Chronic bowel disorders

Question 1

What is coeliac disease ?

Answer 1

autoimmune condition associated with chronic inflamation of small intestine unable to absorb nutrients

Question 2

What causes coeliac disease ?

Answer 2

intolerance to gluten

Question 3

Where is dietary protein gluten found ?

Answer 3

in cereals wheat, barley and rye

Question 4

What are the symptoms of coeliac disease ?

Answer 4

diarrhoea, abdominal pain, bloating

Question 5

Why the patients who have coeliac disease should be assessed for the risk of osteoporosis ?

Answer 5

higher risk of malabsorption of key nutrients: vitamin D and calcium

Question 6

What is the difference between diverticula and diverticulitis ?

Answer 6

Diverticula: small bulges or pockets that develop in the lining of large intestine. Pain in the lower tummy
Diverticulitis when the pockets become inflamed or infected.
No symptoms: diverticulosis

Question 7

What are the symptoms of diverticular ? Fiber can predispose to diverticular ( aim for 30g fiber a day )

Answer 7

tummy pain, usually in your lower left side, that tends to come and go and gets worse during or shortly after eating (pooing or farting eases it)
constipation, diarrhoea, or both
occasionally, blood in your poo

Question 8

What is the treatment for suspected uncomplicated acute diverticulitis ?

Answer 8

Oral first line: Co-amoxiclav.
Alternative in penicillin allergy or co-amoxiclav unsuitable: cefalexin (caution in penicillin allergy) with metronidazole, or trimethoprim with metronidazole, or ciprofloxacin (only if switching from intravenous route with specialist advice) with metronidazole.

Question 9

Inflammatory bowel disease is a term used to describe which two conditions ?

Answer 9

Ulcerative colitis and chrons disease

Question 10

What is ulcerative colitis ?

Answer 10

mucosal inflammation and ulcers restricted to colon and rectum

Question 11

What are the symptoms of ulcerative colitis ?

Answer 11

Symptoms alternate between acute-flares up and remission

• bloody diarrhoea ( may contain mucus or pus)
• abdominal pain, urgent need to defecate

Question 12

What happens in acute flares up of ulcerative colitis ?

Answer 12

mouth ulcers, arthritis, sore skin, weight loss, fatigue

Question 13

What are the long term complications of ulcerative colitis ?

Answer 13

colorectal cancer
secondary osteoporosis (corticosteroid medication, dietary change )
VTE
Toxic megacolon

Question 14

which drugs are contraindicated during acute flares up of ulcerative colitis ?

Answer 14

loperamide, codeine : paralytic illeus= increased risk of toxic megacolon

Question 15

Would you use oral or rectal inflammation for extensive colitis ? ( proximal)

Answer 15

oral

Question 16

IF colitis has affected rectum ( proctitis ), treatment oral or rectal ?

Answer 16

suppositories

Question 17

Left-sided colitis ( distal), would you consider enemas or suppositories ?

Answer 17

Enemas

Question 18

What choice of preparations would be most appropriate in proctosigmoditis ?

Answer 18

Proctosigmoditis: inflamation of rectum and sigmoid colon

Foam preparations

Question 19

For mild-to-moderate first presentation or inflammatory exacerbation of proctitis, proctosigmoiditis, or left-sided ulcerative colitis, what drug treatment is recommended ?

Answer 19

• Aminosalicylates — mesalazine and sulfasalazine, (suppository or enema) initially, and orally if remission is not achieved within four weeks.
• Corticosteroids — monotherapy with a time-limited course of corticosteroids may be used for induction of remission if aminosalicylates are ineffective.
• Calcineurin inhibitors — tacrolimus or ciclosporin may be added to oral corticosteroids to induce remission in people with mild to moderate disease if there is an inadequate response to oral corticosteroids after 2–4 weeks.
• Immunosuppressive drugs — the thiopurines (azathioprine, mercaptopurine) or methotrexate (second-line) may be considered to maintain remission if there are two or more inflammatory exacerbations in a 12-month period that require treatment with oral corticosteroids, or if remission cannot be maintained by aminosalicylates.

Question 20

Thiopurines may increase the risk of which type of cancer ?

Answer 20

thiopurines may increase the risk of non-melanoma skin cancer, and people should be monitored for skin cancer and given appropriate sun protection advice.

Question 21

What treatment is indicated for extensive ulcerative colitis ?

Answer 21

A topical aminosalicylate and a high-dose oral aminosalicylate are recommended as first-line treatment for patients with a mild-to-moderate initial presentation or inflammatory exacerbation of extensive ulcerative colitis. If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid. An oral corticosteroid for 4 to 8 weeks should be considered for patients in whom aminosalicylates are unsuitable.

Question 22

Name all aminosalicylates that can be used in IBD ? ( inflammatory bowel disease?

Answer 22

balsalazide
mesalazine
olsalazine
sulfasalazine

Question 23

What are the side effects of aminosalicylates ?

Answer 23

blood dyscrasias
nephrotoxicity
salicylates hypersensitivity: itching and hives
yellow/orange bodily fluids with sulfasalazine: contact lenses may be stained.

Question 24

What is the interactions between mesalazine and lactulose ?

Answer 24

lactulose lowers stool PH in the intestines: this prevents sufficient release of the active ingredient in E/C or M/R preparations.

Question 25

What are the symptoms of IBS ?

Answer 25

lower abdominal pain/colic bloating alternating constipation/diarrhoea

Question 26

What can aggravate IBS ?

Answer 26

stress, depression, anxiety, lack of dietary fibre. | commonly affects women between 20-30 years.

Question 27

Which drug classes can be used to treat IBS ?

Answer 27

antispasmodics, antimuscarinics, laxatives, anti motility drugs, antidepressants

Question 28

Which antispasmodics can be used in IBS to help with GI spasms ?

Answer 28

alverine mebeverine peppermint oil ( s/e: heartburn, local irrational of mouth, oesophagus)

Question 29

Which antimuscarinics can be used in IBS to help with GI spasms?

Answer 29

hyoscine butylbromide atropine dicycloverine propantheline bromide

Question 30

why lactulose is not recommended in IBS ?

Answer 30

causes bloating

Question 31

Under what circumstances can linaclotide be prescribed in IBS ?

Answer 31

if unresponsive to different laxative classes and have had constipation for 12 months ) -Dispense capsules in original container (contains desiccant); discard any capsules remaining 18 weeks after opening.

Question 32

What is short bowel syndrome ?

Answer 32

characterised by malabsorption following extensive resection of the small bowel

Question 33

What nutritional deficiencies can short bowel syndrome cause ?

Answer 33

Vitamin A, B12, D, E, K, essential fatty acids, zinc, selenium, hypomagnesaemia

Question 34

How can inadequate digestion that leads to diarrhoea and high output stomas be treated in short bowel syndrome ?

Answer 34

High doses of loperamide may be used, if desired response not obtained with loperamide, then codeine can be added. Co-phenotrope has been used alone or in combo with other meds to decrease faecal output. Colestyramine: can be used with intact colon and less than 100cm of ileum resected to bind the unabsorbed bile salts and reduce diarrhoea. Drugs that reduce gastric acid secretion reduce jejunostomy output- omeprazole

Question 35

Which drugs may be incompletely absorbed in patients with short bowel syndrome ?

Answer 35

digoxin, warfarin, oral contraceptives, levothyroxine- thus may need to be given in much higher doses

Question 36

Which intestine is the most important for drug absorption ?

Answer 36

Small intestine: has large surface are and high blood flow, the larger the amount of small intestine removed the higher the possibility that drug absorption will be affected.

Question 37

Which formulation of drugs are unsuitable to use in patients with short bowel syndrome ?

Answer 37

E/C and MR- particularly in patients with ileostomy as there may not be sufficient release of the active ingredient

Question 38

Which tablet formulations should be used in short bowel syndrome ?

Answer 38

soluble tablets, uncoated tablets and liquid formulations may also be suitable