn’s disease?

A

Metronidazole +/- Ciprofloxacin

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99
Q

Chronic Bowel Disorders

In fistulating Crohn’s disease, how long is metronidazole normally given for?

A

1 month

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100
Q

Chronic Bowel Disorders

In fistulating Crohn’s disease, why is there a maximum duration of metronidazole of 3 months?

A

Any more than that increases risk of peripheral neuropathy

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101
Q

Chronic Bowel Disorders

What is first line treatment for maintenance therapy for fistulating Crohn’s disease?

A

Azathioprine/ mercaptopurine

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102
Q

Chronic Bowel Disorders

What is second line treatment for maintenance therapy for fistulating Crohn’s disease (when not responding to primary treatment)?

A

Infliximab

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103
Q

Chronic Bowel Disorders

For maintenance treatment of fistulating Crohn’s disease, how long should maintenance last?

A

At least 1 year

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104
Q

Chronic Bowel Disorders

What is maintenance treatment of Crohn’s disease?

A
  • Monotherapy of mercaptopurine/ azathioprine
    ø (can use methotrexate if used in induction/ unable to tolerate aza/ merc)
  • Encourage to stop smoking
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105
Q

Chronic Bowel Disorders

What is the treatment of Crohn’s disease following surgery?

A

Azathioprine + metronidazole

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106
Q

Chronic Bowel Disorders

In Crohn’s disease, what is the treatment for diarrhoea?

A
  • Loperamide
  • Colestyramine
  • Codeine
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107
Q

Chronic Bowel Disorders

In ulcerative colitis, what is the treatment for diarrhoea?

A
  • Loperamide
  • Colestyramine
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108
Q

Chronic Bowel Disorders

What are some examples of aminosalicylates?

A
  • Sulfasalazine
  • Mesalazine
  • Olsalazine
  • Balsalazide
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109
Q

Chronic Bowel Disorders

What are the cautions for aminosalicylates?

A
  • Nephrotoxic
  • Hepatotoxic
  • Blood disorders
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110
Q

Chronic Bowel Disorders

How often should renal function be monitored for aminosalicylates?

A
  • Before initiation
  • After 3 months
  • Then annually
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111
Q

Chronic Bowel Disorders

How often should liver function be monitored for aminosalicylates?

A

Monitor monthly for first three months

112
Q

Chronic Bowel Disorders

How often should blood be monitored for aminosalicylates?

A

Monitor monthly for first three months

113
Q

Chronic Bowel Disorders

What should be done in treatment with aminosalicylates if there is evidence of blood dyscrasias?

A

Stop drug immediately

114
Q

Chronic Bowel Disorders

(1) Which aminosalicylate can cause discolouration? (2) What does it cause discolouration of? (3) What colour is this?

A

(1) Sulfasalazine

(2) Contact lenses and urine

(3) Orange-yellow

115
Q

Chronic Bowel Disorders

Which area is affected by ulcerative colitis?

A

From the rectum to the whole colon

116
Q

Chronic Bowel Disorders

What are the main differences between Crohn’s disease and ulcerative colitis?

A

UC has continuous pattern - Crohn’s is patchy

UC is rectum to colon - Crohn’s is mouth to rectum

117
Q

Chronic Bowel Disorders

Which symptoms are associated with ulcerative colitis?

A
  • Bloody diarrhoea
  • Defecation urgency
  • Abdominal pain
118
Q

Chronic Bowel Disorders

Which complications may ulcerative colitis lead to?

A
  • Colorectal cancer
  • Secondary osteoporosis
  • Venous thromboembolism
  • Toxic megacolon
119
Q

Chronic Bowel Disorders

At which age is ulcerative colitis most often diagnosed?

A

15-25 years old

120
Q

Chronic Bowel Disorders

Which area does proctitis affect?

121
Q

Chronic Bowel Disorders

Which area does proctosigmoiditis affect?

A

Rectum and MOST of descending colon

122
Q

Chronic Bowel Disorders

Which area does distal/ left-sided ulcerative colitis affect?

A

Rectum and ALL of descending colon

123
Q

Chronic Bowel Disorders

Which area does extensive colitis affect?

A

Transverse, descending AND rectum

124
Q

Chronic Bowel Disorders

Which area does pancolitis affect?

A

Entire colon

125
Q

Chronic Bowel Disorders

What is the treatment for acute mild-moderate distal-rectal ulcerative colitis?

A

Suppositories/ enemas

Foam can be used in patients with difficulty retaining liquid enemas

126
Q

Chronic Bowel Disorders

What is the treatment for acute mild-moderate extended (extensive/ pancolitis) ulcerative colitis?

A

Systemic medication

127
Q

Chronic Bowel Disorders

(1) What is the treatment for diarrhoea in ulcerative colitis? (2) Why?

A

(1) Can use colestyramine. Avoid loperamide/ codeine

(2) Can cause toxic megacolon

128
Q

Chronic Bowel Disorders

What is toxic megacolon?

A

Inflammation/ swelling spreads into deeper layers of colon

Colon widens and stops working

129
Q

Chronic Bowel Disorders

What is the treatment for mild-moderate acute proctitis?

A

(1) Topical aminosalicylate

(2) Add oral aminosalicylate if no improvement after 4 weeks

(3) Topical/ oral corticosteroids for 4-8 weeks

130
Q

Chronic Bowel Disorders

What is the treatment for mild-moderate acute proctitis, when aminosalicylates are contraindicated?

A

Topical/ oral corticosteroids for 4-8 weeks

131
Q

Chronic Bowel Disorders

What is the treatment for mild-moderate acute proctosigmoiditis?

132
Q

Chronic Bowel Disorders

What is the treatment for mild-moderate acute left-sided ulcerative colitis?

A

(1) Topical aminosalicylate

(2) Add high-dose oral aminosalicylate if no improvement after 4 weeks

OR

(1) High-dose oral aminosalicylate AND 4-8 weeks of TOPICAL corticosteroids

(2) High-dose oral aminosalicylate AND 4-8 weeks of ORAL corticosteroids

133
Q

Chronic Bowel Disorders

What is the treatment for mild-moderate acute extensive ulcerative colitis?

A

(1) Topical aminosalicylate + high-dose oral aminosalicylate

(2) Oral aminosalicylate + oral corticosteroid for 4-8 weeks

134
Q

Chronic Bowel Disorders

What is the treatment for mild-moderate acute extensive ulcerative colitis, when aminosalicylates are contraindicated?

A

Oral corticosteroids for 4-8 weeks

135
Q

Chronic Bowel Disorders

What is the treatment for severe acute extensive ulcerative colitis?

A

IV hydrocortisone/ methylprednisolone AND assess need for surgery

136
Q

Chronic Bowel Disorders

What is the treatment for severe acute extensive ulcerative colitis, when steroids are contraindicated?

A

IV ciclosporin/ surgery

137
Q

Chronic Bowel Disorders

What is the treatment for severe acute extensive ulcerative colitis, where symptoms have not improved after 72 hours?

A

(1) IV steroid + IV ciclosporin

(2) Can increase to surgery

138
Q

Chronic Bowel Disorders

What is the treatment for severe acute extensive ulcerative colitis, if steroids and ciclosporin are contraindicated?

A

Infliximab

139
Q

Chronic Bowel Disorders

What is the maintenance treatment for ulcerative colitis?

A

Oral aminosalicylates recommended

140
Q

Chronic Bowel Disorders

Why are corticosteroids not used for maintenance treatment for ulcerative colitis?

A

Not suitable due to side effects

141
Q

Chronic Bowel Disorders

Which dosing of aminosalicylate is more effective for maintenance treatment for ulcerative colitis?

A

OD more effective but increased risk of side effects

142
Q

Chronic Bowel Disorders

What is the maintenance treatment for proctitis/ proctosigmoiditis?

A

Rectal +/- oral aminosalicylates

143
Q

Chronic Bowel Disorders

What is the maintenance treatment for left-sided/ extensive ulcerative colitis?

A

Low dose oral aminosalicylates

144
Q

Chronic Bowel Disorders

(1) What is the maintenance treatment for ulcerative colitis with 2+ flares in 12 months? (2) What can be used if the first line treatment is contraindicated/ not tolerated?

A

(1) Oral azathioprine/ mercaptopurine

(2) Monoclonal antibodies

145
Q

Chronic Bowel Disorders

in which patient group is irritable bowel syndrome most common?

A

Women 20-30

146
Q

Chronic Bowel Disorders

What symptoms are associated with irritable bowel syndrome?

A
  • Abdominal pain
  • Diarrhoea
  • Constipation
  • Urgency
  • Incomplete defecation
  • Passing mucous
147
Q

Chronic Bowel Disorders

What exacerbates irritable bowel syndrome?

A
  • Coffee/ alcohol/ milk
  • Large meals
  • Fried food
  • Stress
148
Q

Chronic Bowel Disorders

What is the non-drug treatment for irritable bowel syndrome?

A
  • Increase exercise
  • Eat regular meals
  • Reduce fresh fruit consumption to 3 portions per day
  • Reduce insoluble fibre
  • Drink at least 8 cups of water daily
  • Reduce alcohol/ caffeine/ fizzy drinks
  • Avoid sorbitol in presence of diarrhoea
  • Reduce stress
149
Q

Chronic Bowel Disorders

What is the treatment for irritable bowel syndrome?

A
  • Antispasmodics
  • Laxatives
  • Loperamide
  • Antimuscarinics
150
Q

Chronic Bowel Disorders

What are some examples of antispasmodics used for treatment of irritable bowel syndrome?

A
  • Alverine
  • Mebeverine
  • Peppermint oil
151
Q

Chronic Bowel Disorders

Which laxative should not be used for treatment of constipation in irritable bowel syndrome?

A

Not lactulose

152
Q

Chronic Bowel Disorders

Which antimuscarinic is used for treatment of irritable bowel syndrome?

A

Hyoscine butylbromide

153
Q

Chronic Bowel Disorders

When should hyoscine butylbromide use be avoided in treatment of irritable bowel syndrome?

A

Cardiac disease

154
Q

Chronic Bowel Disorders

(1) What is the aim of second line treatment of irritable bowel syndrome? (2) What is this second line treatment?

A

(1) Pain management

(2) Low-dose TCA (amitriptyline)

155
Q

Chronic Bowel Disorders

What is the second line treatment of irritable bowel syndrome, when TCAs are contraindicated?

156
Q

Chronic Bowel Disorders

What is shortened bowel syndrome?

A

Small bowel due to large surgical resection

157
Q

Chronic Bowel Disorders

Which nutrients need to be replaced in shortened bowel syndrome?

A
  • Vit A
  • Vit B12
  • Vit D
  • Vit E
  • Vit K
  • Essential Fatty Acids
  • Zinc
  • Selenium
158
Q

Chronic Bowel Disorders

(1) What is the main symptom that is frequently associated with shortened bowel syndrome? (2) What is given to treat this? (3) Why?

A

(1) Diarrhoea (or high output stomas)

(2) Loperamide/ codeine

(3) Reduce intestinal motility

159
Q

Chronic Bowel Disorders

Which patient groups are at highest risk of constipation?

A
  • Women
  • Elderly
  • Pregnancy
160
Q

Chronic Bowel Disorders

What are some red flags, relating to constipation?

A
  • Blood in stool
  • Anaemia
  • Abdominal pain
  • Unexplained weight loss
  • New onset constipation (over 50yrs)
161
Q

Chronic Bowel Disorders

What is the non-drug treatment for constipation?

A
  • Increased dietary fibre
  • Adequate fluid intake
  • Exercise
162
Q

Chronic Bowel Disorders

Which medication are likely to be causing constipation?

A
  • Opioids
  • Aluminium
  • Amitriptyline
  • Clozapine
163
Q

Chronic Bowel Disorders

What is the first line treatment of short duration constipation?

A

Bulk-forming AND good hydration

164
Q

Chronic Bowel Disorders

(1) What is the second line treatment of short duration constipation? (2) When is this appropriate?

A

(1) Osmotic (lactulose)

(2) If bulk-forming does not work

165
Q

Chronic Bowel Disorders

What is the first line treatment of chronic constipation?

A

Bulk-forming AND good hydration

166
Q

Chronic Bowel Disorders

What can be done if stool remains hard after first line treatment for chronic constipation?

A

Add or change to macrogol

OR

Lactulose (2nd line)

167
Q

Chronic Bowel Disorders

(1) What is the treatment of chronic constipation, if there is still no change after 6 months? (2) Is this for men or women?

A

(1) Prucalopride

(2) Men AND women

168
Q

Chronic Bowel Disorders

For second line treatment of constipation, what should be done as the patient’s constipation begins to improve?

A

Withdraw lactulose slowly

169
Q

Chronic Bowel Disorders

What are the different causes of faecal impaction?

A

Hard stools OR soft stools

170
Q

Chronic Bowel Disorders

What is the treatment of hard stools due to faecal impaction?

A

Macrogol

Stimulant laxative (once softened)

171
Q

Chronic Bowel Disorders

What is the treatment of soft stools due to faecal impaction?

A

Stimulant laxative

172
Q

Chronic Bowel Disorders

For faecal impaction, what is the treatment if first line treatments do not work?

A

Rectal bisacodyl +/- glycerol

173
Q

Chronic Bowel Disorders

What is the first line treatment of opioid induced constipation?

A

Osmotic laxative AND stimulant laxative

174
Q

Chronic Bowel Disorders

What is the second line treatment of opioid induced constipation?

A

Naloxegol

(Peripherally acting opioid receptor antagonist)

175
Q

Chronic Bowel Disorders

(1) Which laxative(s) should be avoided in opioid induced constipation? (2) Why?

A

(1) AVOID bulk-forming

(2) Can cause intestinal obstruction/ faecal impaction

176
Q

Chronic Bowel Disorders

Why can opioids cause constipation?

A

Reduced intestinal motility

177
Q

Chronic Bowel Disorders

What is the first line treatment of constipation in pregnancy and breastfeeding?

A
  • Dietary and lifestyle -> Fibre supplements (e.g. bran/ wheat)
  • Bulk-forming, then lactulose
178
Q

Chronic Bowel Disorders

What is the second line treatment of constipation in pregnancy and breastfeeding?

A
  • Bisacodyl/ Senna (Senna should not be used near term)
179
Q

Chronic Bowel Disorders

What is the first line treatment of constipation in children?

A

Dietary advice AND macrogol AND stimulant (if no faecal impaction)

180
Q

Chronic Bowel Disorders

What is the first line treatment of constipation in children, with faecal impaction?

A

Dietary advice AND macrogol

181
Q

Chronic Bowel Disorders

What is the treatment of constipation in children, if their stool is hard?

A

Lactulose (osmotic)

OR

Docusate

182
Q

Chronic Bowel Disorders

How does Senna work?

A

Stimulates colonic nerves

183
Q

Chronic Bowel Disorders

How does bisacodyl work?

A

Stimulates colonic AND rectal nerves

184
Q

Chronic Bowel Disorders

How does sodium picosulfate work?

A

Stimulates colonic AND rectal nerves

185
Q

Chronic Bowel Disorders

Name some stimulant laxatives?

A
  • Senna
  • Bisacodyl
  • Sodium picosulfate
  • Glycerol
  • Docusate
186
Q

Chronic Bowel Disorders

What are some stimulant laxatives that are used only in palliative care?

A
  • Co-danthramer
  • Co-danthrusate
187
Q

Chronic Bowel Disorders

Why are co-danthramer and co-danthrusate only used in palliative care?

A

Potential carcinogenicity

Therefore, only used in terminally i’ll patients

188
Q

Chronic Bowel Disorders

What is the usual adult dose of Senna?

189
Q

Chronic Bowel Disorders

What is the usual adult dose of sodium picosulfate?

190
Q

Chronic Bowel Disorders

What is the usual adult dose of bisacodyl?

191
Q

Chronic Bowel Disorders

What is the max adult dose of Senna?

192
Q

Chronic Bowel Disorders

What is the max adult dose of sodium picosulfate?

193
Q

Chronic Bowel Disorders

What is the max adult dose of bisacodyl?

194
Q

Chronic Bowel Disorders

What are some side-effects of stimulant laxatives?

A
  • Abdominal cramps
  • Diarrhoea
  • N + V
195
Q

Chronic Bowel Disorders

What is the main contraindication to use of stimulant laxatives?

A

Intestinal obstruction

196
Q

Chronic Bowel Disorders

What is the main contraindication to use of stimulant laxatives?

A

Intestinal obstruction

197
Q

Chronic Bowel Disorders

What are some bulk-forming laxatives?

A
  • Ispaghula husk
  • Methylcellulose
  • Sterculia
198
Q

Chronic Bowel Disorders

What are some osmotic laxatives?

A
  • Lactulose
  • Macrogol
  • Phosphate enema
199
Q

Chronic Bowel Disorders

What are some faecal softeners?

A
  • Liquid paraffin
  • Docusate
  • Glycerol
200
Q

Chronic Bowel Disorders

What is the time to effect of bulk-forming laxatives?

201
Q

Chronic Bowel Disorders

What is the time to effect of stimulant laxatives?

A

6-12 hours

202
Q

Chronic Bowel Disorders

What is the time to effect of osmotic laxatives?

203
Q

Chronic Bowel Disorders

What is the time to effect of faecal softeners?

A

5-20 minutes

204
Q

Chronic Bowel Disorders

What is the quickest acting laxative group?

A

Faecal softeners

205
Q

Chronic Bowel Disorders

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

A
  • Retain fluid within the stool
  • Increase faecal mass
  • Stimulate peristalsis
  • Has stool softening properties
206
Q

Chronic Bowel Disorders

What is the administration advice for bulk-forming laxatives?

A

Must be taken with enough water to prevent intestinal blockage

207
Q

Chronic Bowel Disorders

What is the mechanism of action of stimulant laxatives?

A
  • Increase peristalsis (by stimulating colonic nerves)
208
Q

Chronic Bowel Disorders

What discolouration can co-danthramer and co-danthrusate cause?

A

Colours urine red

209
Q

Chronic Bowel Disorders

What is the mechanism of action of osmotic laxatives?

A

Increase amount of fluid in the large bowel

Leads to stimulation of peristalsis

Also has stool softening properties

210
Q

Chronic Bowel Disorders

What is the mechanism of action of faecal softeners?

A

Increases water penetration into stools

211
Q

Chronic Bowel Disorders

When should Senna not be used for treatment of constipation?

A

Do NOT use near term of pregnancy

212
Q

Chronic Bowel Disorders

What is the treatment for acute diarrhoea?

A

Usually settles without medical treatment

Can use oral rehydration therapy (ORT) to prevent/ correct dehydration

213
Q

Chronic Bowel Disorders

What is the treatment for diarrhoea with severe dehydration?

A

Hospital -> IV fluids

214
Q

Chronic Bowel Disorders

What is the treatment for diarrhoea with the inability to drink?

A

Hospital -> IV fluids

215
Q

Chronic Bowel Disorders

What is the treatment for diarrhoea if rapid control is needed?

A

Loperamide

216
Q

Chronic Bowel Disorders

What is the treatment for traveller’s diarrhoea?

A

Loperamide

217
Q

Chronic Bowel Disorders

When should loperamide be avoided for treatment of constipation?

A

Bloody/ suspected inflammatory diarrhoea

218
Q

Chronic Bowel Disorders

(1) When should treatment for diarrhoea be actively avoided? (2) Why?

A

(1) Presence of infection symptoms

(2) Because clearing infection is the priority

219
Q

Chronic Bowel Disorders

What is the first line treatment for faecal impaction diarrhoea?

A

Loperamide

220
Q

Chronic Bowel Disorders

What are the age restrictions on loperamide OTC?

221
Q

Chronic Bowel Disorders

What are the age restrictions on loperamide on prescription?

222
Q

Chronic Bowel Disorders

What is the dosing of loperamide?

A

Take 1-2 doses (2-4mg)

Then one (2mg) with every loose stool

223
Q

Chronic Bowel Disorders

What is the maximum daily dosing of loperamide?

A

MAX 8 doses

16mg

224
Q

Chronic Bowel Disorders

What is an MHRA warning for loperamide?

A

Serious cardiac reactions (QT Prolongation) with high doses

225
Q

Chronic Bowel Disorders

How is an overdose of loperamide treated?

226
Q

Gastric Acid Disorders & Ulceration

What are the urgent referral symptoms for dyspepsia?

A

G - GI bleeding (blood in stool/ vomit)
A - Aged 55+
U - Unexplained weight loss
D - Dysphagia (difficulty swallowing)

227
Q

Gastric Acid Disorders & Ulceration

What is an MHRA warning for PPIs?

A

Low risk of subacute cutaneous lupus erythematosis

228
Q

Gastric Acid Disorders & Ulceration

What are some cautions with PPIs?

A
  • Increases risk of fractures/ osteoporosis
  • Increases risk of C. diff
  • Masks symptoms of gastric cancer
  • B12 deficiency
229
Q

Gastric Acid Disorders & Ulceration

Why do PPis cause increased risk of fractures/ osteoporosis?

A

PPIs cause hypomagnesaemia

230
Q

Gastric Acid Disorders & Ulceration

(1) What is an important interaction with omeprazole and esomeprazole, specifically? (2) What should be used as an alternative?

A

(1) Interaction with clopidogrel

(2) Lansoprazole

231
Q

Gastric Acid Disorders & Ulceration

What drugs can PPIs cause increases in concentration of?

A
  • Methotrexate
  • Phenytoin
  • Warfarin
  • Digoxin
232
Q

Gastric Acid Disorders & Ulceration

What is a caution for H2 receptor antagonists?

A

May mask symptoms of gastric cancer

233
Q

Gastric Acid Disorders & Ulceration

What are some side-effects of H2 receptor antagonists?

A
  • Diarrhoea
  • Dizziness
  • Headache
  • Rash
  • Tiredness
234
Q

Gastric Acid Disorders & Ulceration

What are some important interactions of H2 receptor antagonists?

A
  • Reduced absorption of azole antifungals
  • CYP450 enzyme inhibitor (cimetidine ONLY)
235
Q

Gastro-Oesophageal Reflux Disease

What are some risk factors for GORD?

A
  • Consuming fatty foods
  • Pregnancy
  • Hiatus Hernia
  • FHx
  • Stress + anxiety
  • Obesity
  • Drug Side-effects
  • Smoking
  • Alcohol
236
Q

Gastro-Oesophageal Reflux Disease

Which drugs can increase risk of GORD?

A
  • Alpha blockers
  • Beta blockers
  • CCBs
  • Anticholinergics
  • Benzodiazepines
  • Corticosteroids
  • NSAIDs
  • Nitrates
  • Tricylic Antidepressants
237
Q

Gastro-Oesophageal Reflux Disease

What are the urgent referral symptoms for GORD?

A

G - GI bleeding (blood in stool/ vomit)
A - Aged 55+yrs
U - Unexplained weight loss
D - Dysphagia (difficulty swallowing)

238
Q

Gastro-Oesophageal Reflux Disease

What is the first line treatment of GORD?

A

LIFESTYLE ADVICE FIRST:
- Healthy eating
- Weight loss (if obese)
- Avoiding trigger foods
- Eating smaller meals
- Eating evening meal 3-4hr before bed
- Raising head of bed
- Smoking cessation
- Reducing alcohol consumption

239
Q

Gastro-Oesophageal Reflux Disease

What is the treatment of uninvestigated GORD, if lifestyle advice is insufficient?

A

4 weeks of PPI

(Same as uninvestigated dyspepsia)

240
Q

Gastro-Oesophageal Reflux Disease

What is the treatment of confirmed GORD, that is unresponsive to lifestyle advice?

A

4-8 weeks of PPI

241
Q

Gastro-Oesophageal Reflux Disease

What is the treatment of GORD in pregnancy?

A
  • Dietary and lifestyle advice
  • Antacid/ alginate
  • Omeprazole/ ranitidine
242
Q

Cholestasis

What is cholestasis?

A

Impaired bile formation/ flow

243
Q

Cholestasis

What are some symptoms of cholestasis?

A
  • Fatigue
  • Pruritis
  • Dark urine
  • Pallor
  • Jaundice
244
Q

Cholestasis

What is the treatment of cholestasis?

A
  • Colestyramine
  • Ursodeoxycholic acid
  • Rifampicin
245
Q

Cholestasis

What is the treatment of intrahepatic cholestasis in pregnancy?

A

Ursodeoxycholic acid - to treat pruritis

Treatment will cause adverse foetal outcomes

246
Q

Gallstones

What are gallstones?

A

Hard mineral/ fatty deposits forming stones in gallbladder bile duct

247
Q

Gallstones

What is the treatment for gallstones?

A

Majority do not require treatment

Most are asymptomatic

248
Q

Gallstones

What are the effects of a blocked/ irritated gall bladder?

A
  • Pain
  • Infection
  • Inflammation
249
Q

Gallstones

What may a blocked/ irritated gallbladder lead to if left untreated?

A

COMPLICATIONS:
- Biliary colic
- Cholecystitis
- Colangitis
- Pancreatitis

250
Q

Gallstones

What is the treatment of a blocked/ irritated gallbladder, if symptoms develop?

A

Surgical removal

251
Q

Gallstones

What is the drug treatment of a blocked/ irritated gallbladder?

A

Symptomatic relief only:
- Mild-moderate pain: Paracetamol/ NSAID
- Severe pain: I’M diclofenac

252
Q

Haemorrhoids & Anal Fissures

What are anal fissures?

A

Tears/ ulcers in anal canal

Causing bleeding + pain on defecation

253
Q

Haemorrhoids & Anal Fissures

What is the purpose of acute management of anal fissures?

A

Ensure stools pass easily and help with pain

254
Q

Haemorrhoids & Anal Fissures

What is the acute treatment of anal fissures?

A

Bulk-forming/ osmotic laxatives

Short-term topical local anaesthetic (lidocaine)

255
Q

Haemorrhoids & Anal Fissures

What is the chronic management of anal fissures?

A
  • GTN rectal
  • Topical/ oral diltiazem/ nifedipine
256
Q

Haemorrhoids & Anal Fissures

What is the main specialist treatment of anal fissures?

A

Botulinum toxin type A

257
Q

Haemorrhoids & Anal Fissures

What is the most effective option when there is no drug response for anal fissures?

258
Q

Haemorrhoids & Anal Fissures

What are haemorrhoids?

A

Swelling of the vascular mucosal anal cushions around the anus

259
Q

Haemorrhoids & Anal Fissures

Which patient group are at highest risk of haemorrhoids?

A

Pregnant patients

260
Q

Haemorrhoids & Anal Fissures

What are the symptoms of internal haemorrhoids?

A

None, usually painless

261
Q

Haemorrhoids & Anal Fissures

What are the symptoms of external haemorrhoids?

A

Itchy + painful

262
Q

Haemorrhoids & Anal Fissures

(1) What is the purpose of haemorrhoid treatment? (2) What is this treatment?

A

(1) Maintain easy stools to minimise straining

(2)
- Increase dietary fibre + fluid

OR

  • Bulk-forming laxative + fluid
263
Q

Haemorrhoids & Anal Fissures

(1) Which painkiller would you recommend for haemorrhoids? (2) Why not others?

A

(1) Paracetamol

(2)
- NSAIDs exacerbate rectal bleeding
- Opioids cause constipation

264
Q

Haemorrhoids & Anal Fissures

What is the treatment for pain/ itching associated with haemorrhoids?

A

TOPICAL PREPARATIONS
- Anaesthetics (e.g. lidocaine) - used for a few days
- Corticosteroids - used for a maximum of 7 days

265
Q

Haemorrhoids & Anal Fissures

What is the treatment of haemorrhoids in pregnancy?

A

Bulk-forming laxatives

AVOID topical haemorrhoidal preparations
- although simple soothing preparations may be used

266
Q

Stoma Care

What is a stoma?

A

Artificial opening on the abdomen to divert flow of faeces/ urine into external pouch (located outside the body)

267
Q

Stoma Care

(1) Which formulations are not suitable in stoma care? (2) Why?

A

(1) Effervescent/ modified-release capsules

(2) Insufficient effect from drugs

268
Q

Stoma Care

Which types of formulation are preferred in stoma care?

A
  • Liquids
  • Capsules
  • Uncoated/ soluble tablets
269
Q

Stoma Care

What is the likely drug cause of diarrhoea in stoma care?

A
  • Sorbitol
  • Magnesium antacids
  • Iron (in ileostomy)
270
Q

Stoma Care

What is the likely drug cause of constipation in stoma care?

A
  • Opioids
  • Calcium antacids
  • Iron (in colostomy)
271
Q

Stoma Care

What is the likely drug cause of GI irritation and bleed in stoma care?

A
  • Aspirin
  • NSAIDs
272
Q

Stoma Care

What effects can diuretics and laxatives have in stoma care?

A

Dehydration -> Hypokalaemia -> Increased digoxin toxicity

273
Q

Stoma Care

How can hypokalaemia from laxatives/ diuretics be corrected in stoma care?

A
  • Use potassium-sparing diuretics
  • Use potassium supplements (e.g. SandoK)
274
Q

Stoma Care

Which form of potassium supplementation is preferred in stoma care hypokalaemia correction?

A

Liquid potassium preferred to MR preparations

275
Q

Stoma Care

Why are patients with stomas at higher risk of digoxin toxicity?

A

Dehydration from loss of Na+ and fluid

Due to laxatives/ diuretics

Leads to dehydration

Leads to hypokalaemia

Pre-Reg (Trainee) Pharmacy (31 decks)

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