GI treatments

Question 1

H.pylori (no penicillin allergy) (5)

Answer 1

1. PPI + amoxicillin + clarithromycin/metronidazole 7 days
2. if tried already = PPI + amoxicillin + tetracycline/levofloxacin 7 days
3. Specialist = PPI + Bismuth + 2 drugs mentioned above/rifabutin/furazolidone 10 days

Question 2

H.pylori (penicillin allergy) (5)

Answer 2

1. PPI + + clarithromycin + metronidazole 7 days
2. if clari. tried already = PPI + bismuth + metronidazole + tetracycline 7 days
3. not had fluroquinolone = PPI + metronidazole + levofloaxin 7 days
4. had fluroquinolone = PPI + bismuth + metronidazole + tetracycline 7 days
5. Specialist = PPI + Bismuth + rifabutin/furazolidone 10 days

Question 3

C.difficile (3)

Answer 3

1. Review meds: Withdraw causative Abx, avoid PPI
2. Oral metronidazole or Vancomycin
3. Faecal transplant if not working

Question 4

Aphthous ulcers (6)

Answer 4

1. Protectorants (gelatine, pectin, carmellose)
2. Local anaesthetic (benzocaine, lidocaine)
3. Choline salicylate
4. Benzydamine (difflam)
5. Antibacterials (chlorhexidine (Corsodyl mouthwash))
6. Corticosteroids (hydrocortisone)

Question 5

Oral thrush (2)

Answer 5

1. Miconazole gel (Daktarin 2% ether 1.25ml QDS or 2.5ml QDS after food)
2. Nystatin (1ml QDS for 7 days and 48 hours after resolved

Question 6

Dyspepsia (4)

Answer 6

1. Antacids (rennies, aluminium hydroxide salts, etc…)
2. Alginates (gaviscon)
3. PPIs (omeprazole, etc..)
4. H2 receptor antagonists (famotidine)

Question 7

GORD (no oesophagitis) (3)

Answer 7

1. Full dose PPI 4-8 weeks
2. If not effective, switch PPI and add H2 receptor antagonist
3. If effective switch to low dose - symptom management when needed

Question 8

GORD (with oesophagitis) (3)

Answer 8

1. Full dose PPI 8 weeks
2. If effective, continue at full dose
3. If not effective different full dose PPI + refer to specialist + treat underlying cause

Question 9

GORD mucosal protectors (3)

Answer 9

1. Bismuth subsalicylate (antacid) - 525mg 4 times a day for 7 days
2. Sucralfate (sucrose-aluminium complex) - 2g twice daily or 1g 4 times daily for 4-6 weeks
3. Misoprostol (synthetic prostaglandin E2, useful to counter NSAIDs) - 400mg twice daily or 200mg 4 times daily for at least 4 weeks

Question 10

GORD sphincter strengtheners (3)

Answer 10

1. Improve tone of the lower oesophagus sphincter muscle
2. dopamine antagonists
3. metoclopramide

Question 11

eosinophilic oesophagitis (3)

Answer 11

1. dietary changes - six food elimination diet
2. Swallowed corticosteroids - soluble beclomethasone tablets
3. oesophageal dilation

Question 12

Faecal impaction (3)

Answer 12

1. High-dose osmotic laxative
2. Bisacodyl suppository
3. Sodium citrate enema

Question 13

Constipation (8)

Answer 13

1. increase fibre (soluble and insoluble)
2. increase fluid
3. gentle exercise
4. Stimulant laxatives - Senna
5. Bulk-forming laxatives - Ispaghula husk
6. Osmotic Laxatives - lactulose
7. Bowel Cleansing Preparations
8. Peripheral Opioid-receptor antagonists

Question 14

Diarrhoea (6)

Answer 14

1. Oral rehydration
2. Food and Physical hygiene
3. Antimotility drugs - opiates, loperamide
4. co-phenotrope
5. codeine morphine (not generally recommended, holding back bacteria)
6. Adsorbents- kaolin- no longer recommended (harbours bacteria)

Question 15

Mild ulcerative colitis (2)

Answer 15

1. topical aminosalicylate
2. after 4 weeks = oral aminosalicylate then if required + topical/oral corticosteroid

Question 16

Mild Crohn’s (3)

Answer 16

1. Oral corticosteroid (prednisolone/methylpred.
2. Or budesonide if lower SE needed)
3. If Corticosteroid is contraindicated aminosalicylate

Question 17

Moderate ulcerative colitis (3)

Answer 17

1. Topical aminosalicylate,
2. after 4 weeks = Topical aminosalicylate + high-dose oral aminosalicylate or switch to a high-dose oral aminosalicylate and time-limited topical corticosteroid
3. If more needed switch to oral aminosalicylate + oral corticosteroid

Question 18

Moderate Crohn’s (2)

Answer 18

1. Oral corticosteroid (do not offer budesonide or aminosalicylate as less effective)
2. If ≥ 2 exacerbations in 1 year or glucocorticoid dose cannot be tapered, consider (+Azathioprine or mercaptopurine) or +Methotrexate

Question 19

Severe ulcerative colitis (2)

Answer 19

1. IV corticosteroid (IV ciclosporin as alternative)
2. After 72 hours + IV ciclosporin (+ infliximab if ciclosporin not tolerated)

Question 20

Chronic proctitis/ proctosigmoiditis (rectal inflammation) (3)

Answer 20

1. Topical aminosalicylate
2. Topical + oral aminosalicylate (oral ideally OD)
3. Oral aminosalicylate alone- explaining not as effective

Question 21

Chronic left-sided and extensive UC

Answer 21

Oral aminosalicylate (ideally OD)

Question 22

Chronic all extents of UC (3)

Answer 22

1. If oral aminosalicylate not effective, not tolerated or ≥ 2 exacerbations in a year
2. Oral azathioprine
3. or mercaptopurine

Question 23

Chronic Crohn’s disease (3)

Answer 23

1. Azathioprine or mercaptopurine monotherapy
2. Methotrexate where Aza/MCP not tolerated
3. Do NOT offer corticosteroid

Question 24

Severe Crohn’s

Answer 24

If unresponsive to conventional therapy + infliximab or adalimumab

Question 25

IBS abdominal pain (3)

Answer 25

1. Mebeverine - 135 mg TDS, 20 minutes before food 2. Hyoscine BUTYLbromide (Buscopan) - 10 mg TDS 3. Peppermint oil Colpermin - 1-2 capsules TDS (swallow whole)

Question 26

IBS constipation (3)

Answer 26

1. Senna (S laxative) - 7.5-15 mg ON 2. Movicol (O laxative) - 1 sachet up to three times a day 3. Ispaghula husk (BF laxative) - 1 sachet BD

Question 27

IBS diarrhoea

Answer 27

Loperamide - 4-8 mg in divided doses (max 16 mg/24hours)

Question 28

IBS second line (4)

Answer 28

1. Tricyclic antidepressants (TCAs) e.g. Amitriptyline 5-10mg ON and increase to 30mg ON 2. Selective serotonin reuptake inhibitors (SSRIs) e.g. Citalopram, Fluoxetine, paroxetine 3. cognitive behavioural therapy (CBT) or/ & hypnotherapy for people with IBS who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile 4. probiotics minimum 4 weeks

Question 29

Haemorrhoids (4)

Answer 29

1. Local anaesthetic 2. Bismuth, zinc, allantoin, peru balsam - Anusol 3. Hydrocorticon - Anusol plus HC 4. Shark liver oil, lauromacrogol, yeast cell extract.

Question 30

vestibular (ears and balance) N&V (5)

Answer 30

1. Hyoscine hydrobromide - 30 mins before a journey 2. Antihistamines - less effective but have fewer side effects 3. Cinnarazine (antihistamine) - 2 hrs before journey 4. Promethazine - VERY SEDATIVE, not often used now 5. For Meniere’s Disease Hyoscine hydrobromide or antihistamines are used plus phenothiazines

Question 31

pregnancy N&V (2)

Answer 31

1. Avoid ALL drug treatment in first trimester 2. In severe cases: 24-48 hours of promethazine or metoclopramide: REFER to SPECIALIST

Question 32

Cancer N&V (3)

Answer 32

1. Prevent pre-exposure: phenothiazine, domperidone, dexamethasone 2. Highly emetogenic: as on a 5HT3 antagonist (ondansetron) 3. Second line: dexamethasone, phenothiazines, aprepitant, cannabinoids

Question 33

Parkinson’s N&V (2)

Answer 33

1. Domperidone (not centrally acting, but risk of QT prolongation) 2. Cannabinoids

Question 34

Post-operative N&V (2)

Answer 34

1. Often local guidelines 2. 5HT antagonists and Cyclizine common

Question 35

OTC travel sickness N&V (3)

Answer 35

1. Hyoscine bromide - 30 mins before travelling then every 6 hrs 2. Cinnarazine - 2 hrs before driving then every 8 hrs as needed 3. Promethazine - very drowsy, often abused - avoid

Question 36

OTC migraine nausea (4)

Answer 36

1. Promethazine - 18+ 2. placed on top gum under lip to dissolve 3. Likely to cause drowsiness (aggravated with alcohol, opioids and antidepressants) 4. Avoid use: Parkinson’s, epilepsy, glaucoma