1
Q
What does H. Pylori infection cause
A
Peptic ulcer disease (responsible for more than70%), acute/chronic gastritis, gastric cancer, MALT lymphoma
2
Q
What has an additive effect with H. pylori
A
NSAIDS
3
Q
When to test for H pylori`
A
- Those with dyspepsia that are unresponsive to lifestyle changes, antacids and following a one month treatment of PPI,
- those at high risk (north African, high risk areas, older people - can be tested in parallel with PPI course,
- history of peptic ulcers/bleeds,
- before initiating NSAIDS in those with history of peptic ulcers/bleeds,
- unexplained iron deficiency anaemia after malignancy(and other causes) excluded via endoscopy
4
Q
H pylori tests
A
- The urea (13C) breath test,
- Stool Helicobacter Antigen Test (SAT),
- or laboratory-based serology where its performance has been locally validated
5
Q
When/what h pylori tests should not be done in certain circumstances
A
Urea/SAT within 2 weeks of PPI or 4 weeks of Abx due to false negatives
6
Q
When should h pylori retesting be done
A
Retesting should be performed at least 4 weeks (ideally 8 weeks) after treatment.
7
Q
What instances require a H pylori retest
A
Severe persistent treatment not consistent with GORD, taking aspirin without PPI, peptic ulcer/MALT/resection of gastric carcinoma, high local resistance rates, if first test was done incorrectly like within 2 weeks of PPI etc.
8
Q
H pylori treatment
A
Triple therapy, one PPI Two Abx
9
Q
What Abx courses increase risks of resistance
A
Clarithromycin, metronidazole, or quinolone
10
Q
What bacteria is associated with diarrhoea
A
C diff
11
Q
First/second line treatment if no penicillin allergy h pylori
A
PPI+ amoxicillin + clari/metro (second line = same but use which ever one of clari/metro not used) all for 7 days
12
Q
Alternative second line if no penicillin allergy h pylori
A
PPI+ amoxicillin + tetracycline/levofloxacin (used if clari and metro used)
13
Q
h pylori Third line if no penicillin allergy
A
PPI+bismuth + 2 other unused Abx or rifabutin or furazolidone
14
Q
Pen allergy first/alt first line h pylori treatment
A
PPI+Clari+metro, alt= PPI+ bismuth+ metro + tetracycline (if clari used first line)
15
Q
Penicilin allergy second line h pylori
A
7 days of PPI+ metro+levofloxacin or PPI+ Bismuth+metro+tetra
16
Q
H pylori Third line penicillin allergy
A
PPI+ bismuth+rifabutin/furazolidone
17
Q
Two main types of antispasmodics
A
Antimuscarinics and smooth muscle relaxants
18
Q
Examples of antimuscarinics
A
Atropine, dicycloverine, propantheline, hyoscine
19
Q
Examples of smooth muscle relaxants
A
Alverine citrate, mebeverine, peppermint oil
20
Q
Antimuscarinic GI MOA
A
Reduce intestinal motility and are used for GI smooth muscle spasm
21
Q
What antimuscarinics are less likely to cross the BBB
A
Quaternary ammonium compounds = propantheline, hyoscine butylbromide meaning less CNS side effects
22
Q
What antimuscarinics are less well absorbed from GI tract
A
Quaternary ammonium compounds = propantheline, hyoscine butylbromide
23
Q
Constipation is
A
Infrequent stools, difficult stool passage, or seemingly incomplete defaecation.
24
Q
When is urgent investigation needed for constipation
A
New onset constipation in over 50s / accompanying symptoms like anaemia, abdominal pain, weight loss, overt/occult blood in stool due to risk of malignancy/serious bowl disorder
25
Lifestyle advice for constipation
Increase dietary fibre, adequate fluid intake and exercise advised,, balanced diet, fruits/juice high in sorbitol
26
Why and how should fibre be given
Fibre intake should be increased gradually (to minimise flatulence and bloating). Effects of a high-fibre diet may be seen in a few days although it can take as long as 4 weeks.
27
Key downside to laxative
Hypokalaemia
28
Types of laxative
Bulk forming
Stimulant
Faecal softeners
osmotic
29
Other drugs used in constipation
Linaclotide, prucalopride
30
Bulk forming examples
Methylcellulose, ispaghula husk and sterculia Methylcellulose also acts as a faecal softener.
31
Bulk forming side effects
Exacerbation of flatulence, bloating , cramping
32
When is it best to use bulk forming
Small hard stools if fibre cannot be increased in the diet
33
Onset of bulk forming
72 hours
34
Stimulant laxatives
Bisacodyl, sodium picosulfate, and senna, co-danthramer and co-danthrusate, docusate a stimulant and softener, glycerol a stimulant and lubricant
35
Stimulant laxative MOA
Increase intestinal motility
36
Stimulant side effects
Abdominal cramp
37
When to avoid stimulant
Intestinal obstruction
38
What stimulants are only limited to terminally ill
Co-danthramer, co-fanthrusate
39
Faecal softeners
Docusate, glycerol, arachis oil
40
Faecal softener mechanism of action
Decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass
41
Arachis oil use and ingredients
Ground nut and peanut oil, lubricant, softener and promoter of bowel movement
42
Liquid paraffin use and downfall
Lubricant but caution as it can result in anal seepage and granulomatous disease of GI tract. Liquid pneumonia on aspiration
43
Osmotic laxatives
Lactulose macrogol
44
Osmotic MOA
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.
45
What else can lactulose be used for
Hepatic encephalopathy
46
How to reduce dehydrating effect of osmotic
Fluids
47
Linaclotide indication
IBS associated with constipation
48
Prucalopride indication
Chronic constipation when other options fail
49
Short duration treatment
Bulk forming, ensure adequate fluid then add/switch to osmotic if needed because of hard stools, switch to stimulant if stool soft but hard to pass/ inadequate emptying
50
What to do in opioid induced constipation
Osmotic laxative/docusate and stimulant or naloxegol if other laxatives not effective, methylnaltrexone can also be used
51
What laxative should be avoided in opioid induced constipation
Bulk forming
52
What to do if unresponsive to faecal impaction treatment
Arachis oil or sodium acid phosphate with sodium phosphate sodium, may need to be repeated several times
53
Treating chronic constipation
1. Bulk forming+ water
2. If still hard add/change to osmotic laxative( macrogol then lactulose)
3. If ineffective add stimulant
54
Aim of chronic constipation treatment
Adjust until producing one/two soft stools a day
55
When to use prucalopride in chronic constipation
Only in women that have tried at least two laxatives at highest tolerable dose for at least six months, re-examine if not effective after 4 weeks
56
First choice laxative in breast feeding
Bulk forming if diet changes fail osmotic used or short course stimulant
57
What laxative should not be used in pregnancy
Senna
58
General pregnancy constipation advise
Lifestyle, fibre supplements (bran/wheat), they have no side effects on mother or fetus
59
Treating constipation in pregnancy
Bulk forming first line then osmotic if necessary then bisacodyl senna should definitely be avoided near term and if unstable pregnancy (stimulants more likely to cause side effects. Docusate/glycerol suppositories can be used
60
First line constipation treatment in children
Laxative and diet modification (diet modification alone is not recommended as first line)
61
What dietary suggestions is not recommended for children
Unprocessed bran may cause bloating and flatulence and reduces absorption of micronutrients
62
First line pharmacological treatment of constipation in children
Macrogol if inadequate/not tolerated then stimulant
63
What to do if stools remain hard after treatment in children for constipation
Lactulose or a softener like docusate
64
How to stop constipation treatment in children
Continue several weeks after regular pattern then taper gradually over months based on response
65
In adults what laxative should be stopped first
Stimulant but may need to adapt osmotic dose
66
How to stop laxative in adults
Wait till regular without difficulty then reduce and stop one laxative at a time
67
Treating faecal impaction in > 1 yo in children
Macrogol if disimpaction does not occur after 2 weeks then stimulant added but if stools hard used in combination with an osmotic laxative .
68
Who is cholera vaccine licensed for
Adults and children from 2YO travelling to endemic/epidemic areas
69
When should cholera vaccine be given
At least one week before potential exposure
70
Aim of short bowel syndrome management
Ensuring adequate nutrition and drug absorption reducing risk of complications
71
What deficiencies may arise due to short bowel
Deficiencies in vitamins A, B12, D, E, and K, essential fatty acids, zinc, and selenium - hypomagnesaemia
72
Hypomagnasaemia treatment
Oral/iv magnesium supplementation but may cause diarrhoea
73
Treating diarrhoea/high output stoma
```
Oral rehydration salts
Antimotility drugs like loperamide at high unlicensed doses, co-phenotrope
Colestyramine
Antisecretory drugs(PPI/Octreotide)
Growth factors
```
74
Colestyramine action
Bind unabsorbed bile salts and reduce diarrhoea
75
What do you monitor when giving colestyramine
Fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies
76
Octreotide is/does
Antisecretory drug, reduces
| ileostomy diarrhoea and large volume jejunostomy output by inhibiting multiple pro-secretory substances.
77
Most important part of intestine for drug absorption and why
Small intestine, its large surface area and high blood flow
78
What preparations can’t be used in short bowel
Enteric/ modified release especially in ileostomy
79
What preparations are preferred in short bowel
Soluble tablets for quick dissolution, uncoated tablets, liquid formulations
80
What alters absorption in SBS
Length of intestine left and which section removed
81
What to consider before prescribing liquids in SBS
Osmolarity, excipient content and volume required as Hyperosmolar liquids and some excipients (such as sorbitol) can result in fluid loss.
82
What is coeliac
Autoimmune condition which is associated with chronic inflammation of the small intestine
83
Gluten role
A dietary protein found in wheat barley rye activate abnormal immune response leafing to malabsorption of nutrients
84
Aim of coeliac management
Eliminate symptoms and reduce risk of complications like malabsorption
85
Coeliac symptoms
Diarrhoea, bloating and abdominal pain
86
Coeliac treatment
Strict, life-long, gluten-free diet
87
Stoma is
Artificial opening on the abdomen to divert flow of faeces or urine into an external pouch located outside of the body
88
What preparations are unsuitable with stomas
Modified, enteric, sorbitol excipient (laxative side effects)
89
What to look for when NSAID used with stoma
Gastric irritation and bleeding; faecal output should be monitored for traces of blood
90
Considerations of antacids with stoma
Magnesium can cause diarrhoea, aluminium/calcium = increased constipation
91
Antacid ingredients and GI
Magnesium can cause diarrhoea, aluminium/calcium = increased constipation
92
Role of gastric secretion in stoma
Gastric secretion increases stoma output so antisecretory drugs like octreotide/lareotide used to reduce risk
93
Loperamide/codeine role in stoma
Reduce intestinal motility and decrease water and sodium output from an ileostomy
94
Loperamide effective mechanism of action
Circulates through the enterohepatic circulation, which is disrupted in patients with a short bowel;
95
Digoxin and stoma
Susceptible to hypokalaemia due to fluid and sodium depletion, can consider potassium supplement and potassium sparing diuretic
96
Laxatives and stoma
Ideally should not be used use bulk firming if needed if not then low dose stimulant, try diet and fluid intake first
97
What is sucralfate
A complex of aluminium hydroxide and sulfated sucrose but has minimal antacid properties
98
Role of sucralfate
Protecting the mucosa from acid-pepsin attack in gastric and duodenal ulcers.
99
Sucralfate indication
Benign gastric ulceration, Benign duodenal ulceration, Chronic gastritis, Prophylaxis of stress ulceration,
100
What is crohn's
Chronic, inflammatory bowel disease that mainly affects the gastro-intestinal tract.
101
Crohn's characterisation
Thickened areas of the GI wall, inflammation, deep ulceration/fissuring of mucosa, granulomas in any part of GI tract
102
Crohn's symptoms
Adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in childrens
103
Crohn's complications
Adjacent structures, fistulae, anaemia, malnutrition, colorectal and small bowel cancers, and growth failure and delayed puberty in children
104
Aim of Crohn's treatment
Induce/maintain remission
105
Non drug crohn's treatment
Smoking cessation, nutrition, surgery , closing fistula
106
Treating acute crohns
Corticosteroid (pred/methylpred/IV hydro) to induce remission, budesonide if not then aminosalicylates (sulfasalazine/mesalazine) which have fewer side effects but is less effective than budesonide
107
Add on crohn's treatment
Azathioprine/mercaptopurine if ineffective the methotrexate
108
When can't you use azathioprine/mercaptopurine
Thiopurine methyltransferase TPMT activity deficient
109
What can't be used for maintaining remission
Corticosteroids and budesonide
110
What do you use in severe crohn's
TNF alpha inhibitors, adalimumab, infliximab if not the vedoluzumab/ustkinumab
111
What happens if no maintenance treatment on remission
Unintended weight loss, abdominal pain, diarrhoea and general ill-health
112
What is used to maintain remission
Azathiprine/mercaptopurine or methotrexate onlu in those who used it to induce remission
113
Maintaining remission following surgery
Azathioprine in combination with up to 3 months postop metronidazole (ileocolonic crohn's disease in those with macroscopic resection)
114
Treating diarrhoea in crohns
Loperamide/codeine in those without colitis and colestyramine
115
Why can’t metonidazole be given for more than 3 months
Peripheral neuropathy
116
Treating fistulae
Metronidazole(less than 3 months)/cipro combined or alone if not infliximab
Azathioprine, mercaptopurine, or infliximab should be continued as maintenance treatment for at least one year
117
What is ulcerative colitis
Chronic inflammatory condition
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
Diffuse mucosal inflammation, relapsing-remitting pattern
118
What is ulcerative colitis characterised by
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
119
When does ulcerative colitis commonly present
15-25 years
| ://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
120
What is inflammation of the rectum
Proctitis
121
What is inflammation of the rectum and sigmoid colon
Proctosigmoiditis
122
Common symptoms of active disease of UC
Bloody diarrhoea, urgent need to defecate, abdominal pain
123
Complications due to UC
Increased colorectal cancer, secondary osteoporosis, VTE, toxic megacolon
124
How is severity of UC classified
Truelove and Witts' Severity Index to assess bowel movements, heart rate, erythrocyte sedimentation rate and the presence of pyrexia, melaena or anaemia
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
125
Preparation used to treat distal inflammation
Rectal but systemic if inflammation is extended
126
UC treatment aims
Managing symptoms, inducing and maintaining remission
| https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
127
Types of rectal preparations
Enemas, suppositories
128
What anti-diarrhoeal drugs are contraindicated in UC and why
Loperamide and codeine as they increase risk of toxic megacolon
129
Treating proximal faecal loading in proctitis
Macrogol containing osmotic laxative
130
Pros and cons of single daily dose of aminosaliciylates
Can be more effective than multiple but may result in more side effects
https://bnf.nice.org.uk/treatment-summary/ulcerative-colitis.html
131
Duration of corticosteroid course in UC
4-8 weeks , depends on corticosteroid used
132
Proctitis treatment mild-moderate
Topical aminosalicylate first-line treatment, if remission is not achieved within 4 weeks, adding an oral aminosalicylate. If response remains inadequate, consider topical or an oral corticosteroid for 4 to 8 weeks.
133
Proctosigmoiditis/left sided UC mild-moderate
Topical aminosalicylate first-line treatment, if remission is not achieved within 4 weeks, adding a high dose oral aminosalicylate.
Switching to a high-dose oral aminosalicylate and 4 to 8 weeks of a topical corticosteroid. If response remains inadequate, stop topical and offer an oral corticosteroid for 4 to 8 weeks
134
Extensive UC treatment - mild-moderate
A topical aminosalicylate and a high-dose oral aminosalicylate are recommended as first-line treatment for patients. If remission is not achieved within 4 weeks, stop topical aminosalicylate treatment and offer a high-dose oral aminosalicylate and 4 to 8 weeks of an oral corticosteroid.
135
Treating moderate-severe UC
Treating adalimumab, golimumab, infliximab, vedolizumab
136
Treating acute severe UC
IV corticosteroids, if not then ciclosporin
137
Second line acute severe UC treatment
IV corticosteroid + ciclosporin or surgery if ineffective within 72 hours of IV corticosteroids, infliximab used if ciclosporin not possible
138
Maintaining remission
Aminosalicylate, but azathioprine and mercaptopurine can be considered, no evidence for MTC but often used
139
PPI indications
Short treatment for gastric and duodenal ulcers, prevention/treatment NSAID-associated ulcers, following peptic bleed, reduce bleeding (IV)
140
Why is PPI used in CF
Reduces degradation of enzyme supplements in patients with CF
https://bnf.nice.org.uk/treatment-summary/proton-pump-inhibitors.html
141
What is primary biliary cholangitis/cirrhosis
Chronic cholestatic disease which develops due to progressive destruction of small and intermediate bile ducts within the liver, subsequently evolving to fibrosis and cirrhosis.
142
Treating primary biliary cholangitis
Ursodeoxycholic acid
143
Where does dyspepsia occur
Upper GI
144
How long do dyspepsia symptoms last
4/more weeks
145
Dyspepsia symptoms
Upper abdominal pain or discomfort, heartburn, gastric reflux, bloating, nausea and/or vomiting
146
Underlying cause of dyspepsia symptoms
GORD/ peptic ulcer disease
147
Cause of dyspepsia in pregnant women
Most often GORD
148
Aim of dyspepsia treatment
Manage symptoms and treat underlying cause if possible
149
Lifestyle dyspepsia tips
Healthy eating, weight loss (if obese), avoiding any trigger foods, eating smaller meals, eating the evening meal 3–4 hours before going to bed, raising the head of the bed, stop smoking and reducing alcohol consumption
150
What conditions exacerbate dyspepsia
Stress anxiety depression
151
When is urgent endoscopy needed for dyspepsia
Acute GI bleeding/ in over 55s with unexplained weight loss, upper abdominal pain, reflux or dyspepsia
152
Drugs that cause dyspepsia
Alpha blocker, antimuscarinics, aspirin, benzodiazepines, beta blockers, bisphosphonates, CCB , corticosteroids, nitrates, NSAIDS, theophylline, TCA
153
Short term control of dyspepsia
Alpha blocker, antimuscarinics, aspirin, benzodiazepines, beta blockers, bisphosphonates, CCB , corticosteroids, nitrates, NSAIDS, theophylline, TCA
154
TREATING uninvestigated dyspepsia
PPI for 4 weeks
155
Short term control of dyspepsia
Antacids and/or alginates (not long term)
156
Treating functional dyspepsia
If no h pylori PPI/ Histamine2 receptor antagonist for 4 weeks
157
Dyspepsia and h pylori
Test for h pylori
158
Diverticulosis
Asymptomatic condition with holes in walls of intestine
159
Who is most likely to have diverticulosis
Aged 40 and over
160
Diverticular disease
When diverticula (holes) are present with symptoms
161
Diverticular symptoms
Abdominal tenderness and/or mild, intermittent lower abdominal pain with constipation, diarrhoea, or occasional large rectal bleeds
162
Acute diverticulitis
Diverticula become inflamed
163
Acute diverticulitis symptoms
Fever, sudden change in bowel habits, significant rectal bleeding, palpable abdominal mass, constant lower abdominal pain
164
Diverticular lifestyle tips
Balanced diet, constipation advice - gradually increase fibre
165
Diverticular disease treatment
Management of diarrhoea/constipation (high fibre diet/bulk forming), paracetamol for pain, opioid and NSAID not recommended
166
Why aren't opioids and NSAIDS used in diverticula treatment
May exacerbate diverticular perforation
167
Acute diverticulitis treatment
Paracetamol
168
What is acute diarrhoea
Abnormal passing of loose/liquid stools with increase frequency, volume / both for less than 14 days
169
Cause of diarrhoea
Infection, side effect, GI disorder like IBD/IBS
170
Aim of diarrhoea treatment
Reversal of fluid/electrolyte depletion
171
Antibacterial drugs for acute diarrhoea
Ciprofloxacin prophylactically against travellers diarrhoea
172
Sorting severe acute diarrhoea
IV rehydration fluid
173
How to treat faecal incontinence
Loperamide
174
Traveller’s diarrhoea treatment
Loperamide
175
When can’t you use loperamide
Significant abdominal pain (suggests inflammatory diarrhoea), bloody
176
Treating acute diarrhoea
Oral rehydration therapy
177
Cause of exocrine pancreatic insufficiency
Chronic pancreatitis, cystic fibrosis, constructive pancreatic tumours, coeliac
178
Clinical effect of exocrine pancreatic insufficiency
Maldigestion, malnutrition, low levels of micronutrients, fat soluble vitamins, lipoproteins
179
Exocrine pancreatic insufficiency treatment
Pancreatin
180
Physical manifestations of exocrine pancreatic insufficiency
Diarrhoea, abdominal cramps, Steatorrhoea
181
What food to avoid in exocrine pancreatic insufficiency
Legumes (peas, beans, lentils) and high-fibre foods. Alcohol should be avoided completely. Reduced fat diets are not recommended
182
What are haemorrhoids/piles
Abnormal swellings of the vascular mucosal anal cushions around the anus
183
Who is particularly predisposed to piles
Pregnant women
184
Lifestyle piles treatment
Soft stools by increasing dietary fibre/fluid intake
185
General piles pain treatment
Paracetamol not opioid
186
What do topical piles treatment typically contain
Local anaesthetics, corticosteroids, lubricants, antiseptics, astringents
187
What to avoid with topical local anaesthetics and why
Excessive application as it can cause irritation
188
Local topical anaesthetics
Lidocaine, benzocaine, cinchocaine, pramocaine
189
How long should topical corticosteroid be used for piles and why
7 days due to thinning of perianal skin and ulceration
190
Treating food induced anaphylaxis
Bulk forming laxative
191
Treating symptoms of food allergy
Chlorphenamine
192
Diet avoidance adjunct
Sodium cromoglicate - anti-allergic medicine which is prescribed to help prevent allergic reactions from occurring
193
H2 receptor antagonist indication /moa
gastric and duodenal ulcers by reducing gastric acid output as a result of histamine H2-receptor blockade; they are also used to relieve symptoms of GORD
194
Obese waist sizes
94cm men, 80cm women
195
Drugs that cause weight gain
Atypical antipsychotics, beta-adrenoceptor blocking drugs, insulin (when used in the treatment of type 2 diabetes), lithium carbonate, lithium citrate, sodium valproate, sulphonylureas, thiazolidinediones, and tricyclic antidepressants
196
When should drugs be considered for obesity
>30 BMI, >28 BMI is risk factors
197
What drug is used for obesity
Orlistat
198
When is bariatric surgery considered
>40 BMI
199
Gallstone drug treatment
Paracetamol/ NSAID for pain can give opioid if needed
200
Gallstone treatment
Leave if asymptomatic, or surgical removal
201
Result of excessive laxative use
Hypokalaemia
202
Cholethiases is
Gallstone other name
203
Drugs for GORD in pregnancy
Antacids/alginate if not then omeprazole/ranitidine
204
First line GORD treatment in pregnancy
Diet lifestyle
205
Refractory GORD treatment
Further PPI dose for a month, double PPI dose for a month or add H2 for nocturnal symptoms
206
Severe oesophagitis treatment
PPI 8 weeks
207
What to offer in confirmed GORD
4-8 weeks PPI if not then H2 receptor antagonist
208
What drugs exacerbate GORD
Alpha-blockers, anticholinergics, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), nitrates, theophyllines, and tricyclic antidepressants should be reviewed and lowest dose used
209
When to have urgent endoscopic investigation
Dysphagia and acute GI bleed or if over 55 and unexplained weight loss/upper abdominal symptoms, reflux or dyspepsia
210
GORD symptoms
Chest pain hoarseness cough wheezing genital erosions but more commonly heartburn and acid regurgitation
211
GORD is
Reflux of gastric contents back into the oesophagus
212
Treating IBS
Antispasmodic , laxative if constipation, linaclotide if persistent and loperamide if diarrhoea, A TCA like amitriptyline can be used for abdo pain second line if antispasmodics don't work as can SSRIs
213
Lifestyle tips for IBS
Regular eating no long gaps, physical activity, less than 3 portions of fresh fruit a day, potentially increase dietary fibre via oats or isapaghula husk , increase water less caffeine/alcohol, fizzy, monitor probiotic use to see effectiveness
214
When are IBS symptoms relieved
On defecating
215
IBS symptoms
abdominal pain or discomfort, disordered defaecation (either diarrhoea, or constipation with straining, urgency, and incomplete evacuation), passage of mucus, and bloating
216
Who is IBS more common in
20-30, women
217
IBS is
Common, chronic, relapsing, and often life-long condition
218
Inborn errors of primary bile acid synthesis treatment
Cholic acid, chenodeoxycholic acid, ursodeoxycholic acid
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