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The Patient > Diarrhoea, Constipation, Coeliac Disease and IBS > Flashcards

Diarrhoea, Constipation, Coeliac Disease and IBS Flashcards

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1
Q

What is diarrhoea?

A

A change in bowel habit resulting in substantially more frequent and looser stools than usual
More about the consistency of the stools than the frequency

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2
Q

How does WHO define diarrhoea?

A

The passage of 3 or more loose or liquid stools per day (or more frequent passage than is normal for the individual)

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3
Q

How can diarrhoea be classified?

A

Acute <14 days
Persistent >14 days but <28 days
Chronic >28 days

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4
Q

What is the pathophysiology of diarrhoea?

A 
More than one mechanism than can cause diarrhoea
Increase osmotic load in gut lumen 
Increase in secretions
Inflammation of intestinal lining 
Increased intestinal motility
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5
Q

What is acute diarrhoea?

A

Diarrhoea that is self-limiting and usually resolves within 72 hours

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6
Q

What causes acute diarrhoea?

A

Usually due to infection or ingestion of toxins (contaminated food)
Infection can be bacterial (e.g. E. coli, Salmonella) or viral (e.g. rotavirus, norovirus)
Other causes include drugs, parasites and anxiety

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7
Q

How is acute diarrhoea treated?

A

Symptomatic relief

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8
Q

What diseases associated with acute diarrhoea are ‘notifiable’?

A

Dysentery

Food poisoning

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9
Q

What is travellers diarrhoea?

A

Diarrhoea experienced by travellers

Early onset, usually within the first few days of a trip and usually resolves within 7 days

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10
Q

What are the symptoms of travellers diarrhoea?

A

As per acute diarrhoea but can also contain blood (dysentery)

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11
Q

What is travellers diarrhoea dependent on?

A

Destination, age and diet

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12
Q

What causes travellers diarrhoea?

A

Enterotoxigenic E.coli and campylobacter
Salmonella
Enterohaemorrhagic E. coli and shigella
Viruses, Protozoa and helminths (worm-like parasites)

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13
Q

What can occur as a result of certain infections?

A

E.g. giardiasis and amoebic dysentery

Can cause persistent or recurrent diarrhoea or systemic complications

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14
Q

Is antibiotic prophylaxis used in travellers diarrhoea?

A

Rarely recommended

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15
Q

How can travellers diarrhoea be avoided?

A

Wash hands thoroughly using soap
Antiseptic wipes/gel if there are no washing facilities available
Avoid drinking local water, even for cleaning teeth
Avoid ice cubes, diary produces, ice cream, home distilled drinks and salads
Eat fresh foods
Avoid shell fish and shellfish unless you are sure they are fresh and have not been near a sewage outlet
Only use clean, hygienically run establishments

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16
Q

What is chronic diarrhoea?

A

Recurrent or persistent diarrhoea

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17
Q

What are some of the causes of chronic diarrhoea?

A

IBS
IBD
Malabsorption syndromes e.g. coeliac disease, lactose intolerance
Metabolic disease e.g. diabetes, hyperthyroidism
Laxative abuse

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18
Q

How should you question a patient about their diarrhoea symptoms?

A 
Ask about,
Stool frequency 
Nature e.g. presence of blood, mucus 
Occurrence e.g. isolated or recurrent? 
Duration
Onset
Timing
Food 
Recent travel
Medication
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19
Q

When is referral required in adults?

A

If there symptoms have lasted >72 hours in healthy adults, >48 hours in elderly and >24 hours in diabetes
If there diarrhoea is associated with vomiting and fever
If they have a history of changes to their bowel habits (especially if over 40/50)
If they have blood/mucus in their stools
If you suspect an ADR
If they are elderly and have alternating diarrhoea and constipation (could be faecal impaction)
If they have unintentionally lost weight
If they have recently been in hospital or had antibiotic treatment (could be a HCAI such as C. difficile)
If there is evidence of dehydration
If they are in severe pain or have rectal pain

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20
Q

What is the primary aim in diarrhoea treatment?

A

Prevent dehydration

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21
Q

How can diarrhoea be treated?

A 
Oral rehydration therapy 
Loperamide 
Morphine 
Diphenoxylate 
Absorbents 
Antibiotics
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22
Q

What should Oral Rehydration Solutions (ORS’s) do?

A

Enhance the absorption of water and electrolytes
Replace electrolyte deficit adequately and safety
Contain alkalinising agent to counter acidosis
Be slightly hypo-osmolar (about 250mmol/L) to prevent the possible induction of osmotic diarrhoea
Be simple to use in the hospital and at home
Be palatable and acceptable, especially to children
Be readily available
Should be sipped over a period of time rather than drank all at once

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23
Q

What do Oral Rehydration Solutions (ORS’s) generally contain?

A

Sodium and potassium to replace essential ions
Citrate/bicarbonate to correct acidosis
Glucose or another carbohydrate e.g. rice starch

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24
Q

Which patients can Oral Rehydration Solutions (ORS’s) be used for?

A

Patients of any age

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25
What is the usual dose of an Oral Rehydration Solution (ORS) after a very loose motion?
200-400ml
26
Which patient group must be take extra care in when using Oral Rehydration Solutions (ORS's)?
Diabetics | Blood glucose levels should be monitored carefully (some sachets contain glucose)
27
What is loperamide?
An anti-motility agent It is a synthetic µ opioid receptor agonist Has a direct action on opiate receptors in the gut wall
28
What can be said about the pharmacokinetics of loperamide?
Extensive first pass metabolism so little reaches systemic circulation
29
What are some contraindications to the use of loperamide?
Active UC Antibiotic associated colitis Conditions where inhibition of peristalsis should be avoided Conditions where abdominal distension develops These are all underlying conditions where you do not want to affect gut motility
30
What are some cautions to the use of loperamide?
Avoid in, Bloody/suspected inflammatory diarrhoea Significant abdominal pain
31
What are some of the side effects of loperamide?
Abdominal cramps | Dizziness
32
What MHRA warning was issued surrounding loperamide?
Serious cardiac adverse reactions associated with high doses in abuse/misuse
33
When are antibiotics used in diarrhoea?
Used when the diarrhoea is caused by an infection | In severe infection (fever >39° and prolonged symptoms, in the elderly or immunocompromised)
34
What should be done before antibiotics are given in diarrhoea?
A stool sample should be taken and causative organism identified
35
Why is empiric use of antibiotics in diarrhoea not recommended?
Risk of antimicrobial resistance Prolong symptoms as may cause GI side effects Pre-dispose to C. difficile infection
36
How does morphine act against diarrhoea?
Has a direct action on intestinal smooth muscle
37
What is the morphine content per recommended dose of products available OTC for diarrhoea?
Around 0.5-1mg
38
What is a side effect of opiates?
Constipation, explains their use in the treatment of diarrhoea
39
What is diphenoxylate?
A synthetic derivative of pethidine (opioid)
40
How is diphenoxylate available to treat diarrhoea?
As a combination product, Co-phenotrope, with atropine
41
How do adsorbents act in diarrhoea?
Adsorb microbial toxins and microorganisms
42
Give 2 examples of adsorbents used in diarrhoea.
Kaolin (kaolin and morphine) | Bismuth subsalicylate
43
What advice can we give as pharmacists for the general management of diarrhoea?
Drink plenty of clear fluids Avoid drinks high in sugar Avoid milk and milky drinks Eat light, easily digested food In gastroenteritis infections, precautions including not returning to work until symptom free for 48 hours, hygeine advice and cleaning of sanitary equipment Make patients aware of the danger symptoms and who to go to if they experience these
44
Why is it important to check a patients medication history who is experiencing diarrhoea?
Diarrhoea can reduce the absorption of some medicines
45
What is Clostridium difficile?
A spore forming anaerobic gram-positive bacterium | Asymptomatic commensal in 2-3% of the adult population
46
What can Clostridium difficile cause?
Leading cause of antibiotic associated diarrhoea Common cause of HCAI's Can lead to pseudomembranous colitis (swelling or inflammation of the large intestine due to an overgrowth of C. diff)
47
What are some of the risk factors for Clostridium difficile infection development?
``` Antimicrobial choice Antimicrobial duration (don't want unnecessary continuation) Acid suppressing medications e.g. PPI's Age Length of stay Recent hospitalisation ```
48
How can Clostridium difficile infection be managed?
Depends on the severity of the infection Concomitant antimicrobials and acid suppressing medication should be stopped where possible Anti-motility medications should be stopped Maintain adequate fluid balance Targeted C. difficile antimicrobial treatment Appropriate infection control procedures including hand washing (with soap and water) and isolation
49
What antimicrobial agents are used to treat Clostridium difficile infection?
``` Oral metronidazole (1st line for mild-moderate CDI) Oral vancomycin (mild-moderate or severe CDI) IV metronidazole and oral vancomycin (critically unwell patients) Oral fidaxomicin (not used very often, recurrent CDI and severe CDI with a high risk of reoccurrence) ```
50
How does fidaxomicin act against Clostridium difficile?
Macrolytic antibiotic that inhibits C. difficile sporulation
51
Other than the traditional antimicrobial agents, how else can Clostridium difficile infection be treated?
Probiotics (restore gut microbiome, role uncertain) FMT (still at the clinical trial stage) IV immunoglobulin (used in severe or recurrent cases of colitis where other treatments have failed)
52
What is constipation?
The passage of hard stools less frequently than normal for that patient, typically less than 3 bowel movements per week
53
In which patient groups is constipation more common?
Women, especially when pregnant | Older people
54
What are some of the symptoms of constipation?
``` Abdominal discomfort and distension Abdominal cramping Bloating Nausea Difficulty passing stool ```
55
What is the Bristol Stool Chart and what do the different levels indicate?
Classifies stools according to shape and size to determine whether the patient is constipated, has diarrhoea or is producing healthy stools Type 1 and 2 indicate constipation Type 3 and especially 4 are the preferred types of stools as they are easiest to pass Type 5 and 6 are symptomatic of diarrhoea Type 7 may be a sign of cholera or food poisoning
56
What is functional (idiopathic) constipation?
Constipation with no anatomical or physiological cause known
57
What is secondary constipation?
Constipation induced by a particular condition or medicine
58
What are some non-medical factors which pre-dispose constipation?
Inadequate fluid intake Inadequate dietary fibre Dieting Changes in lifestyle and activity levels Suppressing the urge to defecate (common in children)
59
What are some medical conditions which pre-dispose constipation?
``` Coeliac disease Depression Diabetes IBS Parkinson's disease Hypercalcaemia Hyperkalaemia Hypothyroidism (These patient groups may need a laxative long term) ```
60
What are some medications which pre-dispose constipation?
Antacids containing aluminium and calcium Antihypertensives (diuretics, CCB's) Antidepressants (tricyclics, MAOI's) Antimuscarinics (procyclidine, oxybutynin) Antiparkinsonian medicines (levodopa, dopamine agonists, amantadine) Opioid analgesics (laxative commonly co-prescribed) Iron
61
How can we assess constipation in patients?
As patient about bowel habits Perform an examination Try to identify cause Check for red flags including unexplained weight loss, rectal bleeding, family history of colon cancer or IBD and signs of obstruction
62
What are the treatment aims in constipation?
Restore normal defecation frequency Achieve regular, comfortable defecation Avoid laxative dependence Relieve discomfort
63
What non-pharmacological treatments can be used in constipation?
Increase dietary fibre Ensure adequate fluid intake Lifestyle measures including exercise
64
What pharmacological treatments can be used in constipation?
Laxatives
65
What are the 4 types of laxatives?
Bulk-forming Stimulant Osmotic Faecal softening
66
What are bulk-forming laxatives?
Increase faecal mass through water binding to stimulate peristalsis to stimulate motility
67
How long do bulk-forming laxatives take to work?
Several days for the full effect
68
What must be maintained when taking bulk-forming laxatives and why?
Fluid intake | Can worsen constipation if fluid levels are not kept high
69
Can bulk-forming laxatives be used long term?
Yes
70
Give 2 examples of bulk-forming laxatives.
``` Ispaghula husk (Fybogel) Methylcellulose (also acts as a softener) ```
71
What are stimulant laxatives?
Increase intestinal motility via muscle contractions
72
How long do stimulant laxatives take to work?
A few hours | Patients usually take them before bed and they work by morning
73
What is a side effect of stimulant laxatives?
Abdominal cramps
74
Can stimulant laxatives be used long term?
Prolonged use should be avoided as it can lead to diarrhoea, fluid and electrolyte imbalance
75
Give 3 examples of stimulant laxatives.
Senna (commonly co-prescribed with opioid analgesics) Dantron (terminally ill patients only) Bisacodyl
76
What are osmotic laxatives?
Works with colonic lumen to retain and draw water into the intestine by osmosis
77
What must be maintained when taking osmotic laxatives?
Good fluid intake
78
Give 4 examples of osmotic laxatives and their time to effect.
Macrogel powders - 1-3 days Lactulose (disaccharide, caution in diabetics) - 2-3 days Phosphate enema or suppository - 15-30 minutes Magnesium hydroxide - 3-6 hours
79
What are faecal softening laxatives?
Stimulate peristalsis by increasing faecal mass, act to lower surface tension and allow water and fat to penetrate faeces
80
Give 3 examples of faecal softening laxatives and their time to effect.
Docusate sodium (faecal softener and stimulate) - 1-3 days Glycerol suppository - 1 hour Arachis oil enema - 30 minutes
81
When is an arachis oil enema contraindicated?
In patients with a nut allergy
82
What are some of the complications of constipation?
Faecal impaction Haemorrhoids Rectal prolapse Anal fissures
83
What is coeliac disease?
An autoimmune condition affecting the small intestine | The body's immune system attacks itself when gluten is eaten (adverse reaction to gluten)
84
What is the cause of coeliac disease?
An interaction between genetic predisposition and environmental triggers
85
Is coeliac disease an allergic condition?
The reaction is not an allergic reaction and does not cause anaphylactic shock
86
Who does coeliac disease affect?
Around 1% of all Northern Europeans and North Americans
87
How is coeliac disease diagnosed in adults?
Serology (looking for the presence of certain antibodies) Endoscopy for small intestine biopsy (2nd part of duodenum, at leats 4 biopsies should be taken to ensure the patient is not misdiagnosed) Repeat biopsy on a gluten free diet Gluten challenge (>10g/day, 6/52, to allow for testing and a conclusive diagnosis)
88
What are some of the symptoms of coeliac disease?
Headaches Diarrhoea Abdominal pain Lethargy
89
How do symptoms differ between patients?
Not every patient has symptoms Vary from person to person and from mild to severe They may last a few hours or a few days
90
What are some of the complications of coeliac disease?
Long term malabsorption and osteoporosis Refractory coeliac disease Ulcerative jejunitis Enteropathy associated T-cell lymphoma Autoimmune disease (T1DM, thyroid disease) The longer you eat gluten, the higher the risk of triggering another autoimmune disease
91
Is there a cure for coeliac disease?
There is no cure
92
What happens if gluten is reintroduced into the diet at a later date?
The immune system will react and the gut lining will become damaged again
93
How is coeliac disease treated?
Treatment is a lifelong gluten free diet and there is research underway to develop a vaccine
94
Which foods are gluten free?
``` All fresh meat Fish Cheese Eggs Milk Fruit Vegetables Specially manufactured wheat starch ```
95
How can patients identify gluten free products?
Crossed grain symbol
96
Why are patients reluctant to gluten free diets?
Poor taste meaning lots of sugar has to be added to improve it Expensive Difficult to eat out No agreed international consensus on permissible levels Range of symptoms with ingestion Low fibre, low vitamin D and high calories
97
Can you get gluten free foods on prescription?
Yes but as of Dec 2018 this is restricted to bread and mixes only
98
What is irritable bowel syndrome (IBS)?
A chronic condition characterised by at least 6 months of abdominal pain and bowel symptoms (diarrhoea, constipation or a combination of both)
99
What causes IBS?
The cause is unclear and can differ patient to patient | IBS is a very poorly understood condition
100
How can IBS be treated?
As we don't know the underlying cause, treatment is aimed at symptomatic relief No 'gold' standard as symptoms vary Includes, Dietary changes and exercise Antispasmodics (e.g. mebeverine, hyoscine, peppermint oil) Anti-diarrhoeal (e.g. Loperamide) Laxatives (e.g. bulk-forming, stimulant, osmotic) Probiotics
101
What are antispasmodics?
Smooth muscle relaxants

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