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OG GI Flashcards

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1
Q

What is a Bulk forming Laxative?

A

E.g Isphaghula Husk. Ideal for small hard stools. Swell in gut to increase mass + stimulate peristalsis. Work within 24hrs (2-3 days for full effect). SE: Bloating, flatulence, cramping. Increase fluid intake.

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2
Q

What is an Osmotic Laxative?

A

E.g Macrogel, lactulose. Increase water in colon by drawing fluid from the body. 2-3 days to work. SE: Discomfort, flatulence, cramping and nausea.

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3
Q

What is a Stimulant Laxative?

A

E.g Bisacodyl, Senna, glycerol, docusate. Increase intestinal motility by irritating the gut lining. Glycerol suppositories work within 15-30 mins, others 6-12 hrs. SE: Abdominal cramps. Excessive use can lead to hypokalaemia.

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4
Q

When should Prucalopride or Lubiprostone be used?

A

In cases where 2 laxatives at max dose have failed for 6 months.

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5
Q

What laxatives are recommended for opioid-induced constipation in children?

A

Stimulant + osmotic laxatives.

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6
Q

What laxatives are recommended for pregnant/breastfeeding women?

A

Bulk forming + osmotic if not bisacodyl (NOT SENNA).

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7
Q

What is Oral Rehydration Therapy?

A

Suitable for all ages. E.g Diaroylte (glucose, rile powder, NaCl, KCl).

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8
Q

What is the mechanism of action for Anti-diarrhoeal agents like Loperamide?

A

Reduces gastric motility by acting as an opioid derivative. Not suitable for under 12, Preg, BF.

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9
Q

What is the initial dosing for Loperamide?

A

Initially 4mg, then 2mg after each loose stool for a max of 5 days (max daily dose 16mg). SE: QTC prolongation, Torsade de pointes, cardiac arrest, dizziness. Naloxone for overdose.

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10
Q

What are the red flag symptoms for Diarrhoea?

A

Unexplained weight loss, rectal bleeding, persistent diarrhoea, systemic illness, recent hospital/Abx treatment.

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11
Q

What are the symptoms of an Anal Fissure?

A

Bleeding, sharp pain, split in the anal mucosa. Acute <6 weeks. Acute treatment = Bulk forming, lidocaine topically. Chronic treatment = Glyceryl trinitrate/topical diltiazem/nifedipine.

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12
Q

What are Haemorrhoids?

A

Swelling of anal mucosal cushion containing enlarged blood vessels. Risk factors include constipation/pregnancy. Symptoms: Bleeding, swelling, itchiness, sore skin, pain post-defecation.

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13
Q

What is the treatment for Haemorrhoids?

A

Constipation = Bulk forming. Pain relief = Simple analgesics. Topical: Local anaesthetics (lidocaine, cinchocaine, proliocaine only for 2 weeks). Local perianal inflammation -> Hydrocortisone/Pred for max 7 days.

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14
Q

Why should NSAIDs and Opioids be avoided in haemorrhoids treatment?

A

They increase the risk of bleeding and constipation.

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15
Q

When is an endoscopic investigation required?

A

Dyspepsia symptoms plus one of the following: Difficult swallowing, significant GI bleeding, unexplained weight loss.

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16
Q

What are lifestyle measures for dyspepsia?

A
  • Healthy eating
  • Weight loss
  • Avoid trigger foods
  • Eating smaller meals
  • Evening meal 3-4 hours before bed
  • Stop smoking
  • Reduced alcohol consumption.
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17
Q

What drugs can cause dyspepsia?

A

Alpha blockers, antimuscarinics, aspirin, bisphosphonates, CCB, corticosteroids, NSAIDs, theophylline, TCA.

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18
Q

What are Antacids used for?

A

Should only be used short term. Liquid formulation best. Work by neutralising stomach acid within 15-30 mins. Take after each meal and before bed.

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19
Q

What are the interactions of Antacids?

A

Reduce absorption of tetracyclines, quinolones, bisphosphonates (leave 2 hr gap). High sodium content -> caution in HT, HF, liver, renal and lithium (can precipitate toxicity).

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20
Q

What is the mechanism of action for PPIs?

A

Forms an irreversible bond with Na+/K+ ATPASE pump. Can take up to 3 days for full effect.

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21
Q

What are the long-term complications of PPIs?

A

Inhibition of CYP450: Delayed elimination of warfarin, phenytoin, methotrexate, diazepam. Omeprazole reduces anti-platelet effect of clopidogrel. Changes in pH also affect drug absorption e.g. ketoconazole.

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22
Q

What are H2 antagonists?

A

E.g Cimetidine, famotidine, nizatidine. SE: Headaches, rashes, psychiatric reactions in elderly. Can mask symptoms of gastric cancers.

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23
Q

What is Cholestasis?

A

Impairment of bile formation/flow. Symptoms include fatigue, pruritic skin, dark urine, pale stools, jaundice, signs of fat-soluble vitamin deficiencies.

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24
Q

What is the treatment for Cholestasis?

A

Colestyramine - an anion-exchange resin not absorbed in GI tract. Ursodeoxycholic acid - small and variable impact. Rifampicin (unlicensed) - use in caution with hepatic impairment.

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25
What is Intrahepatic cholestasis in pregnancy?
Ursodeoxycholic acid is used. Occurs in late pregnancy and is associated with adverse fetal outcomes.
26
What are Inborn errors of primary bile acid synthesis?
Group of diseases in which the liver does not produce enough primary bile acid due to enzyme deficiencies. Cholic acid works by replacing some of the missing bile acids.
27
What is Primary biliary cholangitis?
Chronic cholestatic disease developing due to progressive destruction of small + intermediate bile ducts within liver leading to fibrosis and cirrhosis. Ursodeoxycholic acid - slows down disease progression but the effect on overall survival is uncertain.
28
What is Exocrine pancreatic insufficiency?
Exocrine pancreas produces digestive enzymes. Reduced secretion leads to malnutrition, maldigestion and GI symptoms. Common in CF, Coeliac disease.
29
What is the non-pharmacological advice for Exocrine pancreatic insufficiency?
Food intake should be distributed between 3 main meals + 2/3 snacks. Foods difficult to digest should be avoided (high fibre). Alcohol should be completely avoided. Reduced fat diets are not recommended.
30
What is Pancreatic enzyme replacement?
Pancreatin contains lipase, amylase, protease. Should be taken with meals/snacks. Dose should be adjusted to lowest effective dose according to symptoms. Most effective in enteric-coated form.
31
What are the side effects of Pancreatic enzyme replacement?
GI upset, irritation of the perioral and buccal mucosa, perianal irritation. Do not mix with hot drinks/food - will denature enzymes.
32
What is a Peptic Ulcer?
Includes both gastric + duodenal ulceration. Symptoms: Upper abdominal pain. Pain associated with duodenal ulcers improves after meals; pain associated with gastric ulcers intensifies after meals.
33
What drugs can induce Ulcers?
NSAIDs, bisphosphonates, SSRIs, immunosuppressives (corticosteroids), KCL. Should all be stopped.
34
What is the initial pharmacological management for ulcers?
1) Test for H. Pylori. 2) If positive and no NSAID history -> Infection should be eradicated. 3) If NSAID -> PPI/H2 receptor antagonist for 8 weeks followed by H. pylori eradication. 4) If negative + No history of NSAID use -> PPI/H2 for 4-8 weeks.
35
What should be done for NSAID induced ulcers?
Withdraw NSAID. Use PPI/H2 receptor antagonist/Misoprostol.
36
What does Misoprostol do?
Promotes regeneration of cells.
37
Who is at high risk for developing GI complications with NSAIDs?
Patients with a history of complicated peptic ulcers or those with 2 of the following: 65+, high dose of NSAIDs, other drugs that increase GI adverse effects, serious comorbidities, heavy smoker, excessive alcohol, previous adverse reactions to NSAIDs.
38
What should be done if a high-risk patient cannot withdraw from NSAIDs?
Add PPI/Misoprostol.
39
What should be done if there is a history of UGIB?
Switch to COX-2 inhibitor + PPI.
40
What are the criteria for testing for H. Pylori?
1) Patients with uncomplicated dyspepsia + No alarm that are unresponsive to lifestyle changes/antacids following 1 month PPI. 2) Patients considered high risk (older, North African, high risk area) should be tested or in parallel with course of PPI. 3) Previously untested with a history of peptic ulcers/bleeds. 4) Prior to initiating NSAIDs in history of peptic ulcers/bleeds. 5) Unexplained iron deficiency anaemia after endoscopic investigation has excluded other causes.
41
What is the H. Pylori test?
Urea 13C breath test. Not performed within 2 weeks of PPI or 4 weeks of antibacterial as can cause false negatives.
42
When should H. Pylori be retested?
No for patients with functional dyspepsia. Only retest if compliance is poor or high local resistance rates. If on PPI for 2 weeks/4 weeks antibacterial. Patients associated with peptic ulcer, MALT lymphoma. Aspirin without PPI. Severe persistent/recurrent symptoms. Retest at least 4 weeks after treatment.
43
What is the treatment for H. Pylori?
PPI + 2 Antibacterials (Amox/Metronidazole/Clarith). Refer to specialist if H. Pylori positive after second line eradication. If diarrhoea develops -> Consider C. diff. Levofloxacin (unlicensed) or tetracycline can be used if options fail.
44
What is GORD?
Chronic condition where reflux of gastric contents back into the oesophagus. Symptoms include heartburn + regurgitation. The lower oesophageal sphincter is open/weakened.
45
What is Non-erosive GORD?
GORD symptoms but endoscopy is normal.
46
What is Erosive oesophagitis?
Oesophageal inflammation + mucosal erosions seen in endoscopy.
47
What are the risk factors for GORD?
Fatty foods, pregnancy, hiatus hernia, family history, stress, obesity, smoking, alcohol.
48
What are the complications of GORD?
Oesophagitis, ulceration, haemorrhage, Barrett's Oesophagus.
49
What drugs can cause/exacerbate GORD?
Alpha blockers, anticholinergics, benzodiazepines, CCB, bisphosphonates, corticosteroids, NSAIDs, nitrates, theophylline.
50
What is the treatment for GORD?
Mild: Antacids + alginates or H2 receptor antagonist and PPI. In patients with endoscopy confirmed diagnosis -> PPI (4 weeks) if no response offer H2. Severe: PPI (8 weeks). NSAID use: Duration 6-8 weeks. Remission should be maintained on low dose PPI, intermittent PPI or H2 substitution in severe cases.
51
What is the treatment for GORD in pregnancy?
Heartburn/acid reflux commonly caused by GORD. Dietary/lifestyle changes -> 2nd line antacid -> 3rd line omeprazole.
52
What is the treatment for GORD in children?
Resolves after 12-18 months. Use of thickened feeds or alginates. If above fails can use omeprazole.
53
What is Ulcerative Colitis (UC)?
Comes in stages. Symptoms: Bloody diarrhoea, abdominal pain, acute flare-ups. Long term complications include colorectal cancers, secondary osteoporosis with corticosteroid use.
54
What are Aminosalicyates?
MOA: Limit the inflammation in the lining of the GI tract. E.g Sulfasalazine (more SE of blood dyscrasias, nephrotoxicity), mesalazine, balsalazide. All contain 5-ASA.
55
What is Methotrexate?
MOA: Antifolate agent. Inhibits inflammatory response to induce remission. SE: GI toxicity, liver toxicity, blood disorders. FBC, renal, liver every 1-2 weeks until stable then 2-3 monthly.
56
What are Steroids (glucocorticoids)?
MOA: Suppress the immune response. SE: Adrenal suppression (N+V, weight loss, fatigue, muscular weakness), immunosuppression, psychiatric reactions (suicidal ideation, depression, insomnia). Psych may warrant lower dose/withdrawal.
57
What are Azathiopurine and Mercaptopurine?
Inhibit purine metabolism and consequently stop DNA/RNA synthesis + protein synthesis. Usual dose 2-2.5mg/kg daily. SE: Hypersensitivity, nausea common early but usually resolves. Bone marrow suppression. Neutropenia and thrombocytopenia are dose dependent.
58
What should be done when Azathiopurine and Mercaptopurine are used with Allopurinol?
Must reduce when patient is on allopurinol. Manufacturer advised 1/4th of usual dose.
59
What is Ciclosporin?
Can be used IV in UC/Crohn's. Nephrotoxic, hepatotoxic, visual disturbances, gingival hyperplasia and neurotoxic.
60
What is the counselling for Oral Ciclosporin?
Avoid excess sun exposure/UV light. Avoid grapefruit juice/increases in K+ in diet. Must be prescribed by brand.
61
What are the pharmaceutics in UC?
Proctitis - Inflammation in rectum (Suppositories). Proctosigmoiditis - Inflammation of rectum + sigmoid colon (Foam preps for rectal administration). Left sided colitis - Inflammation up to + including the descending colon (enemas). Extensive colitis - Inflammation affects up to transverse colon (oral).
62
What is the initial treatment for Proctitis/Proctosigmoiditis?
Aminosalicytes (rectally alone or with oral).
63
What is the recommended dosage of Aminosalicytes for extensive/left-sided conditions?
Low dose oral aminosalicylates.
64
What should be considered if there are 2 acute flare-ups within 12 months requiring systemic corticosteroids?
Azathiopurine/Mercaptopurine.
65
What should be done if remission is not maintained by Aminosalicytes?
Consider Azathiopurine/Mercaptopurine.
66
What is Crohn's disease?
Inflammation of GI tract from mouth to anus. Seen in patches. Symptoms: Abdominal pain, weight loss, arthritic pain, diarrhoea, skin rashes, rectal bleeding.
67
What are the long-term complications of Crohn's disease?
Strictures (narrowing of GI), perforation.
68
What medication is indicated for acute flare-ups within 12 months requiring systemic corticosteroids?
Azathiopurine/Mercaptopurine
69
What should be done if remission is not maintained by aminosalicylates?
Consider Azathiopurine/Mercaptopurine
70
What is Crohn's disease?
Inflammation of GI tract from mouth to anus
71
How is Crohn's disease characterized?
Seen in patches
72
What are the symptoms of Crohn's disease?
Abdominal pain, weight loss, arthritic pain, diarrhoea, skin rashes, rectal bleeding
73
What are the long-term complications of Crohn's disease?
Strictures (Narrowing of GI), Perforation (Holes in GI), Bowel cancer
74
What is the treatment for Crohn's with 1 flare-up in 12 months?
Pred 20-40mg OD PO until remission, methylpred IV hydrocortisone ## Footnote Alternatives include budesonide 9mg OD PO for 8 weeks or an aminosalicylate in patients with distal ileal, ileocaecal or right-sided colonic disease.
75
What is the treatment for Crohn's with more than 2 flare-ups in 12 months?
Azathiopurine or Mercaptopurine or Methotrexate
76
What is the maintenance treatment for Crohn's disease?
Azathiopurine/Mercaptopurine or aminos

GI factfiles (9 decks)

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