Week 22 - gastrointestinal Flashcards

1
Q

Mouth ulcers - traumatic

A

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

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2
Q

Mouth ulcers – recurrent aphthous stomatitis

A

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

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3
Q

Mouth ulcers - causes

A

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

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4
Q

Mouth ulcers - treatment

A

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

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5
Q

Mouth ulcers - when to refer

A

-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

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6
Q

Dyspepsia

A

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

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7
Q

Dyspepsia – common causes

A

-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

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8
Q

Gastric-oesophageal reflux disease (GORD)

A

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

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9
Q

GORD – triggers/risk factors

A

-Smoking
-Alcohol
-Coffee
-Chocolate
-Fatty foods
-Being overweight
-Stress
-Medicines (calcium channel blockers, nitrates, NSAIDs)
-Tight clothing
-Pregnancy

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10
Q

Peptic Ulcer Disease (PUD)

A

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
Peptic Ulcer Disease (PUD)

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11
Q

Dyspepsia – management

A

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

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12
Q

Dyspepsia – non-pharmacological

A

-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

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13
Q

Dyspepsia - antacids & alginates

A

-Antacid: Compounds that neutralise stomach acid
Examples: sodium bicarbonate, calcium carbonate, magnesium hydroxide
-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
Many products use a combination of both
Liquid Formulations:
-Faster onset of action
-Easier to take
-Bulky bottles and viscous liquid
Solid formulations:
-Portable and convenient
-More palatable
-Chew well then swallow
->Antacid: Pepto-Bismol®, Rennie®
->Alginate: Gaviscon Advance®
->Dual Product: Gaviscon Dual Action®, Peptac®

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14
Q

Dyspepsia – H2 receptor antagonists

A

-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

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15
Q

Dyspepsia – proton pump inhibitors

A

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

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16
Q

Dyspepsia -> when to refer to GP

A

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

17
Q

Nausea and vomiting

A

-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

18
Q

Nausea and vomiting continued

A

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

19
Q

Constipation

A

-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

20
Q

Constipation - symptoms

A

-Abdominal discomfort
-Cramping
-Bloating
-Nausea
-Straining

21
Q

Constipation - red flags (when to refer)

A

-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

22
Q

Medication that can cause constipation:

A

-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

23
Q

Constipation treatment – non-pharmacological

A

-Increase fibre intake
-Increase fluid intake
-Increase exercise

24
Q

Constipation treatment - pharmacological

A

-Bulk-forming
-Osmotic
-Stimulant
-Faecal softener

25
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
26
Diarrhoea - symptoms
-Three or more lose, watery stools in 24 hours -Faecal urgency -Abdominal cramps -Abdominal pain -+/- nausea and vomiting
27
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
28
Diarrhoea - treatments
-Oral re-hydration therapy, e.g. Dioralyte -> first-line therapy even when referring ->Quantities (general rule of thumb) Quantity of solution (per watery stool): -Under 1 -> 50ml -1 to 5 years -> 100ml -6 to 12 years -> 200ml -Adult -> 400ml
29
Diarrhoea - OTC treatment
-Loperamide -> over 12s only -Kaolin +/- morphine
30
Diarrhoea -> when to refer to GP
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
31
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
32
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
33
Haemorrhoids - 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)
34
Haemorrhoids - treatment
Usually self-limiting and heal within a week ->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)
35
Haemorrhoids -> when to refer to GP
Persistent change in bowel habit: -Presence of diarrhoea -Faecal incontinence -Over 40 years Systemic symptoms: -Extreme pain on defecation -Weight loss -Family history of colorectal cancer or IBS Patient can feel a mass: -Manual manipulation of prolapsed haemorrhoids required -Abnormalities on photo image