Session 8 - Group Work

Question 1

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
a) Why has he been getting liquid poo on his pants?

Answer 1

Overflow diarrhoea - always have a liquid poo proximally in the colon but it hasn’t solidified due to a blockage. This also means the liquid passes around the blockage and therefore leaks out.

Question 2

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
i) Lactulose

Answer 2

Mechanism of Action - increase the amount of water in the large bowel

Route

Pro

Con

Question 3

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
ii) Movicol

Answer 3

Mechanism of Action -

Route -

Pro -

Con -

Question 4

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
iii) Senna

Answer 4

Mechanism of Action -

Route -

Pro -

Con -

Question 5

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
iv) Enema (glycerine suppository/phosphate/bisacodyl)

Answer 5

Mechanism of Action -

Route -

Pro -

Con -

Question 6

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
v) Bisacodyl

Answer 6

Mechanism of Action -

Route -

Pro -

Con -

Question 7

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
vi) Co-Danthromer

Answer 7

Mechanism of Action -

Route -

Pro -

Con -

Question 8

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.

b) For each drug, name the Mechanism of Action; Route, Pro and Con
vii) Sodium Docusate

Answer 8

Mechanism of Action - Stimulant laxative that increases intestinal motility. Acts as stimulant or stool softener by decreasing surface tension of stool and increasing penetration of fluid into stool

Route - Orally (takes 1-2 days) or per rectum (PR) (within 20 mins)

Pro - Side effects are rare; Not known to be harmful in pregnancy (use with caution); Oral solutions may be mixed with milk or squash (for children, although not recommended).

Con - Avoid in intestinal obstruction. Don’t use PR if haemorrhoids or anal fissure. Is present in milk when breastfeeding (although not known to have harmful effects - use with caution). Excessive use of stimulant laxatives can cause diarrhoea and related effects such as hypokalaemia.

Question 9

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
c) Using the NICE guidelines and BNF, how would you treat his constipation?

Answer 9

• Prescribe a macrogol (Movicol) using an escalating dose regimen
• If after 2 weeks symptoms haven’t improved, add a stimulant e.g. senna
• Start maintenance laxative treatment as soon as the bowel is disimpacted

Question 10

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
d) What information would you give his mother?

Answer 10

His symptoms will be worse initially (soiling and abdominal pain) so make sure he has easy access to a toilet.

Ensure he goes to the toilet even after the symptoms have cleared and establish a regular routine so that he doesn’t develop a fear of going to the toilet because it will hurt in.

Question 11

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
e) How will you know that your treatment has worked?

Answer 11

He’ll start going to the toilet by himself - regularly and producing a soft stool (e.g. type 4 or 5) without any pain.

Question 12

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
f) Using the NICE guidelines, how will you prevent him becoming faecally impacted again?

Answer 12

Maintenance dose of Movicol for several months after impaction so that he doesn’t develop psychological fear of going to the toilet because it hurts, causing further impaction.

Question 13

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
g) When would you consider using medication per rectum?

Answer 13

Only if oral medications do not work, and if they or their parent (if appropriate, depending on age and capacity) can consent.

Question 14

1) A 9-year-old boy presents to your GP surgery with his mother. He has been struggling to pass stool for a number of months, only opening his bowels once per week. His stools are large, hard and painful to pass. He has begun to have some soiling of liquid poo in his pants most days. On examination, you can palpate a large mass of hard stool in his lower abdomen. You do not do a PR examination as he is a child. You decide that he is faecally impacted.
h) If this history was given in a 34-year-old woman, how would your management change?

Answer 14

• Same regimen as child (Macrogol and Senna)
• If this in ineffective after 6 months then give prucalopride
• Lifestyle advice (e.g. water and fibre, exercise)

Question 15

2) A 58-year-old lady has a diagnosis of terminal malignant melanoma and is undergoing palliative care. She is known to have multiple metastases in her brain and liver. She is admitted to her local hospice for symptom alleviation. She feels nauseous most of the time and vomits 3-4 times each day. Occasionally she is confused and agitated. Her enlarged liver is causing significant abdominal pain, for which she is taking regular opiate analgesia. She has not opened her bowels for 3 days.
a) List some potential reasons for her nausea and vomiting

Answer 15

Palliative chemotherapy

Opiates can cause nausea and constipation

Question 16

2) A 58-year-old lady has a diagnosis of terminal malignant melanoma and is undergoing palliative care. She is known to have multiple metastases in her brain and liver. She is admitted to her local hospice for symptom alleviation. She feels nauseous most of the time and vomits 3-4 times each day. Occasionally she is confused and agitated. Her enlarged liver is causing significant abdominal pain, for which she is taking regular opiate analgesia. She has not opened her bowels for 3 days.

She has not yet been given any antiemetics.

b) Which drugs would you use to begin with? What route would you give them? What would be your second line if she continues to vomit?

Answer 16

• Cyclizine
• Haloperidol
• Dexamethasone

Question 17

2) A 58-year-old lady has a diagnosis of terminal malignant melanoma and is undergoing palliative care. She is known to have multiple metastases in her brain and liver. She is admitted to her local hospice for symptom alleviation. She feels nauseous most of the time and vomits 3-4 times each day. Occasionally she is confused and agitated. Her enlarged liver is causing significant abdominal pain, for which she is taking regular opiate analgesia. She has not opened her bowels for 3 days.

She has not yet been given any antiemetics.

c) We often think about side effects negatively and try to avoid them. Therefore, can you think of 2 antiemetic drugs whose side-effects you could exploit in this situation to help with her other symptoms? (Hint – think about her confusion and potential for raised intracranial pressure).

Answer 17

• Dexamethasone because decrease ICP and is an anti-emetic

- Haloperidol also helps with depression and sickness.

Question 18

2) A 58-year-old lady has a diagnosis of terminal malignant melanoma and is undergoing palliative care. She is known to have multiple metastases in her brain and liver. She is admitted to her local hospice for symptom alleviation. She feels nauseous most of the time and vomits 3-4 times each day. Occasionally she is confused and agitated. Her enlarged liver is causing significant abdominal pain, for which she is taking regular opiate analgesia. She has not opened her bowels for 3 days.

She has not yet been given any antiemetics.

Her abdomen is beginning to become more distended and painful due to hard stools which she is unable to pass.

d) Give 2 reasons why she might be constipated

Answer 18

• Opiates side effect

- Cyclizine is anti-muscarinic and can therefore cause constipation, decreases gastric motility

Question 19

2) A 58-year-old lady has a diagnosis of terminal malignant melanoma and is undergoing palliative care. She is known to have multiple metastases in her brain and liver. She is admitted to her local hospice for symptom alleviation. She feels nauseous most of the time and vomits 3-4 times each day. Occasionally she is confused and agitated. Her enlarged liver is causing significant abdominal pain, for which she is taking regular opiate analgesia. She has not opened her bowels for 3 days.

She has not yet been given any antiemetics.

Her abdomen is beginning to become more distended and painful due to hard stools which she is unable to pass.

e) Using the table you created in case study 1, which laxative/s will you give her and why?

Answer 19

Any is suitable for this patient, it just depends on the patient.

Question 20

2) A 58-year-old lady has a diagnosis of terminal malignant melanoma and is undergoing palliative care. She is known to have multiple metastases in her brain and liver. She is admitted to her local hospice for symptom alleviation. She feels nauseous most of the time and vomits 3-4 times each day. Occasionally she is confused and agitated. Her enlarged liver is causing significant abdominal pain, for which she is taking regular opiate analgesia. She has not opened her bowels for 3 days.

She has not yet been given any antiemetics.

Her abdomen is beginning to become more distended and painful due to hard stools which she is unable to pass.

f) Most hospitals and hospices have local guidelines for palliative care prescribing. Find some guidelines, and compare your choices above with those in the formal document. What would you change?

Answer 20

Methylna

Question 21

3) A 20-year-old medical student presents to A&E on a Saturday lunchtime with vomiting and profuse diarrhoea. He ate a kebab from the local take-away after getting home from a bar last night. He looks pale and sweaty but is able to walk to the examination couch.
a) What is your differential diagnosis?

Answer 21

Food poisoning - acute gastritis

Norovirus
Perforation

Question 22

3) A 20-year-old medical student presents to A&E on a Saturday lunchtime with vomiting and profuse diarrhoea. He ate a kebab from the local take-away after getting home from a bar last night. He looks pale and sweaty but is able to walk to the examination couch.

b) What do his observations show?
HR 85
RR 15
BP 124/86
SpO2 98% in air
CRT 2 secs peripherally
Temp 37.2

Answer 22

Observations are normal

Question 23

3) A 20-year-old medical student presents to A&E on a Saturday lunchtime with vomiting and profuse diarrhoea. He ate a kebab from the local take-away after getting home from a bar last night. He looks pale and sweaty but is able to walk to the examination couch.
c) What additional information do you need?

Answer 23

• Any other people with similar symptoms?
• Any blood in the vomit
• What sort of diarrhoea (define diarrhoea)

Question 24

3) A 20-year-old medical student presents to A&E on a Saturday lunchtime with vomiting and profuse diarrhoea. He ate a kebab from the local take-away after getting home from a bar last night. He looks pale and sweaty but is able to walk to the examination couch.
d) You decide that he does not need admission to hospital. What would have to change for you to keep him in?

Answer 24

Obs to change beyond normal rate

Question 25

3) A 20-year-old medical student presents to A&E on a Saturday lunchtime with vomiting and profuse diarrhoea. He ate a kebab from the local take-away after getting home from a bar last night. He looks pale and sweaty but is able to walk to the examination couch.
e) He asks for anti-sickness medication. How will you respond?

Answer 25

No, being sick is actually beneficial in this case to expel the pathogen (virus).

Question 26

3) A 20-year-old medical student presents to A&E on a Saturday lunchtime with vomiting and profuse diarrhoea. He ate a kebab from the local take-away after getting home from a bar last night. He looks pale and sweaty but is able to walk to the examination couch.
f) What additional advice will you give him?

Answer 26

• If symptoms get worse call 111
• If symptoms persist for 72 hours call 111
• Try to stay out of contact with people for 48 hours as this is the infectious period
• Don’t go to that kebab shop/drink less
• Try to call 111 next time

Question 27

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

a) What drug/s could be used to help her diarrhoea?

Answer 27

a

Question 28

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

b) How do they work?

Answer 28

b

Question 29

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

A few days later, the patient develops sudden onset severe abdominal pain, and is found on erect chest X-ray to have a bowel perforation. She is taken to the operating theatre, 120cm of diseased terminal ileum is resected, and an ileostomy is created. 2 weeks later her stoma output is found to be high.

c) What is the definition of a high output stoma?

Answer 29

c

Question 30

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

A few days later, the patient develops sudden onset severe abdominal pain, and is found on erect chest X-ray to have a bowel perforation. She is taken to the operating theatre, 120cm of diseased terminal ileum is resected, and an ileostomy is created. 2 weeks later her stoma output is found to be high.

d) Why could this be?

Answer 30

Bowel is shortened so there is less absorption, your body is just adapting

Question 31

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

A few days later, the patient develops sudden onset severe abdominal pain, and is found on erect chest X-ray to have a bowel perforation. She is taken to the operating theatre, 120cm of diseased terminal ileum is resected, and an ileostomy is created. 2 weeks later her stoma output is found to be high.

e) What could the complications of this be?

Answer 31

Malnutrition
Dehydration
Electrolyte disturbance

Question 32

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

A few days later, the patient develops sudden onset severe abdominal pain, and is found on erect chest X-ray to have a bowel perforation. She is taken to the operating theatre, 120cm of diseased terminal ileum is resected, and an ileostomy is created. 2 weeks later her stoma output is found to be high.

f) She is already on 1mg BD of loperamide. What interventions could you make to reduce the output?

Answer 32

We could add in codeine (this is more constipatory)

We could titrate the dose: the highest seen by CTF was 16 QDS!

Question 33

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

A few days later, the patient develops sudden onset severe abdominal pain, and is found on erect chest X-ray to have a bowel perforation. She is taken to the operating theatre, 120cm of diseased terminal ileum is resected, and an ileostomy is created. 2 weeks later her stoma output is found to be high.

g) She has not passed any stool per rectum since her operation. Does this mean that she is constipated?

Answer 33

No because it is coming through her ileostomy.

Question 34

4) A 29-year-old female has had a diagnosis of Crohn’s disease for 11 years. She has been treated with a variety of medicines in the past, but never had an operation. She has been admitted to hospital with a ‘flare’ of her disease. She is passing 10 watery stools per day, which contain blood and mucus. She has a temperature of 37.8 and right iliac fossa pain. The gastroenterology team have started her on a course of intravenous hydrocortisone, methotrexate, and are considering embarking on a course of infliximab, although this has not yet started.

This link should help you.
https://fg.bmj.com/content/5/3/203

A few days later, the patient develops sudden onset severe abdominal pain, and is found on erect chest X-ray to have a bowel perforation. She is taken to the operating theatre, 120cm of diseased terminal ileum is resected, and an ileostomy is created. 2 weeks later her stoma output is found to be high.

Octreotide is sometimes used for difficult to manage high output stomas.
h) What is its mechanism of action and how could this improve her situation?

Answer 34

A somatostatin analog, decreases splanchnic blood flow, inhibits serotonin which inhibits parasympathetic activity