R.CHAPTER 1- Gastro Intestinal System Flashcards
Example of chronic bowel disorder?
- Coeliac Disease
- IBD (Inflammatory bowel disease)
- IBS(Irritable bowel syndrome)
- Diverticulitis & diverticulitis disease
- short bowel syndrome
Symptoms chronic bowel disorder?
Abdominal pain
Diarrhoea
Rectal Bleeding
coeliac Disease?
- Autoimmune condition associated with chronic inflammation of small intestines
- Immune response triggered by gluten
- leads to malabsorption of nutrients
Symptoms of coeliac Disease?
- Abdominal Pain
- Bloating
- Constipation
- Diarrhoea
How to reduce complications of Coeliac disease?
Calcium & vit D, folic acid, iron.
Reduce complications of osteoprosis/bone diease. Lack of iron- anaemia
Non-drug treatment of Coeliac Disease?
Strict, lifelong, gluten free diet.
Drugs used in Coeliac Disease?
- Supplementation with calcium, vitamin D and folic Acid
- Osteoprosis & bone disease treatment
- prednisolone (initial management whilst awaiting specialist advice)
- bisphosphonates
Diverticular Disease
-Diverticula causes intermittent lower abdominal pains without inflammation or infection.
Diverticular prevalence
Increase with age, mainly patients >40
Diverticular-Non drug treatment
Diet and lifestyle changes
Eat healthy, balanced diet, increase fibre,
weight loss, stop smoking, exercise.
Diverticular treatment
No antibiotics,
bulk forming laxatives-eg ispaghul husk
Paracetamol
Antispadmotics
Drugs that may increase perforation of diverticular disease?
Nsaids and opioids
Diverticulitis symptoms
- Infected or inflamed diverticula
- more severe abdominal pain
- fever & general malaise
- Large rectal bleeds
- Fistula
Diverticulitis treatment?
- High fibre diet
- bran supplement
- bulk forming laxative
- antispasmodics (relief colic)
- antibiotics (signs of infection)-eg co-amoxiclav
- elective surgery
Drugs to avoid in diverticulitis
Anti-motility drugs (codeine phosphate & loperamide)
Inflammatory Bowel Disease (IBD)
and cause
2 conditions;
-chron’s disease
-ulcerative colitis
caused by genetic factors and problems with immune system
IBS
similarity between chrons & ulcerative colitis
- long term conditions
- inflammation of the gut
IBS- what is Chron’s
inflammation of any part of digestive system from mouth to bottom
IBS- What is Ulcerative colitis
inflammation of colon (large intestine)
Inflammatory bowel disease symptoms
- Abdominal pain
- rectal bleeding
- diarrhoea
- fever
- weight loss
- anal fissure
- ulcers
- anaemia
- mouth ulcers
other sypmtoms of IBS
-Inflammation and pain of some joints (arthritis)
-skin rashes
-inflammation of middle layer of eye (uveitis)
-liver inflammation
NB;symptoms come and go
complications of chron’s
- stricture(narrowing of GI tract)-leads to difficulty in passing food leading to vomiting and sickness
- perforation; holes in the GI tract. contents of GI tract leak out and cause infection or abscess in abdomen (can be serious or life threatening)
- Fistula
- cancer (higher risk of developing colon cancer than general population)
chron’s non-drug treatment
Diet change
stop smoking
stress management
bowel condition worsen by stress
Drugs used to treat IBD
- Aminosalicylates; eg mesalazine, balsalazide, olsalazine and sulphasalazine (may stain some soft contact lenses) >reduce inflammation in gut
- immunosuppresants (affecting immune response):methotrexate, azathioprine, mercaptopurine (reduce activity of immune response
- biologic therapy (monoclonal antibodies):infliximab, adalimumab, golimumab. Require specialist supervision
- corticosteroids - use when symptoms are severe but not for maintainance (oral prednisolone, methylprednisolone, budesonide, hydrocortisone)
- antibiotics
- other medication>to treat diarrhoea and constipation
Ulcerative colitis
Acute mild to moderate ulcerative colitis
1) proctitis-1st line(topical aminosalycilate) if no improvement after 4 weeks then add oral aminosalicylate if no improvement add oral or topical corticosteroid
2) proctosigmoiditis and left sided ulcerative colitis-1st line topical aminosalicylate
3) Extensive ulcerative colitis: 1st line (topical) aminosalicylate and high dose oral aminosalicylate.
Treatment for severe ulcerative colitis (life threatning)
i.v corticosteroids & infliximab
How to maintain remission in mild to moderate ulcerative colitis
- use aminosalicylates
- avoid corticosteroids because of side effects
- oral azathioprine or mercaptopurine used when two or more inflammatory exacerbations in a 12month period that required a systemic corticosteroid.
Drug treatment for UC
- High fibre or low residue diets
- Antimotility drugs (codeine/loperamide)
- colestyramine: can improve diarrhoea
UC- Aminosalicylates
- sulfasalazine- older aminosalicylates>more side effects (stain contact lenses-yellow)
- newer aminosalicylates: mesalazine, basalazine and olsalazine (fewer side effect)
- bone marrow suppression>report any bruising, bleeding, purpura, sore throat, fever or malaise.
- perform blood count and stop drug immediately if suspicion of blood dyscrasia
- monitor renal function before starting at 3 months of treatment and then annually during treatment
uc- Aminosalisylates side effects
- Nephrotoxicity
- Salicylate hypersensitivity
- yellow/orange bodily fluids with sulfasalazine (soft contact lenses may be stained
- corticosteroids, immune response
Irritable bowel syndorme (IBS)
- long term chronic condition of the bowel
- mainly affects people aged 20-30yrs
- more common in women
symptoms of IBS
- abdominal pain
- bloating
- diarrhoea or constipation
Ibs non-drug treatment
- diet and lifestyle changes
- increase physical activity, eat regularly without missing meals
- limit fresh fruit consumption
- if increase in fibre required, then use soluble fibre (e.g oats sterculia &ispaghula husk). Avoid insoluble ones (eg bran) and ‘resistant starch’ because they exacerbate symptoms
- Increase water intake (at least 8 cups daily). Reduce caffeine, alcohol, fizzy drinks
Drugs used in IBS
-Antispasmodics & antimuscarinics for abdominal pains
G.I spasms. They relax the muscles in the gut (e.g mebeverine, hyoscine, peppermint oil).
- Treating constipation: Increase fibre, use laxatives but avoid lactulose (cause bloating)
- Linaclotide works differently from others and shown to reduce pain, bloating and constipation.
- Treating diarrhoea: loperamide
- Treating bloating: peppermint oil
- Antidepressants: tricyclic antidepressants (eg amitriptyline) and SSRI (eg fluoxetine)- is unlicensed (for patients not responding to laxatives, antispasmodics or loperamide)
- cognitive therapy: CBT>relaxed
Causes of constipation
- Inadequate fibre: Fibre adds bulk to stools and improves bowel function eg fruit, vegetables, cereal and whole bread.
- Inadequate fluid intake
- medication (pain killer) eg codeine, morphine, antacids, antidepressants, iron tablets.
- medical conditions: eg underactive thyroid, IBS, some bowel disorders
- pregnancy: due to hormonal changes slowing bowel movement or baby growing bigger
Red flags for constipation
50+ Anaemia Abdo pain weight loss blood in stool
Different laxatives (BOSS)
- Bulk (bran, ispaghula husk, sterculia, methyl cellulose)
- Osmotic (macrogols (laxido), lactulose)
- Stimulant (Bisacodyl, Senna)
- Sofetners (liquid paraffin)
other: linoclotide, prucalopride
Constipation Meds
Bulk foaming laxatives (fecal softner)
- Increase bulk in the stool like fibre
- Onset of action up to 72hrs
- Occasionally can cause symptoms of bloating, cramping and flatulence
- Used in: colostomy, ileostomy, haemorrhoids and anal fissures, IBS, divertular disease & ulcerative colitis
Stimulant laxatives
(eg bisacodyl, sodium picosulfate, senna, glyceral & co-danthrusate)
-co-danthramer (only reserved for terminally ill patients to treat constipation due to its carcinogenecity and colours urine red)
-increase intestinal motility
-onset 8-12hrs (bedtime dose recommended)
-stimulant laxative suppositories act quicker within 20-60mins
-SE-abdominal cramps, abuse risk which may cause hypokalaemia
Faecal softener: decrease surface tension and increase penetration of liquid into faecal mass. softens and wets faeces.
Liquid parafin (avoid, anal seapage with prolonged use)- can cause malabsorption of fat soluble vitamins (ADEK)
Docusate sodium (most commonly used softener, weak stimulant activity)
Peanut (arachis) eneama soften and lubricate faeces.
Ostmotic laxative
2 types (lactulose & macrogols 3350):
Increase amount of water in large bowel either by drawing fluid from body into bowel or maintaining fluid in the bowel
-Lactulose can take up to 2days for max effect, not suitable for immediate relief
-side effects of lactulose (abdominal pain and bloating)
-macrogols act faster e.g movicol
-Stronger osmotic laxatives (e.g phosphate enemas & magnesium salts) used to clear bowel quickly
constipation
MHRA advice on stimulant laxatives?
- new pack size restrictions
- age
- safety warnings
- only use stimulant laxatives if other (bulk, osmotic) are not effective.
- children<12
Constipation Management
- short duration constipation (bulk, osmotic, stimulant)
- pregnancy (BOS)
- chronic constipation (BOS)
- opioid induced constipation (OS/Naloxegol/methylnatrexone-avoid bulk)
- Faecal Impactions (OS)
- children (OS)avoid<12yrs (FOC, OS children)
Patient and carer advice for bulk forming laxative
preperations that swell in contact with liquid should be carefully swallowed with water. not to be taken immediately before going to bed. may take a few days to develop.
