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PMP-103 > Responding to Symptoms – Gastrointestinal > Flashcards

Responding to Symptoms – Gastrointestinal Flashcards

1
Q

GI - diseases and conditions covered:

A

Mouth ulcers
Dyspepsia
Nausea and vomiting (motion sickness covered in ENT)
Constipation
Diarrhoea
Haemorrhoids

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2
Q

Potential oscys questions
Mouth ulcers - Questions to ask

A

Is the ulceration painful?
How many ulcers do you have (clusters? speradic?)?
How long have you had the ulcer(s)?
Which sites in your mouth are affected?
Do you have any concurrent any new medicines?
Have you had a similar episode of ulceration previously? - if so, how long did the ulcers take to heal? - Are you aware away of any factors that predispose to your ulcers?

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3
Q

If the ulcer is large and no relative pain:

A

most likely to be mouth cancer

if it hurts then it is not severe

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4
Q

Mouth ulcers - traumatic

A

Usually a single, irregularly-shaped ulcer

Patient can often recall the cause
Burn – hot/cold/chemical
Biting lining of mouth
Sharp surface of tooth/denture

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5
Q

Mouth ulcers - how to treat toothache?

A

aspirin

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6
Q

Mouth ulcers – recurrent aphthous stomatitis
(condition)

A

Common – affects c.20% of population
Classified as:
Aphthous, minor (about 80% of cases)
Often in groups of up to five
Small ulcers (<1cm)
“uncomfortable”
Heal within 10-14 days
Aphthous, major (about 10% of cases)
Usually 1-3 ulcers
Larger than 1cm
Painful and may affect eating
Can take weeks to heal
Herpetiform (about 10% of cases)
Groups of 10-50 small ulcers
Very painful
Heal within 10-14 days

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7
Q

Minor - recurrent aphthous stomatitis

A

non-keratinised sites in the mouth, such as buccal mucosa, labial mucosa or the floor of the mouth

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8
Q

Major - recurrent aphthous stomatitis

A

involve any oral sites

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9
Q

Herpetiform - non-keratinised sites

A

lots of clusters of ulcers = very painful

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10
Q

What can cause ulcers?

A
  • usually unknown

Iron deficiency anaemia
Vegetarian/vegan diet often implicated
Heavy menstrual loss
Hypersensitivity
Preservatives in food (benzoic acid/benzoates)
Foods (chocolate, tomatoes)
Sodium lauryl sulfate
Psychological stress

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11
Q

How to treat ulcers; list 2 examples.

A

SALINE
Half a teaspoon of salt in a glass of warm water
Rinse frequently until ulcers subside
Any age

ANTISEPTIC (chlorhexidine)
Rinse (or spray) twice a day
Not within 30 minutes of toothpaste
Can cause temporary yellow staining of teeth
Can be used OTC from age 12

ANTI-INFLAMMATORY
Use every 1.5-3 hours
Can be used OTC from age 6

STEROID
One tablet dissolved on ulcer four times a day
Can be used OTC from age12

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12
Q

When to refer - ulcers

A

Lasts longer than 3 weeks
Keeps coming back
Painless and persistent
Grows bigger than usual
At back of throat
Bleeds or gets red and painful

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13
Q

Over the counter (OTC) treatments for ulcers
P products

A
  • Anbesol ointment/cream
    -Bonjela
  • Mouth ulcers patilles
  • Frador
  • Aloclair
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14
Q

What is Dyspepsia?

A

A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks

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15
Q

Symptoms of Dyspepsia:

A

Severity varies from patient to patient (most: mild + intermittent)

Upper abdominal pain or discomfort

Burning sensation starting in stomach, passing upwards to behind the breastbone

Gastric acid reflux

Nausea or vomiting

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16
Q

What are the common causes of Dyspepsia?

A

Gastro-oesophageal reflux disease (GORD)

Peptic ulcer disease (gastric or duodenal ulcers)

Functional dyspepsia

Epigastric Pain Syndrome

Post-prandial distress syndrome (fullness and early satiety)

Barrett’s oesophagus

A premalignant condition

Upper GI malignancy

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17
Q

GORD

A

Gastric-oesophageal reflux disease

Reduced lower oesophageal sphincter (LOS) tone

when acid made in the stomach is PUSHED back up - the OPEN LOS, (valve) allowing reflux

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18
Q

Gastric-oesophageal reflux disease is caused by:

A
  1. Transient relaxation of lower oesophageal sphincter
  2. Increased intra-gastric pressure
  3. Delayed gastric emptying
  4. Impaired oesophageal clearance of acid
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19
Q

GORD – triggers/risk factors
name as many as you can (10 in total)

A

Smoking
Alcohol
Coffee
Chocolate
Fatty foods
Being overweight
Stress
Medicines (calcium channel blockers, nitrates, NSAIDs)
Tight clothing
Pregnancy

impossible to stop all habits - approach by stopping one by one

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20
Q

Peptic Ulcer Disease (PUD)

A

Ulcers may be present in stomach or duodenum
Causes:
Helicobacter pylori infection
Medication, mainly NSAIDs (others can cause them)
Zollinger-Ellison syndrome (rare condition causing high acid secretion)

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21
Q

Can only confirm ulcers with endoscopy

A

H . pylori infection managed with eradication therapy (2 antibiotics and a PPI)

Therefore wouldn’t be managed OTC

However, patients frequently present asking for symptomatic relief

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22
Q

How to manage Dysoepsia, options?

A

Most patients have mild or intermittent symptoms which may be managed through non-pharmacological means and OTC treatments

Options (NOT OTC):
Non-pharmacological
Antacids
Alginates
H2 receptor antagonists
Proton pump inhibitors

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23
Q

Dyspepsia – non-pharmacological

A

Lose weight if overweight

Eating small, frequent meals rather than large meals

Eat several hours before bedtime

Cut down on tea/coffee/cola/alcohols

Avoid triggers, e.g. rich/spicy/fatty foods

If symptoms worse when lying down, raise head of bed (do not prop up head with pillows)

Avoid tight waistbands and belts, or tight clothing

Stop smoking

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24
Q

What is Antacid?
(treatment of dyspepsia)

A

Compounds that neutralise stomach acid

Examples: sodium bicarbonate, calcium carbonate, magnesium hydroxide

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25
Q

What is Alginate?
(treatment of dyspepsia)

A

Form a ‘raft’ on top of stomach contents, creating a physical barrier to prevent reflux

Example: sodium alginate
Usually contain sodium bicarbonate to help ‘raft’ to float to top of stomach

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26
Q

Many products to treat dyspepsia use a combination of …

A

liquid and solid formulations

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27
Q

Liquid formulations (treat dyspepsia)

A

faster onset of action

easier to take

bulky bottles and viscous liquid

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28
Q

Solid formulations

A

Portable and convenient

More palatable (tastes better)

Chew well then swallow

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29
Q

aluminium hydroxide can cause (side-effects)
Aluminium salts:

A

constipation

30
Q

Magnesium salts:

A

diarrhoea

31
Q

What are brands/ products of antacid?

A

Pepto-Bismol®, Rennie®

32
Q

What are brands/ products of Alginate?

A

Gaviscon Advance®

33
Q

Dual Product: contain both antacid and alginate

A

Gaviscon Dual Action®, Peptac®

34
Q

Dose for treatments of dyspepsia?

A

Dose
Usually a PRN dose
After meals and before bedtime

35
Q

Dyspepsia – H2 receptor antagonists

A

Ranitidine and famotidine available OTC

Longer duration of action and longer onset of action than antacids

Block H2 receptors in stomach to prevent acid production

For the short-term symptomatic relief of dyspepsia

Also to prevent symptoms arising if associated with food or drink consumption when they cause sleep disturbances

36
Q

Dyspepsia – proton pump inhibitors

A

PPIs block proton pumps in stomach wall to prevent gastric acid production
Takes 1-4 days to work fully, so may need to cover with antacids until it kicks in

37
Q

Esomeprazole + common s/e =

A

“Nexium control” - branding
GI disturbances, headache, abdo pain

Can increase risk of GI infections such as Campylobacter

38
Q

Can Esomerprozole be sold OTC?

A

Can be sold OTC to adults aged 18 years old and over

39
Q

Dosage for proton pump inhibitors:

A

Omeprazole (Losec®, Pyrocalm®)
Dose: 20mg OD (come as 10mg tablets)

Pantoprazole
Dose: 20mg OD (come as 20mg tablets)

Esomeprazole (Nexium®)
Dose: 20mg OD (come as 20mg tablets)

40
Q

When to refer for dyspepsia?

A

Beware of patients frequently attending for dyspepsia remedies

Dyspepsia remedies may mask signs of gastric cancer

41
Q

Red flag signs:
DYSPEPSIA

A

55 years or over, especially with new onset

Dyspepsia hasn’t responded to treatment

Features including bleeding, dysphagia, recurrent vomiting or unintentional weight loss

42
Q

Serious signs of dyspepsia which leads to referral&raquo_space;»

A

Patients over 55 years with new onset symptoms

Patients over 55 years with unexplained

dyspepsia that hasn’t responded to 2 weeks of treatment

Patients who have continuously taken remedies for 4 weeks (risk of rebound indigestion)
Pregnant or breastfeeding

Red flag symptoms:
Unintentional weight loss
Epigastric mass
Stomach pain, pain/difficulty when swallowing
Persistent vomiting
Jaundice

43
Q

Nausea and vomiting > groups which are most likely to be affected

A

Age: very young and old most at risk of dehydration
Pregnancy: n&v common, consider in women of childbearing potential
Duration: adults >2 days cause for concern, young children (<2 years) any duration

44
Q

Pyloric stenosis (nausea and vomiting)

A

Pyloric stenosis in young children – stricture in stomach, projectile vomiting, differentiate from normal vomit

45
Q

Associated symptoms:

A

diarrhoea – may be gastroenteritis, question about food intake, could be rotavirus in children

blood in vomit – differentiate fresh blood from that of gastric/duodenal origin

faecal smell – GI tract obstruction

46
Q

Medication for nausea and vomiting

A

NSAIDs/aspirin, antibiotics, oestrogens, steroids, digoxin, lithium, etc.

47
Q

Management for nausea and vomiting:

A

Most established vomiting will require referral

Motion sickness covered in ENT lecture

48
Q

Rotavirus
symptoms?
meds?

A

tends to occur in clusters and comes with cold-like symptoms.
Vomiting without other symptoms in the young may be meningitis.
Medication – important to differentiate that which you expect from the abnormal or signs of toxicity

49
Q

Constipation

A

Prevalence of around 8.2% of UK adults

Sometimes difficult to define as need patient info on normal frequency for them

Women and older people (esp. >70 yrs) more frequently affected

50
Q

What chart do we use to recognise constipation?

A

Bristol stool chart

51
Q

It is constipation if:

A

bowel movement less than three times a week
difficult to pass stools
hard, dehydrated stools

52
Q

Patients + constipation

A

Some people think you need to poo every day, but this is not the case.

Women due to hormonal changes – also sometimes an issue in pregnancy.

Older people due to more sedentary lifestyle, lower fluid intake, diet, delaying going to the toilet because of mobility

53
Q

Symptoms of constipation:

A

abdominal discomfort
cramping
bloating
nausea
straining

54
Q

Red flag symptoms (refer) - constipation:

A

rectal bleeding
family history of colon cancer or inflammatory bowel disease
signs of obstruction
co-existing diarrhoea
long-term laxative use
failed OTC > 1 week

55
Q

Constipation = Signs of obstruction:

A

feeling bloated and full, pain (usually colicky tummy pain), feeling sick, vomiting large amounts (including undigested food or bowel fluid), constipation (shown by not passing wind and no bowel sounds) – so some of the “normal” symptoms, but worse and sometimes prolonged

Failed OTC up to 2 weeks if dietary advice given first

56
Q

Medication that can cause constipation
Remember (useful for oscys)

A

Opioid analgesics
Antacids – aluminium
Antimuscarinics (anticholinergics)
Anti-epileptics
Anti-depressants
Anti-histamines
Anti-psychotics
Parkinson’s medication
Calcium-channel blockers
Calcium supplements
Diuretics
Iron
Laxatives (!)

57
Q

Treatment – non-pharmacological
for constipation

A
  • ^ fibre intake
  • ^ fluid intake
  • ^ exercise
58
Q

a) Treatment - pharmacological

A
  1. Bulk-forming, e.g. ispaghula husk, methylcellulose
  2. Osmotic, e.g. lactulose, macrogols

Both take 2-3 days to work
Bulk-forming – essentially undigestible fibre
Osmotic – draw water into the gut and so important to be well hydrated

59
Q

b) Treatment - pharmacological

A
  1. Stimulant, e.g. senna, bisacodyl, sodium picosulfate, glycerin
  2. Faecal softener

stimulate muscles in the lining of the gut, usually work within 6-12 hours (faster in the case of supp – 1hr)
Faecal softener – allow liquids to penetrate hard stools, may help to lubricate gut, work in a couple of days orally – very quickly rectally

60
Q

Diarrhoea

A

90% of acute cases associated with viral or bacterial infection
norovirus and campylobacter most common in the community
may be parasites such as giardiasis following travel to certain areas

  • MOST cases short-lived/ self-limiting and benign

Acute: symptoms less than 14 days
Persistent: symptoms more than 14 days
Chronic: symptoms more than 4 weeks

61
Q

What are the symptoms of diarrhoea?

A

Three or more lose, watery stools in 24 hours
Faecal urgency
Abdominal cramps
Abdominal pain
+/- nausea and vomiting

62
Q

Careful questioning is key
DIAHORREA

A

Age: very young and old most susceptible to dehydration
Duration: in infants > 1 day of symptoms would be worrying, in adults a few days (unless anything else concerning)
Severity: “explosive”, blood, pus
Systemic symptoms: fever, nausea and vomiting
Food intake and fluid intake, esp.in young
Anyone else in household affected
Foreign travel
Any medicines already tried

63
Q

Treatments - diahorrea

A

Oral re-hydration therapy, e.g. Dioralyte
first-line therapy even when referring

Quantities (general rule of thumb)
age 1> 50ml
1-5 years 100ml
6-12 years 200ml
Adult 400ml

[200ml is one glass]

64
Q

treatment - diahorra
give one example for age 12 and over

A

Loperamide, e.g. Imodium
over 12s only

Kaolin +/- morphine

Antimotility drugs should not be used in patients with a high fever or blood and/or mucus present in their stool (dysentery), or in confirmedE. coli(VTEC) orShigellosisinfections

65
Q

When to refer - diahorrea

A

Duration longer than:
1 day in < 1year old
2 days in < 3 year old or in older adults
3 days in older children and adults
Pregnancy
Severe vomiting
Fever
Blood or mucous in stools
Suspected reaction to prescribed medicine
Suspected outbreak of “food poisoning”
Recent foreign travel
Persistent diarrhoea following antibiotic treatment

66
Q

Heamorrhoids

A
  • Thought to affect 13-36% of the population
  • clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal
67
Q

If haemorrhoids bleed it can cause

A

anaemia

68
Q

haemorrhoids - risk factors:

A

Constipation and poor diet
Increased incidence between ages 45-65yrs
Pregnancy
Heavy lifting
Chronic cough
Certain toilet behaviours, such as straining or spending more time on a seated toilet than on a squat toilet

69
Q

Symptoms - heamorrhoids

A

External haemorrhoids
lumps and bumps around the anus
itchy (irritation from faecal matter not being fully removed by wiping)
not usually painful unless severely swollen

Internal haemorrhoids
discomfort/pain
feeling of fullness in rectum
when prolapsed, itchy and irritating
not usually painful unless prolapsed and strangulated

70
Q

Red flags - blood

A

Blood should be fresh and red.
GP referral to exclude other diagnoses should be made if the blood has a different appearance, such as darker red, brown or black, or is mixed with the stool.

These signs suggest a more proximal blood source and may be a ‘red flag’ cancer symptoms.

71
Q

treatment for Haemarrhoids

A

Usually self-limiting and heal within a week or so
Life-style measure in relation to diet and fluid intake
Analgesia as needed

Topical preparation may contain astringents, local anaesthetics, corticosteroids or a combination
Can be internal (creams, suppositories) or external (creams, gels, ointments)

72
Q

When to refer haemorrhoids

A
  • persistant change in bowel habit
  • faecal incontinence
  • over 40 years
  • extreme pain on defecation
  • weight loss
  • patient feel a mass

PMP-103 (33 decks)

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