W11 Further GI Conditions

Question 1

What is Diarrhoea a result of? (4)

Answer 1

Drug
Acute symptom of a chronic GI disorder e.g. IBD or IBS
Can be a red flag symptom so investigate to identify or exclude any serious underlying cause

Question 2

What is Diarrhoea?
How long does acute diarrhoea last?
How long does it take for symptoms to usually improve?

Answer 2

Abnormal passing of loose or liquid stools with increased frequency or volume or both.
2-4 days
<14 days

Question 3

What are the aims of treatment of diarrhoea?
What age groups is this important in?

Answer 3

• Prevention or reversal of fluid and electrolyte depletion and the management of dehydration when it is present.
• This is particularly important in infants, frail and elderly patients, when excessive water and electrolyte loss and dehydration can be life-threatening.

Question 4

Treatment of diarrhoea? (4)

Answer 4

• ORT (oral rehydration therapy) e.g. KCl with NaCl
• Refer to hospital if dehydration is severe.
• The antimotility drug loperamide HCl is the standard treatment when rapid control of symptoms is required. It can also be used for travellers’ diarrhoea.
• Codeine phosphate can be an alternative

Question 5

What is constipation?
What age groups is it common in? (3)
Which symptoms of new onset constipation could signal malignancy?

Answer 5

• Infrequent stools, difficult stool passage, or seemingly incomplete defecation.
• Occurs at any age
• Common in women, during pregnancy, and elderly.
• New onset constipation, especially in patients > 50 years of age, or accompanying symptoms such as anaemia, abdominal pain, weight loss, or blood in stools - risk of malignancy?
• Secondary constipation can be caused by a drug - Review

Question 6

How is constipation treated? (non-pharmacological)

Answer 6

• An increase in dietary fibre, adequate fluid intake and exercise is advised.
• Diet should be balanced and contain whole grains, fruits and vegetables.
• Fibre intake should be increased gradually (to minimise flatulence and bloating).
• The effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks.
• Adequate fluid intake can be difficult for some people (e.g. frail or elderly).
• Fruits high in fibre and sorbitol, and fruit juices high in sorbitol, can help prevent and treat constipation.
• Laxative abuse may lead to hypokalaemia

Question 7

Constipation:
Bulk-forming laxatives:
What are some examples?(4)
Which types of stool on Bristol stool chart are they aimed at?
Onset of action?
What symptoms may be exacerbated? (3)
Which patients should they not be used for?

Answer 7

• Include bran, ispaghula husk, methylcellulose and sterculia.
• They are of particular value in adults with small hard stools (type 1 on bristol stool chart)
• Onset of action is up to 72 hours
• Symptoms of flatulence, bloating, and cramping may be exacerbated.
• Adequate fluid intake must be maintained to avoid intestinal obstruction.
• Methylcellulose also acts as a faecal softener

Avoid in patients who haven’t been to the toilet for long durations as onset=72hrs and further complications can occur.

Question 8

Constipation:
Stimulant laxatives:
What are some examples?(3)
Function? What SE can they cause?
Use of co-danthramer is limited in which patients?
Docusate sodium 2 functions?
Glycerol suppositories 2 functions?

Answer 8

• Include bisacodyl, sodium picosulfate, and senna.
• Increase intestinal motility and often cause abdominal cramp.
• The use of co-danthramer and co-danthrusate is limited to constipation in terminally ill patients because of potential carcinogenicityand genotoxicity.
• Docusate sodium may act as both a stimulant and a faecal softener.
• Glycerol suppositories act as a lubricant and as a rectal stimulant

Question 9

Constipation:
Faecal softeners:
What are some examples?

Answer 9

• Act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass.
• Docusate sodium and glycerol suppositories have softening properties.
• Enemas containing arachis oil (ground-nut oil, peanut oil) lubricate and soften impacted faeces and promote a bowel movement.
• Liquid paraffin has also been used as a lubricant. Its adverse effects include anal seepage

Question 10

Constipation:
Osmotic laxatives:
What are some examples?

Answer 10

• Increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.
• Lactulose is a semi-synthetic disaccharide which is NOT absorbed from the GIT.
• It produces an osmotic diarrhoea of low faecal pH, and discourages the proliferation of ammonia-producing organisms. It is therefore useful in the treatment of hepatic encephalopathy.
• Macrogols are inert polymers of ethylene glycol which sequester fluid in the bowel; giving fluid with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives.

Question 11

Short duration Constipation:
What is the pathway of treatment? (4)

Answer 11

Where dietary measures are ineffective:
1. Dietary changes first- inc fibre, fluid
2. Start with a bulk-forming laxative, ensuring adequate fluid intake.
3. If stools remain hard, add or switch to an osmotic laxative.
4. If stools are soft but difficult to pass/inadequate emptying, a stimulant laxative should be added.

(Ask pt baseline- how often do they usually have a bowel movement?)

Question 12

Chronic Constipation
What is the pathway of treatment?

Answer 12

1. Start with a bulk-forming laxative, whilst ensuring good hydration.
2. If stools remain hard, add or change to an osmotic laxative e.g. a macrogol. Lactulose is an alternative if macrogols are not effective, or not tolerated.
   * If the response is inadequate, a stimulant laxative can be added.
   * The dose of laxative should be adjusted gradually to produce one or two soft, formed stools per day.
   * If at least two laxatives (from different classes) have been tried at the MDD for at least 6 months, the use of prucalopride (in women only) should be considered (review** after 4 weeks).

MDD- max daily dose

Question 13

Constipation in pregnancy:
What is the treatment pathway? (6)
What is first line?

Answer 13

1. Diet
2. Fibre supplements in the form of bran or wheat
3. A bulk-forming laxative is the first choice during pregnancy if fibre supplements fail.
4. An osmotic laxative, such as lactulose, can also be used.
5. Bisacodyl or senna may be suitable if a stimulant effect is necessary but use of senna should be avoided near term or if there is a history of unstable pregnancy.
6. Docusate sodium and glycerol suppositories can also be used
   (BOS)

Question 14

Constipation in breastfeeding:
What is the treatment pathway? (6)
What is first line?

Answer 14

• A bulk-forming laxative is the first choice, if dietary measures fail.
• Lactulose or a macrogol may be used if stools remain hard.
• As an alternative, a short course of a stimulant laxative such as bisacodyl or senna
  can be considered
  (BOS= Bulk, Osmotic, Stimulant laxative)

Question 15

Constipation in Children:
What is first-line treatment?

Answer 15

• Early identification – risk of anal fissure and become chronic.
• The first-line treatment requires the use of:
  a laxative + dietary modification + behavioural interventions
• Diet modification alone is NOT recommended as first-line treatment.
• In children, an increase in dietary fibre, adequate fluid intake, and exercise is advised.
• Unprocessed bran (which may cause bloating and flatulence and reduces the
  absorption of micronutrients) is NOT recommended.
• Laxatives should be administered at a time that produces an effect that is likely to fit in
  with the child’s toilet routine

Question 16

Billary Disorders (bile):
What are the 2 types?

Answer 16

Cholestasis* and Gallstones

*the slowing or stalling of bile flow through your biliary system.

Question 17

What is the description of Cholestasis?
Symptoms?

Answer 17

Impairment of bile formation and/or bile flow, which may clinically present with fatigue, pruritus, dark urine, pale stools,
jaundice and signs of fat-soluble vitamin deficiencies.

Pruritis= Common irritation of the skin

Question 18

How can Cholestatic Pruritus be treated?

Answer 18

• Colestyramine is the drug of choice.
• It is an anion-exchange resin that is NOT
  absorbed from the GIT.
• It relieves pruritus by forming an insoluble
  complex in the intestine with bile acids
• The reduction of serum bile acid levels
  reduces excess deposition in the dermal
  tissue with a resultant decrease in pruritus.

Question 19

What is the description of Gallstones?

Answer 19

Gallstones occur when hard mineral or fatty deposits form in the gallbladder.
* Gallstone disease = presence of one or more stones in the gallbladder.
* Usually asymptomatic.
* When the stones irritate the gallbladder or block part of the biliary system, the patient can experience symptoms such as pain, or infection and inflammation that if left untreated, can lead to severe complications such as biliary colic, acute cholecystitis, pancreatitis, and obstructive jaundice.

Question 20

What is the non-drug treatment for gallstones?

Answer 20

• Asymptomatic gallbladder stones do not need to be treated.
• The definitive treatment of symptomatic gallstones (and all bile duct stones) is surgical removal by laparoscopic cholecystectomy.

Question 21

What is the drug treatment for gallstones? (3)

Answer 21

• Analgesia to control pain: paracetamol or NSAID for intermittent mild-to-moderate pain.
• Intramuscular (IM) diclofenac sodium (NSAID) can be given for severe pain
• If not suitable, give an IM opioid (such as morphine)

Question 22

What health problems link to obesity?

Answer 22

• Obesity is directly linked to many health problems e.g. CVD, DM2, fatty liver disease, gallstones, and GORD.
• It is also linked to psychological and psychiatric morbidities
• BMI>30= Obese
• BMI>25=overweight

Question 23

Obesity:
What are the BMI ranges?
Men and women with what waist circumference are at risk of obesity?

Answer 23

• Obesity = BMI of ≥ 30 kg/m2, though BMI should be interpreted with caution as it is not a direct measure of adiposity, particularly in patients who are very muscular or have muscle weakness or atrophy.
• Waist circumference should also be considered as it may provide an indication of total body fat.
• Men with a waist circumference ≥ 94cm (≥ 90 cm for Asian men), and women with a waist circumference of ≥ 80 cm are at increased risk of obesity-related health problems.
• A waist circumference of ≥ 102 cm in men and ≥ 88 cm in women indicates a very high risk of obesity-related health problems.

Question 24

What are the aims of treatment in obesity?

Answer 24

Aim at modest, sustainable weight loss and maintenance of a healthy weight, to reduce the risk factors associated with obesity.

Question 25

How is obesity monitored?

Answer 25

* Monitor **changes** in weight * Monitor changes in BP and blood lipids, and associated conditions. * Assess potential **underlying causes** (e.g. hypothyroidism) * Review the appropriateness of **current medications** which are known to cause **weight gain** e.g. atypical antipsychotics, some antidepressants, β-blockers and insulin.

Question 26

What are the lifestyle changes in obesity management?

Answer 26

* Change behaviour * Increase physical activity * Improve diet * Improve eating behaviour

Question 27

Drug Treatment in obesity for info

Answer 27

* Drug treatment should never be used as the sole element of treatment. * Drug treatment should be used as part of an overall weight management plan. * An anti-obesity drug should be considered only for those with a BMI of **≥ 30 kg/m2** in whom diet, exercise and behaviour changes fail to achieve a realistic reduction in weight. * In the **presence of associated risk factors**, it may be appropriate to prescribe an anti-obesity drug to individuals with a **BMI of ≥ 28 kg/m2**. * A vitamin and mineral supplement may also be considered if there is concern about inadequate micronutrient intake, particularly for vulnerable groups such as in the elderly and younger patients. * The effect of management should be **monitored** on a regular basis with reinforcement of supporting lifestyle advice. * **Rates** of weight loss may be **slower** in patients with DM2, so less strict goals than in those without diabetes may be appropriate.

Question 28

What is the drug treatment for obesity? How does it work? When should it be stopped?

Answer 28

* Orlistat, is the only drug currently available in the UK; it acts by reducing the absorption of dietary fat. * Orlistat is licensed for use as an **adjunct** in the management of obesity in patients with a BMI of ≥ 30 kg/m2, or, in individuals with a BMI of ≥ 28 kg/m2 in the presence of other risk factors. * Treatment with orlistat may also be used to maintain weight loss rather than to continue to lose weight. * Discontinuation of treatment with orlistat should be considered after **12 weeks** if weight loss has not exceeded **5%** since the start of treatment

Question 29

What are examples of rectal and anal disorders? (3)

Answer 29

1. Anal fissure 2. Haemorerhoids 3. Reduced exocrine secretions

Question 30

What is anal fissure? Clinical features?

Answer 30

* An anal fissure is a tear or ulcer in the lining of the anal canal, immediately within the anal margin. * Clinical features include bleeding and persistent pain on defecation, and a linear split in the anal mucosa.

Question 31

What is the aim of treatment of anal fissure? What is the drug treatment for acute anal fissure? (3)

Answer 31

- Relieve pain and promote healing of the fissure * Initial management of acute anal fissures (**<6 weeks**) should focus on ensuring that stools are soft and easily passed. * **Bulk-forming laxatives** (such as ispaghula husk) are recommended * An **osmotic laxative** (such as lactulose) can be used as an alternative * Short-term use of a topical preparation containing a **local anaesthetic** (e.g.lidocaine) or a simple analgesic (e.g. paracetamol or ibuprofen) may be offered for prolonged burning pain following defecation.

Question 32

What is the drug treatment for Chronic anal fissure? (2) Non-drug treatment?

Answer 32

* Chronic anal fissures **(>6 weeks)**, and associated pain, may be treated with **GTN** rectal ointment 0.4% or 0.2% [unlicensed]. * Alternatives: **topical** diltiazem hydrochloride 2% [unlicensed] or nifedipine 0.2-0.5% [unlicensed]. * Oral nifedipine [unlicensed indication] and oral diltiazem hydrochloride [unlicensed indication] may be as effective as topical treatment, but the incidence of ADRs are higher than topical preparations. NDT= Surgery

Question 33

What is the Description of Haemorrhoids?

Answer 33

* Haemorrhoids, or piles, are abnormal swellings of the vascular mucosal anal cushions around the anus. * Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated. * External haemorrhoids originate below the dentate line and can be itchy or painful. * Women are predisposed to developing haemorrhoids during pregnancy

Question 34

What are the aims of treatment of haemorrhoids?

Answer 34

Reduce the symptoms (pain, bleeding and swelling), promote healing, and prevent recurrence.

Question 35

What is the non-drug treatment for haemorrhoids?

Answer 35

* Stools should be kept soft and easy to pass (to minimise straining) by increasing dietary fibre and fluid intake. * Advice about perianal hygiene is helpful to aid healing and reduce irritation and itching

Question 36

What is the drug treatment for haemorrhoids?

Answer 36

* Constipation: give bulk-forming laxative. * Pain: give a simple analgesic such as paracetamol . * Opioid analgesics should be avoided as they can cause constipation. * NSAIDs should be avoided if rectal bleeding is present. * Topical preparations that contain a combination of local anaesthetics e.g. lidocaine, corticosteroids, astringents, lubricants, and antiseptics can be used. * **Topical corticosteroids** are suitable for occasional short-term use (no more than 7 days – risk of ulceration) after exclusion of infections (e.g. perianal thrush).

Question 36

What is an example of reduced exocrine secretions? What are the clinical manifestations of this? What are the aims of treatment? (2)

Answer 36

* Reduced secretion of pancreatic enzymes into the duodenum. * Clinical manifestations: maldigestion and malnutrition, associated with low circulating levels of micronutrients, fat-soluble vitamins and lipoproteins. Patients also present with GI symptoms such as diarrhoea, abdominal cramps and steatorrhoea-excessive amounts of fat in your stool. Relieve GI symptoms and achieve a normal nutritional status.

Question 37

What is the drug treatment for reduced exocrine secretions?

Answer 37

* Pancreatic enzyme replacement therapy with **pancreatin** is the mainstay of treatment. * Pancreatin contains the three main groups of digestive enzymes: lipase, amylase and protease. * These enzymes respectively digest fats, carbohydrates and proteins into their basic components so that they can be absorbed and utilised by the body. * Pancreatin should be administered with meals and snacks. * Avoid Hot (spicy) food!

Question 38

What is the non-drug treatment for reduced exocrine secretions?

Answer 38

* Dietary advice should be provided. * Food intake should be distributed between three main meals per day and two or three snacks. * Food that is difficult to digest should be avoided, such as legumes (peas, beans, lentils) and high-fibre foods. * Alcohol should be avoided completely. * Reduced fat diets are NOT recommended