GI Flashcards
(118 cards)
1
Q
What is dyspepsia?
A
A broad term for a range of symptoms in upper GI tract:
upper abdominal pain, gastric reflux, heart burn, nausea and vomiting, wind
2
Q
Name common upper GI conditions:
A
Gastro-oesophageal reflux disease (GORD) 10-20%
Duodenal stomach ulcer disease (PUD) 10-25%
Gastritis 30%
Functional dyspepsia 30%
Oesophageal and gastric cancer 2%
3
Q
What are the symptoms of gastritis?
A
For many they can be asymptomatic
Symptoms include indigestion, sickness, burning
4
Q
How can the HP bacteria be tested for and identified?
A
Breath test or stool antigen test
Give radio labelled urea and CO2 (radiolabelled) will be produced in breath
Stool needs to be stored at -20ºC before testing (most common)
For both tests pts need to avoid antibiotics for 4 weeks before to avoid a false negative
5
Q
How would you improve an ulcer if someone has the HP infection?
A
Eradication, it is the cure
6
Q
What is the epidemiology of PUD?
A
10-15% of population will suffer from it
GU rare in under 40
DU predominately in males between 20-50
7
Q
Which drugs can induce dyspepsia?
A
Cause peptic ulcers:
NSAIDs
Sulfasalaizine
Iron preparations
Corticosteroids
K (particularly in mr forms)
Bisphosphonates
May reduce LOS pressure:
Theophylline
Ca agonists
Nitrates
8
Q
How many patients with RA suffer from PUD and what is the safest NSAID to use?
A
1/3
Ibuprofen is the safest
9
Q
What are the gastric symptoms of PUD?
A
Pain on eating
Epigastric area (below sternum but above naval)
9
Q
A
10
Q
What are the duodenal symptoms of PUD?
A
Pain occurring between meals and at night
Localised dull pain
11
Q
What are other symptoms for both gastric and duodenal PUD?
A
Bloatedness
Nausea
Anorexia
Belching
Haematemesis (blood in vomit)
Melaena (dark sticky faeces)
12
Q
Name factors which can contribute to lowering the pressure of the LOS:
A
Dietary factors (fat, chocolate, caffeine, alcohol, large meals)
Cigarette smoking
Endocrine factors (high levels of oestrogen and progesterone e.g pregnancy, HRT, Oral contraception)
Drugs
13
Q
Which drugs can contribute to GORD?
A
Anticholinergics
B2 agonists
Diazepam
CCBs
Nitrates
Alcohol
Progesterones
COC
Theophylline
14
Q
Which drugs can cause oesophageal ulceration?
A
NSAIDs
Bisphosphonates
Clindamycin
Clotrimazole
Doxycyline
Potassium
Tertacycline
Theophylline
Antibiotics responsible for 50% of drug induced oesophagitis, especially clindamycin capsule
15
Q
What is the diagnosis for GORD?
A
Endoscopy is the only diagnosis
16
Q
What is functional dyspepsia?
A
Not associated with risk of cancer
Half of patients with chronic dyspepsia with no evidence of organic disease with investigations done
Could be hypersensitivity to gastric acid
17
Q
What is the treatment for functional dyspepsia?
A
Eradicate HP if present
Neutralise acid or prevent production (symptomatic relief)
Periodic monitoring (safety netting)
18
Q
What should be the management of stomach and duodenum ulcers?
A
Identify and eradicate HP
Stop inappropriate therapy
Reduce production of acid to reduce gastritis and enable mucosa to repair- block H2 or PPI
Once ulcer is healed (8weeks) then test for HP
19
Q
Describe the eradication therapy for HP?
A
2 antibiotics and a PPI
Normally amoxicillin and clarithromycin
85% effective
20
Q
What should be the management of stomach and duodenum ulcers if there are no causes?
A
PPI can be prescribed for 4-8 weeks
If still unhealed look for adherence, stopping NSAIDS e.g OTC, or other diseases present e.g Crohns
21
Q
What should be prescribed if the symptoms of ulcers heals but then the symptoms come back again
A
Low dose PPI
22
Q
Give diet advice for the management of GORD:
A
Eat small meals
Avoid foods which lower LOS pressure (alcohol, caffeine etc)
Avoid fatty foods which slow gastric motility
Avoid eating within 4 hrs and drinking 2 hrs before going to bed
Reduce alcohol intake
23
Q
Give other lifestyle advice for the management of GORD:
A
Avoid drugs which lower LOS pressure
Avoid tight fitting clothes
Attention to posture (bend form knees)
For nocturnal heart burn, raise top head of bed by 15-23cm
Stop smoking
24
Why should antacids only be taken for short term use?
As they only releive symptoms in the short term, can cause an acid rebound
25
When are antacids best taken?
An hour after a meal, when gastric emptying is slow, so they remain in the stomach for longer, DoA = 3hrs
26
What are common side effects with antacids and how are these resolved?
Constipation with Al based salts
Diarrhoea with Mg based salts
Can be used in combo to counteract each other
27
What medical conditions can antacids interact with and why?
Al binds to phosphate in gut- osteoporosis
Al can be absorbed- neurotoxicity
Rebound GA secretion with prolonged use
Na- avoid in patients with cardiac problems and hypertension
28
Are antacids safe to take during pregnancy?
Generally safe but got to look at sodium content
29
Name examples of H2 receptor antagonists:
Cimetidine, Ranitidine, Famotidine, Nizatidine
30
What are the healing rates of H2 antagonists used in PUD?
High healing rates, no reduction in relapse
31
What are the healing rates of H2 antagonists used in GORD?
After 12 weeks, 80-90% of pts with mild oesophagitis improved
Not effective in moderate to severe GORD
Only use if an inadequate response to PPI (NICE)
32
What are the side effects of different H2 antagonists?
Generally safe 1-7% of pts experience ADRs
Headache/ dizziness
Cimetidine- Gynaecomastia, breast tissue in men (0.2%), impaired libido
Nizatidine- sweating/ abnormal dreams
Confusional states in elderly
33
Name interactions of Cimetidine?
Binds to P450
Phenytoin, theophylline, warfarin
Enhances their effects
34
What are short term side effects of PPIs?
Nausea, diarrhoea, flatulence, epigastric pain, dry mouth, headache
Arthralgia and myalgia
35
What can be the concerns of taking PPIs long term?
Bacterial overgrowth as may increase risk of salmonella/ HP
36
When is the best time of day to take a PPI?
Before food as food can decrease bioavailability
37
What is the main treatment used for FD, gastritis and PUD?
H2 antagonists or PPI
38
What is the main treatment used for GORD?
PPIs or alginates (not H2)
39
What is constipation?
A symptom, not a disease
Difficulty opening the bowels:
-less than 3 times a week
-straining to open bowels for more than 25% of occasions
-hard or pellet like stool for more than 25% off occasions
40
What is chronic constipation?
More than 4 weeks
Generally more than 12 weeks in the last 6 months
41
Name some medications which can cause constipation:
Antacids (Ca and Al)
Antispasmodics
Antidepressents
Anticolinergics^
Iron tablets e.g ferrous sulfate
Diuretics (encouraging patient to urinate so decreased fluid)
Painkillers (codeine)
CCBs
ACEi
Ulcer healing (PPI)
Antipsychotics
42
Describe the Bristol stool chart:
Type 1/2 = constipation
separate hard lumps
Type 6/7 = diarrhoea
watery, no solid pieces
Aim for Type 4
43
Name examples of bulking agents:
Ispagula husk
Methylcellulose
44
Name examples of stimulant laxatives:
Bisacodyl (oral/rectal)
Senna
Dantron (co-danthrusate/ co-danthramer)
Sodium picosulfate
45
Name examples of faecal softeners:
Docusate (oral/rectal)
Glycerol (suppository)
Arachis oil (enema)
46
Name examples of osmotic laxatives:
Lactulose, macrogols (inert polymers of ethylene glycol)
MgOH and MgSulfate, phosphate (enema/suppository)
Sodium citrate (microenema)
47
How long does acute constipation last for?
Less than 4 weeks
48
What is the treatment plan for acute constipation?
Lifestyle advice and managing underlying causes
Bulk forming (1-3 days if insufficient response)
+/OR osmotic e.g macrogol (on its own if bulk isn't working)
Stimulant
Gradually reduce and stop after producing soft, formed still without straining at least 3x a week
49
What is the treatment plan for chronic constipation?
Same as acute, but after everything else can try Prucalopride
50
Describe when prucalopride is used:
Used when 2 other laxatives have been used for max dose for at least 6 months
Prokinetic serotonin agonist which stimulates GI motility
51
What is faecal loading?
Build up of faecal matter within the colon
52
What is impaction?
Dry, hard stools as has been in the colon for a long while
53
What would be the first line treatment for impaction (hard stools) and how quick do they work?
High dose oral macrogol (48hrs max)
Stimulant (12hrs)
54
What would be the second line treatment for impaction if there was no initial response or slow?
Glycerol alone or glycerol +bisacodyl suppository (30 mins)
55
What would be the third line treatment for impaction if there was still an inadequate response?
Sodium phosphate (most powerful osmotic laxative) or arachis oil retention enema
56
What would be the first line treatment for faecal loading (soft stools) and how quickly do they work?
Stimulant (12hrs)
57
What would be the second line treatment for faecal loading if there was no initial response or slow?
Docusate or sodium citrate mini enema
58
What laxative would you not give in opioid induced constipation and why not?
Bulk forming laxative (antagonists)
MoA is to increase faecal mass causing colon to become distended leading to peristalsis, opioids decrease peristalsis
59
What would be the first line treatment for opioid induced constipation?
Osmotic laxative (or docusate) and a stimulant laxative
60
What would be the second line treatment for opioid induced constipation if first line unsuccessful and how does it work?
Naloxegol (oral)
Peripherally acting mu-opioid receptor antagonist (PAMORA)
They don't antagonise the important central opioid receptors
61
What would be the third line treatment for opioid induced constipation if all unsuccessful?
Methylnaltrexone (sc)- PAMORA
Naldemedine (oral)
62
What would be some lifestyle advice to give to a patient if they have constipation?
High fibre diet
30g fibre a day with sufficient fluid
Caution in obstructive symptoms or fecal impaction
Ineffective in slow transit constipation or defecatory disorders
Switch from white to wholemeal
Increase physical activity
2L water per day (8 glasses)
63
What would be the guidelines for suggesting a laxative for a person who is pregnant and experiencing constipation?
Offer a bulk forming
Add or switch to an osmotic
Can consider a short course of stimulant such as Senna (NEVER close to term as can stimulate contractions and prescribed only)
Glycerol suppository
64
What would be the guidelines for suggesting a laxative for a person who is breastfeeding and experiencing constipation?
The same as pregnancy but can use bisacodyl or Senna and doesn't need to be prescribed only
65
What would be the treatment steps for children with constipation?
1st- macrogols and negotiated and non punitive behaviour
2nd- add stimulant laxative
3rd- add lactulose (or other softening) if macrogol not tolerated
66
What are the counselling points for ispagula husk?
1 sachet BD (12 years and over)
Sachets poor in a full glass of water and drink straight away
Take after meals, and not before bed as it encourages peristalsis and no peristalsis in sleep
Take 1/2 to 1 hr before/after other meds
Remains effective despite long term use
67
What are the counselling points for methylcellulose?
3-6 tabs BD with atleast 300ml of liquid
Break tabs in mouth before swallowing
Do not take just before bed
Ensure good fluid intake
2-3 days for effect
68
What are the counselling points for macrogol?
1-3 sachets daily, in divided doses
Sachets dissolve in 125ml of water
High in Na so CI in hypertension, heart disease and renal impairment
Don't take other medicines an hour before or after
1-3 days for effect
69
What are the counselling points for lactulose?
15-45ml daily in single or divided doses
Very sweet tasting liquid
Can cause bloating or colic- caution if intolerant to lactose
No issue for diabetic patients as not absorbed through gut wall so no impact on sugar levels
Up to 2 days for effect
70
What are the counselling points for Docusate?
Up to 500mg daily in divided doses
12-72 hrs for effect of tabs, 15 mins for suppositories
Softening agent and stimulant
May be useful alternative for people who find it hard to increase fluid intake
Generally well tolerated
71
What are the counselling points for suppositories and enems?
Quick action, making it better, less likely for hospitalisation
Arachis oil enema contains peanut
72
Describe how you would insert a suppository:
Lay on left side- use a water soluble lubricant
Hold it between thumb and finger and put blunt edge into anus
Go to the depth of your finger
Lie still and hold for 10-15 mins
73
Describe how you would insert an enema:
Warm enema in bowl of warm water
Lay on left side and keep knees up to chest
Push nozzle in 3 inches
Squeeze contents in and hold for 5 mins, go to the toilet when needed
Stay near the toilet for the next hour
Some people have stomach cramps for a while and occasionally people feel faint and dizzy, lay down if this occurs
74
What are the counselling points for senna?
Senokot
Tabs and syrups 7.5-15mg daily (max 30mg)
Onset of action is 8-12 hours, take in evening for morning movement
Syrup is unpalatable
75
What are the counselling points of dantron?
Co-danthramer includes PEG
Co-danthrusate includes docusate
Colours urine red
Avoid prolonged contact with skin
Only in terminally ill patients (potential carcinogen)
Oral solution
Onset of action 6-12 hrs
76
What are the counselling points for sodium picosulphate and name the brand:
Dulcolax (liquid)
5-10mg OD
Tabs and syrup
Syrup is palatable
Onset of action 10-14 hrs
77
What are the counselling points for bisacodyl and name the brand:
Duclolax (tabs and suppositories)
Acts on SI
5-10mg OD, increase to 20mg OD if necessary
Tabs act in 10-12 hrs
Suppositories act in 20-60 mins
Suppositories can cause local inflammation
78
What is the dosing of prucalopride and how long does it take to work?
2mg tabs OD, review treatment if no response after 4 weeks (reduce dose in elderly 1mg)
1-2 weeks for effect, increasing dose will not improve response
79
What are the side effects of prucalopride?
Headache
GI disturbances
80
What is acute diarrhoea?
Abrupt onset of 3 or more loose stools a day and lasts no longer than 14 days
81
How does acute diarrhoea normally resolve?
Majority resolves in 2-3 days without specific treatment, just oral rehydration sachets
82
What is chronic diarrhoea?
Pathological cause which lasts more than 14 days, possible flare up of previously diagnosed condition
83
Name examples of drugs that cause diarrhoea:
Antibiotics- most common are broad spectrum
Laxatives
Metformin
Ferrous sulfate
NSAIDs
Colestryamine
Antacids (Mg salts)
B blockers
Digoxin
Misoprostol
84
Should loperamide be used in pregnancy/ breastfeeding, why/ why not?
Pregnancy:
Manufacturers advise avoid, weigh up risks
Breastfeeding:
Amount PROBABLY too small to be in breastmilk- avoid
85
Should ORT be used in pregnancy/ breastfeeding, why/ why not?
It is essential
If symptoms warrant loperamide, refer in both instances
86
What would be the advise and medications used in children with diarrhoea?
Feeding babies: encourage to still feed with normal breast milk as the milk has the right antibodies to fight off diarrhoea
Children: encourage plenty of fluids/ ORT
Loperamide is not recommended by NICE but BNF does state dose for children via prescription
87
What measures should be taken to prevent the spread of diarrhoea?
Careful washing and drying of hands after using toilet, nappy changes, before meals
Don't share towels
48hr exclusion from school following cessation of symptoms
Avoid swimming for 2 weeks following last episode of diarrhoea
88
How long should an age group have diarrhoea before being referred to GP?
>1 day= infants and children under 1
> 2 days= children under 3 and frail/older people
>3 days= children over 3 and healthy adults
89
What is travellers diarrhoea?
3 or more loose stools in 24 hours with or without at least one symptom of cramps, nausea, fever or vomiting
90
What are signs of dehydration?
Unwell/ deteriorating
Altered responsiveness
Tachycardia
Decrease skin turgor
91
When should you follow the sick day rules?
When unwell with any of the following:
-vomiting or diarrhoea, unless minor
-fevers, sweats, shaking
92
What medications should be stopped when following the sick day rules and when can they be started again?
ACEi
NSAID
ARBs
Diuretics
Metformin- increase risk of causing lactic acidosis
Restart when well again 1-2 says after eating/ drinking normally
93
What is the treatment for a C Diff infection?
Vancomycin 125-500mg every 6 hours for 10 days (orally)
94
What would be the criteria for diagnosis in IBS?
Abdominal pain present for at least 6 months
Relieved by defecation or
Increased/decreased bowel freq or stool formation
Plus at least 2 of the following:
-abdominal bloating/distension
-altered stool passage (straining, urgency, incomplete evacuation)
-worsened by eating
-passing mucus
95
What is the Rome IV criteria?
In secondary care
Abdominal pain 1 day per week in last 3 months
Symptoms began at least 6 months prior
Along side more than 2 of the following:
-related to defecation
-change in stool freq
96
Name and describe the classifications of IBS using the Rome IV criteria:
IBS-C, predominant constipation symptoms
>25% of stools are type 1/2 and <25% are types 6/7
IBS-D, predominant diarrhoea symptoms
>25% are type 6/7 and <25% are types 1/2
IBS-M, mixed
>25% are type 1/2 AND >25% are type 6/7
IBS-U, unclassified
Person has IBS, but bowel habits can't be categorised as above
97
What are the main drug class treatments for IBS?
Antispasmodic drugs
Antidepressants
Laxatives
Loperamide
Linaclotide
98
Name some antispasmodic drugs used for IBS and their dose:
Alverine citrate 60-120mg up to TDS
Mebervine 135mg TDS (20 mins before food) or 200mg BD for MR prep
Peppermint oil caps, 1 or 2 caps up to TDS
Hyoscine butylbromide and dicycloverine can also be used but tend to have more antimuscarinic effects
99
What are the CI for antispasmodic drugs in IBS?
In intestinal obstruction or paralytic ileus- as slowing down motility can be a problem when motility is already an issue
100
Describe the use of antidepressants for IBS:
Use is unlicensed, for people with IBS pain
People usually not respond to typical treatments
Doses given lower than you would see for mental health uses
101
Name some antidepressants used for IBS and their doses:
1st line= TCA e.g amitriptyline 10-30mg at night
2nd line= SSRI e.g sertraline, citalopram, fluoxetine- not a specific one
102
What should you specifically counsel a patient on if they are taking antidepressants for IBS?
They may be shocked when they read the PIL as it says it is for depression
103
Describe the use of laxatives in IBS:
For IBS-C
Ispagula husk can be used for IBS-D
Can use any laxative apart from lactulose as can increase gas production and worsen symptoms
Dose should be titrated according to symptoms
104
Describe the use of loperamide for IBS OTC:
Only for pts over 18
Must have been diagnosed with IBS
Only for attacks lasting up to 48 hrs- refer if longer
Can be used for a max of 2 weeks as long as individual bouts are less than 48 hrs
105
Describe the use of linaclotide for IBS:
For moderate to severe IBS-C in adults
Person must have had IBS-C for at least 12 months
Should only be used if max tolerated doses of laxatives haven't helped
106
What is the dosing for linaclotide for IBS?
290mcg OD 30 mins before food
107
What is the CI for linaclotide?
Avoid in GI obstruction/ IBD
108
What is the advice and management of diverticulosis?
Asymptomatic so no need for routine follow ups
Maintain healthy balanced diet, high in fibre (30g)
Maintain adequate fluid intake
If overweight, advise about benefit of weight loss, exercise and also smoking cessation to prevent progression
If constipated, offer bulk forming laxative
109
What are symptoms of diverticular disease?
Intermittent pain in lower left quadrant (with constipation, diarrhoea, rectal bleeds)
Abdominal pain worsened by eating, relieved by passing stool or wind, flatulence
Lower left quadrant tenderness on palpitation
Asian populations symptoms may present on right quadrant
No systemic symptoms
110
What would be the management of diverticular disease?
High fibre diet
Bran supplements/ bulk forming laxatives
Lifestyle advice as per diverticulosis
Anti-spasmodics when colic/cramping
111
What should you avoid in diverticular disease?
Avoid NSAIDs
Avoid anti-motility drugs which slow transit time e.g codeine and loperamide should NOT be used
Risk of diverticular perforation
112
What are the symptoms of diverticulitis?
Constant lower left abdominal pain with:
-fever
-sudden bowel change
-blood/mucus in stools
-lower left quadrant tender (right if asian)
-palpable abdominal mass/distension
-malaise
-N&V
-tachycarida
-increase in WBC, platelets, anaemia, CRP
113
What are the signs of sepsis?
Increase respiration
Increase heart rate
Decrease systolic BP
No urine output
Skin discolouration
Cognitive impairment
114
What is the treatment for diverticulitis who is systemically unwell?
Co-amoxiclav 500/125 TDS x 5 days
(Cefalexin if penicillin allergy) PLUS metronidazole 400mg TDS for 5 days
OR
Trimethoprim 200mg BD for 5 days PLUS metronidazole 400mg TDS for 5 days
115
What would be the treatment for diverticulitis who is systemically well?
Consider no Ab strategy- stewardship
Analgesia e.g paracetamol
Re-present if symptoms worsen
116
What are the physical symptoms of pancreatic exocrine insufficiency?
Malnutrition:-
Lethargy, depression, poor conc, muscle loss, dry skin, brittle nails
Diarrhoea*
Cramping/ bloating/ flatulence
Steatorrhoea/ fatty/foul smelling stools, usually light in colour
117
What are the counselling points for treatment of pancreatic exocrine insufficiency?
Dose will be tailored according to treatment
Higher doses for main meals
Smaller doses for snacks
Physical symptoms should ease
Clinal manifestations should also improve due to vitamins being digested and absorbed properly
