GI conditions Flashcards
constipation, vomiting, diarrhoea, and respective treatments. IBS and Crohn's disease. Comm pharmacy enquiries
1
Q
what is the definition of diarrhoea and what types of stools are classed as diarrhoea on the Bristol stool chart?
A
the passing of 3+ loose stools or liquid stools a day
- type 5 - 7 on the Bristol Stool Chart
2
Q
What is the difference between acute, persistent and chronic diarrhoea?
A
acute - lasts less than 14 days - often bacterial or viral infection, or due to anxiety, or food intolerance, or acute appendicitis.
persistent - lasts more than 14 days
** chronic** - lasts more than 4 weeks (i.e. a month)
3
Q
what are some causes of acute diarrhoea?
A
bacterial or viral infection
anxiety
food intolerance
acute appendicitis.
4
Q
what are some causes of chronic diarrhoea?
A
IBS, Crohn’s disease, coeliac disease, bowel cancer, long term infection, inflammatory bowel diseases
** these would need referral to a GP for a proper investigation and diagnoses**
5
Q
what are some causes of diarrhoea?
A
- increased osmotic load in the gut lumen (ie use of osmotic laxatives)
- increased chloride secretion into the bowel gut lumen (caffiene)
- inflammation of the intestinal lumen (infection) (ie C. difficile)
- increased intestinal motility, reducing water absorption (ie an increased frequency of intestinal movements, but not an increased volume to hold the poop) (ie prokinetic agents - ie metoclopramide, domperidone, and erythromycin)
6
Q
describe how osmotic agents/ osmotic laxatives cause diarrhoea?
A
The osmotically active API will remain the intestinal gut lumen instead of being absorbed into the blood stream.
As a result, water will move into the intestinal gut lumen to balance the conc gradient.
There is an increased bulk of water in the bowel which thus stimulates gut motility and thus diarrhoea
7
Q
what are prokinetic agents and give 3 examples
A
these are drugs used to promote GI motility, by increasing frequency and strength of the muscle contractions within the GI tract.
- metoclopramide
- erythromycin (macrolide Abx)
- domperidone (D2 receptor antagonist)
8
Q
Counselling for infection as a cause of acute diarrhoea?
A
- usually self limiting
- lasts for abt 2 - 3 days
- can be bacterial or viral
9
Q
How do some broad spectrum antibiotics (ie clindamycin, cephalosporins, fluoroquinolones) increase the risk of infections like C. difficile?
A
They wipe out/ change the composition of the gut microbiota, leaving the virulent and resistant strains such as C. difficule bacterium to survive. These types of bacteria cause diarrhoea
10
Q
Give 5 examples of drugs associated with causing diarrhoea?
A
- Digoxin
- Abx (ie Clindamycin)
- Metformin
- NSAIDS
- PPIs
- SSRIs
11
Q
Describe how you would take a clinical Hix if a patient presents with diarrhoea?
A
- onset, duration and frequency (when did it start, how long, how often)
- could it be something they ate
- ICE - what does the patient think caused it?
- any recent travel abroad - may need to refer to GP - bacterial or viral pathigen not native to UK - need a proper investigation
- any contact with a person who has confirmed diarhoea recently?
- any newly started drugs (ie Abx, Metformin, NSAIDS, SSRIs. PPis?)
- any other symptoms - abdominal pain, blood?, nausea, vomiting?
- known diagnoses?
- red flags
12
Q
if the patient presents diarrhoea within 72hrs, 6hrs, or shortly after eating a certain food, what may be the cause of their diarrhoea?
A
- ** if the patient presents within 3 days after eating a suspicious food - likely a bacterial cause)**
- ** if the patient presents within 6 hrs of eating food - likely a toxin**
- if the patient presents within a few hours, minutes/ shortly after eating food - may be intolerant to that food (i.e. lactose intolerance)**
13
Q
what are the red flag symptoms promoting referral , regarding diarrhoea?
A
- blood in the stool !!!!
- weight loss (unexpected)
- persistent vomiting
- recent hospital treatment or Abx initiation
- painless, high volume diarrhoea – bc there is an v high risk of dehydration
- diarrhoea lasting more than 6 weeks
- family hx of ovarian or bowel cancer
14
Q
what is the supportive, non - pharmacological treatment we can advise to px when treating diarrhoea?
A
- Oral Rehydration Therapy - ie encourage the px to drink fruit juices, fluids and soups - not just water - need to replenish fluid and electrolytes
- wash hands thoroughly to prevent spread
- consider anti - motility drugs - ie essp if diarrhoea is hindering QoL or px productivity by quite a bit - ie Loperamide 1st line,
——–> however if the px mentions they have some blood or mucous in their stools - avoid anti - motility drugs - other anti - motility drugs include diphenoxylate, codeine, and bulk laxatives
15
Q
give 4 examples of anti - motility drugs used to treat diarrhoea?
A
- loperamide (Imodium) (1st line) - used for symptomatic control, only for 24 hrs
- diphenoxylate - have anti cholinergic side effects - so not rlly recommended
- codeine - not usually used for acute diarrhoea - risk of dependance
- bulk laxatives - usually for IBS - D
16
Q
what is the minimum age that a px can use Loperamide OTC
A
children aged 12+
17
Q
If a child aged <11 presents to the pharmacy with acute diarrhoea, can we prescribe loperamide?
A
NO
Acute diarrhoea in children tends to settle spontaneously without the need for medical intervention.
ORT is indicated tho
18
Q
Give the general pharmacokinetics of Loperamide - relating to why its?
A
onset of action 1hr
max effect 16 - 24 hrs
t 1/2 = 11hrs
19
Q
What formulation is Diphenoxylate given as when treating diarrhoea?
A
Co - phenotrope
- diphenoxylate (opioid)
- atropine sulphate (anticholinergic )
20
Q
What are the risks of taking Diphenoxylate / co - phenotrope diarrhoea?
A
- it doesn’t have any analgesic activity
- higher doses - exert opioid SE (dependance, sedation)
- sub clinical doses of atropine - anticholinergic SE (ie dry mouth, headache, urinary retention, tachycardia and dizzyness)
21
Q
What is the rationale for prescribing Codeine and other opioids to treat diarrhoea? ( like how do they do it - MOA?)
A
They have GI SE of constipation - they delay gastric emptying by reducing propulsive peristalsis!
- this allows for enhanced reabsorption of water!
They also increase the tone of the anal sphincter
Overall they cause the decreased movement of faeces through the GIT
22
Q
What is Racecadotril and when is it used?
A
It is a enkephilase inhibitor, used as an adjunct to Oral Rehydration Therapy for uncomplicated acute diarrhoea.
It is only used in px over the age of 3 months when rehydration alone PLUS supportive methods are not sufficient
23
Q
what sort of counselling points would you include when advising px to take Oral Rehydration Therapy for diarrhoea?
A
- diarrhoea - lose alot of water and electrolytes in the stools which can lead to severe dehydration.
- ORT is fluid with electrolytes, and aims to replenish the water and electrolyte balance so that you are not dehydrated
- avoid just drinking plain water - ort must have nutrients and electrolytes to replace the ones lost in diarrhoea
typically contains Na+/Cl-/K+, bicarbs and citrates and alkalising agents too , to counter acidosis)
Can use things like dioralyte sachets, soups, juices - however be careful with juices and sugary fluids if diabetics!
24
Q
What are some complications of vomiting and diarrhoea in patients taking combined oral contraception or progesterone only pills? What advice would we give them?
A
Diarrhoea and vomiting - loss of contents of GIT and thus reduces the extent to which hormonal contraception is being absorbed.
As a result you get reduced effectiveness of contraception - reduced effectiveness when it comes to preventing pregnancy
Advice
- if the woman has a bout of diarrhoea, or vomiting within 2hrs of taking the pill - take another tablet
- for diarrhoea lasting more than 24hrs - continue taking pills at the normal time BUT ALSO USE EXTRA PROTECTION!!!! (ie condoms)
- if diarrhoea continues, count each day as a missed pill and follow pill specific instructions for missed pills!!
25
what is functional diarrhoea?
loose or watery stools without an identifiable cause.
26
what are the symptoms of functional diarrhoea?
- watery or mucous laden stools
- often occurs in the morning
**no pain or cramping with the diarrhoea**
- bloating and abdominal discomfort
- sense of urgency
- frequent bowl movements
27
what are the symptoms of dehydration?
- dark urine - small volume
- thirst
- dry mouth , lips and tongue
- dizziness
- headache
- fatigue
- sunken skin / dry skin
28
what is constipation?
A symptom based disorder describing unsatisfactory defecation due to :
- difficulty passing stools
- the sensation of incomplete emptying
- infrequent passing of stools
29
Describe the characteristics of the stools passed in constipation?
small, hard , dry
sometimes may be abnormally large but mostly they are v small
30
There are 3 types of constipation. What is :
1. functional constipation (i.e. normal transit constipation)
2. Slow transit constipation
3. Outlet constipation/ anorectal dysfunction
1. this is when the px finds it difficult to pass stools, despite the consistency and motility of their GIT being normal
2. when the px doesn't experience peristalsis via the GIT resulting in less frequent bowel movements - the stool can sit in the colon for WEEKS
3. also known as pelvic floor dysfunction diarrhoea, occurs whn the pelvic floor muscles which support the bowel and anus are able to relax properly during bowel movements making it difficult to pass a stool (may occur due to over straining, child birth etc)
31
How can we diagnose functional constipation? (What are the symptoms of it?)
The presence of 2+ of the following symptoms, for more than 25% of the defecations for at least 3 months with onset of symptoms beginning at least 6 months prior to diagnosis :
**- straining**
- lumpy or hard stools (type 1 or 2 on Bristol stool chart)
**- the sensation of incomplete evacuation**
- the sensation of anorectal obstruction, blockage
**- using hands or manual manoeuvres to help to remove the stool**
-** fewer than 3 spontaneous bowel movements per week**
32
Functional constipation shares overlap in regards to symptoms with which other GIT disorder?
IBS
33
what are some causes of secondary constipation?
- organic disease (where physical changes to tissues or organs cause illness)
- drugs (ie opioids - reduce gastric motility)
- systemic diseases
34
What are the red flags for referral regarding constipation?
- failure to respond to the sensation to defecate over a prolonged period - may lead to chronic, habitual constipation (ie NO POO COMES OUT!!)
- long term self medication with laxatives
- blood mixed with stools
- severe pain indicative of bowel obstruction
- constipation w/o flatulence
- alternating diarrhoea and constipation - in young ppl - may be IBS so refer at first presentation , in elderly , spurrious/overflow diarrhoea may be a sign of constipation
35
If an elderly or a young adult px presents with alternating diarrhoea and constipation - what should we do?
young person - may be IBS - essp if px presents with abdominal pain too - refer the px to the GP at the first presentation
in the elderly - if they present with spurious overflow diarrhoea, it may indicate constipation as the liquid or loose stool is leaking around the hardened stool mass in the bowel
36
How may constipation present in the elderly?
- confusion
- spurious / overflow diarrhoea
- abdominal pain
- urinary retention
- nausea and loss of appetite
37
what are some social risk factors for developing constipation?
- lifestyle changes (ie immobility, lack of exercise, difficulty accessing toilets thus holding it in)
- limited privacy (holding it in)
- dietary changes (ie those that lack fibre - white bread and rice, high fat meats, dairy, sugary foods , fast food)
38
what are some **psychological** potential causes/ risk factors for developing constipation?
- anxiety and/or depression
- eating disorders
- hx of sexual abuse
39
what are some **physical** causes and risk factors for developing constipation?
- female sex
- older age
- dehydration
- concurrent disease - IBS/IBD
- medication
- pregnancy
- haemorroids, crohns fissures - difficult to pass stools
40
give 10 examples of drugs that may cause constipation?
- antacids
- anticholinergics (think abt SE!)
- anti - diarrhoeal drugs
- anti - tussive (i.e. codeine)
- diuretics - if dehydration occurs
- Fe (ofc)
- opioid analgesia
- TCA (ie amitriptyline)
- Verapamil
- 5 - HT3 antagonists - ie ondansetron, used for cancer nausea and vom
41
What is the basic NICE pathway for treating short - duration constipation? (lasting <12 weeks)
1. manage the secondary causes (i.e. drugs, underlying physical causes, i.e. dehydration)
2. Lifestyle advice - more water, more fibre, 5 - a day, regular exercise
3. bulk laxative with fluids (i.e. Ispaghula)
4. if bulk laxative and fluids don't work - osmotic laxative (macrogol, lactulose)
5. if osmotic laxatives don't work - stimulant laxative (ie senna)
42
Points for taking a *constipation* presentation clinical history?
- what is the normal pattern of the px opening their bowels - ie how often do you need to pass stools?
- how has this changed? when?
- how would you describe stools, if any?
- what symptoms do you feel when passing stools? 9ie pain? blood? straining? bloating)
- do you feel like you still need to pass a stool even when you've finished? incomplete?
- taking any medications OTC?
- have you recently changed any aspects of diet or lifestyle, or fluid intake?
43
What are some lifestyle changes we can suggest to patients regarding management of constipation?
- incorporate regular exercise into routine
- ensure you are remaining hydrated - abt 8 glasses a day, or drink when thirsty
- increase fibre in diet - i.e. wholegrains, like oats, brown rice, fruits, veg , legumes, nuts and seeds).
-
44
What is the MoA of **bulk forming** laxatives and give 2 examples.
MOA - they swell up digested material to increase the weight of the stool in order to stimulate peristalsis, i.e. gut motility.
These are 1st line.
⚠️ avoid taking at night - risk of shitting the sheets!
eg - Ispaghula, methylcellulose, Sterculia
45
What is the MoA for **osmotic laxatives** and give 2 examples?
These are osmotically active - remain in the lumen of small intestine instead of being absorbed into bloodstream - increase flow of water into intestine to balance conc gradient - produce wetter and softer, easier to pass stool
⚠️ SE - intestinal cramps and wind
eg - Lactulose, macrogols, magnesium hydroxide
46
What is the MoA for **stimulant laxatives** and give 5 examples?
These stimulate the nerve endings in the gut, causing the muscle walls of the GIT to contract and thus speed up peristalsis.
⚠️ short term risk of bowel damage + SE include cramps, gripping pain locally to the stomach
eg - senna, bisacodyl, docusate , glycerin , dantron
47
what are faecal softeners and give some examples?
They are lubricating substances used to make the stools softer and thus easier to pass.
⚠️ admin in small doses bc many contain paraffin which can seep from faeces and can damasge gut wall and also irritate the anuse.
**they are not rlly used very often**
- docusate
- glycerin suppositories
48
what is the name of the medication we use in the treatment of moderate - severe IBS associated with constipation?
Linaclotide
49
Linaclotide MOA
- linaclotide increases fluid secretion in the GIT and decreases visceral pain.
50
What is the name of the drug we use to treat constipation in adults when other laxatives have been exhausted (last line response).
Prucalopride - it is prokinetic
51
Once the patients stools become soft and easily passed again, what should the patient do in regards to their laxative treatment?
Reduce the usage of the laxatives
52
How can we avoid the risk of causing opioid - induced constipation?
We can prescribe a regular laxative when we first prescribe the opioid (including 8/500mg co - codamol)
**osmotic laxative AND stimulant laxative** , ie macrogol (px find lactulose difficult to tolerate!), and senna
53
What are the two alternative drugs we can use to treat **opioid - induced constipation** when laxatives have been exhausted?
- naloxegol (oral)
- methylnaltrexone (sc)
54
How would we manage chronic constipation community and hospital settings?
- community - refer to hospital or GP for further investigations
- hospital
- examine to exclude bowel obstruction, then consider underlying causes (ie drugs? dehydration?), if rectum impacted, use rectal treatment, softener (ie docusate) and then a stimulant. If the rectum is empty - use an oral osmotic laxative (ie macrogol)
- if the px unable to maintain fluid intake - consider use of oral bulk laxative
55
what is the difference between the small and the large bowel?
small bowel - small intestine
large bowel - large intestine (colon) + rectum
56
when is the gut microflora colonised?
immediately after birth
56
describe the composition of the gut microflora?
the composition is pretty constant thus is affected by Abx (ie fluoroquinolones + cephalosporins) and diarrhoeal illnesses
57
Does the microflora have a key role in drug therapies for IBD?
yes
58
What are Inflammatory Bowel Diseases? (IBDs)
- inflammatory conditions of the GIT - they are typically chronic and present with periods of relapse and remission
- often their causes are not known
59
Can we use common anti - inflammatory drugs like **NSAIDS** to treat IBDs?
NO - drugs like NSAIDs and anti - inflammatory drugs tend to be ineffective and sometimes may even **exacerbate the IBD**
60
give two examples of IBDs
- Crohn's disease
- Ulcerative colitis
61
what are the general symptoms of Inflammatory bowel diseases?
**bloody diarrhoea with mucus and pus (possibly)**
**abdominal pain and cramps**
anaemia (due to blood loss)
fever
weight loss
fatigue
62
If a px presents with diarrhoea with abdominal pain , what are the differentials
- diarrhoea
- but also consider - if bloody too - escalte
- IBD
63
what is Ulcerative Colitis?
Inflammation of the colon, with ulcers.
64
which part of the GIT is involved in UC?
- the colon
- the rectum
and it is the submucosal and mucosal layers that are involved
65
Describe the nature of the ulcers present in UC?
- shallow and numerous
some px may acc be ** asymptomatic of ulcers** - thus only present with inflamed colon and rectum
66
What is Crohn's disease?
An inflammatory bowel disease that affects any part of the digestive tract from the mouth to the anus!
- the rectum is often spared!
67
what are the symptoms of Crohn's Disease?
diarrhoea
abdominal pain
weight loss
fatigue
68
Complications of Crohn's disease?
Well inflammation of the SI means that **absorption of food will decline** - hence px is more **fatigued and weight loss may be observed**
furthermore px may be **deficient in certain minerals and vitamins - ie folate from leafy greens, and vitB12 from animal produce - not absorbed**—> may lead to **macrocytic anaemia**
medications taken orally may have reduced efficacy due to subpar absorption
**Oral contraception may be less efficacious - px needs to also use other methods (ie barrier methods , IUD etc)**
69
what are some characteristics / physical complications the patient may develop as a result of Crohn's disease?
- **fistula formation** - these are abnormal channels formed that connect the bowel to the skin or surrounding organs
- **strictures (narrowing) of the small intestine/bowel**
- **peri - anal disease with abscesses** (ie painful collection of pus) and **fissures (tears/breaks in the tissue layer)**
70
What are the 3 drug classes we use to treat IBDs?
1. aminosalicylates - ie mesalazine, sulfalazine
2. anti - inflammatory drugs - ie corticosteroids
3. immunosuppressants (indirectly suppress inflammation) -ie MTX , azathiopurine
4 - surgical option in severe or chronic active disease - need an ileostomy OR COLONOSTOMY
71
Crohn's disease and UC treatment are broadly similar however, CD may be less responsive to some widely used drugs - why is this?
Inflammation and damage to the small intestine will inhibit / reduce the extent to which drugs are absorbed into the blood stream and thus reduce their effectiveness.
72
We use different drugs for different treatment objectives in UC and CD (IBDs).
Which drug classes do we use to treat :
- acute attack
- prevention of recurrence
- chronic active
**acute attack** - corticosteroids, amino salicylates, immunosuppressants
* **prevention of recurrence, thus remission** - aminosalicylates *
**chronic active** - aminosalicylates, corticosteroids, immunosuppressants (AZA)
73
what is the active anti - inflammatory component of amino salicylates?
5 - ASA, 5 - amino salicylate.
The MOA not well defined
74
which IBD do we tend to use amino salicylates for?
- remission of ulcerative colitis
- not v good for CD
75
MOA and SE of Sulfasalazine?
Colonic microflora break down the sulfalazine to liberate 5 - ASA which is the active anti - inflammatory component.
Sulfapyridine is also absorbed resulting in unwanted SE - such as nausea and male infertility
76
what are some other aminosalicylate formulations aside from Sulfasalazine ?
Mesalazine, Olsalazine, Balsalazide
77
We can use anti - inflammatory drugs (ie corticosteroids) as an __________ to aminosalicylate treatment?
adjunct
78
Corticosteroid antiinflammatory drugs cause a plethora of systemic side effects - what are they and how can we formulate them to avoid this?
- glaucoma
- weight gain
- cataracts
- cushings symptoms - moon face, trunkal obesity,
- anxiety and depresssion
- increased body hair
- diabetes
- hyperthyroidism
We can use the **Modified release** formulations which bypass and limit absorption from the GIT (ie SI) and so we get limited systemic side effects.
79
which corticosteroids are the main ones we use in IBD?
- prednisolone
- budesonide
80
what are the indications for anti - inflammatory drugs when treating IBD?
- acute relapse of IBD
- adjunct to aminosalicylate treatment
81
Which 3 immunosuppressant drugs can we use to treat severe IBD?
- Azathioprine (UK )
- 6 mercaptopurine (USA)
- Ciclosporin and similar drugs
82
How do the immunosuppressant drugs work to reduce inflammation in the treatment of IBDs?
They inhibit purine synthesis and subsequently the proliferation of immune cells, i.e. T - lymphocytes used in immune response.
As a result we get a muted / reduced T - cell mediated inflammation.
83
What is the risk of prescribing immunosuppressants such as Azathioprine and Mercaptopurine in patients with LOW TPMT levels?
They are at risk of myelosuppression and thrombocytopenia.
TPMT is an enzyme used to metabolise both drugs, however in px with low levels/ reduced TPMT activity - these drugs are not metabolised and thus remain active - thus will continue to supress the immune system, hence risk of myelosuppression.
83
What are the indications for Biologic drugs in the treatment of IBD?
They are only used to treat moderate - severe Crohn's disease that is unresponsive to other therapies (i.e. corticosteroids, aminosalicylate, immunosuppressants)
84
What is the indication and rationale for using antibiotics in the treatment of Crohn's diease?
- only used in active CD
- **bacterial flora trigger immune response** and thus **worsen inflammation of the GIT** so Abx clear the bacteria
:) they are just as effective as Sulfalazine to treat CD in the colon
84
Which Biologic drugs do we use to treat Crohn's disease?
- anti - TNF alpha agents
- ie Infliximab and Adalimumab
85
what are some non - GI sympotms of IBS?
- lethargy
- anxiety
- depression
85
which two antibacterial drugs do we use to treat Crohn's disease?
Metronidazole
Ciprofloxacin
85
How do we typically treat IBS?
- most treatments are unsatisfactory - however we target symptom control
- ie constipation - laxatives
- diarrhoea - ant- diarrhoea drugs and prokinetics (loperamide, prucalopride, macrolides, domperidone, erythromycin)
we can also use antispasmodics, and anti 5 - HT
we can also treat the depression and anxiety too
86
what is **irritable bowel syndrome**?
A digestive disorder characterised by *abdominal pain* **and** *diarrhoea* **or** *constipation*
⭐ there is an absence of an identifiable gastrointestinal dysfunction that causes it!!
- there is also a psychological component too - associated with **stress**
87
What is the rationale for using anti - spasmodic drugs in the treatment of IBS?
- they reduce gastric motility to relieve gut spasms and associated pain : ) (IBS - C)
- they also have anti - muscarinic activity that increases GI motility - (IBS - D)
87
give 3 examples of anti - spasmodic drugs used to treat IBS?
- Alverine , Mobeverine
- Peppermint oil
87
Which antidepressants are typically used to treat IBS?
TCA - ie amitriptyline
- NOT used for improving the mood --> it's used to treat 'abdominal pain and discomfort instead'
⭐ off - label use
88
why do we use low dose anti - depressants to treat IBS?
reduce risk of SE
- i.e. dry mouth, constipation, urinary retention, nausea, headache and dizziness
88
What is the rationale for using 5 - HT (serotonin) receptor targeted treatments for IBS?
As you know there are lots of serotonin receptors in the stomach - :) when we eat. When serotonin binds to them, we get **increased** GI motility.
89
what is the final alternative we can use to treat IBS however its not common practice yet?
Faecal microbiota transplant - we recolonise the gut with someone else's bugs.
evidence for use still being developed
90
Name 2 5 - HT receptor targeted treatments used to treat IBS and indicate which type (C or D) they are used for?
**ALOSETRON** - 5HT3 receptor antagonist - reduces GI motility - IBS - diarrhoea
**TEGASEROD** - 5HT4 receptor agonist - increases GI motility - thus may be useful in IBS - constipation (T for Tegaserod and consTipaTion)
91
What is indigestion and what tends to trigger it?
A broad term for **digestive discomfort** - including symptoms of **bloating, fullness, nausea, heartburn, burping, farting, bringing up food or bitter tasting fluid into mouth**
It tends to be triggered by **eating certain foods, (i.e. spicy),** **high caffeine intake** , **late night or early morning eating**, **eating too quickly**.
91
What is heartburn?
A **burning sensation in the chest**, typically caused by **stomach acid flowing back into the esophagus (i.e. acid reflux)** 🔥
- may occur after eating or when lying down 🥘 🛌
- sometimes its mixed up with **heart attack!** 🫀
91
What is Gastro - oesophageal reflux disease? (GO/ERD)?
A **chronic** more severe form of acid reflux, where stomach acid is **frequently and persistently** flowing back into the oesophagus.
It differs to heartburn in intensity and frequency - px may also have difficulty swallowing, chest pain and dry cough
92
What are some dietary and lifestyle changes the patients can make when managing indigestion, heartburn and GORD?
- avoid eating offending foods - i.e. spicy foods
- slow down when eating - i.e. try not to eat to quickly (gas brought up)
- avoid eating very late at night and very early in the morning
- reduce alcohol consumption
- smoking cessation (avoid/reduces damage to the oesophagus)
- lose weight if overweight
- avoid lying down within 3hrs of eating
- px with gord - could raise the head of their beds
92
What are the red - flag symptoms for referral regarding px with symptoms of indigestion?
- **dysphagia - difficulty swallowing foods or liquid** ❌ 👄
- **radiation of chest pain to the left arm or neck or jaws, cold sweat, SOB- perhaps a heart attack** 🫀
- **unexplained wieght loss** ⚖️
- **upper epigastric pain** 😩
- **repetitive requests for OTC supply** 💊
- **vomiting** 🤮
- **blood in vomit** 🩸 🤮
92
what are the 4 drug classes we can offer patients with indigestion/ GORD/ heartburn?
- antacids - sodium bicarb, magnesium and aluminium hydroxide (1st line) OTC
- alginates - Gaviscon (1st line) OTC
- PPIs - omeprazole
- H2 receptor antagonists - cimetidine
92
How do antacids work and what is the downside of their MOA?
They neutralise stomach acids, providing rapid relief.
However in neutralising stomach acid, they may alter the absorption of certain drugs - ie those with enteric coatings to bypass acidic envi of stomach - instead will be released early in the stomach bc pH has increased.
eg Sodium bicarbonate
eg Aluminium and Mg Hydroxide
92
Why do we advise px to **avoid taking Mg containing ant - acids at the same time as other drugs**?
- may impair other drugs absorption
- may damage enteric coatings designed to prevent dissolution in the stomach
92
Give 3 examples of Antacids and their side effects
Sodium bicarbonate - may lead to belching of CO2, so not suitable in flatulence
Aluminum Hydroxide - constipation
Mg Hydroxide - diarrhoea
92
What is the MoA of alginates?
To form a 'foam / gelatinous raft' layer on top of the gastric acid in the stomach to prevent reflux of acid into the oesophagus.
92
What is vomiting and how is it controlled?
It is the involuntary expulsion of the stomach contents through the mouth.
It is involuntary and thus a reflex action
92
MoA of H2 receptor antagonists in indigestion? (i.e. Cimetidine, Famotidine, Ranitidine)
These bind competitively to H2 Receptors in parietal cells (stomach), preventing activation by histamine. As a result, the stomach acids are no longer secreted.
** nb we can only supply up to 14 days supply of these drugs**
92
MoA of PPIs in indigestion? (omeprazole, Lansoprazole)
These are prodrugs that are activated in acidic environment of parietal cell canaliculi. They bind with proton pump and block the final step of stomach acid production.
93
when do we refer a patient who is presenting with nausea and vomiting?
- if they have blood in their vomit
- weight loss
- vomiting for > 2 days
- severe abdominal pain
93
What triggers the reflex action associated with nausea and vomiting?
- delayed gastric emptying 🦥
- distension and bloating of the stomach 💨
- sluggish and uncoordinated gastric motility 🦥
- activation of the CTZ (has 5HT and dopamine receptor) and vomiting center in the brain ⚡️
94
what are some causes for nausea and vomiting?
- renal failure
- alcohol
- bacterial and viral infection
drugs - ie anticancer drugs, nsaids, fe salts, macrolides, ssris
- peptic ulcerations
- migraines
- pregnancy
- head trauma - refer
- meniers disease
94
which drug classes can we Rx to patients who are vomiting? (Ie cancer nausea, palliative care, Parkinson’s, motion sickness and pregnancy sickness)
cyclizine , promethazine - general indication
5HT antagonist - ondansetron - cancer/chemotherapy cause
antipsychotic - haloperidol , levomepromazine - palliative care
- domperidone - Parkinson's and SE of dopinergic drugs
-prochlorperazine - motion sickness and pregnancy sickness
95
How do we treat patients who are vomiting?
- ORT
- manage symptoms and cause
- preventative measures
