W20 Gastrointestinal Flashcards
(40 cards)
Mouth ulcers - Questions to ask
Is the ulceration painful?
How many ulcers do you have?
How long have you had the ulcers?
What sites in your mouth are affected?
Do you have any concurrenct signs or symptoms?
Have you recently started any new medicines?
Have you had a similar episode of ulceration previously?
- If so, how long did the ulcers take to heal?
- Are you aware of any factors that predispose to your ulcers?
Describe Mouth ulcers (traumatic)
Usually a single, irregularly-shaped ulcer
*Patient can often recall the cause
- Burn – hot/cold/chemical
- Biting lining of mouth
- Sharp surface of tooth/denture
Mouth ulcers – recurrent aphthous stomatitis
- Common – affects c.20% of population
- Classified as:
- Aphthous, minor (about 80% of cases)
- Often in groups of up to five
- Small ulcers (<1cm)
- “uncomfortable”
- Heal within 10-14 days
- Aphthous, major (about 10% of cases)
- Usually 1-3 ulcers
- Larger than 1cm
- Painful and may affect eating
- Can take weeks to heal
- Herpetiform (about 10% of cases)
- Groups of 10-50 small ulcers
- Very painful
- Heal within 10-14 days
What are the causes of mouth ulcers?(3)
*Usually unknown, but may sometimes be:
*Iron deficiency/ anaemia
=Vegetarian/vegan diet often implicated
=Heavy menstrual loss
*Hypersensitivity
=Preservatives in food (benzoic acid/benzoates)
=Foods (chocolate, tomatoes)
=Sodium lauryl sulfate
*Psychological stress
How are mouth ulcers treated? (4)
- Saline
* Half a teaspoon of salt in a glass of warm water
* Rinse frequently until ulcers subside
* Any age - Antiseptic (chlorhexidine)
* Rinse (or spray) twice a day
* Not within 30 minutes of toothpaste
* Can cause temporary yellow staining of teeth
* Can be used OTC from age 12 - Anti-inflammatory (benzydamine)
* Use every 1.5-3 hours
* Can be used OTC from age 6 - Steroid (hydrocortisone)
* One tablet dissolved on ulcer four times a day
* Can be used OTC from age 12
When should you refer patients with mouth ulcers? (6)
*Lasts longer than 3 weeks
*Keeps coming back
*Painless and persistent
*Grows bigger than usual
*At back of throat
*Bleeds or gets red and painful
Examples of OTC treatments for ulcers
Anbesol
Bonjela
Mouth ulcer Pastilles
Frador
Alloclair (plus)
What is dyspepsia?
What are the symptoms?(4)
- A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks
Symptoms:
* Severity varies from patient to patient (most: mild + intermittent)
* Upper abdominal pain or discomfort
* Burning sensation starting in stomach, passing upwards to behind the breastbone
* Gastric acid reflux
* Nausea or vomiting
What are the common causes of Dyspepsia?
*Gastro-oesophageal reflux disease (GORD)
*Peptic ulcer disease (gastric or duodenal ulcers)
*Functional dyspepsia
- Epigastric Pain Syndrome
- Post-prandial distress syndrome (fullness and early satiety)
*Barrett’s oesophagus
- A premalignant condition
*Upper GI malignancy
What is Gastric-oesophageal reflux disease (GORD)?
- Transient relaxation of lower oesophageal sphincter
- Increased intra-gastric pressure
- Delayed gastric emptying
- Impaired oesophageal clearance of acid
What are the risk factors of GORD?
- Smoking
- Alcohol
- Coffee
- Chocolate
- Fatty foods
- Being overweight
- Stress
- Medicines (calcium channel blockers, nitrates, NSAIDs)
- Tight clothing
- Pregnancy
What is Peptic Ulcer Disease (PUD)?
What are the Causes? (3)
How can you confirm this disease?
Ulcers may be present in stomach or duodenum
Causes:
* Helicobacter pylori infection
* Medication, mainly NSAIDs (others can cause them)
* Zollinger-Ellison syndrome (rare condition causing high acid secretion)
- Can only confirm ulcers with endoscopy
- H. pylori infection managed with eradication therapy (2 antibiotics and a PPI)
- Therefore wouldn’t be managed OTC
- However, patients frequently present asking for symptomatic relief
How can you manage dyspepsia?
*Most patients have mild or intermittent symptoms which may be
managed through non-pharmacological means and OTC treatments
Options
*Non-pharmacological
*Antacids
*Alginates
*H2 receptor antagonists
*Proton pump inhibitors
How can you manage dyspepsia?
*Most patients have mild or intermittent symptoms which may be
managed through non-pharmacological means and OTC treatments
Options
*Non-pharmacological
*Antacids
*Alginates
*H2 receptor antagonists
*Proton pump inhibitors
Dyspepsia – non-pharmacological treatment pathways
*Lose weight if overweight
*Eating small, frequent meals rather than large meals
*Eat several hours before bedtime
*Cut down on tea/coffee/cola/alcohol
*Avoid triggers, e.g. rich/spicy/fatty foods
*If symptoms worse when lying down, raise head of bed (do not prop up head with pillows)
*Avoid tight waistbands and belts, or tight clothing
*Stop smoking
Dyspepsia -
What are antacids?
Examples?
Antacid: Compounds that neutralise stomach acid
Examples: sodium bicarbonate, calcium carbonate, magnesium hydroxide
Pepto-Bismol®, Rennie®
What is Alginate?
Example?
Alginate: Form a ‘raft’ on top of stomach contents, creating a physical barrier to prevent reflux
* Example: sodium alginate
* Usually contain sodium bicarbonate to help ‘raft’ to float to top of stomach
Gaviscon Advance®
Dyspepsia – H2 receptor antagonists
Ranitidine and famotidine available OTC
*Longer duration of action and longer onset of action than antacids
*Block H2 receptors in stomach to prevent acid production
*For the short-term symptomatic relief of dyspepsia
*Also to prevent symptoms arising if associated with food or drink
consumption when they cause sleep disturbances
Dyspepsia – proton pump inhibitors
*PPIs block proton pumps in stomach wall to prevent gastric acid
production
*Takes 1-4 days to work fully, so may need to cover with antacids until
it kicks in
*Esomeprazole:
*Common s/e: GI disturbances, headache, abdo pain
*Can increase risk of GI infections such as Campylobacter
When to refer a patient with symptoms of Dyspepsia:
Red flags?
*Beware of patients frequently attending for dyspepsia remedies
*Dyspepsia remedies may mask signs of gastric cancer
Red flag signs:
*55 years or over, especially with new onset
*Dyspepsia hasn’t responded to treatment
*Features including bleeding, dysphagia, recurrent vomiting or
unintentional weight loss
Nausea and vomiting
*Many possible causes – careful questioning needed to establish
possible cause
*Once vomiting established, little OTC will help
*Age: very young and old most at risk of dehydration
*Pregnancy: n&v common, consider in women of childbearing
potential
*Duration: adults >2 days cause for concern, young children (<2 years) any duration
- Associated symptoms:
- ?diarrhoea – may be gastroenteritis, question about food intake, could be rotavirus in children
- ?blood in vomit – differentiate fresh blood from that of gastric/duodenal origin
- ?faecal smell – GI tract obstruction
- Medication: opioids, NSAIDs/aspirin, antibiotics, oestrogens, steroids, digoxin, lithium, etc.
- Management: most established vomiting will require referral
- Motion sickness covered in ENT lecture
Constipation
- Prevalence of around 8.2% of UK adults
- Sometimes difficult to define as need patient info on normal frequency for them
- However, constipation if:
- Bowel movement less than three times a week
- Difficult to pass stools
- hard, dehydrated stools
- Women and older people (esp. >70 yrs) more frequently affected
Constipation:
Symptoms
Red flag symptoms
- Abdominal discomfort
- cramping
- bloating
- nausea
- straining
Red flag symptoms (refer)* unexplained weight loss
* rectal bleeding
* family history of colon cancer or inflammatory bowel disease
* signs of obstruction
* co-existing diarrhoea
* long-term laxative use
* failed OTC > 1 week
Medication that can cause constipation
- Opioid analgesics
- Antacids – aluminium
- Antimuscarinics (anticholinergics)
- Anti-epileptics
- Anti-depressants
- Anti-histamines
- Anti-psychotics
- Parkinson’s medication
- Calcium-channel blockers
- Calcium supplements
- Diuretics
- Iron
- Laxatives (!)
