Topic 1: GI Conditions Flashcards
(89 cards)
0
Q
What is the principal cause of GORD?
A
Lower oesophageal sphincter incompetence. This is often due to reduced by muscle tone via medicines or overeating
1
Q
What are the 5 main conditions generally described by dyspepsia?
A
Functional/non-ulcer dyspepsia (indigestion) GORD Gastritis Duodenal ulcers Gastric ulcers
2
Q
What is the principle cause of gastritis?
A
Increased acid production resulting in inflammation of the stomach.
3
Q
What is gastritis usually attributable to?
A
H. Pylori infection, NSAID or alcohol indigestion
4
Q
What is h. Pylori infection central to?
A
Peptic ulcer,s
5
Q
How does h. Pylori cause ulceration?
A
H. Pylori secrets certain chemical factors to cause gastric mucosal damage.
7
Q
How is a differential diagnosis of upper GI conditions reached?
A
By conducting a thorough medical and drug history to rule out serious pathology.
By identifying ALARM symptoms and referring if required,
8
Q
What is diarrhoea?
A
- change in normal bowel habit resulting in increased frequency and/or volume of bowel movement and passage of loose, soft or watery motions
- depends on what is ‘normal’ forthe patient
9
Q
What are the different types of diarrhoea and their classifications?
A
Acute- lasts less than 14 days (rutter states less than 7 days)
Persistent - more than 14 days
Chronic - more than 4 weeks
10
Q
What are the causes of acute diarrhoea?
A
Gastroenteritits (most common) drugs anxiety food allergy acute appendicitis
11
Q
What are the common causes of gastroenteritis?
A
Mostly viral e.g. rotaviris
Can be bacterial e.g. shigella, E coli, salmonella. Generally from contaminated food
12
Q
What are the causes of chronic diarrhoea?
A
Irritable bowel syndrome infection inflammatory bowel disease coeliac disease bowel cancer diverticular diease
13
Q
What is diverticular disease?
A
an umbrella of diseases
Diverticulitis = formation of tiny pockets inside the lining of the bowel
symptoms: bleeding etc. refer to doctor
14
Q
What are the complications of diarrhoea?
A
risk of dehydration, especially in the very young and very old
Nappy rash in babies
Prognosis is rarely life threatening
15
Q
When should diarrhoea be referred?
A
- patient is systemically unwell (fever)
- blood or pus in the stool
- recently had antibiotics/been in hospital
- (persistent diarrhoea for 1 week
- diarrhoea lasting for 6 weeks (on/off?)
- unexplained/unintentional weightloss
- abdominal mass
- family history of bowel cancer
- severe abdominal pain
- unable to drink fluids/signs of dehydration in small children and elderly
- suspected faecal impaction (esp. in elderly)
16
Q
What are the key questions to ask regarding diarrhoea?
A
- Who has it
- How is it compared to normal bowel habit
- Freuqency, volume, consistency of bowel motions
- Length
- Have they had it before?
- Was onset sudden/gradual
- Cause?
- Tried anything?
- Blood?
- cramping? vomiting?
- fever?
- anyone else affected?
- medicines induced?
- medical conditions e.g. hyperthyroidism
17
Q
How is diarrhoea managed?
A
1st line treatment: ORT
2nd line treatment: anti-diarrhoeals
18
Q
What is the rationale for using ORT?
A
- re-establish fluid and electrolyte balance
- simple and highly effective with no side effects or interactions
- available as ready-made solutions, powders, effervescent tablets and ice blocks
- very important to make up exactly as directed
19
Q
How are ORT sachets made up?
A
make up 1 sachet to 200mls of water
can be kept in the fridge for up to 25 hours, then discard
Do not add additional flavoring
Use 1 sachet per loos motion in babies less than one year and 2 sachets etc. in older children.
20
Q
What is the rationale for using anti-diarrhoeals?
A
Only to be used when staying at home and resting is impractical (e.g. travelling, work)
Loperamide has the most evidence of effectiveness with least side effects
21
Q
What is the mechanism of anti-diarrhoeals?
A
Loperamide is a synthetic opiod analogue. It slows the intestinal tract time and increases capacity of the gut.
Slows the movement through the guy by increasing the muscle tone to decrease contractility.
22
Q
What is the dose of loperamide given?
A
for acute diarrhoea: 4mg stat, then 2 mg after each loose bowel motion
max 16mg in 24 hours.
Only for patients >12 years
23
Q
Can loperamide be used in chronic diarrhoea?
A
Yes, by adjusting dose until 1-2 formed stools per day: refer to doctor.
24
Q
What other anti-diarrhoeals are there?
A
Diphenoxylate HCl + atropine sulfate (Diastop)
- opiate derivative + anticholinergic
- less evidence of effect and more side effects
- can be given to children down to 2 years of age on mg/kg dose
Codeine- efficacy not well established. Not recommended due to side effects and dependence risk
Bulking agents
25
What is the dose of Diphenoxylate HCl + atropine sulfate for adults and children >12 years of age?
2t stat, then 2 tablet every 6 to 8 hours. maximum of 8 tablets in 24 hours
26
When are bulking agents used?
in chronic diarrhoea such as IBS
-they absorb fluid and bulk out faeces
Should be soluble fibre as psyllium husk.
27
What information would be useful to patients in terms of diarrhoea?
- ORT: sip and swallow small amounts frequently
- follow storage instructions
- drinks like powerade, gatorade contain too much glucose and will make more dehydrated
- discourage flat lemonade/fruit juice as no electrolyte replacement
- rest, stay at home
28
What self care info would be important to patients in terms of diarrhoea?
- hygiene/handwasing/food prep really important
- start with simple carbs like boild rice, plain white bread, plain biscuits or crackers
- avoid dairy, fats, proteins, spicy, raw fruit and veges
- be careful with med absorption esp OC.
29
When should the patient seek follow up medical attention?
for 1 year olds: if diarrhoea lasts more than 1 day
for 3 years and under: if diarrhoea lasts for more than 2 days
for children greater than 3 years: if diarrhoea lasts longer than 3 days
if there is no improvement
30
What is dyspepsia?
upper abdominal discomfort or pain, burning sensation, heaviness or an ache
-often related to eating
31
What are the symptoms of dyspepsia?
- vague abdominal discomfort above ambilicus
- belching
- bloating
- flatulence
- fullness
- nausea
- vomiting
- heart burn
- acid reflux
32
What is functional dyspepsia?
Dyspepsia with the normal symptoms with a normal finding on the endoscopy
33
What causes function dyspepsia?
uncertain, but likely to be psychosocial factors, altered visceral sensation or motor abnormalities
34
What is the prevalance of functional dyspepsia?
Unknown due to self medicating
| occurs more inedlerly
35
What are the risk factors for functional dyspepsia?
H pylori infection
| lifestyle factors like obesity, high levels of coffee, fat, alcohol in diet and smoking
36
What is the general prognosis for functional dyspepsia?
no cure, long term treatment is needed
37
how is functional dyspepsia managed?
primary management: lifestyle adjustment
- encourage healthy eating
- decrease weight if appropriate
- smoking cessation
- avoid precipitants like alcohol, coffees, chocolate, fatty foods, spicy foods
38
How is functional dyspepsia managed?
1st line: antacids for short term relief of symptoms, not for prevention
If there is treatment failure consider H. pylori infection and use of H2 antagonist like ranitidine or PPI like omeprazole
39
What is GORD?
reflux of gastric contents into the oesophagus causing symptoms such as heart burn and acid regurgitation
40
What causes GORD?
Combination of mechanisms:
1) transient relaxation of lower oesophageal sphincter
2) increased lower abdominal pressure
3) reduced lower oesophageal tone
4) gastric emptying
5) impaired gastric clearance
41
What are the risk factors for GORD?
- lifestyle (obesity) and diet
- smoking, alcohol, coffee, chocolate
- stress and anxiety
- drucs (CCB, anticholinergics, theophylline, benzodiazepines, nitrates)
- pregnancy
- hiatus hernia
42
How does fatty foods increase risk of GORD?
fatty foods delay gastric emptying
43
How do smoking, alcohol, coffee and chocolate increase the risk of GORD?
these have pharmacological effects which could reduce the LOS tone
44
What are the complications of GORD?
- oesophageal ulcers or haemorrhage
- aspiration pneumonia
- oral problems
- cough
45
How is GORD managed?
1st line treatment is lifestyle modification:
- avoid trigger foods
- have small meals no later than 3-4 hours before bed
- lose weight
- stop smoking
- raise head of bed
- reduce stress
- reduce contributing drugs if possible
46
How is GORD managed if life style modifications are not enough?
2nd line management:
- full dose PPI for at least 1 month (can continue for 2 months before further investigation is necessay
- if symptoms are noctournal, try H2 antagonist at bedtime
47
Hwat is peptic ulcer?
ulceration of the mucosa of stomach or duodenum
| this means there is a breach of the epithelium which penetrates the muscularis mucosae
48
What are the symptoms of peptic ulcers?
localised mid-epigastric pain
| constaint, gnawing and annoying
49
How do duodenal ulcers differ from gastric ulcers?
Duodenal: pain is experienced 2-3 hours after eating and can wake the patient up at night
Gastric: pain occurs 30minutes or so after eating and is relieved by antacids or food but aggravated by alcohol and caffeine. Gastric ulcers are more commonly associated with GI bleeds and weight loss
50
How are ulcers diagnosed?
by endoscopy
51
What are the causes of peptic ulcers?
1) H. pylori infection
| 2) NSAIDs
52
how does H. pylori infection cause peptic ulcers?
- causes inflammation of mucosal lining of stomach
- this depletes layer of protective alkaline mucous and alters gastric acidict
- increases acid secretion
53
How do NSAIDs cause peptic ulcers?
- inhibit prostaglandin E2 synthesis which reduces production of protective alkaline mucous
- Increases risk of ulceration, particularly in the stomach
- NSAID use may increase gastric ulcer by 3-4fold
54
What are the referral points for peptic ulcers?
- severe pain that wakes the px up
- no improvement in 5 days
- on going change in bowel habit (>1 week)
- vomiting (>1-2 days)
- unexplained weightloss
- referred pain (e.g. arm)
- blood in stools or vomit
- abdominal mass
- food sticking in throat
55
How are peptic ulcers managed?
- avoid precipitating factors
- stop NSAID, f not in long term, then at least long enough for ulcer to heal
- full dose PPI 1-2 months and if still symptoms, investigate for H. pylori
- If intolerant or non responsive to PPI, try H2 antagonist
- Antacids/alginates to relieve symptoms
56
What are acid neutralisers?
Combination products (e.g. gaviscon) with different duration and onset of action
take 5-10 minutes to work and last about 90 minutes
tablets need to be chewed to aid disintegration
Available in liquid for speed and tablets for portability
57
What are the disadvantages of acid neutralisers?
- may interfere with absorption of other medications e.g. tetracyclines
- may affect absorption of enteric coated tablets
- there is sodium content in some products
- need to separate from other medicines to avoid interactions
58
What are the side effects of antacids?
- calcium and aluminium can cause constipation
| - magnesium can cause diarrhoea
59
What are alginates?
-These form a sponge like matrix in ocntact with gastric acid and floats on stomach contents
They appear to be better than placebo and as effective as antacids in reducing heart burn
- can be used with antacid therapy (e.g. PPIs, H2 antagonists)
- safe during pregnancy
- good if patient experiences heart burn
60
What are the disadvantages with using alginates?
sodium and potassium content
61
What are the advantages of using H2 receptor antagonists for GORD?
- act within 1 hour, lasts for 12 hours
- reversible inhibitors of histamine action at H2 receptors which decreases basal and food-stimulated acid secretion
- inhibits about 50-80% of daily gastric acid secretion
- adverse effects relatively low
- can be used with antacids
- longer acting than antacids
62
What are the disadvantages of using H2 receptor antagonists?
Need to take caution:
- not to be used in pregnancy/breastfeeding
- middle aged patients with new undiagnosed symptoms
- NSAID use
63
What are H2 receptor blockers like ranitidine (zantac) and famotidine (pepcid AC) for?
short term symptomatic relief of indigestion and heart burn
64
What are the advantages of using a PPI like omperazole for GORD?
- blocks proton pump once it is activated by food
- longer duration of action
- good acid suppression
- well tolerated
- acts within 1-2 hours and lasts for 17-24 hours
65
What is the recommended OTC dose of omeprazole?
for short term relief of reflux with symptoms once a week or more:
20mg (2 x 10mg tabs) daily before food to relieve symptoms
then reduce to 10mg daily (or increase if symptoms recur)
if symptoms occur daily, need to refer.
66
What is irritable bowel syndrome?
a chronic relapsing and often lifelong disorder of GI unction with no disernable structural or biochemical cause
67
What are the symptoms of IBS?
- presence of abdominal pain or discomfort assoc with or relieved by defecation
- change in bowel habit with constipation, diarrhoea or both
- abdominal bleeding
68
What causes IBS?
-unknown. likely multifactorial with suggested underlying proesses:
- abnormal GI motility
- visceral hypersensitivity
- abnormal GI immune function
- abnormal autonomic activity
- abnormal CNS modulation of GI tract
69
What are the theoretical cuases of IBS?
```
infection following gastroenteritis
inflammation
diet
antibiotics
surgery
family history
```
70
What is the prevalence of IBS?
- most common in people 2-30 years of age
| - twice as common in women
71
What is the prognosis of IBS?
symptoms fluctuates over many years
| chronic on-going life stress hinders recovery
72
How is IBS diagnosed?
```
any of:
Abdominal pain/discomfort OR
Bloating OR
change in bowel habit
Diagnose if pain is relieved by defecation or assoc. wth altered bowel frequency or altered stool form
in the last 6 months
```
AND if the person has at least 2 of the following:
- altered stool passage
- abdominal bloating, distension, tension, hardness
- symptoms made worse by eating
- passage of mucous
- other conditions with similar features have been ruled out
73
How is IBS assessed?
by excluding other conditions and examining history of things like
- diet/nutrition
- amount of physical activity
- psychological status such as physical or psychological stress or presence of depression or anxiety.
74
How is IBS managed?
First line is primary-lifestyle adjustment:
- reduce stress/increase relaxation
- adjust fibre in diet and decrease amount of insoluble fibre (bran, whole meal breads and cereals, brown rice) and increase soluble fibre like oats and ispaghula husk
- advise regular meals and times
- advise 8 cups of water daily and reduce tea, coffee, alcohol, fizzy drinks
- increase physical activity
75
What is 2nd line for IBS management?
drug treatment:
- treat according to symptoms (pain, constipation, diarrhoa)
- antipasmodicis like peppermint oil e.g. mintec or hyoscine butyl bromide (Buscopan or gastrosoothe)
- laxatives - bulk forming (metamucil) or macrogols (movicol) are preferred .
- stimulant laxatives like senna for short term only.
- Loperamide for diarrhoea preferred. Adjust dose until 1-2 soft well formed stools are passed per day
76
When should IBS be referred?
- patient 40 years with recent change in bowel habit
- change in symptom presentation
- suspect need of psychological intervention
77
What is constipation?
subjective again as different people have different ideas of normal defecation
- usually unsatisfactory defecation due to infrequent, difficult stool passage or seemingly incomplete defecation
- often hard, dry, abnormally large or small stool
78
What is the prevalence of constipation?
- common in all ages
- 2x common in women
- more common in elderly
- particularly common in pregnancy (~40%)
79
How is constipation diagnosed?
following discussion about what is normal for the patient reports of symptoms as definition or it may be overflow diarrhoea in elderly due to faecal impaction
80
How is constipation assessed?
- what is normal for patient, when did it become a problem
- frequency and character of stools
- stools hard? large?
- discomfort, straining, pain, bleeding
- nausea, vomiting, abdominal pain, distention
- predisposing factors like (diet, fluid, drugs, physical activity
- lack of privacy, access to toilet, hurried habits
- hange to diet, routine
- other medical conditions e.g. hypothyroidism
81
When should constipation be referred?
- suspect IBS, colorectal cancer or IBD or family history of these
- > 7 days with no identifiable cause
- weight loss
- fever
- nausea
- vomiting
- blood in stools
82
How is short duration constipation managed?
first remove causative factor like drugs.
| then increase fluid, fibre and exercise
83
What are the 1st line drugs for constipation?
bulk forming laxatives
osmotic laxatives
lubricants/softeners
stimulat laxatives
84
What are bulk forming laxatives?
e. g. metamucil
- fluid with these is extremely important
- takes 2-3 days to take effect
- mimic fibre consumption
- side effects: bloating, discomfort, flatulence, distention
85
What are osmotic laxatives?
e. g. macrogols (movicol) or lactulose
- these draw water into lumen and stimulate peristalsis
- lactulose not suitable for diabetics
86
What are lubricants or softners?
glycerin suppositories or docusate sodium
87
What are stimulant laxatives?
e. g. senna, bicosodyl
- increase intestinal motiliy
- take at night and work in 6-12 hours.
- Can cause abdominal cramps
- suppositories work in 20-30 minutes
- add into the softener if stool is soft, but difficult to pass, or there is inadequate emptying
- can cause atonic colon if used long term
88
When would stimulant + softener OR lactulose be used?
if constipation is caused by opiods
89
What lifestyle management is appropriate for constipation?
- defecation should be unhurried (make time)
- ensure privacy and access
- establish a routine e.g. 1st thing in the morning
- respond immediately to urge
- keep up fluids, soluble fibre, exercise
