Responding to Symptoms – Gastrointestinal Flashcards
GI - diseases and conditions covered:
Mouth ulcers
Dyspepsia
Nausea and vomiting (motion sickness covered in ENT)
Constipation
Diarrhoea
Haemorrhoids
Potential oscys questions
Mouth ulcers - Questions to ask
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?
If the ulcer is large and no relative pain:
most likely to be mouth cancer
if it hurts then it is not severe
Mouth ulcers - traumatic
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
Mouth ulcers - how to treat toothache?
aspirin
Mouth ulcers – recurrent aphthous stomatitis
(condition)
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
Minor - recurrent aphthous stomatitis
non-keratinised sites in the mouth, such as buccal mucosa, labial mucosa or the floor of the mouth
Major - recurrent aphthous stomatitis
involve any oral sites
Herpetiform - non-keratinised sites
lots of clusters of ulcers = very painful
What can cause ulcers?
- 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
How to treat ulcers; list 2 examples.
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
When to refer - ulcers
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
Over the counter (OTC) treatments for ulcers
P products
- Anbesol ointment/cream
-Bonjela - Mouth ulcers patilles
- Frador
- Aloclair
What is Dyspepsia?
A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks
Symptoms of Dyspepsia:
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
What are the common causes of Dyspepsia?
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
GORD
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
Gastric-oesophageal reflux disease is caused by:
- Transient relaxation of lower oesophageal sphincter
- Increased intra-gastric pressure
- Delayed gastric emptying
- Impaired oesophageal clearance of acid
GORD – triggers/risk factors
name as many as you can (10 in total)
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
Peptic Ulcer Disease (PUD)
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)
Can only confirm ulcers with endoscopy
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
How to manage Dysoepsia, options?
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
Dyspepsia – non-pharmacological
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
What is Antacid?
(treatment of dyspepsia)
Compounds that neutralise stomach acid
Examples: sodium bicarbonate, calcium carbonate, magnesium hydroxide
What is Alginate?
(treatment of dyspepsia)
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
Many products to treat dyspepsia use a combination of …
liquid and solid formulations
Liquid formulations (treat dyspepsia)
faster onset of action
easier to take
bulky bottles and viscous liquid
Solid formulations
Portable and convenient
More palatable (tastes better)
Chew well then swallow
aluminium hydroxide can cause (side-effects)
Aluminium salts:
constipation
Magnesium salts:
diarrhoea
What are brands/ products of antacid?
Pepto-Bismol®, Rennie®
What are brands/ products of Alginate?
Gaviscon Advance®
Dual Product: contain both antacid and alginate
Gaviscon Dual Action®, Peptac®
Dose for treatments of dyspepsia?
Dose
Usually a PRN dose
After meals and before bedtime
Dyspepsia – H2 receptor antagonists
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
Dyspepsia – proton pump inhibitors
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
Esomeprazole + common s/e =
“Nexium control” - branding
GI disturbances, headache, abdo pain
Can increase risk of GI infections such as Campylobacter
Can Esomerprozole be sold OTC?
Can be sold OTC to adults aged 18 years old and over
Dosage for proton pump inhibitors:
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)
When to refer for dyspepsia?
Beware of patients frequently attending for dyspepsia remedies
Dyspepsia remedies may mask signs of gastric cancer
Red flag signs:
DYSPEPSIA
55 years or over, especially with new onset
Dyspepsia hasn’t responded to treatment
Features including bleeding, dysphagia, recurrent vomiting or unintentional weight loss
Serious signs of dyspepsia which leads to referral»_space;»
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
Nausea and vomiting > groups which are most likely to be affected
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
Pyloric stenosis (nausea and vomiting)
Pyloric stenosis in young children – stricture in stomach, projectile vomiting, differentiate from normal vomit
Associated symptoms:
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
Medication for nausea and vomiting
NSAIDs/aspirin, antibiotics, oestrogens, steroids, digoxin, lithium, etc.
Management for nausea and vomiting:
Most established vomiting will require referral
Motion sickness covered in ENT lecture
Rotavirus
symptoms?
meds?
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
Constipation
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
What chart do we use to recognise constipation?
Bristol stool chart
It is constipation if:
bowel movement less than three times a week
difficult to pass stools
hard, dehydrated stools
Patients + constipation
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
Symptoms of constipation:
abdominal discomfort
cramping
bloating
nausea
straining
Red flag symptoms (refer) - constipation:
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
Constipation = Signs of obstruction:
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
Medication that can cause constipation
Remember (useful for oscys)
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 (!)
Treatment – non-pharmacological
for constipation
- ^ fibre intake
- ^ fluid intake
- ^ exercise
a) Treatment - pharmacological
- Bulk-forming, e.g. ispaghula husk, methylcellulose
- 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
b) Treatment - pharmacological
- Stimulant, e.g. senna, bisacodyl, sodium picosulfate, glycerin
- 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
Diarrhoea
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
What are the symptoms of diarrhoea?
Three or more lose, watery stools in 24 hours
Faecal urgency
Abdominal cramps
Abdominal pain
+/- nausea and vomiting
Careful questioning is key
DIAHORREA
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
Treatments - diahorrea
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]
treatment - diahorra
give one example for age 12 and over
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
When to refer - diahorrea
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
Heamorrhoids
- 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
If haemorrhoids bleed it can cause
anaemia
haemorrhoids - risk factors:
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
Symptoms - heamorrhoids
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
Red flags - blood
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.
treatment for Haemarrhoids
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)
When to refer haemorrhoids
- persistant change in bowel habit
- faecal incontinence
- over 40 years
- extreme pain on defecation
- weight loss
- patient feel a mass
