Minor Ailments - Gastrointestinal queries in Community Pharmacy Flashcards
What are Common GI Queries?
- Dyspepsia/Indigestion
- Gastro-Oesephogeal Reflux Disease (GORD)
- Constipation
- Diarrhoea
- Nausea and Vomiting
- Piles
- Irritable Bowel Syndrome (IBS)
How to deal w/ common GI queries?
- Define each condition
- Symptoms
- Causes
- Referral (red-flags)
- Treatment/management (life-style changes)
- Remember WWHAM
what is ‘Dyspepsia/Indigestion’?
- Refers to a group of symptoms, that are linked to eating and drinking – associated with excess acid
SYMPTOMS: - Bloating
- Burping
- Stomach cramps
- Flatulence
CAUSES: - Certain foods
- Time of eating
- Caffeine
- Medication
- GI tract problems (ulcer,cancer, infection)
What is GORD?
- Indigestion or Heartburn or Acid Reflux or GORD
- Often terms are used interchangeably by patients
- Heartburn (acid reflux) occurs when the sphincter muscle between the stomach and oesophagus open allowing stomach acid to leak back up into the oesophagus
- Indigestion (dyspepsia) occurs when acid from the stomach comes into contact with the lining of the digestive system
- GORD is a more chronic severe form of acid reflux
What is Gastro-oesophageal
Reflux Disease (GORD)?
- Reflux of gastric content into the oesophagus
**SYMPTOMS **: - Gastric pain
- Discomfort and wind
- Nausea
- Acidity (back of throat)
- Abdominal pain
CAUSES: - Diet and lifestyle:Overeating, drinking,obesity
- Pregnancy
- Incompetence of oesophageal sphincter (hernia, drug induced)
treatment of GORD = lifestyle advice
- Diet changes: avoid large meals, fatty/hot spicy
food, reducing alcohol consumption and stop
smoking - Avoid aggravating factors
- Raising the head of the bed and not lying down
within three hours of taking a meal - Loosing weight if overweight
treatment of GORD = antacids
- Raise pH (neutralize/ counteract excess acid) & provide rapid relief
- Alter absorption of certain drugs and damage enteric coating of tablets
** Sodium Bicarbonate** - Belching of CO2, less suitable in flatulence
- Sodium content
** Aluminium and Magnesium Hydroxide** - Aluminium causes constipation
- Magnesium causes diarrhoea
- Used in combination – counteract both problems
- i.e Remegel, Rennie, Gaviscon
treatment of GORD = Alginates
- Rafting agents
- Could be mixed with antacids = raft forming alginate & antacid
- Forms a raft/viscous foam
- Floats on top of the stomach contents
- Protects oesophagus during reflux
- i.e Gaviscon Advance
what is a H2-receptor antagonist?
- Competitive antagonist of H2-receptor
- Inhibit histamine-induced acid secretion
- Effective at night
- OTC: Ranitidine (Zantac) no longer available OTC due to international recall – minimal amounts of NMDA (probable carcinogen) found.
- Slower acting than antacids
- i.e Famotidine – POM
What is Diarrhoea?
- Passing soft or watery stool at an increased
frequency (> 3 times/day) - Common and debilitating condition
- Can be life-threatening due to dehydration
- Symptoms include: crampy stomach pains, fever, loss of appetite, nausea and vomiting
When to refer GORD?
- Dysphagia= difficulty / discomfort swallowing
- Hematemesis= vomiting caused by internal bleeding
- Weight loss
- Vomiting
- Upper abdominal masses
- Repetitive request for OTC supply
- Onset of new symptoms
- Upper epigastric pain= pain in upper abdomen
- Hunger pain
- Night pain relieved by eating
- Drug induced
How to manage Diarrhoea?
- General advice - drink plenty of fluid, high
carbohydrate food - if Drug induced = review medication and counselling
- Oral rehydration therapy
- Antibiotics
- Antimotility drugs
What are Proton pump inhibitors (PPIs)?
- Inhibit a chemical system called the hydrogen-potassium adenosine triphosphatase enzyme system (otherwise known as the ‘proton pump’)
- PPIs are converted to active drugs at acid pH
- Regular use to be effective as they have preventative role rather than symptomatic (think NSAIDs)
- Inhibit certain drugs metabolism thus increase their concentration
- i.e Omeprazole, Pantoprazole & Esomeprazole
What causes Diarrhoea?
- Bacterial or viral infection - food is culprit
- Broad spectrum antibiotics – alter natural gut flora leading to superinfection
- Medication: PPIs, Magnesium salts, NSAIDs, Metformin, Iron salts. Excessive use of laxatives
- Change of climate and country – body not used to different water and food
- Anxiety and too much alcohol
what are the signs of dehydration?
DRY:
* Mouth, lips cracked, eyes
* Loose skin, lack of elasticity
* Sunken features
URINE/GI:
* Low output
* Concentrated
* Low abdominal pain, burning sensation in stomach, loss of appetite
HEAD:
* Dizziness, light-headedness, tiredness,
headaches
* Clammy hands and feet
* Confusion and irritability
Treatment for dehydration = Oral Rehydration Therapy (treatment for diarrhoea)
- Dehydration causes electrolyte disturbances – problems with certain drugs (e.g. diuretics)
- Specific mixture of electrolytes and glucose
- Made up to correct osmolality- freshly boiled and cooled water
- Number required depends on number of watery stools
- Dioralyte/Rehydration salts
Treatment of diarrhoea = Antimotility agents
- Symptomatic but limited use
- Reduce motility of the gut, allowing reabsorption or water and minerals
- Allow control of diarrhoea- less disturbances to daily activities
- Loperamide widely used – less central side effects
Treatment of diarrhoea = Antibiotics
- Most cases are viral in nature
- If bacterial infection confirmed by stool culture, then correct antibiotic prescribed
- Traveller’s diarrhoea: need to ascertain any recent travel history
When to refer diarrhoea?
- Length of diarrhoea >3 days
- Blood in stool
- Moderate to severe dehydration- not properly self managed- elderly
- Drug induced (clindamycin, colchicine)
- Recent travel – check
- Regular purchase of codeine based products
What causes constipation?
LIFESTYLE:
* Diet lacking fibres,/fluid lack of exercise
* Hospital admission, depression, anxiety
* Ignoring call to stool ( go tot teh bathroom)
Metabolic/drugs/neurological:
* Hypothyroidism, hypercalcemia, hypokalaemia,
diabetes
* Opiates, irons, antacids, antidepressants,
* Dementia, stroke, multiple sclerosis, parkinsonism
Bowel disorders:
* Anal pathology
* Tumour
* Diverticular disease ( a condition that ffects the large intestine)
What is Constipation?
- Altered bowel habits, reduced frequency and passing hardened faeces
- The Rome IV diagnostic criteria for constipation
include spontaneous bowel movements occurring fewer than three times a week. - Usually harmless but can indicate underlying serious disorders
- What is important is REGULARITY not FREQUENCY
How to manage Constipation?
Lifestyle changes
* Balanced diet , high in fibre and non-starch
polysaccharides
* High fluid intake Increased exercise
Laxatives
* Medicines that increases the number of bowel
movements
* Osmotic/Stimulant/Bulk-forming/Softeners
When to consider laxatives?
- Straining to pass stool that might affect other conditions like haemorrhoids or angina
- Temporary illness which causes constipation e.g. lack of movement or loss of appetite
- Elderly person develop constipation due to low mobility
- Drugs taken concomitantly
- Also (not related to constipation): before colonoscopy
treatment of constipation = stimulant laxatives
- Stimulate nerve endings in gut which causes muscle to contract - speeds up peristalsis
- Taken at bedtime, takes 8-12 hours to work
- Rapid relief of symptoms
- Short term- risk of bowel nerve damage
- Can cause cramps/gripping pain
- i.e Senna, bisacodyl, glycerol (also osmotic in its action
treatment of constipation = bulk forming agents
- Swell up in gut to increase faecal mass
- Stimulates peristalsis
- Take few days to work , should be taken with plenty of water and not immediately before bed - risk of bowel obstruction
- Equivalent to high fibre diet
- Can cause wind/bloating
- i.e Isphagula, methycellulose, sterculia
treatment of constipation = osmotic laxatives
- Increase the flow of water into the intestines to produce softer and easier-to-pass stools
- Variable onset of action: phosphate enema (within 1 hour), lactulose (2-3 days), macrogols (12-24 hrs) and Magnesium salts (2-4 hours)
- Lactulose is broken down in the gut and increases volume of faeces and water content
- Can cause abdominal ramp and wind
- i.e Lactulose, macrogols, (phosphates and sodium citrates in enemas for urgent relief of constipation), magnesium salts, glycerol
treatment of constipation = Faecal softeners
- Lubricating and softening faeces making them easier to pass
- Small quantities due to serious side effects
- Include: paraffin seepage from faeces which irritate the anus
- Absorption of paraffin from the gut can cause damage to the gut wall
- Interferes with absorption of fat-soluble vitamins (A, D, E, and K)
- i.e Docusate
what is Nausea and Vomiting?
- Common occurrence
- Could following exposure to bacterial toxin
- May reflect serious underlying pathology
- Focus on GI related nausea and vomiting for OTC supply
when to refer constipation?
- Drug induced when regular laxatives are needed
- Sudden onset of symptoms with no apparent reason especially in elderly
- Blood in faeces (bare in mind haemorrhoids and straining)
- Overuse – slimming purposes
- Severe abdominal pain
What causes Nausea and Vomitting?
- Alcohol
- Bacterial and viral infection
- Motion sickness
- Drugs (anticancer, NSAIDs, iron salts,
erythromycin, SSRIs….) - Peptic ulceration, migraine, pregnancy, head
trauma - Meniere’s disease ( inner ear issue) , renal failure
Treatment for Nausea & vomittting
- Manage the symptoms
- Oral rehydration therapy
- Preventative measures (diet)
- i.e Dioralyte, Pepto-bismol
When to refer Nausea & vomitting?
- Blood in vomit
- Duration > 2 days
- Weight loss
- Severe abdominal pain
What are the symptoms of Haemorrhoids?
- Common bleeding after going to the toilet
- Itching and irritation
- Sense of not fully emptying rectum when going
to the toilet - Sense of fullness around the anus
How to manage Haemorrhoids?
- Eat plenty of fibre: fruit, vegetables, wholemeal
bread…. - Drink plenty of water: adults advised to drink 2 L
a day. Alcoholic drinks can be dehydrating - Fibre supplements: bulk forming agents/bran
- Toileting: respond to the call to toilet/not
postpone, resist straining - Treating and managing constipation if present
- Choice of preparation depends on location
- Creams/Ointments more suitable for external use
- Suppositories for internal use
- Topical Corticosteroids to reduce inflammation and itching
- i.e Germoloids, Anusul plus HC ointment, Anusol suppositories
What are Haemorrhoids (Piles)?
- Swollen veins in the lining of the anus and rectum
- External at the anus or internal in the rectum
- Occur because of increased pressure on
haemorrhoidal vein - Made worse by straining and constipation
- Pregnant women are particularly prone
What are the symptoms of IBS?
Gripy, colicky pain across lower abdomen
* Wind and bloating
* Fatigue and disturbed bowel habits
* Diarrhoea and constipation
* OTC supply will be based on whether patient has confirmed IBS
What is Irritable bowel syndrome (IBS)?
- Common bowel disorder
- Ages 20-30, more common in women
- Abnormal contractions of the muscles in the
large intestine and increased sensitivity of the
bowel to the presence of gas and movement - Causes are poorly understood - may be related
to anxiety and depression or certain food types
How to manage IBS?
- Diary of diet, activity – define aggravating factors and avoid
- Diarrhoea and constipation management as discussed in previous section
Non-medical treatment - Cognitive behavioural therapy
- Hypnotherapy
- Acupuncture
Antispasmodics= - work by relaxing the intestine muscle so relive muscle spams
- i.e Hyoscine, mebeverine, peppemint oil, alverine
