Symptoms In Pharmacy - Gastrointestinal (w20) Flashcards
What questions should you ask when dealing with a patient who has mouth ulcers ?
- is the ulceration painful ?
- how many ulcers do you have ?
- how long have you had the ulcer(s) ?
- which sites in your mouth are affected ?
- do you have any concurrent signs or symptoms ?
- have you recently started any new medicines ?
- have you had a similar episodes of ulceration previously ?
If so, how long did the ulcers take to heal ?
Are you aware of any factors that predispose to your ulcers ?
What is an aphthous minor mouth ulcer (about 80% of cases) ?
- Often in groups of up to five
- Small ulcers (<1cm)
- “uncomfortable”
- Heal within 10-14 days
What if a aphthous major mouth ulcer (about 10% of cases) ?
- Usually 1-3 ulcers
- Larger than 1cm
- Painful and may affect eating
- Can take weeks to heal
What is a herpetiform mouth ulcer (about 10% of cases) ?
- Groups of 10-50 small ulcers
- Very painful
- Heal within 10-14 days
What is a traumatic ulcer ?
And how are these typically caused ?
- usually a single, irregularly shaped ulcer.
caused by :
- burn- hot/ cold/ chemical
- biting lining of mouth
- sharp surface of tooth/denture
What can cause mouth ulcers ?
- 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
What are some treatments given to patients with mouth ulcers ?
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 (benzydamine)
Use every 1.5-3 hours
Can be used OTC from age 6
Steroid (hydrocortisone)
One tablet dissolved on ulcer four times a day
Can be used OTC from age12
When do you refer a patient with a mouth ulcer ?
- if it 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.
What is dyspepsia ?
A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks
What are the symptoms of dyspepsia ?
Symptoms
- 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
List 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
What mechanisms cause gastric-oesophageal reflux disease (GORD) ?
Caused be a range of mechanisms:
1) Transient relaxation of lower oesophageal sphincter
2) Increased intra-gastric pressure
3) Delayed gastric emptying
4) Impaired oesophageal clearance of acid
What are some triggers/ risk factors of GORD ?
- Smoking
- Alcohol
- Coffee
- Chocolate
- Fatty foods
- Being overweight
- Stress
- Medicines (calcium channel blockers, nitrates, NSAIDs)
- Tight clothing
- Pregnancy
What causes Peptic ulcer disease (PUD) ?
- Helicobacter pylori infection
- Medication, mainly NSAIDs (others can cause them)
- Zollinger-Ellison syndrome (rare condition causing high acid secretion)
How is dyspepsia managed ?
Give some options for management ….
- Most patients have mild or intermittent symptoms which may be managed through non-pharmacological means and OTC treatments
Options :
- Non-pharmacological
- Antacids
- Alginates
- H2 receptor antagonists
- Proton pump inhibitors
What are non-pharmacological treatments to treat dyspepsia ?
- Lose weight if overweight
- Eating small, frequent meals rather than large meals
- Eat several hours before bedtime
- Cut down on tea/coffee/cola/alcohol
- 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 are antacids ?
(Used in treatment of dyspepsia)
Compound that neutralise stomach acid
E.g. sodium bicarbonate, calcium carbonate, magnesium hydroxide
What’s are alginates ?
(Used in treatment of dyspepsia)
They 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
What is the point of H2 receptor antagonists ?
- 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
Esomepraole is a proton pump inhibitor (PPI) what is its function ?
- 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
When to refer patients with dyspepsia >?
Beware of patients frequently attending for dyspepsia remedies
Dyspepsia remedies may mask signs of gastric cancer
What’s red flag signs of 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
What are three associated symptoms to nausea and vomiting ?
- 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
What are some medications given to patients with nausea/ vomiting ?
Medication: opioids, NSAIDs/aspirin, antibiotics, oestrogens, steroids, digoxin, lithium, etc.
How can you help identify constipation ?
- bowel movement less than three times a week
- difficult to pass stools
- hard, dehydrated stools
Who is mainly affected by constipation ?
- women and older people (esp. >70yrs) more frequently affected
What are some symptoms of constipation ?
- abdominal discomfort
- cramping
- bloating
- nausea
- straining
What are some red flags symptoms of constipation which may lead to referral ?
- unexplained weight loss
- 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
What are some medications that can cause constipation ?
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 (!)
What are some non-pharmacological treatment options fro constipation ?
- increase fibre intake
- increase fluid intake
- increase exercise
What are some pharmacological treatment options for constipation ?
- bulk forming e.g. methylcellulose, ispaghula husk
- osmotic e.g. lactulose, macrogols
- stimulates e.g. senna, glycerin, bisacodyl
- faecal softener
What is classed as chronic diarrhoea ?
Symptoms more than 4 weeks
What is acute diarrhoea ?
When symptoms last less than 14 days
What is persistent diarrhoea ?
Symptoms last more than 14 days
What are some symptoms of diarrhoea ?
- Three or more lose, watery stools in 24 hours
- Faecal urgency
- Abdominal cramps
- Abdominal pain
- +/- nausea and vomiting
What are some treatment options for diarrhoea ?
- oral re-hydration therapy e.g. dioralyte (first lien of therapy even when referring)
- loperamide e.g. Imodium - 12 + only
- kaolin +/- morphine
When do you refer a patient with diarrhoea ?
- 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
What are heamorrhoids ?
Haemorrhoids are clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal
What risk factors are there surrounding haemorrhoids ?
- 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
What are symptoms of internal and external haemorrhoids ?
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
Both may bleed (especially after passing stools)
What is the treatment for haemorrhoids ?
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)
