unit 6 Flashcards

Question

What are Proton Pump Inhibitors (PPIs) used for?

Answer 1

PPIs are used to treat: * Peptic ulcers * Erosive oesophagitis * Gastro-oesophageal reflux disease (GORD) * GORD-related laryngitis * Hypersecretory conditions (e.g., Zollinger-Ellison syndrome) ## Footnote Some generic PPIs are available OTC for acid reflux disorders.

Answer 2

PPIs are suicide inhibitors that block the final step of gastric acid secretion. They irreversibly inhibit the proton pump (H⁺/K⁺-ATPase) in parietal cells. ## Footnote PPIs are prodrugs activated in acidic environments of parietal cells, forming a potent electrophilic drug that binds to cysteine residues.

Answer 3

Omeprazole’s selectivity is due to its accumulation in highly acidic environments (pH 1–2) in parietal cell canaliculi, where the prodrug is converted into the active drug. ## Footnote Activation occurs at low pH, ensuring the drug works specifically on parietal cells.

Answer 4

PPIs are primarily metabolized by CYP450 oxidation, with pantoprazole also undergoing sulphate conjugation. 3% of white Europeans are slow PPI metabolizers, affecting dosing considerations. ## Footnote The (S)-enantiomer of omeprazole (Nexium) has a superior pharmacokinetic profile, leading to longer half-life and higher drug concentrations.

Answer 5

PPIs are lipophilic and cross cell membranes easily. They are activated by low pH in the acidic environment of parietal cells. ## Footnote Their prodrug form becomes protonated and activated at low pH, covalently binding to the proton pump (H⁺/K⁺-ATPase).

Answer 6

Activation occurs only at low pH (pH 1–2), ensuring they act specifically on parietal cells. ## Footnote The ionised form of the drug is too polar to cross membranes, restricting its action.

Answer 7

Prokinetic drugs increase oesophageal sphincter pressure, enhance gastric peristalsis, and speed up gastric emptying ## Footnote These actions help prevent oesophagitis and improve gastrointestinal motility.

Answer 8

5-HT4 agonists stimulate the enteric nervous system, increasing acetylcholine release. Dopamine D2 antagonists promote gastric motility by blocking dopamine’s inhibitory effect on motility ## Footnote Some prokinetic drugs (e.g., metoclopramide) also have 5-HT3 antagonism effects, which can help with nausea and vomiting.

Answer 9

Prokinetic drugs are used to treat: * Gastro-oesophageal reflux disease (GORD) * Diabetic gastroparesis * Chemotherapy-induced nausea and vomiting ## Footnote They help improve gastric motility and alleviate symptoms of delayed gastric emptying.

Answer 10

Domperidone does not cross the blood-brain barrier, leading to fewer central nervous system side effects. Metoclopramide crosses the blood-brain barrier and can cause side effects like sedation and extrapyramidal symptoms ## Footnote This is due to its dopamine D2 antagonism.

Answer 11

Prucalopride is a selective 5-HT4 agonist that promotes motility further down the gastrointestinal tract than other prokinetic drugs like metoclopramide or domperidone ## Footnote It is used primarily for the treatment of chronic constipation when other laxatives fail.

Answer 12

Paramax is used for migraine treatment and offers dual benefits: * Paracetamol: Provides pain relief by inhibiting prostaglandin synthesis in the brain * Metoclopramide: Enhances gastric emptying, improving the absorption of paracetamol ## Footnote It also acts as an antiemetic, helping alleviate nausea and vomiting commonly associated with migraines.

Answer 13

Peptic ulcers are mainly caused by: * H. pylori infection * NSAID use ## Footnote None

Answer 14

Diagnosis of H. pylori infection includes: * 13C-urea breath test (detects labeled CO2 in breath) * Endoscopy and serological antigen tests for confirmation ## Footnote None

Answer 15

H. pylori survives in the stomach by: * Producing ammonia and bicarbonate, which help it penetrate gastric mucus and withstand stomach acid ## Footnote None

Answer 16

Over 90% of duodenal ulcer patients (excluding those with gastrinomas or on NSAIDs) have H. pylori infection ## Footnote None

Answer 17

The treatment for H. pylori infection is triple therapy consisting of: * A Proton Pump Inhibitor (PPI) * Two antibiotics (e.g., omeprazole + amoxicillin + clarithromycin or metronidazole) ## Footnote None

Answer 18

Eradication of H. pylori significantly reduces ulcer recurrence. Triple therapy is 90% successful in eradicating the infection ## Footnote None

Answer 19

ORT is used to treat acute diarrhoea by maintaining fluid and electrolyte balance. ## Footnote It helps prevent severe dehydration, especially in infants, children, the elderly, and those with underlying conditions.

Answer 20

Simple ORS contains: * Glucose * Sodium * Potassium * Chloride * Citrate These ingredients promote water absorption and help rehydrate the body. ## Footnote It is easy to prepare and doesn't require special equipment.

Answer 21

Starch-based ORS is more effective in treating cholera and rotavirus. It enhances sodium transport and reduces diarrhoea duration compared to glucose-based solutions. ## Footnote Dioralyte Relief is a starch-based ORS available in the UK.

Answer 22

Signs and symptoms of dehydration include: * Dry mouth and tongue * Thirst * Dark yellow urine * Fatigue or dizziness * Decreased skin elasticity * Rapid heartbeat or breathing * Sunken eyes (especially in infants) ## Footnote Recognition of these symptoms is crucial for timely intervention.

Answer 23

lack of excercise

Answer 24

Essential for managing Alcoholic Liver Disease (ALD), especially alcoholic cirrhosis. ## Footnote Reduces the risk of complications and associated mortality. Managing cofactors such as obesity, insulin resistance, smoking, malnutrition, iron overload, and viral hepatitis is crucial.

Answer 25

Beneficial for patients with Child-Pugh C ALD (severe alcoholic cirrhosis) and/or MELD score ≥ 15. ## Footnote Requires a 6-month abstinence period to assess potential spontaneous improvement and avoid transplantation.

Answer 26

Defined by jaundice and/or ascites in patients with ongoing alcohol misuse.

Answer 27

Corticosteroids (prednisolone): 40 mg daily for 1 month, shown to potentially reduce short-term mortality. ## Footnote Non-response to steroids indicates therapy cessation.

Answer 28

Previously considered an alternative to steroids in patients with AH and ongoing sepsis. ## Footnote However, the STOPAH trial showed no improvement in outcomes with pentoxifylline.

Answer 29

NAC is an antioxidant that replenishes glutathione stores in hepatocytes. ## Footnote It is considered in combination with steroids, as this regimen has shown better 1-month survival rates.

Answer 30

Liver: Alcoholic hepatitis, cirrhosis, liver cancer. Gastrointestinal tract: Oral cavity cancer, esophageal neoplasm, esophageal varices, pancreatitis. Cardiovascular system: Atrial fibrillation, hypertension, strokes, cardiomyopathy with heart failure. Neurological system: Acute intoxication, loss of consciousness, withdrawal, seizures, subdural hemorrhage, peripheral neuropathy, Wernicke-Korsakoff syndrome, cerebellar degeneration, psychiatric problems.

Answer 31

Patients should avoid abruptly stopping alcohol without medical assistance. ## Footnote Abrupt cessation can cause neurological complications, including withdrawal seizures.

Answer 32

Generalized tonic-clonic seizures typically occur 12-48 hours after the last drink, but can happen as early as 2 hours. ## Footnote Most common in individuals in their 4th and 5th decades of life.

Answer 33

Alcohol as a CNS depressant: Chronic use leads to adaptive changes in neurotransmitters. GABA system: Ethanol mimics GABA, leading to receptor insensitivity over time. Cessation reduces inhibitory tone. Glutamate system: Upregulation of NMDA receptors during chronic alcohol exposure. Stopping alcohol causes hyperexcitability, leading to seizures.

Answer 34

Benzodiazepines (Chlordiazepoxide, Diazepam, etc.) are first-line treatments. ## Footnote Treatment can be dosed using fixed-dose or symptom-triggered regimens. The CIWA-Ar scale is used to assess symptom severity and guide medication dosing.

Answer 35

Occurs in thiamine-deficient heavy drinkers. ## Footnote Wernicke’s encephalopathy: Confusion, ataxia, nystagmus. Korsakoff’s syndrome: Profound memory impairment with preservation of other intellectual functions; confabulation may be present.

Answer 36

Oral thiamine supplementation is recommended for malnourished patients or those at risk of malnourishment or those with decompensated liver disease. ## Footnote IV thiamine (Pabrinex) is recommended for patients with neurological withdrawal symptoms.

Answer 37

Fatty liver: Accumulation of fat within the hepatocytes. Alcoholic hepatitis: Acute right upper quadrant (RUQ) pain with jaundice, fever, and marked derangement of liver function tests (LFTs). Microscopically, there is liver inflammation. Liver cirrhosis: Hepatocytes are damaged to the extent that they are replaced by scar tissue. This is a permanent condition. It may lead to encephalopathy, portal vein hypertension, hepatorenal syndrome, and an increased risk of infections. These patients are often malnourished. ## Footnote Stages of liver damage highlight the progression from fatty liver to cirrhosis due to alcohol abuse.

Answer 38

Abstinence from alcohol is essential. Good nutrition is critical for recovery. Treat complications such as ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, and oesophageal varices. Diuretics may be needed for patients with ascites. ## Footnote Emphasis on abstinence and nutrition as pillars of treatment.

Answer 39

Admission is recommended for acute withdrawal or high risk of seizures or delirium tremens. Consider admission for patients who are frail, have cognitive impairment, multiple comorbidities, or lack social support. ## Footnote Criteria for admission focus on the severity of withdrawal and patient vulnerability.

Answer 40

Urgent hospital admission is required. Parenteral thiamine should be administered if symptoms (ataxia, ophthalmoplegia, nystagmus, acute confusion, hypotension, or hypothermia) are present. ## Footnote Timely treatment of Wernicke’s is crucial to prevent lasting neurological damage.

Answer 41

Suicide risk: High-risk individuals should be urgently referred to mental health services. Coexisting psychotic disorders: Refer to secondary mental health services for assessment and management. ## Footnote The importance of addressing mental health in alcohol dependence is highlighted.

Answer 42

Avoid sudden alcohol reduction to prevent severe withdrawal symptoms. Referral to specialist services is required for moderate/severe dependence, alcohol-related impairment, or comorbid conditions (e.g., liver disease, mental health problems). ## Footnote Caution against abrupt cessation is necessary to mitigate withdrawal risks.

Answer 43

Dependent drinkers must notify the DVLA (Driver and Vehicle Licensing Agency) and surrender their driving license. Healthcare professionals may need to disclose relevant information to the DVLA. ## Footnote Legal obligations surrounding driving and alcohol dependence must be adhered to for patient safety.

Answer 44

Treat alcohol misuse first. Assess and treat mental health disorders if symptoms persist after 3-4 weeks of abstinence. ## Footnote Addressing alcohol misuse as a priority can improve mental health treatment outcomes.

Answer 45

Use the FRAMES principles: * Feedback * Responsibility * Advice * Menu of options * Empathy * Self-efficacy Monitor progress and offer extended interventions if necessary. ## Footnote FRAMES provides a structured approach for delivering brief interventions.

Answer 46

Conducted by trained professionals. 20-30 minute sessions, up to five sessions. Focus on reducing alcohol consumption, risk-taking behavior, or considering abstinence. ## Footnote Extended interventions are designed to provide more in-depth support.

Answer 47

Cognitive-behavioral therapies (weekly 60-minute sessions for 12 weeks). Social network/environment-based therapies (eight 50-minute sessions over 12 weeks). Behavioral couples therapy (60-minute weekly sessions for 12 weeks). ## Footnote Various therapeutic approaches cater to different needs and contexts in treating alcohol misuse.

Answer 48

Encourage self-help and participation in community networks such as Alcoholics Anonymous or SMART Recovery. Refer to organizations like Action on Addiction and Alcohol Change UK for additional support. Provide carer support through written/verbal information on alcohol misuse management and conduct carer assessments when needed. ## Footnote Community resources play a vital role in recovery and support for families.

Answer 49

Acute withdrawal or high risk of seizures or delirium tremens. ## Footnote Lower the threshold for admission in patients who are frail, have cognitive impairment, multiple comorbidities, or lack social support.

Answer 50

Urgent hospital admission is required. ## Footnote Treat with parenteral thiamine if symptoms like ataxia, ophthalmoplegia, nystagmus, acute confusion, hypotension, or hypothermia are present.

Answer 51

Suicide risk: Urgently refer high-risk individuals to mental health services. * Coexisting psychotic disorders: Refer to secondary mental health services for assessment and management.

Answer 52

Avoid sudden alcohol reduction to prevent severe withdrawal. * Consider GP-supervised alcohol detoxification when feasible.

Answer 53

For moderate/severe dependence, severe alcohol-related impairment, or comorbid conditions (e.g., liver disease, alcohol-related mental health problems).

Answer 54

Notify the DVLA and surrender their driving license. ## Footnote Healthcare professionals may need to disclose relevant information to the DVLA.

Answer 55

Treat alcohol misuse first. * Assess and treat mental health disorders if symptoms persist after 3-4 weeks of abstinence.

Answer 56

Use the FRAMES principles: * Feedback * Responsibility * Advice * Menu of options * Empathy * Self-efficacy ## Footnote Monitor progress and offer extended interventions if needed.

Answer 57

Conducted by trained professionals, lasting 20-30 minutes, with up to five sessions. * Focus on reducing alcohol consumption, risk-taking behavior, or considering abstinence.

Answer 58

Cognitive-behavioral therapies (weekly 60-minute sessions for 12 weeks). * Social network/environment-based therapies (eight 50-minute sessions over 12 weeks). * Behavioral couples therapy (60-minute weekly sessions for 12 weeks).

Answer 59

Encourage self-help and participation in community networks such as Alcoholics Anonymous or SMART Recovery. * Refer to organizations like Action on Addiction and Alcohol Change UK for additional support. * Provide carer support through written/verbal information on alcohol misuse management and conduct carer assessments when needed.

Answer 60

Early symptoms include nausea and vomiting, which usually settle within 24 hours. ## Footnote None

Answer 61

Recurrence of nausea and vomiting, along with right subcostal pain and tenderness, often indicates hepatic necrosis. ## Footnote None

Answer 62

Liver damage is maximal 3-4 days after overdose. ## Footnote None

Answer 63

Liver failure, encephalopathy, coma, and death. ## Footnote None

Answer 64

For obese patients (weight >110 kg), calculate the paracetamol dose using 110 kg body weight to avoid underestimating toxicity. ## Footnote None

Answer 65

For pregnant patients, use the pre-pregnancy weight to calculate the potentially toxic dose. ## Footnote None

Answer 66

Acetylcysteine. ## Footnote None

Answer 67

Acetylcysteine is most effective if given within 8 hours of ingestion. Its effectiveness declines after 8 hours but may still work up to 24 hours in patients at risk of severe liver damage. ## Footnote None

Answer 68

Oral acetylcysteine may be used as a very rare alternative if intravenous access is not possible (unlicensed use). ## Footnote None

Answer 69

Symptoms of dyspepsia include: * trapped wind * grumbling stomach * feeling bloated * burping/belching * acid reflux * pain usually starting centrally or behind the breastbone * heartburn ## Footnote Heartburn is a common symptom of dyspepsia.

Answer 70

Causes include: * H. pylori infection * history of anxiety or depression * being female or pregnant * smoking * use of NSAIDs, alpha blockers, CCB, BB, aspirin, or tricyclic antidepressants * history of abuse ## Footnote CCB = calcium channel blockers; BB = beta blockers; NSAIDs = non-steroidal anti-inflammatory drugs.

Answer 71

Recommendations include: * avoiding large meals before bedtime (3-4 hours before) * eating frequent small meals * losing weight if overweight * avoiding bending or stooping * raising the head of the bed * stopping smoking * reducing caffeine, chocolate, and fat intake ## Footnote These changes help avoid affecting esophageal sphincter tone.

Answer 72

First-line treatments include: * H2 antagonists (e.g., Cimetidine, Ranitidine) for no longer than 2 weeks * proton pump inhibitors (PPIs) which should not be taken over-the-counter for longer than 2 weeks ## Footnote PPIs typically take 2 days to take effect and should be taken 30-60 minutes before food for maximum effectiveness.

Answer 73

Other treatments include: * Antacids (e.g., Rennie chewable tablets) * Alginates (e.g., Gaviscon) ## Footnote Antacids can be taken an hour before or after food.

Answer 74

Red flags include: * suspected H. pylori infection * persistent vomiting * unintentional weight loss * significant GI bleeding (usually dark red stools) * iron-deficient anemia * suspicious barium meal * epigastric mass * persistent dyspepsia for 2 weeks ## Footnote These symptoms warrant referral for testing and treatment.

Answer 75

Symptoms: * Regurgitation of food * Oesophagitis * Acid reflux * Less common – chest pain, cough, hoarseness, wheezing Causes: * Consumption of fatty foods * NSAIDS, alpha blocker, CCB, BB, aspirin, tric anti (review, low dose/stop) * Pregnancy * Family history of GORD * Hiatus hernia * Pressure from straining/coughing * Stress or anxiety * Smoking or alcohol Management: * Lifestyle measures – healthy eating, weight loss, avoiding trigger food * Eat smaller meals, 3-4hrs before bed, raise head of bed * Smoking cessation, reducing alcohol intake Drug Management: Mild to Moderate * Alginate * Antacid (long term use not recommended) Moderate – Severe * PPI * H2 antagonist GORD in Pregnancy: * First line dietary and lifestyle * Second line antacid or alginate * Third line omeprazole or ranitidine (unlicensed) Red Flags: * Persistent Vomiting * Unintentional weight loss * Significant GI bleeding (usually appears dark red in stools) * Iron deficient Anaemia * Suspicious Barium meal * Epigastric mass * Signs of heartburn/GORD in those who are on bisphosphonates - This is often a sign that they are not taking the bisphosphonate correctly

Answer 76

Symptoms: * Abdominal pain * Usually 1-3 hours after a meal * Relieved by food or antacids Treatment: Full tabled outline in BNF 72 Page 65 * Infection confirmed before eradication treatment * Triple therapy – PPI and two antibacterial (H2 used if PPI untolerated) * No Penicillin allergy; o 1st line, 7 days – PPI, amox, either clarithromycin or metronidazole o 2nd line, 7 days – PP1, amox, other of two above o Alt 2nd line, 7 days – PPI, amox, tetracy or levofloxacin o 3rd line – Specialist * Penicillin Allergy – same as above, omit amox and use both clarithro and metra Referral: * Specialist referral after positive infection following 2nd line therapy

Answer 77

Symptoms: * Abdominal pain * Usually 1-3 hours after a meal * Relieved by food or antacids Treatment: * Full dose PPI 4-8 weeks * Do carbon 13 urea breath test to test for H. Pylori * If positive finish 8 week use of PPI, then follow H. Pylori treatment Management: * Stop NSAID being used if possible * Switch to NSAID with lowest GI side effects such as ibuprofen * Or switch to a Cox-2 inhibitor * Provide gastro protection with a PPI long term post treatment * This is essential in the elderly (over 65)

Answer 78

Symptoms: * Abdominal pain * Bloated * Constipation or Diarrhoea (straining urgency or incomplete evacuation) * Passage of mucus Causes: * Female Management: * If constipation is an issue, then increased dietary fibre intake * Ensure hydration levels (8 cups), reduce fizzy or caffeine intake * Increase should be gradual and benefits may be seen in first few days but can take up to a few weeks to be seen properly * Fruit and veg portion should be increased to 5 a day but limit fresh fruit to 3 portion * Oats and Linseeds can ease bloating * Soluble fibre is good for both diarrhoea and constipation * For diarrhoea encourage adequate hydration Treatment: Antispasmodics (prevent muscle spasm) * Mebeverine * Peppermint oil * Alverine Citrate * Hyoscine Pain * Paracetamol or Ibuprofen Constipation * Bulk forming e.g. ispaghula husk (fybogel), methylcellulose * Macrogol is the only osmotic laxative that can be used * Short term stimulant laxative use e.g. Senna, bisacodyl * NEVER USE LACTULOSE as cause bloating Diarrhoea * Loperamide Second line if unresponsive: * Low dose tricyclic antidepressant * If uresponsive, SSRI considered Red Flags: * Children * Older person with no previous history of IBS * Pregnant women * Blood in stools * Unexplained weight loss * Caution in patients aged over 55 years with changed bowel habit * Symptoms/signs of bowel obstruction * Unresponsive to treatment in 1 WEEK

unit 6 Flashcards

condition (131 cards)