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Gastro Flashcards

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1
Q

What is diverticulitis?

A

When the pockets (diverticula) in the lining of the intestine become inflamed or infected

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2
Q

What are the symptoms of diverticulitis?

A

Lower abdominal pain
Constipation
Diarrhoea

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3
Q

What are the treatment options for diverticulitis?

A

High-fibre diet
Bulk-forming drugs
Antibiotics

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4
Q

What is first-line oral treatment for suspected/ confirmed acute diverticulitis?

A

Co-amoxiclav

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5
Q

What are the oral treatment options for diverticulitis in a patient who is allergic to penicillin?

A

Cefalexin with metronidazole
Trimethoprim with metronidazole
Ciprofloxacin with metronidazole (only if switching from IV)

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6
Q

What is first-line IV treatments for suspected/confirmed diverticulitis? (2 options)

A

Co-amoxiclav or cefuroxime with metronidazole
Amoxicillin with gentamicin and metronidazole

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7
Q

What is first-line IV treatments for suspected/confirmed diverticulitis with a penicillin allergy?

A

Ciprofloxacin with metronidazole

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8
Q

What are the symptoms of UC?

A

Bloody diarrhoea
Abdominal pain
Urgent need to defecate

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9
Q

What are the signs of an acute flare-up in UC?

A

Mouth ulcers
Arthritis
Sore skin
Weight loss
Fatigue

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10
Q

What are the long-term complications of UC?

A

Colorectal cancer
Secondary osteoporosis (corticosteroids)
Venous thromboembolism
Toxic megacolon

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11
Q

What is toxic megacolon?

A

Swelling and inflammation spread into deeper laters of the colon, which makes it stop working and widens.

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11
Q

What is contraindicated during an acute flare up in UC and why?

A

Loperamide
Codeine
Increases the risk of toxic megacolon. Avoid anti-motility / antispasmodics - can cause paralytic ileus

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11
Q

What type of formulation is best to treat proctitis?

A

Suppositories

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11
Q

What type of formulation is best to treat proctosigmoiditis?

A

Foam preparations
(foam/suppositories easier to retain than liquid)

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12
Q

What type of formulation is best to treat left-sided colitis? (distal)

A

Enemas

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12
Q

What type of formulation is best to treat extensive colitis? (proximal)

A

Oral

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13
Q

What scoring system is used to asses the severity of UC and how is it classified?

A

Truelove and Witts Severity Index
Mild, Moderate, Severe

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14
Q

What is the treatment for acute mild-moderate UC proctitis/proctosigmoiditis?

A

First line: Aminosalicylate (rectal)
Alternative: rectal corticosteroid, oral prednisolone

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15
Q

What is the treatment for acute mild-moderate UC extensive colitis/ left sided?

A

First line: High dose oral aminosalicylate
Plus rectal aminosalicylate or oral beclometasone if prn
Alternative: Oral prednisolone alone

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16
Q

What can be given if treatment fails in all extents of acute mild-moderate UC?

A

Oral prednisolone (after 4 weeks with aminosalicylate)
Add tacrolimus if no response after 2-4 weeks

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17
Q

What is the treatment for subacute moderate-severe UC?

A

Oral prednisolone
Alternative: MABs

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18
Q

What is the treatment for severe acute UC?

A

IV corticosteroid
Alternative: IV ciclosporin
If symptoms dont improve or worsen in 72 hours give IV corticosteroids and ciclosporin

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18
Q

What is the treatment for proctitis/ proctosigmoiditis for remaining in remission in UC?

A

Rectal aminosalicylate alone
Or with oral aminosalicylate

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19
Q

What is the treatment for extensive colitis / left sided for remaining in remission in UC?

A

Low dose oral aminosalicylate

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20
When is azathioprine / mercaptopurine indicated for maintaining remission in UC?
If there has been 2+ acute flare ups in 12 months that require systemic corticosteroids Or if remission has not maintained by aminosalicylates Or after a severe flare up
21
What are the symptoms of Crohn's Disease?
Abdominal pain Diarrhoea Rectal bleeding Weight loss Low grade fever Fatigue
22
What is fistulating Crohn's disease?
Involves formation of a fistula between the intestine and adjacent structures such as perianal skin, bladder and vagina
23
How is the first presentation of Crohn's disease treated? (1 acute flare in 12 months)
Corticosteroid (pred, methylpred, hydrocortisone) Alternative: budesonide or aminosalicylates in patients with distal ileal, ileocaecal or right sided colonic disease
24
How is 2 acute flare ups in 12 months treated in Crohn's disease?
Azathioprine or mercaptopurine Alternative: Methotrexate Alternative: MABS
25
Give examples of aminosalicylates
Balsalazide Mesalazine Olsalazine Sulfasalazine
26
Which aminosalicylate can colour urine / stain contact lenses?
Sulfasalazine
27
What are the side effects of aminosalicylates?
Blood dyscrasias Nephrotoxicity Hypersensitivity Yellow/orange bodily fluids with sulfasalazine
28
What is the interaction between lactulose and mesalazine?
Lactulose lowers stool pH in the intestines. This prevents sufficient release of the AI in E/C or M/R preparations
29
What is the difference between budesonide and prednisolone?
Budesonide is locally acting with minimal systemic absorption, whereas prednisolone is metabolised throughout the body.
30
List the immunosuppressants used in Crohn's Disease
Azathioprine Ciclosporin Mercaptopurine Methotrexate MABS
31
What is a contraindication for starting azathioprine treatment?
Absent thiopurine methyltransferase (TPMT) activity
32
What pre-treatment screening is need for azathioprine?
TPMT activity (metabolises thiopurine drugs. Risk of myleosuppression is increased in patients with reduced activity of the enzyme)
33
What are side effects of azathioprine?
Bone marrow depression Increased risk of infection Leucopenia Pancreatitis Thrombocytopenia
34
What drug classes can be used for GI spasms in IBS?
Antispasmodics (alverine, mebeverine, peppermint oil) Antimuscarinics (hyoscine butylbromide, atropine, dicycloverine, propantheline bromide)
35
Is lactulose recommended in IBS?
No - causes bloating
36
What is first line for diarrhoea in IBS?
Loperamide
37
What class of drugs has an unlicensed use for abdominal pain in IBS?
Antidepressants -Tricyclic -SSRI
38
What is the NICE CKS definition of constipation?
Bowel opening less than 3 times a week
39
List the red flag symptoms for constipation
New onset in over 50 years Anaemia Abdo pain Unexplained weight loss Blood
40
Give examples of Bulk-Forming laxatives
Sterculia Isphaghula husk Methylcellulose
41
How long do Bulk-Forming Laxatives take to have their full effect
72 hours
42
How do Bulk-Forming laxatives work?
Swells into gut to increase faecal mass to stimulate peristalsis
43
What are the side effects of Bulk-Forming Laxatives?
Bloating Cramping Flatulence Gut obstruction
44
What are counselling points to give with Bulk-Forming Laxatives?
Maintain adequate fluid intake to avoid gut obstruction Swallow with plenty of water and not immediately before bed
45
Name examples of osmotic laxatives
Macrogol Lactulose Magnesium hydroxide
46
What laxative is used first line after dietary advice
Bulk-Forming
47
What type of laxatives are used second line?
Osmotic If stools remain hard add or switch to osmotic
48
How do osmotic laxatives work?
Increase water into colon by drawing fluid from the body
49
How long does it take for lactulose to work?
Within 48 hours
50
How long does it take for macrogol to work?
Works within 2-3 days
51
List examples of stimulant laxatives
Bisacodyl Sodium picosulfate Senna Glycerol Docusate
52
What type of laxatives are used third line?
Stimulant Add if stools are soft but difficult to pass / incomplete emptying
53
How do stimulant laxatives work?
Increases intestinal motility by irritating the gut lining. Work within 6-12 hours
54
What are the side effects of stimulant laxatives?
Abdominal cramps Senna colours urine yellow/brown Excessive use= diarrhoea, hypokalaemia, lazy bowel
55
What is Dantron and what type of patients is it used in?
Co-danthramer, codanthrusate Used in terminally ill patients only Red urine Local irritation Genetoxic and carcinogenic
56
What laxatives are given for opioid induced constipation?
Osmotic or Docusate + Stimulant
57
What type of laxatives should be avoided in opioid induced constipation
Bulk-forming laxatives = obstruction
58
What laxatives should be used in children (who are not faecally impacted)
First line: Macrogol (along with diet/behaviour intervention Add stimulant laxative if inadequate response Add lactulose or facecal soften if stool remains hard
59
What laxative is first line for constipation in pregnancy?
First line: Bulk forming (if fibre supplements fail) Osmotic (lactulose) can be used Bisacodyl or senna if a stimulant effect is necessary Docusate or glycerol suppositories
60
What laxative should be avoided near term or in patients with a history of an unstable pregnancy?
Senna - can stimulate uterine contractions
61
What type of laxatives are first line in patients who have constipation and are breastfeeding?
Bulk-forming (if dietary measures fail)
62
What is first line treatment for diarrhoea?
Oral rehydration therapy (dioralyte) Replaces electrolytes and fluid depletion
63
What drug is occasionally used for propylaxis against travellers diarrhoea, but routine use is not recommended?
Ciprofloxacin
64
What type of drug is loperamide and how does it work?
Antipropulsive Prolongs the duration of intestinl transit by binding to opioid receptors in the GI tract
65
What is the adult dose of loperamide?
Initially 4mg (2 tabs), then 2mg (1 tab) for up to 5 days. Take a dose after each loose stool
66
What is the max dose of loperamide?
16mg (8 caps) a day
67
What is the MHRA warning for loperamide?
September 2017 Cardiac adverse reactions with high doses (overdose, misuse or abuse) QT prolongations, torsade de pointes, cardiac arrest and fatalities
68
What are the common side effects of loperamide?
Dizziness, flatulence, headache, nausea
69
What are the contraindications of loperamide?
Active UC Antibiotic associated colitis Conditions where peristalisis is inhibited Avoid in bloody diarrhoea/inflammatory diarrhoea
70
What is dyspepsia?
Range of upper GI symptoms which are typically present for 4 or more weeks
71
What are the symptoms of dyspepsia?
Upper GI pain Fullness Heartburn Gastric reflux Bloating N&V
72
What are the treatment options for uninvestigated dyspepsia?
Antacids for symptomatic relief PPI for 4 weeks if symptoms persist H Pylori test if no response to PPI
73
What are the treatment options for investigated functional dyspepsia?
H Pylori test PPI or H2 antagonist for 4 weeks
74
What are the 3 common salts used in antacids?
Aluminium (constipating, long acting) Magnesium (laxating, long acting) Calcium (induce rebound acid secretion)
75
What are examples of low sodium preparations of antacids?
Maalox Mucogel Altacite plus
76
List interactions with antacids
Tetracyclines Quinolones (cipro) Bisphosphonates Impaired absorption of drugs - leave 2 hour gap Damages enteric coating by increasing gastric pH
77
What conditions should antacids be avoided in?
High sodium content Avoid in HTN, heart/liver/kidney failure Avoid in sodium-restricted diet eg. lithium
78
Which PPI is the most safe in pregnancy?
Omeprazole
79
What are the cautions with PPIs?
Mask symptoms of gastric cancer Increased risk of osteoporosis Increased risk of fractures Increased risk of GI infections (c diff - reduced acidity)
80
What are the side effects of PPIs?
GI upset: abdominal pain, constipation, diarrhoea, nausea
81
What is the MHRA alert associated with PPIs?
September 2015 Very low risk of subacute cutaneous Lupus Lesions occur, consider stopping PPI
82
What are consequences of long term uses of PPIs?
Hypomagnesaemia / hyponatraemia Fractures Rebound acid secretion, protracted dysepsia after stopping
83
What is a monitoring requirement with PPI
Measurement of serum magnesium before/during prolonged treatment. Especially when used with other drugs that cause hypomagnesaemia or with digoxin
84
Which PPI interacts with clopidogrel and what is the interaction?
Omeprazole Reduced antiplatelet effect
85
Which PPI interacts with methotrexate and what is the interaction?
Omeprazole Decreased clearance of methotrexate
86
What are side effects of H2 receptor antagonists?
Headaches, rashes, dizziness, diarrhoea, confusion, depression
87
What class of drugs can reduce the risk of acid aspiration in obsteric patients at delivery? (menedelson's syndrome)
H2 receptor antagonists
88
When are H2 receptor antagonists cautioned?
Gastric cancer, can mask symptoms
89
What are common causes of peptic ulcer disease?
NSAIDs H Pylori Smoking Alcohol consumption Stress
90
How should peptic ulcer disease be treated if the ulcer is associated with NSAID use?
PPI or H2 receptor antagonist for 8 weeks
91
What is the treatment regime for H Pylori ulcer eradication?
Triple therapy with PPI + CLARITHROMYCIN + AMOX/MET
92
What is the first line treatment of GORD?
PPI for 4 or 8 weeks If no response then offer H2 receptor antagonist
93
What should severe oesophagitis be treated with and how long for?
PPI and 8 weeks
94
What are the treatment options for GORD in pregnancy?
Dietary and lifestyle - first line Antacid and alginate if fails If ineffective - omeprazole or ranitidine (unlicensed) may be used
95
How does cholestasis present in a patient?
Fatigue Pruritus Dark urine Pale stools Jaundice Signs of fat soluble vitamin deficiencies
96
What is the drug of choice to treat cholestatic pruritus?
Colestyramine
97
What are second/third line drugs used to treat cholestatic pruritus?
Ursodeoxycholic acid Rifampicin (unlicensed) - caution in liver disease Sertraline, naltrexone - use is limited due to side effects
98
What is the treatment for intrahepatic cholestasis in pregnancy?
Ursodeoxycholic acid
99
What is the treatment for primary biliary cholangitis?
Ursodeoxycholic acid
100
What is the treatment for oesohageal varices?
Tazocin 4.5g TDS for 5 days Terlipressin 2mg IV QDS
101
What are the cautions with terlipressin?
Arrhythmia, elderly, electrolyte and fluid disturbances, heart disease, history of QT interval, respiratory disease, uncontrolled hypertension, vascular disease
102
What is Gilbert's syndrome?
Slightly higher than normal levels of bilirubin build up in the blood
103
What is the treatment for ascites?
Spironolactone - it is an aldosterone antagonist Furosemide can be used if spiro fails
104
What is the treatment for hepatic encephalopathy?
Lactulose 10-30ml prn qds and/or phosphate enema If treatment fails can add in PO rifaxamin 550mg BD
105
What is the treatment for Wernicke's encephalopathy?
IV pabrinex 2 pairs TDS for 3-5 days then thiamine 100mg tds and multi vits OD
106
What drug can be given to patients with a high bilirubin?
Fluconazole
107

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