W20 Gastrointestinal Flashcards
Mouth ulcers - Questions to ask
Is the ulceration painful?
How many ulcers do you have?
How long have you had the ulcers?
What sites in your mouth are affected?
Do you have any concurrenct signs or symptoms?
Have you recently started 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 of any factors that predispose to your ulcers?
Describe 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 – recurrent aphthous stomatitis
- 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
What are the causes of mouth ulcers?(3)
*Usually unknown, but may sometimes be:
*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 are mouth ulcers treated? (4)
- 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 age 12
When should you refer patients with mouth ulcers? (6)
*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
Examples of OTC treatments for ulcers
Anbesol
Bonjela
Mouth ulcer Pastilles
Frador
Alloclair (plus)
What is dyspepsia?
What are the symptoms?(4)
- A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks
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
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
What is Gastric-oesophageal reflux disease (GORD)?
- Transient relaxation of lower oesophageal sphincter
- Increased intra-gastric pressure
- Delayed gastric emptying
- Impaired oesophageal clearance of acid
What are the risk factors of GORD?
- Smoking
- Alcohol
- Coffee
- Chocolate
- Fatty foods
- Being overweight
- Stress
- Medicines (calcium channel blockers, nitrates, NSAIDs)
- Tight clothing
- Pregnancy
What is Peptic Ulcer Disease (PUD)?
What are the Causes? (3)
How can you confirm this disease?
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 can you manage dyspepsia?
*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
How can you manage dyspepsia?
*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
Dyspepsia – non-pharmacological treatment pathways
*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
Dyspepsia -
What are antacids?
Examples?
Antacid: Compounds that neutralise stomach acid
Examples: sodium bicarbonate, calcium carbonate, magnesium hydroxide
Pepto-Bismol®, Rennie®
What is Alginate?
Example?
Alginate: 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
Gaviscon Advance®
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: GI disturbances, headache, abdo pain
*Can increase risk of GI infections such as Campylobacter
When to refer a patient with symptoms of Dyspepsia:
Red flags?
*Beware of patients frequently attending for dyspepsia remedies
*Dyspepsia remedies may mask signs of gastric cancer
Red flag signs:
*55 years or over, especially with new onset
*Dyspepsia hasn’t responded to treatment
*Features including bleeding, dysphagia, recurrent vomiting or
unintentional weight loss
Nausea and vomiting
*Many possible causes – careful questioning needed to establish
possible cause
*Once vomiting established, little OTC will help
*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
- 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: opioids, NSAIDs/aspirin, antibiotics, oestrogens, steroids, digoxin, lithium, etc.
- Management: most established vomiting will require referral
- Motion sickness covered in ENT lecture
Constipation
- Prevalence of around 8.2% of UK adults
- Sometimes difficult to define as need patient info on normal frequency for them
- However, constipation if:
- Bowel movement less than three times a week
- Difficult to pass stools
- hard, dehydrated stools
- Women and older people (esp. >70 yrs) more frequently affected
Constipation:
Symptoms
Red flag symptoms
- Abdominal discomfort
- cramping
- bloating
- nausea
- straining
Red flag symptoms (refer)* 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
Medication 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 (!)
Non-pharmacological treatment of Constipation:
*Increase fibre intake
*Increase fluid intake
*Increase exercise
Pharmacological treatment of Constipation:
*Stimulant, e.g. senna, bisacodyl, sodium picosulfate, glycerin
Senna, Constipation relief tablets, Dulcolax, Sodium Picosulfate
*Faecal softener
- DulcoEase, Arachis Oil
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 are 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 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: diarrhoea
*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 of diarrhoea:
*Oral re-hydration therapy, e.g. Dioralyte
* First-line therapy even when referring
*Quantities (general rule of thumb)
*Loperamide, e.g. Imodium
*Over 12s only
Kaolin +/- morphine
When to refer 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
Haemorrhoids
*Thought to affect 13-36% of the population
*Haemorrhoids are clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal
*Are actually normal structures that help maintain continence in healthy people
*Name has become synonymous with “piles”, which are haemorrhoids in an abnormally swollen and symptomatic state
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
- 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)
Treatment of 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)
When to refer a patient with haemorrhoids to GP
Persistent change in bowel habit:
Presence of diarrhoea
Faecal incontinence
Systemic symptoms:
Extreme pain on defecation
Weight loss
Family history of colorectal cancer or inflammatory bowel disease
Patient can feel a mass
Manual manipulation of prolapsed haemorrhoids required
Abnormalities on photographic image
Case study:
Mr Carpenter, a 56 year old gentleman:
Experiencing Infrequent stools, difficult stool passage or seemingly incomplete defecation. He explained that it is separate dry hard lumps
Advice if you will make an OTC sale (if yes, which product?) Or will you refer to GP
Start treatment with bulk-forming laxative
If stools remain hard, add on or switch to an osmotic laxative
If stools are still soft but difficult to pass, add a stimulant laxative (Senna, bisacodyl) or decussate
Adjust doses according to symptoms and response
Advise that laxatives should be stopped once the stool becomes soft and passes easily.
Case study:
Miss Lola, a 23 year old female patient
Sore throat lasting 8 days, temp is 38.5°C but no cough. This is her 2nd episode in the last 3 months. She’s increasingly unable to swallow and feeling very unwell
What should be done?
Urgent referral (to A&E if unwell)
She has many red flag symptoms
e.g. Unable to swallow
Long duration of symptoms
Absence of cough
How to identify Scarlett fever?
Strawberry tongue in appearance
Case study:
Mrs Almond Grey
Quite distressed and suffering from menopausal symptoms. Asking for advice on self management and OTC products that can help manage her symptoms:
Menopausal symptoms include:
Vasomotor symptoms- Hot slushes, sweats
Musculoskeletal symptoms- Joint and muscle pain
Urogenital symptoms- Vaginal dryness, urinary frequency, UTIs
Other symptoms e.g. low mood and reduced libido
Self management:
- Keep cool, light clothing, cool showers, use fans
- Keep bedroom cool at night
- Avoid triggers- caffeine, spicy food, smoking, alc
- Exercise & lose weight if overweight
Mood changes
OTC preparations limited:
- Refer to GP to discuss options e.g. HRT
Vasomotor symptoms:
- Black cohosh
- Isoflavones
Urogenital symptoms:
- OTC vaginal moisturisers/lubricants for Vaginal dryness = Vagisil, Vagisan
