GI CASE STUDIES

Question 1

CASE STUDY
Peter comes into the pharmacy complaining of constipation. He says its been on and off for 3 weeks and is starting to make him very uncomfortable and distressed. He also has abdominal pain with cramps, What other info do you want to find out?

Answer 1

• his usual bowel habit - how is it different now?
• other symptoms
• any blood in stools
• medical history
• diet
• current medication
• any recent change in medication

Question 2

Explanations for blood in the stool?

Answer 2

• not always serious
• blood on tissue after straining or passing a hard stool is usually due to haemirrhoids. (bright red)
• bleeding that occurs higher up in the GI tract may make stools appear black with a tarry appearance. You should refer patient to GP for further investigation

Question 3

PETER CASE STUDY CONTINUED: No blood, tried senna but since then having painful cramps. Upon further questioning you find out that peter recently started work as a lorry driver and due to his shifts, eating pattern has changed quite drastically. He eats quite a lot of fast food and hardly any exercise. He has also been recently Rxed co-codamol 30/500mg tabs for back pain. What do you think cause of the condition is?

Answer 3

• change in lifestyle and eating pattern
• lack of dietary fibre
• Fairly sedentary lifestyle
• codeine can also cause constipation (find out how often he takes and dose)

Question 4

What drugs commonly cause constipation?

Answer 4

• opioid analgesics
• verapamil
• diltiazem
• iron supplements
• sedating antihistamines
• antipsychotics
• antimuscarinics
• antidepressants (not all)
• aluminium and calcium based antacids

Question 5

What is used for the treatment of constipation?

Answer 5

• stimulant laxatives
• bulk forming
• osmotic
• lubricant laxatives

Question 6

Would a stimulant laxative be suitable for peter?

Answer 6

NO

• has already tried senna and experienced abdominal pain
• likely that his stools are hard and hence causing straining when he tries to go to the toilet

Question 7

Can you recommend a bulk forming to Peter?

Answer 7

NO
- it can cause obstruction and increase the risk of faecal impaction in constipation caused by codeine (especially if there is insufficient intake of fluid). Taking codeine can result in hard stools and constipation. This is because opioids can reduce peristalsis, increase the tone of the anal sphincter and increase water absorption from the large intestine,

Question 8

Why is adequate fluid intake required for bulk forming laxatives?

Answer 8

Adequate fluid intake must be maintained to avoid intestinal obstruction

Question 9

What are some of the adverse effects of liquid paraffin (faecal softener)?

Answer 9

• abdominal pain
• irritation of back passage
• nausea and vomiting
• skin disorders
• liquid paraffin may leak from the back passage

Question 10

Can patients with diabetes use lactulose?

Answer 10

Yes, usually they can. If you have diabetes, ask your doctor or pharmacist whether this medicine is suitable you. If you have diabetes and are taking normal doses of lactulose for constipation, the medicine will have little, if any, effect on your blood sugar levels.

Question 11

Osmotic laxatives?

Answer 11

• milk of magnesia
• movicol
• lactulose

Question 12

What would be most suitable course of action for peter:
A. Offer peter an osmotic laxative and advise him to drink plenty of fluids. Advise him that the full effect may take 3 days to develop so he can use a glycerol suppository for quicker effect
B. Advise peter to switch senna to night time and advise it will take 8-12 hours for full effect
C. Advise peter to make dietary changes such as increase fluid intake and fibre. If changes do not work in 5 days go to GP
D. Refer peter to GP
E. Advise peter to try a bulk forming laxative such as ispaghula husk and counsel him to drink plenty of fluids and avoid taking medication immediately before bed

Answer 12

D –> refer peter to GP

Question 13

What are the referral signs and symptoms for peter?

Answer 13

• change in bowel habit over 2 weeks
• abdominal pain, vomiting or bloating
• suspect the symptoms are caused by medication
• OTC has failed to ease the symptoms
• severe pain on defaecation

Other non-relevant to peter:

• blood in stools
• suspected depression
• patietns over 40 sudden bowel habit change with no identifiable cause

Question 14

What would the GP do for peter?

Answer 14

Trial of lifestyle changes:

• increasing dietary fibre intake (need approx 30g a day)
• drinking adequate fluid intake
• Start on a bulk forming laxatve, if stools are hard then an osmotic laxative can be added/switched.
• for soft stools that are hard to pass then a stimulant laxative can be added
• laxatives can be stopped once the stools become soft and easy to pass
• consider whether an alternative analgesic can be prescribed; co-codamol shouldn’t be rxed for a lorry driver

Question 15

Which laxative will work the fastest?

Answer 15

• Glycerol suppositories (15 mins)
• Senna (8-12 hours)
• Bisacodyl tabs (10-12 hours)
• ispaghula husk (2-3 days)

Question 16

CASE STUDY MARIA: Maria comes in to pick up her repeat prescription for naproxen 250mg tabs. She wants to buy an indigestion remedy as she is experiencing a burning pain in her stomach which is worse before food and is temporarily relieved by eating. The pain often makes her feel sick. What other info do you want to find out?

Answer 16

• associated symptoms
• current medication
• how does she take naproxen and what for?
• how long has she been taking naproxen
• medical history
• diet
• family history
• lifestyle
• nature of the pain

Question 17

CASE STUDY MARIA cont: I smoke approx 30 cigarettes a day, often due to stress at work. I go to the pub after work for drinks most days of the week. Are smoking, alcohol consumption and stress risk factors for peptic ulcer disease?

Answer 17

YES - as well as frequent NSAIDs ad family history (if relevant)

Question 18

Which drugs can cause adverse GI symptoms?

Answer 18

• NSAIDs: inhibit COX1 mediated production of prostaglandins. Can cause GI ulceration, bleeding
• Antibiotics: can cause diarrhoea and abdominal cramps
• Antidiarrheal: GI motility - can cause cramps and bloating
• Iron supplements: constipation, darkened stools, diarrhoea, abdominal cramps/pain

Question 19

MARIA CASE CONTINUED: Maria has been taking naproxen 250mg TDS for the past 3 months for a frozen shoulder. Does not take any other regular medication. What advice would you give maria?

Answer 19

• prop head off the bed with more pillows
• avoid dinner 3-4 hours before bed
• avoid known precipitants that are associated with dyspepsia; this may include coffee, tea, alcohol, fatty foods, spicy foods
• smoking cessation
• stop naproxen and switch to an alternative

Question 20

What would the next steps and treatment plan be for Maria?

Answer 20

1. Review and manage lifestyle factors known to exacerbate PUD
   - manage stress
   - stop/reduce intake of food/drink associated with worsening symptoms
2. Review medication: stop naproxen if possible
   - offer alterative analgesia, such as paracetamol or opioid based analgesic
   - test for H.pylori and treat if present
3. Consider full blood count to check for anaemia and/or raised platelet count

Question 21

After a couple of days Maria brings a prescription issued for H.pylori. Lansoprazole 30mg 1 BD, Amoxicillin 500mg caps 2 BD and Clarithromycin 500mg tabs 1 BD. Are you happy with this prescription?

Answer 21

Yes

Question 22

CASE STUDY LARA: Lara is a 26 yr old lady who was recently diagnosed with Ulcerative Colitis. She comes into your pharmacy which a prescription which she has been told is to prevent exacerbations of her condition.
- Asacol MR 800mg tabs ONE to be taken THREE times a day. What counselling points would be appropriate for Lara?

Answer 22

Label 5 - do not take indigestion remedies 2 hours before or after you take this medication

Label 25 - swallow this medication whole. Do not chew or crush

Question 23

What is Ulcerative Colitis?

Answer 23

• Long term auto-immune condition affecting the colon and rectum
• small ulcers can develop along the lining of the large intestine and bleed
• relapsing-remitting disease

Question 24

What are aminosalicylates and how do they work?

Answer 24

• always initiated by specialist in secondary care
• MOA: reduce inflammation by scavenging free radicals, inhibiting prostaglandin and leukotriene production and/or decreasing neutrohil chemotaxis
• Examples; mesalazine, olsalazine, sulfasalazine
• Sulfasalzine: may colour tears yellow, colour urine orange and/or stain contact lenses
• Patients should be counselled to avoid bright sunlight and sunbeds and use high SPF

Question 25

LARA CASE CONTINUED: Lara comes into the pharmacy the following week and wants to purchase some lozenges for her sore throat and paracetamol for a high temperature. What can you recommend for Lara?

Answer 25

- All aminosalicylates can cause blood disorders! - Patients should be advised to report any: - unexplained bleeding - bruising - purpura (purple spots from burst blood vessels) - sore throat - fevere or malaise that occurs during the treatment Lara must be referred to her GP or A&E depending on severity

Question 26

What would happen if Lara was unable to tolerate the aminosalicylate?

Answer 26

- treatment of UC varies depending on the severity - in acute mild-to-moderate UC, aminosalicylates are usually first line option, if these cannot be tolerated, a corticosteroid (e.g. prednisolone) can be given - selection of corticosteroid and formulation depends on which part of the colon is affected by UC (rectal corticosteroid or oral prednisolone)

Question 27

Are the drugs used in remission vs relapse the same?

Answer 27

NO (remission) : 1. Oral or rectal aminosalicylate 2. Oral azathiopurine/mercaptopurine (unlicensed) 3. Methotrexate - used in common clinical practice

Question 28

Tablet advantages and dissadvantages in UC?

Answer 28

Advantages: - easier to use - less intruisive Disadvantages: - greater systemic absorption results in more side effects

Question 29

Advantages and disadvantages of suppositories in UC?

Answer 29

Advantages: - easier to use than enemas Disadvantages: - some leak or are expelled after insertion

Question 30

Advantages and disadvantages of foam enemas in UC?

Answer 30

Advantages: - can be eaiser to retain compared to liquid enemas Disadvantages: - inconvenient

Question 31

Smoking and ulcerative colitis?

Answer 31

- Smoking actually DECREASES the risk of developing UC - This differs from Crohns's disease, where smoking is a risk factor - However, ex-smokers have an appoximately 70% greater risk of developing UC than people who have never smoked

Question 32

CASE STUDY MR KONSTANTINOS: Mrs Konstatinos comes to your pharmacy and asks for advice regarding her children aged 2 and 6. Daughter is complaining about an "itchy bum" and discomfort. Mrs K has also noticed her son scratching around the anus for the last few days but thought it was due to the nappies. However, last night she noticed "white threads" in her sons stools. How would you respond to the situation? What other info do you need?

Answer 32

- how many in the family - is mrs K pregnant/breastfeeding - nocturnal itching? -

Question 33

What is the medication of choice for treating threadworms?

Answer 33

- mebendazole - single 100mg dose in tablet of 5ml suspension - 2nd dose should be taken 2 weeks later if reinfestation is suspected - For adults and children aged over 6 months, an anthelmintic (mebendazole) combined with hygiene measures is recommended — mebendazole is not licensed for children under the age of 2 years. (if under 2 refer to GP - doctor will prescribe it) - For children aged 6 months and under, hygiene measures alone for 6 weeks, are recommended. - pregnant or breastfeeding women, the recommended treatment is hygiene measures for 6 weeks. Treatment with mebendazole is contraindicated in the first trimester of pregnancy and the manufacturer recommends avoidance throughout pregnancy and breastfeeding.

Question 34

How does mebendazole work?

Answer 34

- inhibits glucose uptake by the worm - immobilisation and eventual death - only licensed treatment for threadworm in the UK - can be bought OTC - abdominal pain/rash side effects

Question 35

What if someone doesnt want to take their medication? What other options are there?

Answer 35

- physical removal of eggs | - strict hygeine measures (regular peri-anal washing, bathing in the morning) for approx 6 weeks

Question 36

CASE STUDY MRS K CONTINUED: Mrs Konstantinos has returned to your pharmacy to buy treatment for threadworm for the third time in six months. She says her son keeps on getting infected even though she is vigilant with the hygeine measures. She says "I have no idea how he keeps catching it". What further advice can you provide?

Answer 36

If infestation recurs this is usually due to re-infection and not failure of anti-helmintic therapy: Other causes of symptoms should be considered. If the diagnosis is certain, re-treatment of the person and household contacts with mebendazole is recommended (unless contraindicated). The importance of strict hygiene measures should be reinforced. If the person has frequent recurrences advice should be sought from a paediatrician or consultant in infectious diseases. RE-INFORCE VERY STRICT HYGEINE BY ALL FAMILY MEMBERS - washing immediately in morning - wiping every 2-3 hours - washing hands regularly - washing bed sheets and towels regularly - loose fitting cotton underwear

Question 37

What symptoms and circumstances would need a referral for threadworms?

Answer 37

- recent travel abroad - failed treatment - children under 2 years

Question 38

CASE STUDY LENNY: Lenny asks to speak to you in the consultation room. For a while he has had enexplained bouts of diarhoea and bloating. He also feels constantly tired and recently noticed that he has been losing weight too. He currently takes Levothyroxine 50mcg OD. What differential diagnosis can be made? What advice can you give to the patient?

Answer 38

- coeliac/IBS etc - cancer? (unexplained weight loss) - hyperthyroidism? - weight loss/fatugie - blood test - refer based on symptoms - advise to keep food diary to track what foods may be triggering

Question 39

LENNY CASE CONTINUED: lenny enters pharmacy a couple days later and hands over a prescription for gluten free bread. What condition could Lenny have based on this prescription, and where in the drug tariff would you find if this allowed on prescription?

Answer 39

- Coeliac | - Part 15 boderline substances, only breads and mixes are allowed

Question 40

Exam question: Mr SZ is a 53yr old man and is travelling to bangladesh. He does not take any regular medication and has no known drug allergies. He asks you for advice regarding prevention of traveller's diarrhoea. Which ONE of the following statements is correct: A. Vaccination against traveller's diarrhoea is recommended before travel B. Prophylactic antibiotic treatment is recommended C. Traveller's diarrhoea may be caused by eating seafood D. H.pylori is the main cause of Traveller's diarrhoea E. Bismuth salicylate is recommended for prohylaxis of traveller's diarrhoea

Answer 40

C. Traveller's diarrhoea may be caused by eating seafood

Question 41

``` EXAM Q: Mrs JK is a 46yr old lady who presents to your pharmacy complaining of indigestion and worsening stomach upset over the last 2 weeks. Which ONE of the following medicines that she is taking may be responsible for these symptoms? A. Mesalazine 2g OD B. Prednisolone 30mg OM C. Perindopril 4mg OD D. Pantoprazole 40mg OD E. Co-dydramol 10/500mg PRN ```

Answer 41

B. Prednisolone 30mg OM Common side effects are indigestion and stomach upset

Question 42

``` EXAM Q: Mr MA, a regular patient in your pharmacy, has started taking Buscopan to treat his stomach cramps. He presents in the pharmacy complaining of side effects from the medication. Which of the following if NOT a side effect of Buscopan? A. Dilated pupils B. Dry mouth C. Urinary retention D. Increased secretions E. Constipation ```

Answer 42

D. increased secretions Antimuscarinic - decreased secretions

Question 43

EXAM Q: Your local GP phones you to ask advice on what to prescribe for Mr JM, a patient who has tested positive for H.pylori. Mr JM is allergic to penicillin. Which of the following regimens is the most appropriate? A. Amoxicillin 1g BD + clarithromycin 500mg BD + lansoprazole 30mg BD B. Clarithromycin 250mg BD + metronidazole 400mg BD + omeprazole 20mg BD C. Clarithromycin 250mg BD + metronidazole 400mg BD + pantoprazole 40mg OD D. Amoxicillin 1g BD + metronidazole 400mg BD + rabeprazole 20mg BD E. Clarithromycin 250mg OD + metronidazole 400mg BD + esomeprazole 20mg BD

Answer 43

B. Clarithromycin 250mg BD + metronidazole 400mg BD + omeprazole 20mg BD

Question 44

QUESTION: This medicine should be taken with plenty of water to avoid intestinnal impaction (laxative)?

Answer 44

Ispaghula husk (fybogel sachets)

Question 45

QUESTION: This is a powerful stimulant and is no longer used to treat constipation? (laxative)

Answer 45

Phosphate enema - rarely used now

Question 46

QUESTION: this medication should not be taken immediately before bed due to risk of oesophageal obstruction? (Laxative)

Answer 46

Ispaghula husk

Question 47

QUESTION: this is a first line treatment in pregnancy following dietary and lifestyle changes (laxatives)

Answer 47

Ispaghula husk Osmotic (lactulose) second line

Question 48

QUESTION: Used in the treatment of hepatic encephalopathy ? (laxative)

Answer 48

Lactulose (much higher dose )