PH1122 - Gastroenterology

Question 1

What is the most common cause of diarrhoea in all age groups?

Answer 1

Acute gastroenteritis, the most common cause of diarrhoea in all age groups, is usually viral in origin.

Question 2

How is diarrhoea classified ?

Answer 2

It can be classified as acute (< 14 days),
persistent (> 14 days), or
chronic (lasting longer than a month).

Question 3

When should a person be referred for diarrhoea ?

Answer 3

A person who presents with a history of chronic diarrhoea should be referred. The most frequent causes of chronic diarrhoea are irritable bowel syndrome (IBS), inflammatory disease, and colon cancer.

A history of recurrent diarrhoea of no known cause should be referred for further investigation.

Diarrhoea associated with blood and mucus (dysentery) requires referral to eliminate invasive infection such as Shigella, Campylobacter jejuni, Salmonella, Clostridium difficile and Escherichia coli O157. - A&E

If medication induced diarrhoea is suspected then GP should be contacted for alternative.

If Giardiasis is suspected (from drinking contaminated water, should refer to GP for appropriate antibiotics.

If faecal impaction is suspected referral is needed

Question 4

What are symptoms of acute diarrhoea ?

Further add symptoms if rotavirus was the cause.

Answer 4

normally rapid in onset
Nausea and vomiting might be present before or during the bout
Abdominal cramping, flatulence and tenderness

Rota virus: Might also have viral symptoms such as cough or cold

Question 5

How long would it usually take to recover from acute diarrhoea ?

Answer 5

Complete resolution of symptoms should be observed in 2 to 4 days.

Question 6

which medications can induce diarrhoea ?

Answer 6

ACE inhibitor Lisinopril, perindopril
Angiotensin receptor blocker Telmisartan
Acetylcholinesterase inhibitor Donepezil, galantamine, rivastigmine
Antacid Magnesium salts
Antibacterial All
Antidiabetic Metformin, acarbose
Antidepressant SSRIs, clomipramine, venlafaxine
Antiemetic Aprepitant, dolasetron
Antiepileptic Carbamazepine, oxcarbazepine, tiagabine, zonisamide, pregabalin, levetiracetam
Antifungal Caspofungin, fluconazole, flucytosine, nystatin (in large doses), terbinafine, voriconazole
Antimalarial Mefloquine
Antiprotozoal Metronidazole, sodium stibogluconate
Antipsychotic Aripiprazole
Antiviral Abacavir, emtricitabine, stavudine, tenofovir, zalcitabine, zidovudine, amprenavir, atazanavir, indinavir, lopinavir, nelfinavir, saquinavir, efavirenz, ganciclovir, valganciclovir, adefovir, oseltamivir, ribavirin, fosamprenavir
Beta blocker Bisoprolol, carvedilol, nebivolol
Bisphosphonate Alendronic acid, disodium etidronate, ibandronic acid, risedronate, sodium clodronate, disodium pamidronate, tiludronic acid
Cytokine inhibitor Adalimumab, infliximab
Cytotoxic All classes of cytotoxics
Dopaminergic Levodopa, entacapone
Growth hormone antagonist Pegvisomant
Immunosuppressant Cyclosporin, mycophenolate, leflunomide
NSAIDs All
Ulcer healing Proton pump inhibitors
Vaccines Pediacel, Haemophilus , meningococcal
Miscellaneous Calcitonin, strontium ranelate, colchicine, dantrolene, olsalazine, anagrelide, nicotinic acid, pancreatin, eplerenone, acamprosate

Question 7

What are some unlikely causes of diarrhoea

Answer 7

Irritable bowel syndrome
Patients younger than 50 years who have had abdominal pain and discomfort, bloating, or a change in bowel habit for 6 months are likely to have IBS

Giardiasis
a protozoan infection of the small intestine, is contracted through drinking contaminated drinking water. It is an uncommon cause of diarrhoea in the West. However, with more people taking foreign holidays to non-Western countries, enquiry about recent travel should be made. The patient will present with watery and foul-smelling diarrhoea, accompanied with symptoms of bloating, flatulence, and epigastric pain.

Faecal impaction
is usually seen in older adults and those with poor mobility. Patients might present with continuous soiling as a result of liquid passing around hard stools and mistakenly believe they have diarrhoea. On questioning, the patient might describe the passage of regular, poorly formed hard stools that are difficult to pass. Referral is needed because manual removal of the faeces is often required.

Question 8

What are symptoms of Ulcerative colitis and Crohn’s disease

Answer 8

Both conditions are characterized by chronic inflammation at various sites in the GI tract and follow periods of remission and relapse.

bloody diarrhoea is one of the major presenting symptoms. Patients often have left lower quadrant abdominal pain and suffer from urgency, nocturnal diarrhoea and early morning rushes.

In the acute phase, patients will appear unwell and have malaise.

Question 9

What OTC treatment can be used for diarrhoea ?

Answer 9

Before considering treatment, it is important to stress to patients the importance of hand washing. Interventions that promote hand washing can reduce diarrhoea episodes by about one third

ORS (Oral rehydration sachets) (diorylite)

Loperamide - should be reserved for those patients who will find it inconvenient to use a toilet.

Bismuth subsalicylate PeptoBismol - less effective than loperamide

Rotavirus vaccine -The oral vaccine is given as two doses, the first at 2 months and the second at 3 months

Question 10

What are the side effects of: ORS, Loperamide and bismuth

Answer 10

ORS- None
Loperamide - Headache, flatulence, Nausea
Bismuth (peptonismol) - Black stools or tongue - interacts with Quinolone antibiotics

Question 11

What lifestyle behaviours should be questioned when investigating constipation?

Answer 11

Inactive lifestyle, a decreased fluid intake, poor nutrition, avoidance of fibrous foods and chronic illness.

Question 12

What is the most common cause of constipation ?

Answer 12

is decrease in intestinal tract transit time of food, which allows greater water resorption from the large bowel, leading to harder stools that are more difficult to pass. This is usually caused by a deficiency in dietary fibre, a change in lifestyle and/or environment, and medication.

Question 13

What are some key questions to ask when suspecting constipation ?

Answer 13

Change of diet or routine Constipation usually has a social or behavioural cause. There will usually be some event that has precipitated the onset of symptoms.

Pain on defecation Associated pain when going to the toilet is usually due to a local anorectal problem. Constipation is often secondary to the suppression of defecation because it induces pain. These cases are best referred for physical examination.

Presence of blood Bright red specks in the toilet or smears on toilet tissue suggest haemorrhoids or a tear in the anal canal (fissure). However, if blood is mixed in the stool (melaena), referral to the doctor is necessary. A stool that appears black and tarry is suggestive of an upper gastrointestinal bleed.

Duration (chronic or recent?) If a patient suffers from long-standing constipation and has been previously seen by the doctor, treatment could be given. However, cases >14 days with no identifiable cause or previous investigation by the doctor should be referred.

Lifestyle changes For example, changes in job or marital status can precipitate depressive illness that can manifest with physiological symptoms, such as constipation.

Question 14

When should you refer someone experiencing blood loss on defecation?

Answer 14

if blood loss is substantial (stools appear tarry, red or black), referral is needed.
acute constipation with no other symptoms apart from very small amounts of bright red blood can be managed in the pharmacy

Question 15

name some common medicines that can cause constipation ?

Answer 15

Alpha blocker Prazosin
Antacid Aluminium and calcium salts
Anticholinergic Trihexyphenidyl, hyoscine, oxybutynin, procyclidine, tolterodine
Antidepressant Tricyclics, SSRIs, reboxetine, venlafaxine, duloxetine, mirtazapine
Antiemetic Palonosetron, dolasetron, aprepitant
Antiepileptic Carbamazepine, oxcarbazepine
Antipsychotic Phenothiazines, haloperidol, pimozide and atypical antipsychotics such as amisulpride, aripiprazole, olanzapine, quetiapine, risperidone, zotepine, clozapine
Antiviral Foscarnet
Beta blocker Oxprenolol, bisoprolol, nebivolol; other beta-blockers tend to cause constipation more rarely
Bisphosphonate Alendronic acid
CNS stimulant Atomoxetine
Calcium channel blocker Diltiazem, verapamil
Cytotoxic Bortezomib, buserelin, cladribine, docetaxel, doxorubicin, exemestane, gemcitabine, irinotecan, mitoxantrone, pentostatin, temozolomide, topotecan, vinblastine, vincristine, vindesine, vinorelbine
Dopaminergic Amantadine, bromocriptine, cabergoline, entacapone, tolcapone, levodopa, pergolide, pramipexole, quinagolide
Growth hormone antagonist Pegvisomant
Immunosuppressant Basiliximab, mycophenolate, tacrolimus
Lipid-lowering agent Cholestyramine, colestipol, rosuvastatin, atorvastatin (other statins uncommon), gemfibrozil
Iron Ferrous sulphate
Metabolic disorders Miglustat
Muscle relaxant Baclofen
NSAID Meloxicam; other NSAIDs, e.g., aceclofenac and COX-2 inhibitors reported as uncommon
Smoking cessation Bupropion
Opioid analgesic All opioid analgesics and derivatives
Ulcer healing All proton pump inhibitors, sucralfate

Question 16

When is IBS suspected ?

Answer 16

Patients younger than 50 years who have had abdominal pain and discomfort, bloating or a change in bowel habit for 6 months are likely to have IBS.

Question 17

What is the link between constipation and depression ?

Answer 17

Depression
Upwards of 20% of the population will suffer from depression at some time. Many will present with physical as well as emotional symptoms. It has been reported that one-third of all patients suffering from depression present with gastrointestinal complaints in a primary care setting. Core symptoms of persistent low mood and loss of interest in most activities should trigger referral.

Question 18

What are the signs and symptoms of hypothyroidism ?

Answer 18

The signs and symptoms of hypothyroidism are often subtle and insidious in onset. Patients might experience weight gain, lethargy, cold intolerance, coarse hair, menstrual irregularities, dry skin and constipation.

Constipation is often less pronounced than lethargy and cold intolerance.

Question 19

What are some reasons to refer a patient suspecting constipation ?

Answer 19

Patients >40 years with a marked change in bowel habits with no obvious cause Suspect rectal carcinoma Same-day referral
Longer than 14 days’ duration, with no identifiable cause This requires further investigation to rule out more sinister causes As soon as practicable
Tiredness Check for anaemia or thyroid dysfunction
Pain on defecation that might cause the patient to suppress the defecation reflex Check for anal fissure

Question 20

What is the advice for treating constipation ?

Answer 20

For uncomplicated constipation, nondrug treatment is advocated as first-line treatment for all patient groups because simple dietary and lifestyle modifications (increasing exercise) will relieve most acute cases of constipation. Advice includes increasing fluid and fibre intake.

Fibre intake should be increased to approximately 30 g/day in the form of fruit, vegetables, cereals, grain foods, and whole-grain bread.

No standout better laxative
- Lactulose- Infants and older- SIDE EFFECTS: Flatulence, abdominal pain, colic
-Senna > 2 years - SIDE EFFECTS: Abdominal pain, NO drug interactions-OK in pregnancy, but use other laxatives in preference to stimulants in pregnancy and breastfeeding
-Bisacodyl > 4 years- SIDE EFFECTS: abdominal pain,
OK in pregnancy, but use other laxatives in preference to stimulants in pregnancy and breastfeeding

Avoid drinks with caffeine These can act as a diuretic and serve to make constipation worse.

fybogel- Ispaghula husk has to be reconstituted with water before taking. Adults should take one sachet or two level, 5-mL spoonsful twice daily; for children between 6 and 12 years, ½ to one. 5-mL spoonful twice daily.
exert their effect by mimicking increased fibre consumption, swelling in the bowel and increasing faecal mass. In addition, they encourage the proliferation of colonic bacteria, and this helps further increase faecal bulk and stool softness. Patients should be advised to increase their fluid intake while taking bulk-forming medicines. The effect is usually seen in 12 to 36 hours but can take as long as 72 hours.

Glycerol suppositories
Glycerol suppositories are normally used when a bowel movement is needed quickly. The patient should experience a bowel movement in 15 to 30 minutes.

Question 21

How would you advise a patient to administer suppositories ?

Answer 21

1. Wash your hands.
2. Lie on one side with your knees pulled up towards your chest.
3. Gently push the suppository, pointed end first, into your back passage with your finger.
4. Push the suppository in as far as possible.
5. Lower your legs, roll over onto your stomach, and remain still for a few minutes. If you feel your body trying to expel the suppository, try to resist this. Lie still and press your buttocks together.
6. Wash your hands.

Question 22

what is something to be cautious about with bisacodyl ?

Answer 22

Bisacodyl- Bisacodyl tablets are enteric-coated, and patients should be told to avoid taking antacids and milk at the same time because the coating can be broken down, leading to dyspepsia and gastric irritation.

Question 23

define IBS.

Answer 23

a functional bowel disorder (i.e., absence of abnormality) in which abdominal pain and bloating are associated with a change in bowel habits.

The key symptom differentiating it to constipation or diarrhoea is abdominal pain

Question 24

What are the clinical features of IBS ?

Answer 24

• A bdominal pain or discomfort
• B loating
• C hange in bowel habit

Question 25

what is dietary advice for IBS

Answer 25

Dietary advice a Have regular meals and avoid missing meals.
Drink at least eight cups of fluid per day, especially noncaffeinated drinks.
Reduce intake of alcohol and fizzy drinks.
Consider limiting intake of high-fibre food.
Reduce intake of so-called resistant starch often found in processed or recooked foods.
Limit fresh fruit to three portions per day.

Question 26

What are haemorrhoids ?

Answer 26

Swollen veins in the wall of the rectum and anus.

Question 27

What causes haemorrhoids ?

Answer 27

Hemorrhoids are usually caused by increased pressure due to pregnancy, being overweight, or straining during bowel movements.

Question 28

what relevance would the duration, pain, rectal bleeding, associated symptoms and diet have on haemorrhoids ?

Answer 28

Duration- Patients with haemorrhoids tend to have had symptoms for some time before requesting advice. However, patients with symptoms that have been constantly present for > 3 weeks should be referred.
Pain Pain, if experienced, tends to occur on defecation but is also noticed at other times for example when sitting. Pain is usually described as a dull ache.
Sharp or stabbing pain at the time of defecation can suggest an anal fissure or tear.
Rectal bleeding- Slight rectal bleeding is often associated with haemorrhoids. Blood appears bright red and might be visible on the toilet bowl, surface of the stool or pink-coloured water in the toilet bowl. Rectal bleeding is usually a direct referral sign but if due to haemorrhoids referral is usually not necessary unless the patient is unduly anxious.
Blood mixed in the stool has to be referred to eliminate a GI bleed.
Large volumes of blood or blood loss not associated with defecation must be referred to eliminate possible carcinoma.
Associated symptoms- Symptoms associated with haemorrhoids are usually localized; for example, anal itching. Other symptoms such as nausea, vomiting, loss of appetite and altered bowel habits should be viewed with caution and underlying pathology suspected. Referral would be needed.
Diet-A lack of dietary fibre that leads to constipation is a contributory factor to haemorrhoids. The passage of hard stools and straining during defecation can cause haemorrhoids. Find out about the patient’s diet and current bowel habits.

Question 29

Name some clinical features of haemorrhoids.

Answer 29

Bright red painless rectal bleeding is the most common symptom. Blood is usually seen as spotting around the toilet, streaking on toilet tissue or visible on the surface of the stool. Itching and irritation are also commonly observed. Symptoms are often intermittent, and each episode usually lasts from a few days to a few weeks. Internal haemorrhoids are rarely painful, whereas external haemorrhoids can cause pain due to the cushion becoming thrombosed. Pain is described as a dull ache that increases in severity when the patient defecates, leading to patients ignoring the urge to defecate. This can then lead to constipation, which in turn will lead to more difficulty in passing stools and further increase the pain associated with defecation.

Question 30

describe the symptoms of an anal fissure in order to rule it out when suspecting haemorrhoids.

Answer 30

Anal fissures are common, with the 15- to 40-year-old age group most affected; they are also often experienced during pregnancy. Symptoms often follow a period of constipation and are normally caused by straining at stool. Pain always occurs with defecation, which can be severe and sharp, with pain lasting for a number of hours after defecation. Bright red blood is commonly seen. Nonurgent referral is necessary for confirmation of the diagnosis.

Question 31

How would you treat haemorrhoids ?

Answer 31

Reviews by Alonso-Coello et al. (2005, 2006) have concluded that general measures to prevent constipation will help decrease straining during defecation, ease the symptoms of haemorrhoids, and reduce recurrence. Patients should therefore be asked about their normal diet to determine fibre intake. Those with diets low in fibre should be encouraged to increase their fibre and fluid intake because this will help produce softer stools and reduce constipation. Patients should try to eat more fruit, vegetables, bran and whole-grain bread. If this is not possible, fibre supplementation with a bulk-forming laxative could be recommended. Bulk-forming laxatives will take 2 to 3 days to relieve constipation and may take up to 6 weeks to improve symptoms of haemorrhoids.

Question 32

when would you refer someone with haemorrhoids ?

Answer 32

Any person complaining of prolapsing haemorrhoids(leaving the anus), which need reducing by the patient, should be referred because these patients might require nonsurgical intervention with sclerotherapy or rubber band ligation.

symptoms such as nausea, vomiting, loss of appetite and altered bowel habits should be viewed with caution and underlying pathology suspected. Referral would be needed.

Blood mixed in the stool has to be referred to eliminate a GI bleed.

patients with symptoms that have been constantly present for > 3 weeks should be referred.

good practice dictates that people under 20 years suspected of haemorrhoids should be referred.)

Question 33

what is dyspepsia

Answer 33

• Functional dyspepsia, nonulcer dyspepsia (indigestion)
• Gastro-oesophageal reflux disease (GORD, heartburn)
• Gastritis
• Duodenal ulcers
• Gastric ulcers

Question 34

What are some clinical features of dyspepsia ?

Answer 34

Patients with dyspepsia present with a range of symptoms commonly involving the following:
Vague abdominal discomfort (aching) above the umbilicus associated with belching
BLOATING
FLATULENCE
A FEELING OF FULLNESS
NAUSEA AND/OR VOMITING
HEARTBURN

Question 35

What is the main condition to rule out when suspecting dyspepsia

Answer 35

Peptic Ulceration

Question 36

What are some signs of peptic ulceration ?

Answer 36

Pain associated with dyspepsia is described as aching or discomfort. Pain described as gnawing, sharp or stabbing is more likely to be ulcer-related.

Persistent vomiting with or without blood is suggestive of ulceration or even cancer and must be referred.

Pain shortly after eating (1–3 hours) and relieved by food or antacids are classic symptoms of ulcers.
Symptoms of dyspepsia are often brought on by certain types of food; for example, caffeine-containing products and spicy food.

Typically, the patient will have well-localized, midepigastric pain described as constant, annoying, gnawing or boring. With gastric ulcers, the pain comes on whenever the stomach is empty, usually 30 minutes after eating, and is generally relieved by antacids or food and aggravated by alcohol and caffeine. Gastric ulcers are also more commonly associated with weight loss and GI bleeds than duodenal ulcers

Duodenal ulcers tend to be more consistent in symptom presentation. Pain occurs 2 to 3 hours after eating, and pain that awakens a person at night is highly suggestive of a duodenal ulcer.

Question 37

How can lifestyle effect the chances of experiencing dyspepsia ?

Answer 37

Bouts of excessive drinking are commonly implicated in dyspepsia. Likewise, eating food on the move or too quickly is often the cause of the symptoms. A person’s lifestyle is often a good clue to whether these are contributing to the symptoms.
Risk factors for GORD Stress, smoking, being overweight, and taking medicines that decrease lower oesophageal sphincter tone predispose people to

Question 38

What are some reasons for referral with dyspepsia ?

Answer 38

ALARM signs and symptoms
• A naemia (signs include tiredness, pale complexion, shortness of breath)
• L oss of weight
• A norexia
• R ecent onset of progressive symptoms
• M elaena, dysphagia, and haematemesis
Symptoms requiring further investigation Urgent referral to GP
Pain described as severe, debilitating or that awakens the patient at night
Persistent vomiting Suggests ulceration As soon as practicable
Referred pain Possible cardiovascular or biliary cause

Question 39

what is some advice for treating dyspepsia ?

Answer 39

• Change diet to a lower fat diet.
• Keep alcohol intake to recommended levels.
• Stop smoking.
• Decrease weight.
• Reduce caffeine intake.

Commonly implicated foods that precipitate dyspepsia are spicy or fatty foods, caffeine, chocolate and alcohol

Sodium and potassium salts are the most highly soluble, which enables them to have a quicker onset, but are shorter acting. Magnesium and aluminium salts are less soluble, so these have a slower onset, but longer duration of action. Calcium salts have the advantage of being quick acting and have a prolonged action.

Alginate products are promoted as first-line treatment for patients suffering from GORD. When in contact with gastric acid the alginate precipitates out, forming a spongelike matrix that floats on top of the stomach contents. Alginate preparations are also commonly combined with antacids to help neutralize stomach acid

Question 40

what are some things to be cautious about when recommending medication for dyspepsia ?

Answer 40

Overuse of antacids Misuse and chronic use of antacids will result in significant systemic absorption, leading to various unwanted medical conditions. Milk-alkali syndrome has been reported with chronic abuse of calcium-containing antacids, as has osteomalacia with aluminium-containing products.
Antacid therapy should ideally not be longer than 2 weeks. If symptoms have not resolved in this time, other treatments and/or evaluation from the GP should be recommended.
When is the best time to take antacids? Antacids should be taken after food because gastric emptying is delayed in the presence of food. This allows antacids to exert their effect for up to 3 hours.
Salt (sodium) content Be aware that some antacid preparations contain significant amounts of sodium; for example, Gaviscon Advance contains 4.6 mmol of sodium/10 mL. UK Medicines Information (UKMi) has produced a document detailing medicines with high sodium content. a

Older adults Avoid constipating products because older adults are prone to constipation.
Possible solutions to minimize symptoms Simple suggestions such as eating less but eating more often or eating smaller meals might help control symptoms. Avoid eating late at night and lying flat at night; use a pillow to prop up the person.

Question 41

What is the OTC treatment for coldsores ?

Answer 41

Aciclovir is the first-line therapy for the treatment of cold sores. However, it should be used as soon as the patient experiences symptoms for them to have any effect

Use within 6-48 hours of symptoms appearing for it to work.

If the prodromal phase is missed then A hydrating cream e.g Cymex or Blistex relief cream would be appropriate.

Question 42

What is general advise for Coldsores ?

Answer 42

General hygiene advice – only touch sores when applying cream. Dab cream onto sore rather than rubbing as this may increase risk of spreading the virus and causing pain by damaging the blister or scabs. Wash hands after applying cream. If a contact lens wearer make sure hands are thoroughly washed before inserting or removing as there is a risk of eye infection. If coldsores triggered by sunlight, use sunscreen lip balm (at least spf 15). The blisters are infectious until the sores scab over.

Question 43

What is good general advise for someone with dyspepsia ?

Answer 43

Patients lifestyle is a large contributing factor to symptoms therefore lifestyle advice is key to managing his symptoms. (Reducing fatty & spicy foods, reducing caffeine intake, increasing exercise (weight loss if overweight), smaller more regular meals – not eating just before bed, posture while sat at work and at home – more upright to reduce reflux)

Question 44

How would you treat minor aphthous ulcers ?

Answer 44

Re-assures the patient that the symptoms described are indicative of someone suffering from minor aphthous ulcers that some individuals are more prone to suffering.

Treatment options include local anaesthetic or analgesic gels e.g orajel applied QDS, Bonjela applied max every 3 hours.

Question 45

What are some symptom specific questions to ask when investigating mouth ulcers ?

Answer 45

Number of ulcers Minor aphthous ulcers (MAUs) occur singly or in small crops. A single large ulcerated area is more indicative of pathology outside the remit of the community pharmacist.
Patients with numerous ulcers are more likely to be suffering from major or herpetiform ulcers rather than MAUs.

Location of ulcers Ulcers on the side of the cheeks, tongue and inside of the lips are likely to be MAUs.
Ulcers located towards the back of the mouth are more consistent with major or herpetiform ulcers.
Size and shape Irregular-shaped ulcers tend to be caused by trauma. If trauma is not the cause, referral is necessary to exclude sinister pathology.
If ulcers are large or very small, they are unlikely to be caused by MAUs.

Painless ulcers Any patient presenting with a painless ulcer in the oral cavity must be referred. This can indicate sinister pathology such as leukoplakia or carcinoma.

Age MAUs in young children (< 10 years) are not common, and other causes such as primary infection with herpes simplex should be considered.

Question 46

How long do minor aphthous ulcers last ?

Answer 46

pain subsides after 3 or 4 days.
They rarely occur on the gingival mucosa and occur singly or in small crops of up to five ulcers. It normally takes 7 to 14 days for the ulcers to heal, but recurrence typically occurs after an interval of 1 to 4 months

Question 47

What medication could cause mouth ulcers ?

Answer 47

A number of case reports have been received of medication causing ulcers. These include cytotoxic agents, nicorandil, alendronate, nonsteroidal antiinflammatory drugs (NSAIDs), and beta blockers. Ulcers are often seen at the start of therapy or when the dose is increased.

Question 48

when would you refer someone when investigating mouth ulcers?

Answer 48

Children < 10 years MAUs rare; hand, foot, and mouth disease possible in this age group As soon as practicable

Ulcers > 1 cm in diameter
Ulcers in crops of 5–10 or more
Associated eye involvement
Duration longer than 14 days	
any of these suggest other causes of ulceration outside scope of community pharmacist

Painless ulcer-Possible sinister pathology- refer as soon as possible

Question 49

What are the treatments for Minor aphthous ulcers ?

Answer 49

None of them really reduce duration but pain

Choline salicylate- Bonjela - >16 years
Lidocaine > 7 years (Iglu)
Benzocaine - Orajel - >12 years
lidocaine - bonjela junior - >5 months

Question 50

What are some symptom specific questions when investigating diarrhoea ?

Answer 50

Nature of the stools Diarrhoea associated with blood and mucus (dysentery) requires referral to eliminate invasive infection such as Shigella, Campylobacter jejuni, Salmonella, Clostridium difficile and Escherichia coli O157.
Bloody stools are also associated with conditions such as inflammatory bowel disease.

Periodicity A history of recurrent diarrhoea of no known cause should be referred for further investigation.

Duration A person who presents with a history of chronic diarrhoea should be referred. The most frequent causes of chronic diarrhoea are irritable bowel syndrome (IBS), inflammatory disease, and colon cancer.

Onset of symptoms Ingestion of bacterial pathogens can give rise to symptoms in a matter of a few hours (toxin-producing bacteria) after eating contaminated food or up to 3 days later. It is therefore important to ask about food consumption over the last few days, establish if anyone else ate the same food, and check the status of his or her health.

Timing of diarrhoea Patients who experience diarrhoea first thing in the morning might have underlying pathology such as IBS.

Recent change of diet Changes in diet can cause changes to bowel function; for example, when away on holiday. If the person has recently been to a non-Western country, giardiasis is a possibility.

Signs of dehydration Mild (< 5%) dehydration can be vague but includes tiredness, anorexia, nausea and light-headedness
Moderate (5%–10%) dehydration is characterized by dry mouth, sunken eyes, decreased urine output, moderate thirst and decreased skin turgor (pinch test of 1–2 seconds or longer).

Question 51

What would advise be for constipation during pregnancy ?

Answer 51

Advice in Pregnancy would be largely unchanged. If dietary and lifestyle measures fail, then the use of Bulk Forming laxatives like Fybogel are first-line treatment. Osmitic laxatives such as Lactulose are an option also.

Stimulant laxatives like Senna or Bisacodyl should be avoided near term or if there is any history of unstable pregnancy. Over the counter, Fybogel or Lactulose are the preferred choice….with a conditional referral to the GP if symptoms do not improve.

Question 52

What would you advise a patient with opioid induced constipation ?

Answer 52

This is not a consideration with this patient, but if you ever encounter a patient with opioid-induced constipation bulk-forming laxatives should not be used. An osmotic laxative and a stimulant laxative are recommended, as well as advice to see GP.

Question 53

What are the symptoms of colic?

Answer 53

• Inconsolable loud crying with limb flexure in an otherwise healthy, thriving infant
• which lasts for more than 3 hours per day,
• occurs on 3 or more days per week,
• has persisted for more than 3 weeks starting in the first weeks of life and ceasing around 3 to 4 months of age.
• The crying most often occurs in the late afternoon and/or evening and the baby typically draws its knees up to its abdomen or arches its back when crying.
• The baby cannot be distracted from crying and usual soothing techniques are ineffective.
• The baby will often become red and flushed in the face.

Question 54

What are warning signs that you need to check for in colic?

Answer 54

• bile-stained vomiting
• forceful vomiting
• vomiting onset after 6 months of age
• faltering growth
• abdominal tenderness/distension
• fever
• lethargy
• enlarged spleen and/or liver
• bulging anterior fontanelle
• small or enlarged head circumference
• seizures
• significantly disturbed stool pattern
• sudden onset inconsolable crying
• documented or suspected genetic/metabolic syndrome

Question 55

What is the best advise for colic?

Answer 55

• Reassure the parents that their baby is well; they are not doing something wrong, the baby is not rejecting them and that colic is a common phase that will pass within a few months.
• Holding the baby through the crying episode may be helpful.
• However, if there are times when the crying feels intolerable, it is best to put the baby down somewhere safe (such as their cot) and take a few minutes time-out.
• Burping meticulously post-feeds, gentle motion (pushing pram or ride in the car), ‘white noise’ (vacuum cleaner, hairdryer etc.) and bathing in a warm bath may help.
• Parents should also be encouraged to look after their own well-being, e.g. by asking family and friends for support and resting when the baby is asleep.