MID WEIGHTING - Gastrointestinal System Flashcards
(275 cards)
1
Q
Gastric Acid Disorders & Ulceration
What is the most common cause of peptic ulcers?
A
H pylori
2
Q
Gastric Acid Disorders & Ulceration
How is H Pylori diagnosed?
A
(1) Urea (13C) breath test
(2) Stool Helicobacter Antigen Test (SAT)
3
Q
Gastric Acid Disorders & Ulceration
What requirements are there before taking a test for H Pylori?
A
(1) PPIs should be stopped 2 weeks before test
(2) Antibiotics should be stopped 4 weeks before test
4
Q
Gastric Acid Disorders & Ulceration
What is the treatment for H Pylori?
A
Triple Therapy for 7 days
(1) PPI - BD
(2)
- Amoxicillin 1g BD
- Clarithromycin 500mg BD
- Metronidazole 400mg BD
5
Q
Gastric Acid Disorders & Ulceration
What is the duration of treatment for H Pylori infections?
A
7 days
6
Q
Gastric Acid Disorders & Ulceration
Give the acronyms for three different H Pylori treatment regimes.
A
(1) PAC
(2) PMC
(3) PAM
7
Q
Exocrine Pancreatic Insufficiency
What is the effect of a pancreatic insufficiency?
A
Reduces secretion of pancreatic enzymes into the duodenum.
8
Q
Exocrine Pancreatic Insufficiency
Name some common causes of pancreatic insufficiency.
A
- Pancreatitis
- Cystic Fibrosis
- Pancreatic Tumours
- GI resection (can lead to maldigestion + malnutrition)
9
Q
Exocrine Pancreatic Insufficiency
How can GI resection lead to pancreatic insufficieny?
A
Maldigestion -> Malnutrition
10
Q
Exocrine Pancreatic Insufficiency
What is the treatment for exocrine pancreatic insufficiency?
A
Pancreatic enzyme replacement (Pancreatin)
11
Q
Exocrine Pancreatic Insufficiency
What is the name for pancreatic replacement enzyme?
A
Pancreatin
12
Q
Exocrine Pancreatic Insufficiency
What is Pancreatin?
A
Pancreatic enzyme replacement
13
Q
Exocrine Pancreatic Insufficiency
What is the contents of Pancreatin?
A
Lipase, amylase, protease
14
Q
Exocrine Pancreatic Insufficiency
(1) What instructions should be given for Pancreatin? (2) Why?
A
(1) Take with meals and snacks
(2) Can be broken down very quickly without a meal
15
Q
Exocrine Pancreatic Insufficiency
What limit is there for lipase in cystic fibrosis patients?
A
10,000units/kg/day
16
Q
Exocrine Pancreatic Insufficiency
What should cystic fibrosis patients report if initiated on Pancreatin?
A
Any new abdominal symptoms
17
Q
Exocrine Pancreatic Insufficiency
What monitoring requirements are there for patients taking Pancreatin?c
A
Levels of fat soluble vitamins & micronutrients
- Supplements should be given if needed
18
Q
Gastric Acid Disorders & Ulceration
What does the term ‘dyspepsia’ refer to?
A
Describes a range of upper GI symptoms
Typically presenting for 4 or more weeks
19
Q
Gastric Acid Disorders & Ulceration
Name some symptoms of dyspepsia.
A
- Upper abdominal pain/ discomfort
- Heartburn
- Gastric reflux
- Bloating
- Nausea/ vomiting
20
Q
Gastric Acid Disorders & Ulceration
What is the most common cause of dyspepsia?
A
Functional dyspepsia
- No known cause
21
Q
Gastric Acid Disorders & Ulceration
What are dyspepsia symptoms in pregnancy often due to?
A
GORD
22
Q
Gastric Acid Disorders & Ulceration
What are the aims of treatment for dyspepsia?
A
(1) Manage symptoms
(2) Treat underlying cause (where possible)
23
Q
Gastric Acid Disorders & Ulceration
Which non-drug treatments may help reduce dyspepsia?
A
- Healthy eating
- Weight loss (if obese)
- Eating smaller meals
- Eating (minimum) 3-4 hours before bed
- Avoiding trigger foods
- Raising the head of the bed
- Smoking cessation
- Reducing alcohol consumption
- Assessment and resolution of anxiety/ depression/ stress
24
Q
Gastric Acid Disorders & Ulceration
For which patients is urgent endoscopy required for?
A
Those experiencing:
- Dysphagia
- Significant acute GI bleeding
- Aged >55yrs with unexplained weight loss + symptoms of upper abdominal pain/ reflux/ dyspepsia
25
***Gastric Acid Disorders & Ulceration***
Which drugs may cause dyspepsia?
- Alpha-blockers
- Antimuscarinics
- Aspirin
- Benzodiazepines
- Beta-blockers
- Bisphosphonates
- Calcium channel blockers
- Corticosteroids
- Nitrates
- NSAIDs
- Theophyllines
- TCAs
26
***Gastric Acid Disorders & Ulceration***
When are antacids/ alginates indicated in dyspepsia?
Short-term symptom control only
Continuous use is not recommended
27
***Gastric Acid Disorders & Ulceration***
What is the initial management for uninvestigated dyspepsia?
PPI for 4 weeks
Tested for H. pylori (treated if positive)
28
***Gastric Acid Disorders & Ulceration***
What test should be run, alongside treatment, for initial management of uninvestigated dyspepsia?
H. pylori test
29
***Gastric Acid Disorders & Ulceration***
What is Public Health England's recommendation regarding initial management of uninvestigated dyspepsia?
H. pylori test should be undertaken first/ in parallel with PPI treatment
30
***Gastric Acid Disorders & Ulceration***
What is the initial management for function dyspepsia?
H. pylori infection test (treated if positive)
(If negative)
- PPI/ H2-receptor antagonist for 4 weeks
31
***Gastric Acid Disorders & Ulceration***
If symptoms persist/ recur following initial management of dyspepsia, how should the patient be treated?
PPI/ H2-receptor antagonist at lowest dose that controls symptoms
32
***Gastric Acid Disorders & Ulceration***
If a patient with refractory dyspepsia is on an NSAID and initial treatment was unsuccessful, how should they be managed?
Stop NSAID if possible
If not possible, switch to non-NSAID, e.g. paracetamol/ COX-2 inhibitor
33
***Gastric Acid Disorders & Ulceration***
(1) How often should patients with dyspepsia be reviewed? (2) What should be encouraged at these reviews?
(1) Annual review to reassess symptoms and treatment
(2) Step-down approach/ stopping treatment
- If possible AND clinically appropriate
34
***Gastric Acid Disorders & Ulceration***
When should a patient be referred to a specialist?
Gastro-oesophageal symptoms:
- Unexplained
- Non-responsive to treatment
- H. pylori infection non-responsive to second-line eradication therapy
35
***Gastric Acid Disorders & Ulceration***
What is peptic ulcer disease?
Gastric/ duodenal ulceration
Breach of epithelium of mucosa
36
***Gastric Acid Disorders & Ulceration***
What is the main symptom of a peptic ulcer?
Upper abdominal pain
37
***Gastric Acid Disorders & Ulceration***
What are some less common symptoms of a peptic ulcer?
- Nausea
- Indigestion
- Heartburn
- Loss of appetite
- Weight loss
- Bloated feeling
38
***Gastric Acid Disorders & Ulceration***
What are the most common causes of peptic ulcers?
(1) NSAIDs
(2) H. pylori infection
39
***Gastric Acid Disorders & Ulceration***
Which factors may contribute to developing peptic ulcer disease?
- Smoking
- Alcohol consumption
- Stress
40
***Gastric Acid Disorders & Ulceration***
What are some complications of peptic ulcer disease?
- Gastric outlet obstruction
- Potentially life-threatening GI perforation & haemorrhage
41
***Gastric Acid Disorders & Ulceration***
Which patients are at high risk of developing GI complications with an NSAID?
- Hx of complicated peptic ulcer OR
- Those with ≥2 of the following:
o >65yrs
o High dose NSAIDs
o Drugs that increase risk of GI side-effects
o Serious co-morbidity
o Heavy smoker
o Excessive alcohol consumption
o Previous ADR to NSAIDs
o Prolonged requirement for NSAIDs
42
***Gastric Acid Disorders & Ulceration***
What are the aims of treatment for peptic ulcer disease?
Promote ulcer healing
Manage symptoms
Treat H. pylori infection (if positive)
Reduce risk of ulcer complications + recurrence
43
***Gastric Acid Disorders & Ulceration***
Describe the non-drug treatment of peptic ulcer disease.
- Healthy eating
- Weight loss (if obese)
- Avoiding trigger foods
- Eating smaller meals
- Eat 3-4hours (minimum) before going to bed
- Raise head of bed
- Smoking cessation
- Reduction in alcohol consumption
- Assessment & resolution of anxiety/ depression/ stress
44
***Gastric Acid Disorders & Ulceration***
Describe the initial management of peptic ulcer disease.
- Review/ stop drugs that induce peptic ulcers, if clinically appropriate
- Antacids/ alginates may be used for short-term symptom control
45
***Gastric Acid Disorders & Ulceration***
When are antacids/ alginates recommended?
Short-term symptom control
46
***Gastric Acid Disorders & Ulceration***
What does the treatment strategy for peptic ulcer disease depend on?
(1) Presence of H. pylori infection
(2) Recently taken NSAIDs
47
***Gastric Acid Disorders & Ulceration***
What test should be taken for patients presenting with peptic ulcer disease?
H. pylori test
48
***Gastric Acid Disorders & Ulceration***
What is the management of a patient with peptic ulcer disease who has a positive H. pylori infection test result and have no history of NSAID use?
H. pylori infection should be eradicated
49
***Gastric Acid Disorders & Ulceration***
What is the management of a patient with peptic ulcer disease who has a positive H. pylori that is associated with NSAID use?
(1) PPI/ H2-receptor antagonist for 8 weeks
(2) Followed by H. pylori eradication treatment
50
***Gastric Acid Disorders & Ulceration***
What is the the management of a patient with peptic ulcer disease who has a negative H. pylori that is not associated with NSAID use?
PPI/ H2-receptor antagonist for 4-8 weeks
51
***Gastric Acid Disorders & Ulceration***
(1) When should patients with peptic ulcers who have tested positive for H. pylori be reviewed? (2) What can this depend on?
(1) 6-8 weeks after starting eradication treatment
(2) Re-tested depending on size of lesion
52
***Gastric Acid Disorders & Ulceration***
(1) When should patients with peptic ulcers who have tested positive for H. pylori have a repeat endoscopy? (2) For which patients does this apply?
(1) 6-8 weeks after treatment
(2) Gastric ulcers ONLY
53
***Gastric Acid Disorders & Ulceration***
For patients on long-term NSAID use with peptic ulcer disease, how often should NSAID treatment be reviewed?
At least every 6 months
54
***Gastric Acid Disorders & Ulceration***
For patients on long-term NSAID use with peptic ulcer disease, what should be assessed in their NSAID reviews?
- Consider dose reduction
- NSAID substitution with paracetamol
- Use of alternative analgesic/ low-dose ibuprofen
55
***Gastric Acid Disorders & Ulceration***
When should a COX-2 inhibitor be considered for patients with peptic ulcer disease?
Previous ulceration for whom:
- NSAID continuation is necessary
- High risk of GI side-effects
56
***Gastric Acid Disorders & Ulceration***
(1) What is the preferred choice for gastro-protection with acid suppression therapy? (2) What are some alternative options of acid suppression therapy?
(1) PPI
(2) H2-receptor antagonist/ misoprostol
57
***Gastric Acid Disorders & Ulceration***
What limits the use of misoprostol as acid suppression therapy?
Side-effects limit its use
58
***Gastric Acid Disorders & Ulceration***
When should acid suppression therapy for gastro-protection be prescribed in patients with peptic ulcer disease?
Always
59
***Gastric Acid Disorders & Ulceration***
In patients with peptic ulcer disease, how should the patient be managed if symptoms recur after initial treatment?
PPI at lowest possible dose to control symptoms
Treatment used on as-needed basis
- Managed by patient
60
***Gastric Acid Disorders & Ulceration***
What differentials can be considered if a patient has persistent symptoms of peptic ulcer disease or an unhealed ulcer following initial treatment?
- Malignancy
- Failure to detect H. pylori
- Inadvertent NSAID use
- Other ulcer-inducing medication
- Zollinger-Ellison syndrome
- Crohn's disease
61
***Gastric Acid Disorders & Ulceration***
If response to a PPI is inadequate, as acid suppression therapy, what is the alternative?
H2-receptor antagonist
62
***Gastric Acid Disorders & Ulceration***
How often should patients on long-term treatment for peptic ulcer disease be reviewed and what should be assessed in this review?
Annual review of symptoms of treatment
Step-down approach/ stopping treatment
- If possible + clinically appropriate
63
***Gastric Acid Disorders & Ulceration***
What is GORD?
Gastro-oesophageal Reflux Disease
Reflux of gastric contents (acid, bile, pepsin)
64
***Gastric Acid Disorders & Ulceration***
What are some common symptoms of GORD?
- Heartburn
- Acid regurgitation
65
***Gastric Acid Disorders & Ulceration***
What are some less common symptoms of GORD?
- Chest pain
- Hoarseness
- Cough
- Wheezing
- Asthma
- Dental erosions
66
***Gastric Acid Disorders & Ulceration***
What is required for GORD to be classified as non-erosive?
Symptoms of GORD with normal endoscopy
67
***Gastric Acid Disorders & Ulceration***
What is required for GORD to be classified as erosive oesophagitis?
Oesophageal inflammation AND mucosal erosions are seen on endoscopy
68
***Gastric Acid Disorders & Ulceration***
What are the risk factors for GORD?
- Consumption of trigger foods
- Consumption of fatty foods
- Pregnancy
- Hiatus hernia
- FHx of GORD
- Increased intra-gastric pressure from straining and coughing
- Stress
- Anxiety
- Obesity
- Drug side-effects
- Smoking and alcohol consumption
69
***Gastric Acid Disorders & Ulceration***
Name some complications of GORD.
- Oesophageal inflammation (oesophagitis)
- Ulceration
- Haemorrhage
- Stricture formation
- Anaemia due to chronic blood loss
- Aspiration pneumonia
- Barrett's oesophagus
70
***Gastric Acid Disorders & Ulceration***
What are the aims of treatment of GORD?
Manage symptoms of GORD
Reduce risk of recurrence & complications associated with the disease
71
***Chronic Bowel Disorders***
Where does Coeliac disease occur?
Small intestine
72
***Chronic Bowel Disorders***
What is Coeliac disease?
Intolerance to gluten
-> Causes an immune response in intestinal mucosa
(Wheat, barley, rye)
73
***Chronic Bowel Disorders***
What can an immune response in the intestinal mucosa lead to?
Malabsorption of nutrients
74
***Chronic Bowel Disorders***
What are the aims of treatment of Coeliac disease?
(1) Manage symptoms
(2) Avoid malnutrition
75
***Chronic Bowel Disorders***
What are some symptoms of Coeliac disease?
- Diarrhoea
- Bloating
- Abdominal pain
76
***Chronic Bowel Disorders***
What is done to help avoid malnutrition in Coeliac disease?
Supplement:
- Vitamin D
- Calcium
77
***Chronic Bowel Disorders***
What is currently the only effective treatment option for Coeliac disease?
AVOID gluten
78
***Chronic Bowel Disorders***
What is the difference between diverticular disease and diverticulitis?
Diverticulitis = Small pouches (asymptomatic)
Diverticular disease = Small pouches (symptomatic)
79
***Chronic Bowel Disorders***
What are some symptoms of diverticular disease?
- Abdominal pain
- Constipation
- Diarrhoea
- Rectal bleed
80
***Chronic Bowel Disorders***
What is the treatment for diverticular disease?
- Fibre
- Bulk-forming laxatives
81
***Chronic Bowel Disorders***
What is acute diverticulitis?
When pouches become inflamed or infected
82
***Chronic Bowel Disorders***
What are some symptoms of acute diverticulitis?
- Severe abdominal pain
- Fever
- Significant rectal bleeding
83
***Chronic Bowel Disorders***
What is complicated acute diverticulitis?
Abscess, perforation, fistula, obstruction, sepsis, haemorrhage
In presence of acute diverticulitis (severe abdominal pain/ fever/ significant rectal bleeding)
84
***Chronic Bowel Disorders***
Where does Crohn's disease occur?
Whole GI tract (mouth to rectum)
85
***Chronic Bowel Disorders***
Describe the pathophysiology of Crohn's disease?
Associated with thickened wall (extending through all layers)
Deep ulceration
86
***Chronic Bowel Disorders***
What does the treatment of acute Crohn's disease depend on?
Number of flare ups in 12 month period
87
***Chronic Bowel Disorders***
What complications can Crohn's disease lead to?
- Intestinal strictures/ fistulae
- Anaemia/ malnutrition (unable to absorb nutrients)
- Colorectal/ small bowel cancers
- Growth failure/ delayed puberty in children
- Extra-intestinal manifestation
ø Arthritis of joints/ eyes/ liver/ skin abnormalities
88
***Chronic Bowel Disorders***
What is the treatment of acute Crohn's disease for the first flare-up in a 12 month period?
MONOTHERAPY:
- Prednisolone/ methylprednisolone/ IV hydrocortisone
OR
Aminosalicylates (sulfasalazine/ mesalazine)
89
***Chronic Bowel Disorders***
How does the use of aminosalicylates compare to that of steroids for treatment of acute Crohn's disease?
Fewer side effects, but less effective
90
***Chronic Bowel Disorders***
What is the treatment for the first flare-up of acute Crohn's with distal ileal/ ileocaecal/ right-sided disease?
Usual steroid monotherapy
Use budesonide if normal treatment does not work
91
***Chronic Bowel Disorders***
What is the treatment for acute Crohn's disease with 2+ flare-ups in a 12 month period?
Prednisolone/ methylprednisolone/ IV hydrocortisone
ADD azathioprine/ mercaptopurine
92
***Chronic Bowel Disorders***
What should be measured before initiating treatment of Crohn's disease with mercaptopurine?
TMPT
Thiopurine methyltransferase
93
***Chronic Bowel Disorders***
What should be measured before initiating treatment of Crohn's disease with azathioprine?
TMPT
Thiopurine methyltransferase
94
***Chronic Bowel Disorders***
Why are TMPT levels measured before initiating azathioprine/ mercaptopurine?
TMPT enzyme is needed for metabolising these drugs
Deficiency can lead to inadequate metabolism and risk of immunosuppression
95
***Chronic Bowel Disorders***
When should methotrexate be considered for treatment of Crohn's disease?
2+ flare ups in 12 month period
When azathioprine/ mercaptopurine are contraindicated
96
***Chronic Bowel Disorders***
What is the treatment for severe Crohn's disease?
Monoclonal Antibodies
97
***Chronic Bowel Disorders***
What is fistulating Crohn's disease?
Development of a fistula between intestine and perianal skin, bladder, vagina
98
***Chronic Bowel Disorders***
What can be used to improve symptoms of fistulating Crohn's disease?
Metronidazole +/- Ciprofloxacin
99
***Chronic Bowel Disorders***
In fistulating Crohn's disease, how long is metronidazole normally given for?
1 month
100
***Chronic Bowel Disorders***
In fistulating Crohn's disease, why is there a maximum duration of metronidazole of 3 months?
Any more than that increases risk of peripheral neuropathy
101
***Chronic Bowel Disorders***
What is first line treatment for maintenance therapy for fistulating Crohn's disease?
Azathioprine/ mercaptopurine
102
***Chronic Bowel Disorders***
What is second line treatment for maintenance therapy for fistulating Crohn's disease (when not responding to primary treatment)?
Infliximab
103
***Chronic Bowel Disorders***
For maintenance treatment of fistulating Crohn's disease, how long should maintenance last?
At least 1 year
104
***Chronic Bowel Disorders***
What is maintenance treatment of Crohn's disease?
- Monotherapy of mercaptopurine/ azathioprine
ø (can use methotrexate if used in induction/ unable to tolerate aza/ merc)
- Encourage to stop smoking
105
***Chronic Bowel Disorders***
What is the treatment of Crohn's disease following surgery?
Azathioprine + metronidazole
106
***Chronic Bowel Disorders***
In Crohn's disease, what is the treatment for diarrhoea?
- Loperamide
- Colestyramine
- Codeine
107
***Chronic Bowel Disorders***
In ulcerative colitis, what is the treatment for diarrhoea?
- Loperamide
- Colestyramine
108
***Chronic Bowel Disorders***
What are some examples of aminosalicylates?
- Sulfasalazine
- Mesalazine
- Olsalazine
- Balsalazide
109
***Chronic Bowel Disorders***
What are the cautions for aminosalicylates?
- Nephrotoxic
- Hepatotoxic
- Blood disorders
110
***Chronic Bowel Disorders***
How often should renal function be monitored for aminosalicylates?
- Before initiation
- After 3 months
- Then annually
111
***Chronic Bowel Disorders***
How often should liver function be monitored for aminosalicylates?
Monitor monthly for first three months
112
***Chronic Bowel Disorders***
How often should blood be monitored for aminosalicylates?
Monitor monthly for first three months
113
***Chronic Bowel Disorders***
What should be done in treatment with aminosalicylates if there is evidence of blood dyscrasias?
Stop drug immediately
114
***Chronic Bowel Disorders***
(1) Which aminosalicylate can cause discolouration? (2) What does it cause discolouration of? (3) What colour is this?
(1) Sulfasalazine
(2) Contact lenses and urine
(3) Orange-yellow
115
***Chronic Bowel Disorders***
Which area is affected by ulcerative colitis?
From the rectum to the whole colon
116
***Chronic Bowel Disorders***
What are the main differences between Crohn's disease and ulcerative colitis?
UC has continuous pattern - Crohn's is patchy
UC is rectum to colon - Crohn's is mouth to rectum
117
***Chronic Bowel Disorders***
Which symptoms are associated with ulcerative colitis?
- Bloody diarrhoea
- Defecation urgency
- Abdominal pain
118
***Chronic Bowel Disorders***
Which complications may ulcerative colitis lead to?
- Colorectal cancer
- Secondary osteoporosis
- Venous thromboembolism
- Toxic megacolon
119
***Chronic Bowel Disorders***
At which age is ulcerative colitis most often diagnosed?
15-25 years old
120
***Chronic Bowel Disorders***
Which area does proctitis affect?
Rectum
121
***Chronic Bowel Disorders***
Which area does proctosigmoiditis affect?
Rectum and MOST of descending colon
122
***Chronic Bowel Disorders***
Which area does distal/ left-sided ulcerative colitis affect?
Rectum and ALL of descending colon
123
***Chronic Bowel Disorders***
Which area does extensive colitis affect?
Transverse, descending AND rectum
124
***Chronic Bowel Disorders***
Which area does pancolitis affect?
Entire colon
125
***Chronic Bowel Disorders***
What is the treatment for acute mild-moderate distal-rectal ulcerative colitis?
Suppositories/ enemas
Foam can be used in patients with difficulty retaining liquid enemas
126
***Chronic Bowel Disorders***
What is the treatment for acute mild-moderate extended (extensive/ pancolitis) ulcerative colitis?
Systemic medication
127
***Chronic Bowel Disorders***
(1) What is the treatment for diarrhoea in ulcerative colitis? (2) Why?
(1) Can use colestyramine. Avoid loperamide/ codeine
(2) Can cause toxic megacolon
128
***Chronic Bowel Disorders***
What is toxic megacolon?
Inflammation/ swelling spreads into deeper layers of colon
Colon widens and stops working
129
***Chronic Bowel Disorders***
What is the treatment for mild-moderate acute proctitis?
(1) Topical aminosalicylate
(2) Add oral aminosalicylate if no improvement after 4 weeks
(3) Topical/ oral corticosteroids for 4-8 weeks
130
***Chronic Bowel Disorders***
What is the treatment for mild-moderate acute proctitis, when aminosalicylates are contraindicated?
Topical/ oral corticosteroids for 4-8 weeks
131
***Chronic Bowel Disorders***
What is the treatment for mild-moderate acute proctosigmoiditis?
dfgg
132
***Chronic Bowel Disorders***
What is the treatment for mild-moderate acute left-sided ulcerative colitis?
(1) Topical aminosalicylate
(2) Add high-dose oral aminosalicylate if no improvement after 4 weeks
OR
(1) High-dose oral aminosalicylate AND 4-8 weeks of TOPICAL corticosteroids
(2) High-dose oral aminosalicylate AND 4-8 weeks of ORAL corticosteroids
133
***Chronic Bowel Disorders***
What is the treatment for mild-moderate acute extensive ulcerative colitis?
(1) Topical aminosalicylate + high-dose oral aminosalicylate
(2) Oral aminosalicylate + oral corticosteroid for 4-8 weeks
134
***Chronic Bowel Disorders***
What is the treatment for mild-moderate acute extensive ulcerative colitis, when aminosalicylates are contraindicated?
Oral corticosteroids for 4-8 weeks
135
***Chronic Bowel Disorders***
What is the treatment for severe acute extensive ulcerative colitis?
IV hydrocortisone/ methylprednisolone AND assess need for surgery
136
***Chronic Bowel Disorders***
What is the treatment for severe acute extensive ulcerative colitis, when steroids are contraindicated?
IV ciclosporin/ surgery
137
***Chronic Bowel Disorders***
What is the treatment for severe acute extensive ulcerative colitis, where symptoms have not improved after 72 hours?
(1) IV steroid + IV ciclosporin
(2) Can increase to surgery
138
***Chronic Bowel Disorders***
What is the treatment for severe acute extensive ulcerative colitis, if steroids and ciclosporin are contraindicated?
Infliximab
139
***Chronic Bowel Disorders***
What is the maintenance treatment for ulcerative colitis?
Oral aminosalicylates recommended
140
***Chronic Bowel Disorders***
Why are corticosteroids not used for maintenance treatment for ulcerative colitis?
Not suitable due to side effects
141
***Chronic Bowel Disorders***
Which dosing of aminosalicylate is more effective for maintenance treatment for ulcerative colitis?
OD more effective but increased risk of side effects
142
***Chronic Bowel Disorders***
What is the maintenance treatment for proctitis/ proctosigmoiditis?
Rectal +/- oral aminosalicylates
143
***Chronic Bowel Disorders***
What is the maintenance treatment for left-sided/ extensive ulcerative colitis?
Low dose oral aminosalicylates
144
***Chronic Bowel Disorders***
(1) What is the maintenance treatment for ulcerative colitis with 2+ flares in 12 months? (2) What can be used if the first line treatment is contraindicated/ not tolerated?
(1) Oral azathioprine/ mercaptopurine
(2) Monoclonal antibodies
145
***Chronic Bowel Disorders***
in which patient group is irritable bowel syndrome most common?
Women 20-30
146
***Chronic Bowel Disorders***
What symptoms are associated with irritable bowel syndrome?
- Abdominal pain
- Diarrhoea
- Constipation
- Urgency
- Incomplete defecation
- Passing mucous
147
***Chronic Bowel Disorders***
What exacerbates irritable bowel syndrome?
- Coffee/ alcohol/ milk
- Large meals
- Fried food
- Stress
148
***Chronic Bowel Disorders***
What is the non-drug treatment for irritable bowel syndrome?
- Increase exercise
- Eat regular meals
- Reduce fresh fruit consumption to 3 portions per day
- Reduce insoluble fibre
- Drink at least 8 cups of water daily
- Reduce alcohol/ caffeine/ fizzy drinks
- Avoid sorbitol in presence of diarrhoea
- Reduce stress
149
***Chronic Bowel Disorders***
What is the treatment for irritable bowel syndrome?
- Antispasmodics
- Laxatives
- Loperamide
- Antimuscarinics
150
***Chronic Bowel Disorders***
What are some examples of antispasmodics used for treatment of irritable bowel syndrome?
- Alverine
- Mebeverine
- Peppermint oil
151
***Chronic Bowel Disorders***
Which laxative should not be used for treatment of constipation in irritable bowel syndrome?
Not lactulose
152
***Chronic Bowel Disorders***
Which antimuscarinic is used for treatment of irritable bowel syndrome?
Hyoscine butylbromide
153
***Chronic Bowel Disorders***
When should hyoscine butylbromide use be avoided in treatment of irritable bowel syndrome?
Cardiac disease
154
***Chronic Bowel Disorders***
(1) What is the aim of second line treatment of irritable bowel syndrome? (2) What is this second line treatment?
(1) Pain management
(2) Low-dose TCA (amitriptyline)
155
***Chronic Bowel Disorders***
What is the second line treatment of irritable bowel syndrome, when TCAs are contraindicated?
SSRI
156
***Chronic Bowel Disorders***
What is shortened bowel syndrome?
Small bowel due to large surgical resection
157
***Chronic Bowel Disorders***
Which nutrients need to be replaced in shortened bowel syndrome?
- Vit A
- Vit B12
- Vit D
- Vit E
- Vit K
- Essential Fatty Acids
- Zinc
- Selenium
158
***Chronic Bowel Disorders***
(1) What is the main symptom that is frequently associated with shortened bowel syndrome? (2) What is given to treat this? (3) Why?
(1) Diarrhoea (or high output stomas)
(2) Loperamide/ codeine
(3) Reduce intestinal motility
159
***Chronic Bowel Disorders***
Which patient groups are at highest risk of constipation?
- Women
- Elderly
- Pregnancy
160
***Chronic Bowel Disorders***
What are some red flags, relating to constipation?
- Blood in stool
- Anaemia
- Abdominal pain
- Unexplained weight loss
- New onset constipation (over 50yrs)
161
***Chronic Bowel Disorders***
What is the non-drug treatment for constipation?
- Increased dietary fibre
- Adequate fluid intake
- Exercise
162
***Chronic Bowel Disorders***
Which medication are likely to be causing constipation?
- Opioids
- Aluminium
- Amitriptyline
- Clozapine
163
***Chronic Bowel Disorders***
What is the first line treatment of short duration constipation?
Bulk-forming AND good hydration
164
***Chronic Bowel Disorders***
(1) What is the second line treatment of short duration constipation? (2) When is this appropriate?
(1) Osmotic (lactulose)
(2) If bulk-forming does not work
165
***Chronic Bowel Disorders***
What is the first line treatment of chronic constipation?
Bulk-forming AND good hydration
166
***Chronic Bowel Disorders***
What can be done if stool remains hard after first line treatment for chronic constipation?
Add or change to macrogol
OR
Lactulose (2nd line)
167
***Chronic Bowel Disorders***
(1) What is the treatment of chronic constipation, if there is still no change after 6 months? (2) Is this for men or women?
(1) Prucalopride
(2) Men AND women
168
***Chronic Bowel Disorders***
For second line treatment of constipation, what should be done as the patient's constipation begins to improve?
Withdraw lactulose slowly
169
***Chronic Bowel Disorders***
What are the different causes of faecal impaction?
Hard stools OR soft stools
170
***Chronic Bowel Disorders***
What is the treatment of hard stools due to faecal impaction?
Macrogol
Stimulant laxative (once softened)
171
***Chronic Bowel Disorders***
What is the treatment of soft stools due to faecal impaction?
Stimulant laxative
172
***Chronic Bowel Disorders***
For faecal impaction, what is the treatment if first line treatments do not work?
Rectal bisacodyl +/- glycerol
173
***Chronic Bowel Disorders***
What is the first line treatment of opioid induced constipation?
Osmotic laxative AND stimulant laxative
174
***Chronic Bowel Disorders***
What is the second line treatment of opioid induced constipation?
Naloxegol
(Peripherally acting opioid receptor antagonist)
175
***Chronic Bowel Disorders***
(1) Which laxative(s) should be avoided in opioid induced constipation? (2) Why?
(1) AVOID bulk-forming
(2) Can cause intestinal obstruction/ faecal impaction
176
***Chronic Bowel Disorders***
Why can opioids cause constipation?
Reduced intestinal motility
177
***Chronic Bowel Disorders***
What is the first line treatment of constipation in pregnancy and breastfeeding?
- Dietary and lifestyle -> Fibre supplements (e.g. bran/ wheat)
- Bulk-forming, then lactulose
178
***Chronic Bowel Disorders***
What is the second line treatment of constipation in pregnancy and breastfeeding?
- Bisacodyl/ Senna (Senna should not be used near term)
179
***Chronic Bowel Disorders***
What is the first line treatment of constipation in children?
Dietary advice AND macrogol AND stimulant (if no faecal impaction)
180
***Chronic Bowel Disorders***
What is the first line treatment of constipation in children, with faecal impaction?
Dietary advice AND macrogol
181
***Chronic Bowel Disorders***
What is the treatment of constipation in children, if their stool is hard?
Lactulose (osmotic)
OR
Docusate
182
***Chronic Bowel Disorders***
How does Senna work?
Stimulates colonic nerves
183
***Chronic Bowel Disorders***
How does bisacodyl work?
Stimulates colonic AND rectal nerves
184
***Chronic Bowel Disorders***
How does sodium picosulfate work?
Stimulates colonic AND rectal nerves
185
***Chronic Bowel Disorders***
Name some stimulant laxatives?
- Senna
- Bisacodyl
- Sodium picosulfate
- Glycerol
- Docusate
186
***Chronic Bowel Disorders***
What are some stimulant laxatives that are used only in palliative care?
- Co-danthramer
- Co-danthrusate
187
***Chronic Bowel Disorders***
Why are co-danthramer and co-danthrusate only used in palliative care?
Potential carcinogenicity
Therefore, only used in terminally i'll patients
188
***Chronic Bowel Disorders***
What is the usual adult dose of Senna?
7.5-15mg
189
***Chronic Bowel Disorders***
What is the usual adult dose of sodium picosulfate?
5-10mg
190
***Chronic Bowel Disorders***
What is the usual adult dose of bisacodyl?
10mg
191
***Chronic Bowel Disorders***
What is the max adult dose of Senna?
30mg
192
***Chronic Bowel Disorders***
What is the max adult dose of sodium picosulfate?
10mg
193
***Chronic Bowel Disorders***
What is the max adult dose of bisacodyl?
20mg
194
***Chronic Bowel Disorders***
What are some side-effects of stimulant laxatives?
- Abdominal cramps
- Diarrhoea
- N + V
195
***Chronic Bowel Disorders***
What is the main contraindication to use of stimulant laxatives?
Intestinal obstruction
196
***Chronic Bowel Disorders***
What is the main contraindication to use of stimulant laxatives?
Intestinal obstruction
197
***Chronic Bowel Disorders***
What are some bulk-forming laxatives?
- Ispaghula husk
- Methylcellulose
- Sterculia
198
***Chronic Bowel Disorders***
What are some osmotic laxatives?
- Lactulose
- Macrogol
- Phosphate enema
199
***Chronic Bowel Disorders***
What are some faecal softeners?
- Liquid paraffin
- Docusate
- Glycerol
200
***Chronic Bowel Disorders***
What is the time to effect of bulk-forming laxatives?
2-3 days
201
***Chronic Bowel Disorders***
What is the time to effect of stimulant laxatives?
6-12 hours
202
***Chronic Bowel Disorders***
What is the time to effect of osmotic laxatives?
2-3 days
203
***Chronic Bowel Disorders***
What is the time to effect of faecal softeners?
5-20 minutes
204
***Chronic Bowel Disorders***
What is the quickest acting laxative group?
Faecal softeners
205
***Chronic Bowel Disorders***
What is the mechanism of action of bulk-forming laxatives?
- Retain fluid within the stool
- Increase faecal mass
- Stimulate peristalsis
- Has stool softening properties
206
***Chronic Bowel Disorders***
What is the administration advice for bulk-forming laxatives?
Must be taken with enough water to prevent intestinal blockage
207
***Chronic Bowel Disorders***
What is the mechanism of action of stimulant laxatives?
- Increase peristalsis (by stimulating colonic nerves)
208
***Chronic Bowel Disorders***
What discolouration can co-danthramer and co-danthrusate cause?
Colours urine red
209
***Chronic Bowel Disorders***
What is the mechanism of action of osmotic laxatives?
Increase amount of fluid in the large bowel
Leads to stimulation of peristalsis
Also has stool softening properties
210
***Chronic Bowel Disorders***
What is the mechanism of action of faecal softeners?
Increases water penetration into stools
211
***Chronic Bowel Disorders***
When should Senna not be used for treatment of constipation?
Do NOT use near term of pregnancy
212
***Chronic Bowel Disorders***
What is the treatment for acute diarrhoea?
Usually settles without medical treatment
Can use oral rehydration therapy (ORT) to prevent/ correct dehydration
213
***Chronic Bowel Disorders***
What is the treatment for diarrhoea with severe dehydration?
Hospital -> IV fluids
214
***Chronic Bowel Disorders***
What is the treatment for diarrhoea with the inability to drink?
Hospital -> IV fluids
215
***Chronic Bowel Disorders***
What is the treatment for diarrhoea if rapid control is needed?
Loperamide
216
***Chronic Bowel Disorders***
What is the treatment for traveller's diarrhoea?
Loperamide
217
***Chronic Bowel Disorders***
When should loperamide be avoided for treatment of constipation?
Bloody/ suspected inflammatory diarrhoea
218
***Chronic Bowel Disorders***
(1) When should treatment for diarrhoea be actively avoided? (2) Why?
(1) Presence of infection symptoms
(2) Because clearing infection is the priority
219
***Chronic Bowel Disorders***
What is the first line treatment for faecal impaction diarrhoea?
Loperamide
220
***Chronic Bowel Disorders***
What are the age restrictions on loperamide OTC?
12+
221
***Chronic Bowel Disorders***
What are the age restrictions on loperamide on prescription?
4+
222
***Chronic Bowel Disorders***
What is the dosing of loperamide?
Take 1-2 doses (2-4mg)
Then one (2mg) with every loose stool
223
***Chronic Bowel Disorders***
What is the maximum daily dosing of loperamide?
MAX 8 doses
16mg
224
***Chronic Bowel Disorders***
What is an MHRA warning for loperamide?
Serious cardiac reactions (QT Prolongation) with high doses
225
***Chronic Bowel Disorders***
How is an overdose of loperamide treated?
Naloxone
226
***Gastric Acid Disorders & Ulceration***
What are the urgent referral symptoms for dyspepsia?
G - GI bleeding (blood in stool/ vomit)
A - Aged 55+
U - Unexplained weight loss
D - Dysphagia (difficulty swallowing)
227
***Gastric Acid Disorders & Ulceration***
What is an MHRA warning for PPIs?
Low risk of subacute cutaneous lupus erythematosis
228
***Gastric Acid Disorders & Ulceration***
What are some cautions with PPIs?
- Increases risk of fractures/ osteoporosis
- Increases risk of C. diff
- Masks symptoms of gastric cancer
- B12 deficiency
229
***Gastric Acid Disorders & Ulceration***
Why do PPis cause increased risk of fractures/ osteoporosis?
PPIs cause hypomagnesaemia
230
***Gastric Acid Disorders & Ulceration***
(1) What is an important interaction with omeprazole and esomeprazole, specifically? (2) What should be used as an alternative?
(1) Interaction with clopidogrel
(2) Lansoprazole
231
***Gastric Acid Disorders & Ulceration***
What drugs can PPIs cause increases in concentration of?
- Methotrexate
- Phenytoin
- Warfarin
- Digoxin
232
***Gastric Acid Disorders & Ulceration***
What is a caution for H2 receptor antagonists?
May mask symptoms of gastric cancer
233
***Gastric Acid Disorders & Ulceration***
What are some side-effects of H2 receptor antagonists?
- Diarrhoea
- Dizziness
- Headache
- Rash
- Tiredness
234
***Gastric Acid Disorders & Ulceration***
What are some important interactions of H2 receptor antagonists?
- Reduced absorption of azole antifungals
- CYP450 enzyme inhibitor (cimetidine ONLY)
235
***Gastro-Oesophageal Reflux Disease***
What are some risk factors for GORD?
- Consuming fatty foods
- Pregnancy
- Hiatus Hernia
- FHx
- Stress + anxiety
- Obesity
- Drug Side-effects
- Smoking
- Alcohol
236
***Gastro-Oesophageal Reflux Disease***
Which drugs can increase risk of GORD?
- Alpha blockers
- Beta blockers
- CCBs
- Anticholinergics
- Benzodiazepines
- Corticosteroids
- NSAIDs
- Nitrates
- Tricylic Antidepressants
237
***Gastro-Oesophageal Reflux Disease***
What are the urgent referral symptoms for GORD?
G - GI bleeding (blood in stool/ vomit)
A - Aged 55+yrs
U - Unexplained weight loss
D - Dysphagia (difficulty swallowing)
238
***Gastro-Oesophageal Reflux Disease***
What is the first line treatment of GORD?
LIFESTYLE ADVICE FIRST:
- Healthy eating
- Weight loss (if obese)
- Avoiding trigger foods
- Eating smaller meals
- Eating evening meal 3-4hr before bed
- Raising head of bed
- Smoking cessation
- Reducing alcohol consumption
239
***Gastro-Oesophageal Reflux Disease***
What is the treatment of uninvestigated GORD, if lifestyle advice is insufficient?
4 weeks of PPI
(Same as uninvestigated dyspepsia)
240
***Gastro-Oesophageal Reflux Disease***
What is the treatment of confirmed GORD, that is unresponsive to lifestyle advice?
4-8 weeks of PPI
241
***Gastro-Oesophageal Reflux Disease***
What is the treatment of GORD in pregnancy?
- Dietary and lifestyle advice
- Antacid/ alginate
- Omeprazole/ ranitidine
242
***Cholestasis***
What is cholestasis?
Impaired bile formation/ flow
243
***Cholestasis***
What are some symptoms of cholestasis?
- Fatigue
- Pruritis
- Dark urine
- Pallor
- Jaundice
244
***Cholestasis***
What is the treatment of cholestasis?
- Colestyramine
- Ursodeoxycholic acid
- Rifampicin
245
***Cholestasis***
What is the treatment of intrahepatic cholestasis in pregnancy?
Ursodeoxycholic acid - to treat pruritis
Treatment will cause adverse foetal outcomes
246
***Gallstones***
What are gallstones?
Hard mineral/ fatty deposits forming stones in gallbladder bile duct
247
***Gallstones***
What is the treatment for gallstones?
Majority do not require treatment
Most are asymptomatic
248
***Gallstones***
What are the effects of a blocked/ irritated gall bladder?
- Pain
- Infection
- Inflammation
249
***Gallstones***
What may a blocked/ irritated gallbladder lead to if left untreated?
COMPLICATIONS:
- Biliary colic
- Cholecystitis
- Colangitis
- Pancreatitis
250
***Gallstones***
What is the treatment of a blocked/ irritated gallbladder, if symptoms develop?
Surgical removal
251
***Gallstones***
What is the drug treatment of a blocked/ irritated gallbladder?
Symptomatic relief only:
- Mild-moderate pain: Paracetamol/ NSAID
- Severe pain: I'M diclofenac
252
***Haemorrhoids & Anal Fissures***
What are anal fissures?
Tears/ ulcers in anal canal
Causing bleeding + pain on defecation
253
***Haemorrhoids & Anal Fissures***
What is the purpose of acute management of anal fissures?
Ensure stools pass easily and help with pain
254
***Haemorrhoids & Anal Fissures***
What is the acute treatment of anal fissures?
Bulk-forming/ osmotic laxatives
Short-term topical local anaesthetic (lidocaine)
255
***Haemorrhoids & Anal Fissures***
What is the chronic management of anal fissures?
- GTN rectal
- Topical/ oral diltiazem/ nifedipine
256
***Haemorrhoids & Anal Fissures***
What is the main specialist treatment of anal fissures?
Botulinum toxin type A
257
***Haemorrhoids & Anal Fissures***
What is the most effective option when there is no drug response for anal fissures?
Surgery
258
***Haemorrhoids & Anal Fissures***
What are haemorrhoids?
Swelling of the vascular mucosal anal cushions around the anus
259
***Haemorrhoids & Anal Fissures***
Which patient group are at highest risk of haemorrhoids?
Pregnant patients
260
***Haemorrhoids & Anal Fissures***
What are the symptoms of internal haemorrhoids?
None, usually painless
261
***Haemorrhoids & Anal Fissures***
What are the symptoms of external haemorrhoids?
Itchy + painful
262
***Haemorrhoids & Anal Fissures***
(1) What is the purpose of haemorrhoid treatment? (2) What is this treatment?
(1) Maintain easy stools to minimise straining
(2)
- Increase dietary fibre + fluid
OR
- Bulk-forming laxative + fluid
263
***Haemorrhoids & Anal Fissures***
(1) Which painkiller would you recommend for haemorrhoids? (2) Why not others?
(1) Paracetamol
(2)
- NSAIDs exacerbate rectal bleeding
- Opioids cause constipation
264
***Haemorrhoids & Anal Fissures***
What is the treatment for pain/ itching associated with haemorrhoids?
TOPICAL PREPARATIONS
- Anaesthetics (e.g. lidocaine) - used for a few days
- Corticosteroids - used for a maximum of 7 days
265
***Haemorrhoids & Anal Fissures***
What is the treatment of haemorrhoids in pregnancy?
Bulk-forming laxatives
AVOID topical haemorrhoidal preparations
- although simple soothing preparations may be used
266
***Stoma Care***
What is a stoma?
Artificial opening on the abdomen to divert flow of faeces/ urine into external pouch (located outside the body)
267
***Stoma Care***
(1) Which formulations are not suitable in stoma care? (2) Why?
(1) Effervescent/ modified-release capsules
(2) Insufficient effect from drugs
268
***Stoma Care***
Which types of formulation are preferred in stoma care?
- Liquids
- Capsules
- Uncoated/ soluble tablets
269
***Stoma Care***
What is the likely drug cause of diarrhoea in stoma care?
- Sorbitol
- Magnesium antacids
- Iron (in ileostomy)
270
***Stoma Care***
What is the likely drug cause of constipation in stoma care?
- Opioids
- Calcium antacids
- Iron (in colostomy)
271
***Stoma Care***
What is the likely drug cause of GI irritation and bleed in stoma care?
- Aspirin
- NSAIDs
272
***Stoma Care***
What effects can diuretics and laxatives have in stoma care?
Dehydration -> Hypokalaemia -> Increased digoxin toxicity
273
***Stoma Care***
How can hypokalaemia from laxatives/ diuretics be corrected in stoma care?
- Use potassium-sparing diuretics
- Use potassium supplements (e.g. SandoK)
274
***Stoma Care***
Which form of potassium supplementation is preferred in stoma care hypokalaemia correction?
Liquid potassium preferred to MR preparations
275
***Stoma Care***
Why are patients with stomas at higher risk of digoxin toxicity?
Dehydration from loss of Na+ and fluid
Due to laxatives/ diuretics
Leads to dehydration
Leads to hypokalaemia
