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1
Q

Define coeliac disease:

A

It is an autoimmune condition, associated with chronic inflammation of the small intestine

Dietary proteins known as gluten present in wheat, barley rye activates an abnormal immune response in intestinal mucosa, leading to malabsorption

Note: patients with celiac disease are at an increased risk of malabsorption of key nutrients (calcium, vitamin-d)

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2
Q

State the 3 symptoms associated with coeliac disease?

A

Diarrhea, abdominal pain and bloating

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3
Q

What dietary protein to avoid in patients with celiac disease:

A

Gluten

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4
Q

State the complications of celiac disease:

A

Weakening of the bones, osteoporosis

Iron deficiency anaemia

Vitamin b12 and folate deficiency

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5
Q

State the only effective treatment for coeliac disease?

A

Strict, life-long gluten-free diet

No drug treatment for celiac disease

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6
Q

What is the drug treatment of choice for the confirmed cases of refractory coeliac disease while awaiting specialist advice?

A

Prednisolone

unlike celiac disease, it is resistant or unresponsive to at least 12 months of treatment with a strict gluten-free diet

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7
Q

State the symptoms of diverticular disease?

A

Abdominal tenderness

and/or mild intermittent lower abdominal pain

with constipation, diarrhea and occasional rectal bleeds

Symptoms may overlap with other Gl complications

Diverticular disease is a condition where small pouches (diverticula) form in the lining of the digestive system, usually in the colon. These pouches can become inflamed or infected, leading to symptoms like abdominal pain, bloating, constipation, or diarrhea.

Diverticula can form due to weak spots in the colon wall, which can happen because of factors like a low-fiber diet, aging, or genetic predisposition. When there’s not enough fiber in the diet, the colon has to work harder to move stool, which can lead to increased pressure and the formation of diverticula.

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8
Q

What is the treatment of uncomplicated diverticulitis?

A

Low residue diet and bowel rest

Antibiotics are only given when patients are immunocompromised / signs of infection

A low residue diet is a way of eating that limits foods high in fiber and other indigestible materials. It’s designed to reduce the amount of undigested food passing through the gut, which can help alleviate symptoms like diarrhea, abdominal pain, and bloating.

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9
Q

State symptoms of diverticulosis:

A

Asymptomatic presence of diverticula (small pouches protruding from walls of large intestine)

Common in patients aged 40 and over

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10
Q

What surgery is required for patients with diffuse peritonitis?

A

Urgent sigmoid colectomy

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11
Q

State the two-side effects associated with sulfasalazine?

A

Blood disorders and lupus-like syndrome

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12
Q

State side effects of aminosalicylates:

A

Common = Cough, dizziness, fever, arthralgia, gastro discomfort, leucopoenia

(reduction of white blood cells = increased risk of infection), nausea, vomiting, skin reactions

Uncommon = alopecia, depression, myalgia, photosensitivity reaction,

thrombocytopenia

Very rare = agranulocytosis, cardiac inflammation, pancreatitis

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13
Q

State patient and carer advice for aminosalicylates:

A

Report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise

For sulfasalazine = some soft contact lens may be stained

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14
Q

State monitoring requirements for aminosalicylates:

A

Renal function should be monitored before starting an oral aminosalicylate, at 3 months of treatment and then annually during treatment

Full blood counts (including differential white cell count and platelet count) are necessarily initially, and at monthly intervals during the first 3 months

Liver function test should be performed at monthly intervals for first 3 months

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15
Q

What should be co-prescribed with methotrexate and why?

A

Folic acid, usually dosage once weekly, why because to avoid methotrexate toxicity

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16
Q

Define Crohn’s disease:

A

Chronic inflammatory bowel disease mainly affects the Gl tract, thickened area of GI wall with inflammation extending to all layers

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17
Q

State the symptoms of Crohn’s disease?

A

Abdominal pain, diarrhea, fever, weight loss, rectal bleeding, mouth ulcers, sore eyes, arthritis, fatigue

Crohn’s also a cause of secondary osteoporosis

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18
Q

State the non-drug treatment for Crohn’s disease:

A

Stop smoking and attention to nutrition

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19
Q

What is the monotherapy treatment of Crohn’s disease?

A

Prednisolone or methylprednisolone or IV hydrocortisone (to reduce remission / within first 12 months)

Budesonide (distal ileal, ileocecal or right sided colonic disease)

Sulfasalazine /mesalazine

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20
Q

What is the add-on treatment of Crohn’s disease?

A

Azathioprine or mercaptopurine
Methotrexate

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21
Q

In patients who are deficient to thiopurine methyltransferase what drug can be added to their Crohn’s treatment?

A

Methotrexate

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22
Q

Specialist treatment of Crohn’s disease?

A

Adalimumab or infliximab
Vedolizumab

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23
Q

Which two drugs can be used to treat diarrhea associated with Crohn’s disease without colitis?

A

Loperamide or codeine

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24
Q

Which drug is licensed for relief of diarrhea associated with Crohn’s disease?

A

Colestyramine

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25
Which is the treatment of fistulating Crohn's disease?
Metronidazole or/and ciprofloxacin
26
State some factual information regarding ulcerative colitis:
Common in 15-25 age range It is life-long Characterised by diffuse mucosal inflammation, relapse remitting pattern
27
What ages is ulcerative colitis most common in?
15-25
28
State the symptoms of ulcerative colitis:
Bloody diarrhea, urgent need to go to toilet, abdominal pain, > 6 weeks of faecal urgency, painful persistent urge to pass stool when rectum is empty
29
What are the complications associated with ulcerative colitis?
Secondary osteoporosis Increased risk of colorectal cancer Toxic megacolon Venous thromboembolism
30
How should you manage symptoms of ulcerative colitis:
Diarrhoea - exclude any alternative cause Do not prescribe loperamide unless advised by specialist as they do not usually reduce stool frequency and can increase the risk of toxic megacolon Constipation - assess for bowel obstruction, if bowel obstruction is unlikely, ensure that diet includes adequate fluid and soluble fibre, and warn that soluble fibre sometimes increases bloating and distension. If symptoms persist despite dietary advice consider a bulk-forming laxative, such as ispaghula husk, methylcellulose, sterculia Abdominal pain - persistent or recurrent abdominal pain is common in ulcerative colitis and may be caused by inflammatory exacerbations and poor disease control, obstruction, intestinal dilatation: Give paracetamol for pain relief and avoid NSAIDs
31
Why is it a risk of using loperamide for relief of diarrhea in patients with ulcerative colitis?
Increases risk of toxic megacolon
32
State some side effects for aminosalicylates?
Blood disorders, lupus-like syndrome, cough, gastrointestinal discomfort, leucopoenia, skin reactions
33
State one patient and carer advice for patients taking aminosalicylates?
To report any unexplained bruising, bleeding, purpura, fever, sore throat, malaise (blood disorders)
34
What is the monitoring requirement for aminosalicylates?
Monitor Renal function before treatment, 3 months and then annually
35
What do you monitor in breast-fed infants whose mother is taking balsalazide sodium?
Monitor for diarrhea in infant
36
State common side effects for Sulfasalazine?
Taste altered, urine abnormalities, insomnia, tinnitus, yellow discolouration of bodily fluids
37
State the monitoring requirements for sulfasalazine?
FBC, white cell count, platelet count initially, and at monthly intervals during first 3 months LFTs at monthly intervals for first 3 months
38
What are the monitoring requirements for budesonide when used in autoimmune hepatitis?
LFTs should be done every 2 weeks for 1 month, and then at least every 3 months
39
What age is IBS common in?
20-30's and is more common in women
40
What are the symptoms of IBS?
Abdominal pain, discomfort, diarrhea or constipation, passage of mucus and bloating
41
State counselling points for patients with IBS?
Increase physical activity, adults should aim to do 30 mins of moderate intensity of physical activity at-least 5 days of the week Advised to eat more regularly Limit fresh fruit consumption to no more than 3 portions a day Fluid intake mostly water should be increased to 8 cups a day Sorbitol should be avoided in patients with diarrhoea Probiotics can be used for at least 12 weeks Encourage the patient to identify any associated stress, anxiety and/or depression If there are predominant symptoms of constipation, advise patient to: Try soluble fibre supplements for e.g.: ispaghula or food high in soluble fibre i.e., oats and linseed If there are predominant symptoms of diarrhea and/or bloating advise the patient to: Reduce intake of insoluble fibre, such as wholemeal or high fibre flour and breads
42
State the drug treatment for IBS?
Alverine citrate, mebeverine and peppermint oil all OTC medication that can be purchased OTC
43
Which drug laxative would you avoid in patients with IBS?
Lactulose due to it causing bloating
44
What can be prescribed if patients who have not responded to laxatives from different classes and who have had constipation for past 12 months for patients with IBS and is also licensed for moderate to severe IBS syndrome associated with constipation?
Linaclotide
45
State drug treatment for IBS:
Dietary food advice Bulk forming laxative if constipation persist Loperamide if diarrhea persist Mebeverine, alverine or peppermint oil if ongoing symptoms of abdominal pain or spasm If antispasmodic is ineffective, consider low dose TCA such as amitriptyline (off-label indication) If TCA is ineffective or not tolerated, consider citalopram or fluoxetine (off-label indication
46
What are the red flags for constipation?
New onset of constipation especially patients 50+ Anaemia Abdominal pain Blood in stool Weight loss
47
State the counselling patient for patients with constipation?
Dietary fibre, increase in fluid and exercise advised Fruits high in fire and sorbitol and fruit juices high in sorbitol can help prevent and treat constipation Note: laxative abuse may lead to hypokalaemia
48
How do bulk-forming laxatives work?
Increases the bulk or weight of poo, which in turn stimulates bowel Onset of action is up-to 72 hours
49
State four bulk-forming laxatives?
Sterculia, methylcellulose, Bran, Ispaghula husk
50
How do stimulant laxatives work?
Increases intestinal motility
51
Give examples of stimulant laxatives?
Bisacodyl, sodium-picosulfate, senna, docusate, co-danthromer Onset of action is 6-12 hours.
52
Which laxative acts as a stimulant and faecal softener?
Docusate - docusate can be used as a stimulant and can also soften hard stools
53
How do faecal softeners work?
Decreases surface tension and increases penetration of intestinal fluid into faecal mass
54
State 2 side effects for liquid paraffin?
Anal seepage, malabsorption of ADEK fat soluble vitamins, lipoid pneumonia
55
Excessive use of stimulants can cause what?
Hypokalaemia
56
State the drugs which colour urine and bodily secretions:
Nefopam = pink Triamterene = blue Sulfasalazine = yellow orange Rifampicin = orange-red Nitrofurantoin = yellow-brown Senna = red-yellow Co-danthramer = red Co-danthrusate = red Levodopa = red B-vitamins = bright yellow Entacapone = red-brown
57
What colour does co-danthromer, co-danthrusate discolour urine?
Red - danthron is genotoxic and carcinogenic used in terminally ill patients
58
Which laxative can only be used in females?
Prucalopride - licensed for treatment of chronic constipation in adults
59
What is the management of opioid induced constipation?
Stimulant AND osmotic laxative (or docusate to soften stools) Naloxegol/methylnaltrexone Note: bulk-forming laxatives should be avoided!
60
What is the management of chronic constipation?
Bulk forming, whilst ensuring good hydration If stools remain hard, add or change to an Osmotic laxative e.g., macrogol Lactulose is an alternative if macrogols are not tolerated Stimulant can be added to treatment Prucalopride in women only once at-least 2 laxatives from different classes have been tried at the highest tolerated recommended dose for at-least 6 months
61
What is the management of constipation in pregnancy?
Fibre supplements in form of bran or wheat Bulk-forming laxative first choice if fibre supplements fail Osmotic laxative such as lactulose can be used Bisacodyl or senna may be suitable if stimulant effect is necessary but senna should be avoided near term of if there is history of unstable pregnancy Stimulant laxatives are more effective than bulk-forming but are more likely to cause side effects diarrhea and abdominal discomfort
62
Which laxative do you avoid at near term in pregnancy?
Senna avoid at term as can induce uterine contractions
63
What is the management of constipation in breastfeeding?
Bulk-forming, if dietary measures fail Lactulose or macrogol may be used if stools remain hard Senna / bisacodyl as short course of stimulant laxative
64
What is the management of constipation in children?
Macrogol Laxative + diet modification/behavioural intervention Stimulant Lactulose or docusate faecal stool softener
65
What are the red flags for diarrhoea?
Unexplained weight loss, rectal bleeding, persistent diarrhea, following course of antibiotics, following foreign abroad travel
66
State two drugs which have diarrhoea as a side effect?
Metformin and Iron supplements
67
What is the treatment of diarrhea?
ORS (oral rehydration salts) + appropriate adequate fluid intake Loperamide (also for traveller's diarrhoea) (and first line for faecal incontinence)
68
Which antibiotic is occasionally used for prophylaxis against traveller's diarrhea?
Rifaximin
69
Which drug is licensed as an adjunct to rehydration for the symptomatic treatment of uncomplicated acute diarrhea in adults and children 3 months+?
Raecadotril
70
What is the maximum amount (in mg) of loperamide an adult can take in one day?
16 mg
71
What are the side effects of loperamide in overdose?
QT prolongation, torsade's de pointes, cardiac arrest
72
What should you monitor if a patient has been detected to have consumed large amounts of loperamide?
CNS depression
73
What is the antidote to loperamide?
Naloxone
74
What are the symptoms of dyspepsia?
Upper abdominal pain, fullness, early satiety, bloating and nausea
75
What are the red flags for dyspepsia?
Bleeding, dysphagia, recurrent vomiting, weight loss, blood in stools, new onset dyspepsia in patients 55+ age, significant acute gastrointestinal bleeding, reflux
76
State the non-drug treatments for dyspepsia:
Lifestyle measures such as healthy eating Weight loss if obese Avoid any trigger foods Eating smaller meals and eating the evening meal 3-4 hours before going to bed Raising the heads of the bed Reduce or quit smoking and reducing alcohol consumption
77
Treatment for un-investigated dyspepsia?
Proton pump inhibitor for 4 weeks Test for H.pylori infection (test first for patients who are at high risk of h.pylori infection)
78
What is the treatment for investigated functional dyspepsia?
1) PPI or H2 receptor antagonist for 4 weeks
79
State which drugs can cause dyspepsia:
Alpha-blockers Beta-blockers Bisphosphonates Calcium channel blockers Corticosteroids Nitrates, Nsaids Theophylline's, TCAs
80
State a function of simethicone?
Relief of hiccups in palliative care Anti-relief foaming agent to relieve flatulence
81
Which PPI do you have to take 30-60 mins before food?
Lansoprazole - key!
82
What do PPI's (proton-pump inhibitors) increase the risk of?
Fractures, osteoporosis, gastric cancer, Clostrium difficile, hypomagnesaemia Very low risk of subacute cutaneous lupus erythematosus
83
What is the initial treatment of H. Pylori Infection?
No penicillin allergy: PPI + amoxicillin + clarithromycin/metronidazole PPI + amoxicillin + clarithromycin/metronidazole (whichever was not used first) PPI + amoxicillin + tetracycline/levofloxacin Penicillin allergy: PPI + clarithromycin + metronidazole Ppl + bismuth subsalicylate + metronidazole/tetracycline PPI + metronidazole + levofloxacin What is the test for H.Pylori? Urea-C13 breath test is most popular test, stool helicobacter antigen test can also be done Note: PHE advises that these 2 tests should not be performed within 2 weeks of treatment with a PPI or within 4-week of antibacterial treatment as this can lead to false negatives
84
Side effects of H2 receptor antagonists?
Headaches, rashes, dizziness, diarrhea, depression, hallucinations, confusion
85
State the common food allergens?
Soya, wheat, nuts, shellfish, eggs, soy, cow's milk, tree nuts, fish
86
State the licensed treatment of food allergy?
Chlorphenamine
87
State the treatment of food-induced anaphylaxis?
Adrenaline/Epinepherine - know your child and aduit doses!
88
State what drug is licensed as an adjunct to dietary avoidance in patients with food allergy:
Sodium cromoglicate
89
State what drug may be offered an adjunct to dietary avoidance in patients with peanut allergy in childhood:
Peanut protein
90
State the MHRA safety information for hyoscine butylbromide?
Injection can cause serious effects: tachycardia, hypotension, anaphylaxis (more fatal in those with CHD)
91
What foods to avoid with MAOIs:
Tyramine rich containing foods i.e.: Strong aged cheeses, cured meats, processed meats, alcohol, marmite, soybeans, pickled fermented foods, caviar, kimchi
92
What juice interacts with statin and CCB's:
Grapefruit juice
93
This specific juice can aid the absorption of iron:
Fresh orange juice
94
State symptoms of anal fissure:
Tear or ulcer in lining of the anal canal which causes pain on defecation, with or without bright red rectal bleeding and anal spasm Acute = if present for less than 6 weeks Chronic = present for 6 weeks or longer Primary = no clear underlying cause Secondary = related to constipation, IBD, STI, colorectal cancer
95
State treatment of anal fissure:
Dietary and lifestyle advice to ensure stools are soft and easy to pass High fibre diet and increased fluid intake Good anal hygiene Paracetamol or ibuprofen for pain relief For adults with extreme pain on defecation, prescribe lidocaine 5% ointment or adults who have persisted for 1 week or more without improvement consider a 6- 8-week course of rectal GTN 0.4% ointment
96
What colour does the following drug colour your uri ne and bodily secretions: nefopam?
pink
97
What colour does the following drug colour your uri ne and bodily secretions: triamterene
blue
98
What colour does the following drug colour your uri ne and bodily secretions: sulfasalazine
yellow orange
99
What colour does the following drug colour your uri ne and bodily secretions: rifampicin
orange- red
100
What colour does the following drug colour your uri ne and bodily secretions: nitrofuruantoin
yellow- brown
101
What colour does the following drug colour your uri ne and bodily secretions: senna
red- yellow
102
What colour does the following drug colour your uri ne and bodily secretions: co- dranthramer
red
103
What colour does the following drug colour your uri ne and bodily secretions: co- dranthrusate
red
104
What colour does the following drug colour your uri ne and bodily secretions: levedopa
red
105
What colour does the following drug colour your uri ne and bodily secretions: b vitamins
bright yellow
106
What colour does the following drug colour your uri ne and bodily secretions: entacaoine
red- brown
107
State treatment of diverticulosis:
Specific treatments are not recommended as asymptomatic condition Bulk-forming laxatives considered for constipation
108
State treatment of acute uncomplicated diverticulitis:
Co-amoxiclav Cefalexin AND metronidazole or trimethoprim and metronidazole or ciprofloxacin
109
What is the treatment of complicated / severe diverticulitis?
Intravenous antibacterial (gram negative organisms / anaerobes) and bowel rest
110
What is the recommended treatment for symptomatic diverticular disease?
High fibre diet (bulk-forming drugs but evidence is lacking) Paracetamol for abdominal pain treatment NSAIDs not advised as may increase risk of diverticular perforation

afsha - GI (31 decks)

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