Week 22 - gastrointestinal Flashcards
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
Mouth ulcers - causes
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
Mouth ulcers - treatment
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
Mouth ulcers - when to refer
-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
Dyspepsia
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
Dyspepsia – common causes
-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
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
GORD – triggers/risk factors
-Smoking
-Alcohol
-Coffee
-Chocolate
-Fatty foods
-Being overweight
-Stress
-Medicines (calcium channel blockers, nitrates, NSAIDs)
-Tight clothing
-Pregnancy
Peptic Ulcer Disease (PUD)
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)
Dyspepsia – 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
Dyspepsia – non-pharmacological
-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 - antacids & alginates
-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®
Dyspepsia – H2 receptor antagonists
-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
Dyspepsia -> when to refer to GP
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
Nausea and vomiting continued
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
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
-Abdominal discomfort
-Cramping
-Bloating
-Nausea
-Straining
Constipation - red flags (when to 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
Constipation treatment – non-pharmacological
-Increase fibre intake
-Increase fluid intake
-Increase exercise
Constipation treatment - pharmacological
-Bulk-forming
-Osmotic
-Stimulant
-Faecal softener
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
Diarrhoea - symptoms
-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
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
Diarrhoea - OTC treatment
-Loperamide -> over 12s only
-Kaolin +/- morphine
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
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
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)
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)
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
