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gphc exam > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

What is Crohn’s Disease

A

affect whole GI tract (mouth to rectum) but patchy - thickened wall, extending through all layers with deep ulceration

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2
Q

Crohn’s complications

A
  • intestinal strictures or fistulae
  • anaemia and malnutrition
  • colorectal and small bowel cancers
  • growth failure
  • delayed puberty in children
  • extra-intestinal manifestation
  • arthritis
  • joints, eyes, liver and skin abnormalities
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3
Q

Crohn’s acute treatment if 1st flare in 12 months

A
  • monotherapy with either: pred, methylpred or IV hydrocortisone
  • if distal ileal, ileocaecal or right sided disease: budesonide if normal tx doesn’t work
  • aminosalicylates (sulfasalazine/mesalazine) can be used - reduced side effects but reduced effectiveness
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4
Q

Crohn’s acute treatment if 2+ flares in 12 months

A
  1. azathioprine or mercaptopurine
  2. methotrexate if aza/merc contraindicated
  3. severe = monoclonal antibodies
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5
Q

Crohn’s maintenance treatment

A
  • stop smoking
  • mono therapy of either azathioprine or mercaptopurine
  • methotrexate in induction or if can’t tolerate aza/merc
  • after surgery = azathioprine and metronidazole - aza alone if metro not tolerated
  • diarrhoea associated = loperamide, codeine, colestyramine (can’t use loperamide & codeine in UC)
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6
Q

What is fistulating Crohn’s disease

A

when fistula develops between intestines and perianal skin, bladder and vagina

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7
Q

Fistulating Crohn’s disease treatment

A
  • left alone if asymptomatic
  • to improve symptoms (not heal) = metronidazole +/- ciprofloxacin - metro for 1 month - no longer due to peripheral neuropathy
  • maintenance = aza/merc - infliximab if not responding - tx must last at least one year
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8
Q

Name aminosalicylates

A

sulfasalazine, balsalazine, mesalazine, olsalazine

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9
Q

Aminosalicylates side effects

A
  • nephrotoxic - monitor before inititiation, at 3 months, then annually
  • hepatotoxic - monitor monthly for first 3 months
  • blood disorders - bloods monthly for first 3 months - stop if blood dyscrasias
  • contraindicated in salicylate hypersensitivity
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10
Q

Sulfasalazine specific side effect

A

stains contact lenses and bodily fluids orangey-yellow

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11
Q

What is Ulcerative Colitis

A
  • can affect region from rectum to whole colon = bloody diarrhoea, defecation urgency, abdominal pain (affects colon)
  • common in ages 15 - 25
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12
Q

Complications of ulcerative colitis

A
  • colorectal cancer
  • secondary osteoporosis
  • VTE
  • toxic megacolon
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13
Q

Acute treatment of mild - mod ulcerative colitis summary

A
  • distal = rectal preps (suppos/enemas) - foam preparations if can’t retain liquid enema
  • extended = systemic medication
  • diarrhoea = avoid loperamide and codeine = can cause toxic megacolon (big infection)
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14
Q

Acute treatment of mild - mod proctitis UC

A
  1. topical aminosalicylate
  2. & oral aminosalicylate
  3. & topical or oral corticosteroid for 4 - 8 weeks
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15
Q

When do you move to the next stage of acute treatment of UC

A

if no improvement after 4 weeks

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16
Q

What is the difference between Crohn’s and UC

A
  • UC = continuous
  • Crohn’s = patchy
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17
Q

What if people don’t want topical aminosalicylate for acute treatment of UC

A
  • oral aminosalicylate 1st if preferred but not as effective as topical
  • if aminosalicylates contraindicated then topical or oral corticosteroid for 4 - 8 weeks
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18
Q

Acute treatment of mild - mod proctosigmoiditis and left-sided UC

A
  1. topical aminosalicylate
  2. & high dose oral aminosalicylate

2.1 OR switch to high dose oral aminosalicylate + 4-8 weeks topical corticosteroid
3. stop topicals and give oral aminosalicylate + 4-8 wks oral corticosteroids

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19
Q

Acute treatment of mild - mod extensive UC

A
  1. topical + high dose oral aminosalicylate
  2. stop topical and give high dose oral aminosalicylate + 4-8 wks oral corticosteroid
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20
Q

Acute treatment of severe UC

A
  • life-threatening = medical emergency
  • IV hydrocortisone or methylpred and assess need for surgery
  • If IV steroids contraindicated - give IV ciclosporin or surgery
  • symptoms not reducing within 72 hours = IV steroid + IV ciclosporin OR surgery
  • infliximab if ciclosporin contraindicated
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21
Q

Maintenance treatment of UC

A
  • oral aminosalicylates - more effective as OD dose but more side effects
  • not corticosteroids due to side effects
  • proctitis/proctosigmoiditis = rectal +/- oral aminosalicylate (oral alone if rectal not worked)
  • left-sided/extensive = low dose oral aminosalicylates
  • 2+ flares in 12 months = oral azathioprine or mercaptopurine - monoclonal antibodies if no effect
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22
Q

What is Coeliac disease

A
  • in small intestine - associated with gluten, wheat, barley and rye = immune response in intestinal mucosa
  • may cause malabsorption of nutrients
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23
Q

Coeliac disease treatment aims

A
  • manage symptoms - diarrhoea, bloating, abdo pain
  • avoid malnutrition - give vitamin D, calcium, and other nutrients (under supervision)
  • only effective option = avoid gluten
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24
Q

What is diverticulosis

A

small pouches along intestinal tract but asymptomatic

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25
Q

What is diverticular disease

A

small pouches along intestinal tract but symptomatic - abdo pain, constipation, diarrhoea, rectal bleed

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26
Q

What is acute diverticulitis

A

when pouches inflames/infected = severe abdo pain, constipation, diarrhoea, rectal bleed, fever

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27
Q

What is complicated acute diverticulitis

A
  • abscess
  • perforation
  • fistulas
  • obstruction
  • sepsis
  • haemorrhage
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28
Q

Diverticular disease treatment

A
  • fibre
  • laxatives
  • paracetamol
  • if needed in earlier stages
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29
Q

What is irritable bowel syndrome

A

common, chronic, relapsing, life long - abdo pain, diarrhoea or constipation, urgency, incomplete defection, passing mucus

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30
Q

Who is IBS more common in

A
  • women
  • people aged 20 - 30
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31
Q

What is IBS exacerbated by

A
  • coffee
  • alcohol
  • milk
  • large meals
  • fried foods
  • stress
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32
Q

IBS non-drug treatment

A
  • increased exercise
  • eat regular meals
  • reduce fresh fruit to 3 portions a day
  • reduce insoluble fibres
  • 8 cups of water daily
  • reduce caffeine/alcohol/fizzy drinks
  • avoid sorbitol if diarrhoea
  • reduce stress
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33
Q

OTC drug treatment of IBS

A
  • antispasmodics = alverine, mebeverine, peppermint oil
  • laxatives = if constipated (not lactulose = bloating)
  • loperamide if diarrhoea
  • antimuscarinics = hyoscine butylbromide (avoid in cardiac disease)
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34
Q

IBS treatment if OTC treatment doesn’t work

A
  • low does TCA (amitriptyline)
  • SSRI if TCA doesn’t work = unlicensed use
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35
Q

What is short bowel syndrome

A
  • shortened bowel due to large surgical resection
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36
Q

Short bowel syndrome treatment

A
  • need to ensure adequate absorption of nutrients and fluid
  • nutritional deficiencies: replace vitamin D, E, A, K, B12, essential fatty acids, zinc, selenium
  • diarrhoea and high output stomas = loperamide and codeine to reduce intestinal motility
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37
Q

What is constipation

A

infrequent, difficult stools - common in women, elderly, pregnant

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38
Q

Constipation red flags

A
  • blood in stool
  • anaemia
  • abdo pain
  • weight loss
  • new onset constipation over 50 years
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39
Q

Constipation non-drug treatment

A
  • increase fibre
  • adequate fluid intake
  • exercise
  • r/v meds e.g. opioids, aluminium, clozapine
40
Q

Bulk-forming laxatives information

A
  • methylcellulose, ispaghula husk, sterculia
  • small hard stools - increases faecal mass, stimulating peristalsis
  • takes 2-3 days to work
  • take with water to prevent intestinal blockage
41
Q

Stimulant laxatives information

A
  • bisacodyl, sodium picosulfate, senna, docusate, glycerol
  • stimulate colonic nerves = peristalsis
  • takes 6-12 hours to work
  • avoid in intestinal obstruction
  • co-danthramer & co-danthrusate in terminal illness due to carcinogenity = red urine
42
Q

Faecal softener laxatives information

A
  • liquid paraffin, docusate, glycerol
  • increases water penetration into stool
  • quickest acting = docusate enema (15-20 minutes)
  • liquid paraffin - avoided due to anal seepage, granulomatous disease of the GI tract, lipid pneumonia on aspiration
43
Q

Osmotic laxatives

A
  • lactulose, macrogol
  • increases amount of fluid in large bowel = peristalsis
  • 2-3 days to work
  • also have faecal softening properties
44
Q

Constipation short duration treatment

A
  1. bulk-forming and good hydration
  2. osmotic
45
Q

Chronic constipation treatment

A
  1. bulk-forming and good hydration
  2. +/change to macrogol (or lactulose 2nd line)
  3. no change after 6 months = prucalopride (women only)
    - withdraw lactulose slowly when patient improves
46
Q

Faecal impaction treatment

A
  • hard stool = macrogol & stimulant once softened
  • soft stool = stimulant
  • rectal bisacodyl and/or glycerol if remain constipated
47
Q

Opioid induced constipation treatment

A
  • osmotic and stimulant
  • naloxegol if no response to first line
  • AVOID BULK FORMING - peristalsis already slow so can cause obstruction faecal impaction
48
Q

Constipation in pregnancy and breastfeeeding

A
  1. dietary & lifestyle - fibre supplements e.g. bran/wheat
  2. bulk-forming - ispaghula
  3. osmotic
  4. bisacodyl or senna (not senna near term)
49
Q

Constipation in children

A
  1. dietary advice & macrogol (if no faecal impaction)
  2. stimulant
    - if stool hard = lactulose or docusate
50
Q

Acute diarrhoea treatment

A
  • usually settles w/o medical treatment
  • can use oral rehydration therapy to prevent/correct dehydration
  • severe dehydration/can’t drink = hospital for IV fluids
51
Q

Rapid control for diarrhoea/traveler’s diarrhoea

A
  • loperamide
  • avoid in bloody or suspected inflammatory diarrhoea
52
Q

Loperamide information

A
  • 1st line for faecal incontinence
  • OTC = 12 yrs +, prescribed = 4 yrs +
  • 1-2 caps (2-4mg) initially, then 1 with every loose stool
  • max = 8 caps (16mg)
  • MHRA = serious cardiac reactions (QT prolongation) with high doses
  • treat overdose with naloxone
53
Q

What is dyspepsia

A

upper abdo pain, heart burn, gastric reflux, bloating, NV

54
Q

Dyspepsia referral symptoms

A
  • GI bleed
  • Age 55 +
  • Unexplained weight loss
  • Dysphagia
    GAUD
55
Q

Dyspepsia drug treatment

A
  • uninvestigated = PPI for 4 wks first, if doesn’t work = test for H.pylori - tx if +ve
  • functional dyspepsia (investigated but no cause present) = test for H. pylori - tx if +ve, no infected = 3 wksPPI or H2 receptor antagonist
56
Q

H. pylori diagnostic test

A
  • most common cause of peptic ulcers
  • urea 13c breath test or stool helicobacter antigen test
  • stop PPI 2 wks before test and abx 4 wks before test
57
Q

H. pylori treatment

A
  • Triple therapy
    1. PPI - BD 7 days
    2. Clarithromycin - 500mg BD 7 days
    3. Amoxicillin - 1g BD 7 days (other 2 in pen allergy)
    3. Metronidazole - 400mg BD 7 days
58
Q

What is GORD caused by

A
  • increased with: fatty foods, pregnancy, hiatus hernia, family Hx, stress, anxiety, obesity, smoking, alcohol
  • drug side effects due to loosening sphincter e.g. a/b-blockers, CCBs, anticholinergics, benzos, bisphosphonates, corticosteroids, NSAIDs, nitrates, TCAs
59
Q

GORD urgent referral criteria

A

GAUD
- GI bleed
- Age 55 +
- Unexplained weight loss
- Dysphagia

60
Q

GORD lifestyle advice

A
  • healthy eating
  • weight loss
  • avoid trigger foods
  • smaller meals
  • evening meals 3-4 hours before bed
  • raised head of bed
  • smoking cessation
  • reduce alcohol
61
Q

GORD treatment

A
  • medicines review if taking a drug that exacerbates GORD
  • uninvestigated GORD = PPI for 4 wks - test for H. pylori if doesn’t work
  • confirmed GORD = 4-8 wks PPI
  • pregnancy = dietary/lifestyle advice -> antacid or an alginate -> omeprazole/famotidine
62
Q

Antacids

A
  • Mg containing = laxative effect
  • Aluminium containing = constipating effect
  • Ca containing = induces rebound acid secretion
  • simeticone (antifoaming agent) added to antacid = relieves flactulence
  • Alginates and antacids = increase in viscosity of stomach content = viscous gel ‘raft’ that floats on surface of stomach contents
63
Q

Antacids interactions

A
  • increased stomach pH = enteric coated damaged before reaching intestine
  • check Na in antacid - don’t take with lithium/in hypertension
  • low Na = co-magaldrox
  • antacids no with other drug due to impairing absorption - bisphosphonates, tetracyclines, ciprofloxacin
64
Q

Name PPIs

A

omeprazole, esomeprazole, lansoprazole, rabeprazole, pantoprazole

65
Q

PPIs MHRA Warning

A

low risk of subacute cutaneous lupus erythematosus

66
Q

PPIs risks

A
  • increased risk of fractures/osteoporosis - due to hypomagnesaemia
  • increase risk of C. diff
  • masks symptoms of gastric cancer
  • can’t use eso/omeprazole with clopidogrel - lansop instead
  • increases concentration of methotrexate, warfarin, digoxin
67
Q

Name H2 receptor antagonists

A

cimetidine, famotidine, nizatidine

68
Q

H2 receptor antagonists risks

A
  • masks symptoms of gastric cancer - rule out alarm features before tx
  • side effects = diarrhoea, headache, dizziness, rash, tiredness
  • interactions = reduced absorption of -azole antifungals
  • cimetidine = CYP450 enzyme inhibitor
69
Q

what is cholestasis

A
  • impaired bile formation or flow = fatigue, pruritus, dark urine, pale, jaundice
70
Q

cholestatic pruritus treatment

A
  • relieved by cholestyramine, ursodexycholic acid, rifampicin
71
Q

Intrahepatic cholestasis in pregnancy

A
  • during late pregnancy = adverse foetal outcomes
  • treatment of pruritus associated = ursodexycholic acid
72
Q

What are gall stones

A

hard mineral or fatty deposits forming stones in gall bladder bile duct

73
Q

Gall stones symptoms

A
  • most patients - asymptomatic
  • irritated/blocked gall bladder = pain, infection and inflammation
  • untreated = complications = biliary colic, cholecystitis, cholangitis, pancreatitis
  • symptoms develop = surgical removal
74
Q

Gall stones drug treatment

A
  • mild-mod pain = paracetamol/NSAID
  • severe pain = IM diclofenac
  • whilst waiting for surgery
75
Q

What is an anal fissure

A

tear or ulcer in anal canal = bleeding and pain on defecation

76
Q

anal fissures acute management

A
  • help stool pass easily and pain management
  • bulk-forming or osmotic laxatives
  • short term topical with local anaesthetic (lidocaine) (not for preg) or analgesic
77
Q

anal fissure chronic management

A
  • 6 wks or longer = GTN rectal (high incidence of headache)
  • topical/oral diltiazem or nifedipine (reduced adverse effects especially topical)
  • specialist = bolinum toxin type A (botox type A)
  • surgery effective when no drug response
78
Q

What are haemorrhoids

A
  • swelling of vascular mucosal anal cushions around anus (high risk during pregnancy)
  • internal = painless
  • external = itchy or painful
79
Q

Haemorrhoids management

A
  • maintain easy stools to minimise straining = increased fibre/fluid or bulk forming
  • pain = paracetamol (opioids = constipation, NSAIDs = rectal bleeding)
  • pain/itching = topicals (anaesthetics, corticosteroids, lubricant, antiseptics)
  • topical anaesthetics (lidocaine) = use for a few days
  • topical corticosteroids = no more than 7 days due to side effects
  • pregnancy = bulk-forming laxatives - no topicals, only simple soothing prep if needed
80
Q

What is pancreatic insufficiency

A
  • reduced secretion of pancreatic enzymes into the duodenum
  • can be due to pancreatitis, CF, pancreatic tumours, coeliac disease, GI resection
  • can lead to maldigestion and malnutrition
81
Q

Treatment of exocrine pancreatic insufficiency

A
  • pancreatic enzyme replacement (pancreatin)
  • levels of fat soluble vits (DEAK) and micronutrients monitored - give supplements when needed
82
Q

What is in pancreatin

A
  • lipase, amylase, protease, which digests fats, carbohydrates and proteins so it can be absorbed
  • take with meals and snacks - prevent early breakdown
83
Q

Pancreatin in cystic fibrosis

A
  • fibrosing colonopathy at high dose pancreatin
  • don’t exceed 10000 units/kg/day of lipase
  • report new abdominal symptoms
84
Q

What is a stoma

A

artificial opening on abdomen to divert flow of faeces/urine to external pouch

85
Q

Drug suitability with stomas

A

EC/MR capsules not suited - insufficient effect from drug - use quick acting forms e.g. liquids, caps, uncoated/soluble tabs

86
Q

Stoma Care

A
  • diarrhoea = sorbitol, Mg antacids, iron (ileostomy)
  • constipation = opioids, aluminium and calcium antacids, iron (colostomy)
  • GI irritation and bleed = aspirin and NSAIDs
  • diuretics/laxatives = dehydration = hypokalaemia = use K+ sparing diuretics or K+ supplements. Liquid K+ preferred to MR forms.
  • fluid and Na depletion = hypokalaemia = increased risk of digoxin toxicity
87
Q

What are pesto-bismol and milk of magnesia used for

A

indigestion

88
Q

Clarithromycin and ciclosporin interaction

A

clarithromycin increases concentration of ciclosporin

89
Q

What is an astringent and give an example

A
  • substance that draws water out of tissue and causes the tissue to shrink
  • bismuth oxide
90
Q

Classic symptom of colic in a baby and treatment

A
  • baby pulls legs to chest and crying, red in the face
  • OTC simethicone (infacol)
91
Q

Colestyramine side effects

A
  • constipation, diarrhoea, NV, GI discomfort
  • increased tendency to bleed
  • decreased absorption of DEAK = hypoprothrombinaemia due to low K
  • hypertriclycerideaemia = aggravation
92
Q

Colestyramine administration

A

1 hour before or 4 hours after other medication to reduce interference with absorption

93
Q

Ranitidine OTC max supply

A

2 weeks

94
Q

Antacids containing both magnesium and aluminium

A
  • reduced colonic side effects
  • insoluble in water so long-acting if retained in the stomach
95
Q

PPIs and GI infections

A

PPIs increased risk of GI infections

96
Q

Orlistat advice

A

take with vitamins and minerals if concerns about inadequate micronutrient intake

97
Q

Misoprostol key information

A
  • synthetic prostaglandin analogue
  • has antisecretory and protective properties, promoting healing of gastric and duodenal ulcers
  • used for termination in pregnancy following mifepristone
  • common SE = NV, rash
  • cautioned on effects on driving

gphc exam (22 decks)

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