unit 6 Flashcards
condition
What is Mumps and its risks?
Mumps is an infection of the parotid gland caused by the mumps virus (myxovirus).
5% risk of inducing sterility in males. Childhood vaccinations help prevent mumps.
What is Xerostomia and its causes?
Xerostomia is dry mouth, affecting 2-20% of people on medications.
Causes include:
* Autoimmune diseases
* Diabetes
* Age-related atrophy of glands
* Side effects of medications
What is Sjogren’s Syndrome?
Sjogren’s syndrome is an autoimmune inflammatory disease that reduces secretion of saliva and tears.
Symptoms include dry mouth (xerostomia) and dry eyes (xerophthalmia).
What are the consequences of Xerostomia?
Consequences of Xerostomia include:
* Difficulty swallowing
* Halitosis (bad breath)
* Dental caries (cavities)
* Gum disease
* Mouth infections
* Ulcers in the mouth
* Impaired speech
* Problems with dentures
How does Xerostomia affect digestion?
Impaired digestion due to a lack of sufficient salivary amylase being secreted from the pancreas.
What are the symptoms of disorders of deglutition?
Symptoms include:
* Dysphagia (difficulty swallowing)
* Odynophagia (painful swallowing)
* Heartburn
Sensations arising from the oesophagus are usually felt in the lower chest.
What are some causes of disorders of deglutition?
Causes include:
* Damage to cranial nerves or the swallowing center in the medulla
* Degenerative diseases affecting striate muscle or neuromuscular transmission (e.g., Myasthenia Gravis, Polio, Myotonic dystrophy)
* Defects in autonomic nerves or intrinsic nerves of the oesophagus (e.g., Chagas disease, Achalasia)
* Cancers of the oesophagus (e.g., Squamous cell carcinoma, Adenocarcinomas)
What happens to the swallowing reflex in unconscious or anesthetized individuals?
The swallowing reflex becomes inactive in unconscious or anesthetized individuals.
What is Hiatus Hernia and how does it relate to reflux oesophagitis?
Hiatus Hernia occurs when the hiatus in the diaphragm widens, allowing the upper part of the stomach to slide into the thorax.
This condition increases the risk of reflux oesophagitis.
What is Diffuse Oesophageal Spasm?
Diffuse oesophageal spasm is a condition of unknown origin characterized by thickening of smooth muscle in the oesophagus.
What is Gastro-oesophageal Reflux Disease (GORD)?
GORD occurs when gastric contents reflux into the oesophagus, often leading to symptoms like heartburn and discomfort.
What are some preventable oral diseases?
Preventable oral diseases include:
* Dental caries (cavities)
* Gum disease
* Oral pharyngeal cancers
Underprivileged groups are more impacted by these diseases.
What is the role of sugars in oral diseases?
Sugar plays a key role in the development of dental caries.
Bacteria on teeth break down carbohydrates into sugars, releasing acids that damage the enamel.
What are the benefits of using fluoride for oral health?
Fluoride helps to stop tooth decay by:
* Improving the structure of tooth enamel
* Encouraging remineralization
* Reducing the ability of bacteria to produce acids
Fluoride can be utilized through water fluoridation, salt fluoridation, or fluoridated toothpaste.
What are the adverse effects of excessive fluoride exposure?
Dental fluorosis may occur, ranging from:
* Mild (pearly flecking of teeth)
* Severe (pitting and discoloration of tooth enamel)
Legislation limits fluoride content in water to 1.5 mg/l.
What are anti-plaque agents used in oral care?
Anti-plaque agents inhibit bacterial plaque formation. Examples include:
* Bisguanide antiseptics (e.g., Chlorhexidine)
* Quaternary ammonium compounds (e.g., Cetylpyridinium chloride)
* Phenols (e.g., Listerine)
* Triclosan
What is the most effective way to prevent tooth decay?
Toothbrushing twice a day is the most effective way to prevent tooth decay.
How can oral bacteria affect overall health?
Oral bacteria can travel through the blood vessels and cause inflammation, leading to blood clots, heart attacks, and strokes.
What are antacids used for?
Antacids are used to neutralize gastric acid and provide symptomatic relief in conditions like non-ulcer dyspepsia and GORD. Common types include aluminium, magnesium, calcium, and sodium-based antacids. They are often used in combination and sometimes formulated with alginic acid to form foams that coat the epithelium and reduce reflux. Dimeticone is included to reduce flatulence.
Antacids are a common over-the-counter treatment for acid-related disorders.
How do antacids work?
Antacids neutralize hydrogen ions, increasing the pH and denaturing pepsin, reducing its activity. They may increase lower oesophageal sphincter (LOS) pressure, reduce acid reflux, protect the gastric mucosa by stimulating prostaglandin synthesis, and delay gastric emptying.
Antacids provide symptomatic relief by addressing multiple mechanisms of acid-related discomfort.
What is the role of alginates in treating acid reflux?
Alginates form a viscous mass at a high pH, trapping air bubbles and CO2, which float on the surface of the stomach contents, exerting a ‘barrier effect’ to reduce reflux. When reflux occurs, the raft formed by alginates floats above stomach contents, coating the oesophagus and protecting it from irritants. Alginates are primarily used for heartburn and reflux.
Alginates are not effective for dyspepsia.
When should antacids and alginates be used?
Antacids provide rapid relief of heartburn and dyspepsia. Alginates are useful for heartburn and reflux but not for dyspepsia. Dimeticone helps with flatulence and may reduce intragastric pressure in oesophagitis. Regular doses of antacids can be beneficial after meals or bedtime. Combination (Antacid/Alginates) is superior to plain antacids and may be useful in mild oesophagitis. Higher doses may be needed for acute treatment.
The timing and combination of these treatments can maximize their effectiveness in symptom relief.
What are H2 antagonists used for?
H2 antagonists are effective in treating:
* Peptic ulcers
* Gastro-oesophageal reflux disease (GORD)
* Upper gastrointestinal bleeding in critically ill patients
* OTC relief of acid indigestion
They are also included in multidrug regimens for eradicating H. pylori in peptic ulcer patients. H2 antagonists are less commonly used than PPIs due to limitations in inhibiting acid secretion.
H2 antagonists provide an alternative to PPIs for managing acid-related disorders.
How do proton pump inhibitors (PPIs) work?
PPIs inhibit the final step of acid secretion by irreversibly binding to the proton pump enzyme complex in the stomach. They are widely used for:
* Peptic ulcers (both duodenal and gastric)
* Erosive oesophagitis
* GORD
* GORD-related laryngitis
* Hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
Generic PPIs are available OTC for acid reflux.
PPIs are considered more effective than H2 antagonists for long-term management of acid-related disorders.
What are Proton Pump Inhibitors (PPIs) used for?
PPIs are used to treat:
- Peptic ulcers
- Erosive oesophagitis
- Gastro-oesophageal reflux disease (GORD)
- GORD-related laryngitis
- Hypersecretory conditions (e.g., Zollinger-Ellison syndrome)
Some generic PPIs are available OTC for acid reflux disorders.
How do Proton Pump Inhibitors (PPIs) work?
PPIs are suicide inhibitors that block the final step of gastric acid secretion. They irreversibly inhibit the proton pump (H⁺/K⁺-ATPase) in parietal cells.
PPIs are prodrugs activated in acidic environments of parietal cells, forming a potent electrophilic drug that binds to cysteine residues.
What is the selectivity of PPIs?
Omeprazole’s selectivity is due to its accumulation in highly acidic environments (pH 1–2) in parietal cell canaliculi, where the prodrug is converted into the active drug.
Activation occurs at low pH, ensuring the drug works specifically on parietal cells.
How are PPIs metabolized and how does metabolism affect dosing?
PPIs are primarily metabolized by CYP450 oxidation, with pantoprazole also undergoing sulphate conjugation. 3% of white Europeans are slow PPI metabolizers, affecting dosing considerations.
The (S)-enantiomer of omeprazole (Nexium) has a superior pharmacokinetic profile, leading to longer half-life and higher drug concentrations.
What are the key characteristics of PPIs in terms of their pharmacokinetics?
PPIs are lipophilic and cross cell membranes easily. They are activated by low pH in the acidic environment of parietal cells.
Their prodrug form becomes protonated and activated at low pH, covalently binding to the proton pump (H⁺/K⁺-ATPase).
Fill in the blank: PPIs are _______ inhibitors that block the final step of gastric acid secretion.
suicide
True or False: PPIs can be activated in a neutral pH environment.
False
What percentage of white Europeans are slow PPI metabolizers?
3%
Fill in the blank: The (S)-enantiomer of omeprazole is marketed as _______.
Nexium
What is the role of pH in the activation of PPIs?
Activation occurs only at low pH (pH 1–2), ensuring they act specifically on parietal cells.
The ionised form of the drug is too polar to cross membranes, restricting its action.
What is the function of prokinetic drugs?
Prokinetic drugs increase oesophageal sphincter pressure, enhance gastric peristalsis, and speed up gastric emptying
These actions help prevent oesophagitis and improve gastrointestinal motility.
What is the mechanism of action of prokinetic drugs?
5-HT4 agonists stimulate the enteric nervous system, increasing acetylcholine release. Dopamine D2 antagonists promote gastric motility by blocking dopamine’s inhibitory effect on motility
Some prokinetic drugs (e.g., metoclopramide) also have 5-HT3 antagonism effects, which can help with nausea and vomiting.
What are the common uses of prokinetic drugs?
Prokinetic drugs are used to treat:
* Gastro-oesophageal reflux disease (GORD)
* Diabetic gastroparesis
* Chemotherapy-induced nausea and vomiting
They help improve gastric motility and alleviate symptoms of delayed gastric emptying.
What are the differences between domperidone and metoclopramide?
Domperidone does not cross the blood-brain barrier, leading to fewer central nervous system side effects. Metoclopramide crosses the blood-brain barrier and can cause side effects like sedation and extrapyramidal symptoms
This is due to its dopamine D2 antagonism.
What is prucalopride, and how does it differ from other prokinetic drugs?
Prucalopride is a selective 5-HT4 agonist that promotes motility further down the gastrointestinal tract than other prokinetic drugs like metoclopramide or domperidone
It is used primarily for the treatment of chronic constipation when other laxatives fail.
What is the combination Paramax (paracetamol + metoclopramide) used for?
Paramax is used for migraine treatment and offers dual benefits:
* Paracetamol: Provides pain relief by inhibiting prostaglandin synthesis in the brain
* Metoclopramide: Enhances gastric emptying, improving the absorption of paracetamol
It also acts as an antiemetic, helping alleviate nausea and vomiting commonly associated with migraines.
What are the main causes of peptic ulcers?
Peptic ulcers are mainly caused by:
- H. pylori infection
- NSAID use
None
How is H. pylori infection diagnosed?
Diagnosis of H. pylori infection includes:
- 13C-urea breath test (detects labeled CO2 in breath)
- Endoscopy and serological antigen tests for confirmation
None
What is the survival mechanism of H. pylori in the stomach?
H. pylori survives in the stomach by:
- Producing ammonia and bicarbonate, which help it penetrate gastric mucus and withstand stomach acid
None
What is the prevalence of H. pylori in duodenal ulcer patients?
Over 90% of duodenal ulcer patients (excluding those with gastrinomas or on NSAIDs) have H. pylori infection
None
What is the treatment for H. pylori infection?
The treatment for H. pylori infection is triple therapy consisting of:
- A Proton Pump Inhibitor (PPI)
- Two antibiotics (e.g., omeprazole + amoxicillin + clarithromycin or metronidazole)
None
How effective is the treatment for H. pylori infection?
Eradication of H. pylori significantly reduces ulcer recurrence. Triple therapy is 90% successful in eradicating the infection
None
What is Oral Rehydration Therapy (ORT) used for?
ORT is used to treat acute diarrhoea by maintaining fluid and electrolyte balance.
It helps prevent severe dehydration, especially in infants, children, the elderly, and those with underlying conditions.
What does a simple ORS (Oral Rehydration Solution) contain, and why is it important?
Simple ORS contains:
* Glucose
* Sodium
* Potassium
* Chloride
* Citrate
These ingredients promote water absorption and help rehydrate the body.
It is easy to prepare and doesn’t require special equipment.
What is the difference between starch-based ORS and glucose-based ORS?
Starch-based ORS is more effective in treating cholera and rotavirus. It enhances sodium transport and reduces diarrhoea duration compared to glucose-based solutions.
Dioralyte Relief is a starch-based ORS available in the UK.
What are the signs and symptoms of dehydration?
Signs and symptoms of dehydration include:
* Dry mouth and tongue
* Thirst
* Dark yellow urine
* Fatigue or dizziness
* Decreased skin elasticity
* Rapid heartbeat or breathing
* Sunken eyes (especially in infants)
Recognition of these symptoms is crucial for timely intervention.
diarrhoea causes and key points
osmotic D
SECRETORY D
IMFLAMM D
ABNORMAL MOT D
Steatorrhoea
constipation
diarrhoea treatment
functional constipation
lack of excercise
idiopathic constipation
drug induced constipation
secondary constipation
non drug constipation therapy
constipation treatment
anti emetics
compylobacter
e choli
common viral infections
pain types
appendicitis
drug interactions
What is the role of abstinence from alcohol in managing Alcoholic Liver Disease (ALD)?
Essential for managing Alcoholic Liver Disease (ALD), especially alcoholic cirrhosis.
Reduces the risk of complications and associated mortality. Managing cofactors such as obesity, insulin resistance, smoking, malnutrition, iron overload, and viral hepatitis is crucial.
When is liver transplantation beneficial for patients with ALD?
Beneficial for patients with Child-Pugh C ALD (severe alcoholic cirrhosis) and/or MELD score ≥ 15.
Requires a 6-month abstinence period to assess potential spontaneous improvement and avoid transplantation.
What defines Alcoholic Hepatitis (AH)?
Defined by jaundice and/or ascites in patients with ongoing alcohol misuse.
What is the first-line treatment for Alcoholic Hepatitis (AH)?
Corticosteroids (prednisolone): 40 mg daily for 1 month, shown to potentially reduce short-term mortality.
Non-response to steroids indicates therapy cessation.
What is the role of Pentoxifylline in treating Alcoholic Hepatitis?
Previously considered an alternative to steroids in patients with AH and ongoing sepsis.
However, the STOPAH trial showed no improvement in outcomes with pentoxifylline.
What is the role of N-Acetylcysteine (NAC) in Alcoholic Hepatitis?
NAC is an antioxidant that replenishes glutathione stores in hepatocytes.
It is considered in combination with steroids, as this regimen has shown better 1-month survival rates.
What are the medical problems associated with hazardous alcohol consumption?
Liver: Alcoholic hepatitis, cirrhosis, liver cancer.
Gastrointestinal tract: Oral cavity cancer, esophageal neoplasm, esophageal varices, pancreatitis.
Cardiovascular system: Atrial fibrillation, hypertension, strokes, cardiomyopathy with heart failure.
Neurological system: Acute intoxication, loss of consciousness, withdrawal, seizures, subdural hemorrhage, peripheral neuropathy, Wernicke-Korsakoff syndrome, cerebellar degeneration, psychiatric problems.
What is harm reduction advice for patients with alcohol use?
Patients should avoid abruptly stopping alcohol without medical assistance.
Abrupt cessation can cause neurological complications, including withdrawal seizures.
What are withdrawal seizures in alcohol-dependent individuals?
Generalized tonic-clonic seizures typically occur 12-48 hours after the last drink, but can happen as early as 2 hours.
Most common in individuals in their 4th and 5th decades of life.
What is the mechanism of withdrawal symptoms in alcohol use?
Alcohol as a CNS depressant: Chronic use leads to adaptive changes in neurotransmitters.
GABA system: Ethanol mimics GABA, leading to receptor insensitivity over time. Cessation reduces inhibitory tone.
Glutamate system: Upregulation of NMDA receptors during chronic alcohol exposure. Stopping alcohol causes hyperexcitability, leading to seizures.
What is the first-line treatment for alcohol withdrawal?
Benzodiazepines (Chlordiazepoxide, Diazepam, etc.) are first-line treatments.
Treatment can be dosed using fixed-dose or symptom-triggered regimens. The CIWA-Ar scale is used to assess symptom severity and guide medication dosing.
What is Wernicke-Korsakoff Syndrome?
Occurs in thiamine-deficient heavy drinkers.
Wernicke’s encephalopathy: Confusion, ataxia, nystagmus. Korsakoff’s syndrome: Profound memory impairment with preservation of other intellectual functions; confabulation may be present.
How is thiamine supplementation used in alcohol-related conditions?
Oral thiamine supplementation is recommended for malnourished patients or those at risk of malnourishment or those with decompensated liver disease.
IV thiamine (Pabrinex) is recommended for patients with neurological withdrawal symptoms.
What are the key stages of liver damage caused by alcohol abuse?
Fatty liver: Accumulation of fat within the hepatocytes.
Alcoholic hepatitis: Acute right upper quadrant (RUQ) pain with jaundice, fever, and marked derangement of liver function tests (LFTs). Microscopically, there is liver inflammation.
Liver cirrhosis: Hepatocytes are damaged to the extent that they are replaced by scar tissue. This is a permanent condition. It may lead to encephalopathy, portal vein hypertension, hepatorenal syndrome, and an increased risk of infections. These patients are often malnourished.
Stages of liver damage highlight the progression from fatty liver to cirrhosis due to alcohol abuse.
What is the treatment for alcoholic liver disease?
Abstinence from alcohol is essential.
Good nutrition is critical for recovery.
Treat complications such as ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and oesophageal varices.
Diuretics may be needed for patients with ascites.
Emphasis on abstinence and nutrition as pillars of treatment.
When should a patient with alcohol withdrawal be admitted to the hospital?
Admission is recommended for acute withdrawal or high risk of seizures or delirium tremens.
Consider admission for patients who are frail, have cognitive impairment, multiple comorbidities, or lack social support.
Criteria for admission focus on the severity of withdrawal and patient vulnerability.
How should Wernicke’s encephalopathy be treated?
Urgent hospital admission is required.
Parenteral thiamine should be administered if symptoms (ataxia, ophthalmoplegia, nystagmus, acute confusion, hypotension, or hypothermia) are present.
Timely treatment of Wernicke’s is crucial to prevent lasting neurological damage.
How should individuals with mental health issues and alcohol dependence be managed?
Suicide risk: High-risk individuals should be urgently referred to mental health services.
Coexisting psychotic disorders: Refer to secondary mental health services for assessment and management.
The importance of addressing mental health in alcohol dependence is highlighted.
What advice should be given to patients with non-hospital alcohol dependence?
Avoid sudden alcohol reduction to prevent severe withdrawal symptoms.
Referral to specialist services is required for moderate/severe dependence, alcohol-related impairment, or comorbid conditions (e.g., liver disease, mental health problems).
Caution against abrupt cessation is necessary to mitigate withdrawal risks.
What is the procedure for patients with alcohol dependence regarding driving?
Dependent drinkers must notify the DVLA (Driver and Vehicle Licensing Agency) and surrender their driving license.
Healthcare professionals may need to disclose relevant information to the DVLA.
Legal obligations surrounding driving and alcohol dependence must be adhered to for patient safety.
How should comorbid conditions like depression or anxiety be managed in alcohol-dependent patients?
Treat alcohol misuse first.
Assess and treat mental health disorders if symptoms persist after 3-4 weeks of abstinence.
Addressing alcohol misuse as a priority can improve mental health treatment outcomes.
What are the principles of brief advice for alcohol misuse in primary care?
Use the FRAMES principles:
* Feedback
* Responsibility
* Advice
* Menu of options
* Empathy
* Self-efficacy
Monitor progress and offer extended interventions if necessary.
FRAMES provides a structured approach for delivering brief interventions.
What is extended brief intervention for alcohol misuse?
Conducted by trained professionals.
20-30 minute sessions, up to five sessions.
Focus on reducing alcohol consumption, risk-taking behavior, or considering abstinence.
Extended interventions are designed to provide more in-depth support.
What are the psychological interventions for alcohol misuse?
Cognitive-behavioral therapies (weekly 60-minute sessions for 12 weeks).
Social network/environment-based therapies (eight 50-minute sessions over 12 weeks).
Behavioral couples therapy (60-minute weekly sessions for 12 weeks).
Various therapeutic approaches cater to different needs and contexts in treating alcohol misuse.
What support should be offered to patients and families dealing with alcohol misuse?
Encourage self-help and participation in community networks such as Alcoholics Anonymous or SMART Recovery.
Refer to organizations like Action on Addiction and Alcohol Change UK for additional support.
Provide carer support through written/verbal information on alcohol misuse management and conduct carer assessments when needed.
Community resources play a vital role in recovery and support for families.
alcohol drugs
When should hospital admission be considered for alcohol withdrawal?
Acute withdrawal or high risk of seizures or delirium tremens.
Lower the threshold for admission in patients who are frail, have cognitive impairment, multiple comorbidities, or lack social support.
How should Wernicke’s encephalopathy be managed?
Urgent hospital admission is required.
Treat with parenteral thiamine if symptoms like ataxia, ophthalmoplegia, nystagmus, acute confusion, hypotension, or hypothermia are present.
How should mental health and psychotic disorders be managed in alcohol-dependent patients?
Suicide risk: Urgently refer high-risk individuals to mental health services.
* Coexisting psychotic disorders: Refer to secondary mental health services for assessment and management.
What is the advice for patients with non-hospital alcohol dependence?
Avoid sudden alcohol reduction to prevent severe withdrawal.
* Consider GP-supervised alcohol detoxification when feasible.
When should a specialist referral be made for alcohol-dependent patients?
For moderate/severe dependence, severe alcohol-related impairment, or comorbid conditions (e.g., liver disease, alcohol-related mental health problems).
What should dependent drinkers do regarding DVLA notification?
Notify the DVLA and surrender their driving license.
Healthcare professionals may need to disclose relevant information to the DVLA.
How should comorbid conditions like depression or anxiety be managed in alcohol-dependent patients?
Treat alcohol misuse first.
* Assess and treat mental health disorders if symptoms persist after 3-4 weeks of abstinence.
What is involved in brief advice for alcohol misuse in primary care?
Use the FRAMES principles:
* Feedback
* Responsibility
* Advice
* Menu of options
* Empathy
* Self-efficacy
Monitor progress and offer extended interventions if needed.
What is extended brief intervention in alcohol misuse treatment?
Conducted by trained professionals, lasting 20-30 minutes, with up to five sessions.
* Focus on reducing alcohol consumption, risk-taking behavior, or considering abstinence.
What are the psychological interventions for alcohol misuse?
Cognitive-behavioral therapies (weekly 60-minute sessions for 12 weeks).
* Social network/environment-based therapies (eight 50-minute sessions over 12 weeks).
* Behavioral couples therapy (60-minute weekly sessions for 12 weeks).
What support should be provided to patients and families dealing with alcohol misuse?
Encourage self-help and participation in community networks such as Alcoholics Anonymous or SMART Recovery.
* Refer to organizations like Action on Addiction and Alcohol Change UK for additional support.
* Provide carer support through written/verbal information on alcohol misuse management and conduct carer assessments when needed.
What are the early symptoms of intravenous paracetamol poisoning?
Early symptoms include nausea and vomiting, which usually settle within 24 hours.
None
What indicates the recurrence of nausea and vomiting after 2-3 days in paracetamol poisoning?
Recurrence of nausea and vomiting, along with right subcostal pain and tenderness, often indicates hepatic necrosis.
None
What is the maximum time after overdose when liver damage from paracetamol is most severe?
Liver damage is maximal 3-4 days after overdose.
None
What are the potential severe outcomes of paracetamol overdose after liver damage?
Liver failure, encephalopathy, coma, and death.
None
How should paracetamol doses be calculated for obese patients?
For obese patients (weight >110 kg), calculate the paracetamol dose using 110 kg body weight to avoid underestimating toxicity.
None
How should paracetamol doses be calculated for pregnant patients?
For pregnant patients, use the pre-pregnancy weight to calculate the potentially toxic dose.
None
What is the antidote for paracetamol poisoning?
Acetylcysteine.
None
When is acetylcysteine most effective in preventing liver damage from paracetamol poisoning?
Acetylcysteine is most effective if given within 8 hours of ingestion. Its effectiveness declines after 8 hours but may still work up to 24 hours in patients at risk of severe liver damage.
None
When might oral acetylcysteine be used in paracetamol poisoning?
Oral acetylcysteine may be used as a very rare alternative if intravenous access is not possible (unlicensed use).
None
What are the common symptoms of dyspepsia?
Symptoms of dyspepsia include:
* trapped wind
* grumbling stomach
* feeling bloated
* burping/belching
* acid reflux
* pain usually starting centrally or behind the breastbone
* heartburn
Heartburn is a common symptom of dyspepsia.
What are the main causes of dyspepsia?
Causes include:
* H. pylori infection
* history of anxiety or depression
* being female or pregnant
* smoking
* use of NSAIDs, alpha blockers, CCB, BB, aspirin, or tricyclic antidepressants
* history of abuse
CCB = calcium channel blockers; BB = beta blockers; NSAIDs = non-steroidal anti-inflammatory drugs.
What lifestyle changes are recommended for managing dyspepsia?
Recommendations include:
* avoiding large meals before bedtime (3-4 hours before)
* eating frequent small meals
* losing weight if overweight
* avoiding bending or stooping
* raising the head of the bed
* stopping smoking
* reducing caffeine, chocolate, and fat intake
These changes help avoid affecting esophageal sphincter tone.
What are the first-line treatments for dyspepsia?
First-line treatments include:
* H2 antagonists (e.g., Cimetidine, Ranitidine) for no longer than 2 weeks
* proton pump inhibitors (PPIs) which should not be taken over-the-counter for longer than 2 weeks
PPIs typically take 2 days to take effect and should be taken 30-60 minutes before food for maximum effectiveness.
What other treatments can be used for dyspepsia, although their efficacy is uncertain?
Other treatments include:
* Antacids (e.g., Rennie chewable tablets)
* Alginates (e.g., Gaviscon)
Antacids can be taken an hour before or after food.
What are the red flags that require further investigation in dyspepsia?
Red flags include:
* suspected H. pylori infection
* persistent vomiting
* unintentional weight loss
* significant GI bleeding (usually dark red stools)
* iron-deficient anemia
* suspicious barium meal
* epigastric mass
* persistent dyspepsia for 2 weeks
These symptoms warrant referral for testing and treatment.
GORD
Symptoms:
- Regurgitation of food
- Oesophagitis
- Acid reflux
- Less common – chest pain, cough, hoarseness, wheezing
Causes:
* Consumption of fatty foods
* NSAIDS, alpha blocker, CCB, BB, aspirin, tric anti (review, low dose/stop)
* Pregnancy
* Family history of GORD
* Hiatus hernia
* Pressure from straining/coughing
* Stress or anxiety
* Smoking or alcohol
Management:
* Lifestyle measures – healthy eating, weight loss, avoiding trigger food
* Eat smaller meals, 3-4hrs before bed, raise head of bed
* Smoking cessation, reducing alcohol intake
Drug Management:
Mild to Moderate
* Alginate
* Antacid (long term use not recommended)
Moderate – Severe
* PPI
* H2 antagonist
GORD in Pregnancy:
* First line dietary and lifestyle
* Second line antacid or alginate
* Third line omeprazole or ranitidine (unlicensed)
Red Flags:
- Persistent Vomiting
- Unintentional weight loss
- Significant GI bleeding (usually appears dark red in stools)
- Iron deficient Anaemia
- Suspicious Barium meal
- Epigastric mass
- Signs of heartburn/GORD in those who are on bisphosphonates - This is often a sign that they are not taking the bisphosphonate correctly
H. Pylori associated ulcer
Symptoms:
- Abdominal pain
- Usually 1-3 hours after a meal
- Relieved by food or antacids
Treatment: Full tabled outline in BNF 72 Page 65 - Infection confirmed before eradication treatment
- Triple therapy – PPI and two antibacterial (H2 used if PPI untolerated)
- No Penicillin allergy;
o 1st line, 7 days – PPI, amox, either clarithromycin or metronidazole
o 2nd line, 7 days – PP1, amox, other of two above
o Alt 2nd line, 7 days – PPI, amox, tetracy or levofloxacin
o 3rd line – Specialist - Penicillin Allergy – same as above, omit amox and use both clarithro and metra
Referral: - Specialist referral after positive infection following 2nd line therapy
NSAID associated Ulcer
Symptoms:
- Abdominal pain
- Usually 1-3 hours after a meal
- Relieved by food or antacids
Treatment: - Full dose PPI 4-8 weeks
- Do carbon 13 urea breath test to test for H. Pylori
- If positive finish 8 week use of PPI, then follow H. Pylori treatment
Management: - Stop NSAID being used if possible
- Switch to NSAID with lowest GI side effects such as ibuprofen
- Or switch to a Cox-2 inhibitor
- Provide gastro protection with a PPI long term post treatment
- This is essential in the elderly (over 65)
Irritable Bowel Syndrome (IBS)
Symptoms:
- Abdominal pain
- Bloated
- Constipation or Diarrhoea (straining urgency or incomplete evacuation)
- Passage of mucus
Causes:
* Female
Management:
- If constipation is an issue, then increased dietary fibre intake
- Ensure hydration levels (8 cups), reduce fizzy or caffeine intake
- Increase should be gradual and benefits may be seen in first few days but can take up to a few weeks to be seen properly
- Fruit and veg portion should be increased to 5 a day but limit fresh fruit to 3 portion
- Oats and Linseeds can ease bloating
- Soluble fibre is good for both diarrhoea and constipation
- For diarrhoea encourage adequate hydration
Treatment:
Antispasmodics (prevent muscle spasm)
* Mebeverine
* Peppermint oil
* Alverine Citrate
* Hyoscine
Pain
* Paracetamol or Ibuprofen
Constipation
* Bulk forming e.g. ispaghula husk (fybogel), methylcellulose
* Macrogol is the only osmotic laxative that can be used
* Short term stimulant laxative use e.g. Senna, bisacodyl
* NEVER USE LACTULOSE as cause bloating
Diarrhoea
* Loperamide
Second line if unresponsive:
* Low dose tricyclic antidepressant
* If uresponsive, SSRI considered
Red Flags:
* Children
* Older person with no previous history of IBS
* Pregnant women
* Blood in stools
* Unexplained weight loss
* Caution in patients aged over 55 years with changed bowel habit
* Symptoms/signs of bowel obstruction
* Unresponsive to treatment in 1 WEEK
