PH2113 - GI

Question 1

What drugs cause gastric bleeding?

Answer 1

SSRIs, NSAIDs and anti-platlets.

Question 2

Why do NSAIDs cause gastric bleeding?

Answer 2

COX-1 inhibition disrupts production of prostaglandins and disrupts barrier methods in mucosa.

Question 3

What are drugs causing dyspepsia?

Answer 3

Anti-biotics, biophosphates, CCBs, corticosteriods, tricyclic anti-depressants, nitrates, theophylline and potassium chloride.

Commonly used medications associated with dyspepsia include aspirin, NSAIDs, corticosteroids, bisphosphonates, iron, selective serotonin reuptake inhibitors, erythromycin, acarbose, metformin, orlistat, potassium (particularly modified-release forms) and nicorandil.

Question 4

What are alarm symptoms of dyspepsia?

Answer 4

Dysphagia, weight loss, anaemia, persistent vomitting, mass somewhere.

Question 5

What are signs of constipation?

Answer 5

Not having bowel movement for > 3days to a week. Difficulty with bowel movement, stool is dry hard and lumpy.

Question 6

What are some lifestyle advice you can give to patients with dyspepsia?

Answer 6

• Avoid eating large meals, especially late at night
• Raise the head of the bed 10-20cm, using blocks rather than pillows (only for patients with nocturnal symptoms)
• Reduce bodyweight if obese
• Tight clothing should not be worn
• Avoid heavy lifting, stooping and bending from the waist
• Avoid fatty or spicy foods, caffeine, mint, chocolate and alcohol
• Discourage smoking

Question 7

What are antacids?

Answer 7

Most antacids contain aluminium salts, magnesium salts, or both.
Combinations may be preferable to magnesium salts alone (which may cause diarrhoea) or aluminium salts alone (which may cause constipation).

magnesium trisilicate.
magnesium hydroxide.
magnesium carbonate. - in rennies
calcium carbonate. in rennies
sodium bicarbonate.

other antacid types:
Bismuth salts: similar to AL and Mg salts. Neutralising acid and coating the gastric mucosa, acting as a mechanical barrier against acid.

Question 8

Why is Dimeethicone added to some antacids?

Answer 8

• Anti foaming agent used to reduce flatulence

Question 9

How are Antacids formulated?

Answer 9

Liquids and powders have a higher neutralising capacity than tablets but empty from the stomach quicker than tablets and thus have a shorter duration of action. Tablets should not be swallowed whole but either chewed or sucked to provide a slow but sustained delivery to the stomach.

Question 10

What should look you out for in patients taking antacids with high sodium content?

Answer 10

Patients with:

• hypertension
• chronic kidney disease
• Heart failure and those on lithium therapy or a salt-restricted diet or pregnant women
• Due to interactions with other drugs, a two-hour gap should be left between antacids and other medicines.

Question 11

What are H2RA?

Answer 11

• H2-receptor antagonist

Examples:

• Famotidine (Pepcid AC, Pepcid Oral)
• Cimetidine (Tagamet, Tagamet HB)
• Ranitidine (Zantac, Zantac 75, Zantac Efferdose, Zantac injection, and Zantac Syrup)
• Nizatidine Capsules (Axid AR, Axid Capsules, Nizatidine Capsules)

-licensed for the short-term treatment of dyspepsia, indigestion, hyperacidity and heartburn.

Question 12

What are some restrictions of H2RA use?

Answer 12

• Restricted to use in adults and children over 16 years.

- Not be sold to patients taking NSAIDs or to pregnant or breastfeeding women.

Question 13

What are PPIs?

Answer 13

Examples:
Omperazole Gastro-resistant Capsules
Pantoprazole 20mg tablets
Esomeprazole (Nexium) - OTC
Lansoprazole 
Rabeprazole
-For people aged 18-45 or the relief of reflux-like symptoms.
- More effective than antacids o H2RA in reducing dyspeptic symptoms.

Question 14

When should patients be advised to take PPIs?

Answer 14

• 30 minutes before a meal

- Why? theoretically this will block meal-induced activation of the acid pumps most effectively

Question 15

What are some interactation or concerns relating to ppi?

Answer 15

-Possible interaction between PPIs and clopidogrel with a consequent loss of antiplatelet protection.

Concerns about PPI:

• Serious hypomagnesaemia with long-term use (low level of magnesium in the blood)
• Increased risk of osteoporosis ( bones become brittle and fragile)in postmenopausal women
• Increased risk of Clostridium difficile infection, particularly in patients receiving antibiotics
• Increased risk of community-acquired pneumonia

Question 16

What are some specific groups of people who should be referred to the gp?

Answer 16

-Those aged 45 years or over with new onset of symptoms within the last year that has lasted for at least four weeks or whose symptoms have changed (routine referral).

people who have had to take an antacid or acid suppressor continuously for four weeks or more to control their symptoms or who have taken an indigestion or heartburn remedy for two weeks with no relief of symptoms (routine referral)

people who are particularly anxious regarding the significance of their symptoms

people with any other significant medical condition (including hepatic or renal impairment)

pregnant or breastfeeding women.

Question 17

NICE guidance recommends that initial strategies for managing uninvestigated dyspepsia (Uninvestigated dyspepsia refers to patients with new or recurrent dyspeptic symptoms in whom no investigations have previously been undertaken)?

Answer 17

1. Lifestyle advice
(no response next step)
2. Full dose PPI for a moth
(no response next step)
3. Test and treat
(no response next step)
4.H2RA or prokinetic for 1 month
(no response next step)
5. Review

Question 18

How can uninvestigated dyspepsia be tested and treated? (stage 3)

Answer 18

• In GP.
• There are two treatment options:
  1. Empirical acid suppression therapy with full dose PPI for one month. - Cost effective since PPI cheap.
• Patients with predominantly heartburn-type symptoms are more likely to have reflux disease and will respond better to PPIs

2. Testing for and treating Helicobacter pylori (H. pylori) to eradicate. Imporved hygein= less prevelnace of H.pylori
   so: over time, fewer patients with dyspepsia will benefit from eradication therapy.
   - patients with predominantly epigastric symptoms and discomfort will benefit more from H. pylori eradication.

Question 19

What should be done If the response to a PPI is inadequate? (Stage 4)

Answer 19

• trial of H2RA or prokinetic therapy is appropriate:
• Domperidone and metoclopramide are both used to reduce symptoms such as bloating and early satiety.
• Metoclopramide: cross BBB and casues CNS side effects, inc. drowsiness, anxiety, and depression.
• elderly: increased risk of hyperprolactinaemia: (elevated serum prolactin)
• Patients over 55- endoscopy should be considered, with persistent symptoms.

Question 20

What should be done for persistent dyspepsia?

Answer 20

If symptoms persist or return, the patient should be offered the first-line therapy that has not been used - full dose PPI or test-and-treat

Question 21

What is the review stage?

Answer 21

• People with dyspepsia with long-term treatment have an annual review of their condition, and lifestyle advice should be reinforced.
• review weather patient could step down to self- care with antacids/aligates (OTC)
• BUT patients with the following should not step down or stop treatment:
• Patients with complicated oesophagitis (past strictures, ulcers, haemorrhage, or Barrett’s oesophagus).
• Taking a PPI for gastroprotection against NSAIDs
• With a previous bleeding peptic ulcer who remain H. pylori-positive after at least two attempts at eradication.

Question 22

What are the 3 categories NSAID SIDE EFFECTS are divided up into?

Answer 22

1. Nuisance symptoms: such as heartburn, nausea, dyspepsia and abdominal pains are experienced by an average 10-12% of patients taking an NSAID.
2. Mucosal lesions: such as ulcers, seen on endoscopy or radiographic studies. NSAIDs result in changes to the GI mucosa, which include an erythematous mucosa, small submucosal haemorrhages, multiple erosions and discrete ulceration.
3. Serious gastro-intestinal complications- perforated ulcers (untreated ulcer can burn through the wall of the stomach or GI tract, digestive juices and food to leach into the abdominal cavity) and bleeding

Question 23

what does the highly acidic nature around the gastric lumen of (around ph 1-2) result in?

Answer 23

• Causes ingested proteins to denature, or lose their characteristic folded structure.
• beneficial because allows proteolytic enzymes better access to the bonds linking the amino acids (proteolysis), facilitating peptide breakdown
• Activates proteolytic enzymes by converting inactive pepsinogen (from chief cells within the stomach) to active pepsin. Pepsin exhibits greatest activity at a pH of 2.
• helpful to prevent infection because.

Question 24

What is the role of the mucus and bicarbonate layer surrounding the gastric lumen?

Answer 24

• neutralisation of acid
• Carbonic acid is further catalysed by carbonic anhydrase in the gut epithelium to liberate carbon dioxide
• mucus is secreted by the cheif cells
• mucus role: protecting the mucosa from bacterial colonisation and mechanical injury, and forms a viscous microenvironment over sites of superficial injury, allowing rapid restitution to occur.

Question 25

what is the cell migration/regeneration layer?

Answer 25

-Tissue destruction can occur if hydrogen ions accumulate in the submucosa. Thus, the submucosal blood flow is important in diluting hydrogen ions and transporting them away from the submucosa. Anything that adversely affects this blood flow will also interfere with this process and tissue destruction may occur.

Question 26

OTC treatment for dyspesia: Antacids

Answer 26

``` Active Ingredients Aluminium salts, Magnesium salts, Bismuth Salts, Calcium salts, ``` ``` OTC brands - gaviscon advance Rennie, Tums, Pepto-Bismol ``` -Mechanism of Action Direct neutralising action on stomach acid. Counselling points QDS after meals and at bed. Leave 2 hour gap between other meds.

Question 27

OTC treatment for dyspesia: Alginates

Answer 27

Active ingredients: Sodium Alginate - OTC brands- Gaviscon Advance Mechanism of Action - Increases viscosity of stomach contents 'forms a raft'. Counselling- Counselling the same as with antacids

Question 28

OTC treatment for dyspesia: Histamine-2 Receptor Antagonists(H2RAs)

Answer 28

Active ingredients- Ranitidine - Taken off the market due to possible cancer risks. OTC brands - Zantac and many generics Mechanism: Reduce stomach acid production. Conselling points - Longer acting than antacids but not as fast acting. Can give with antacid for dual abenefits.

Question 29

Proton Pump Inhibitors (PPIs)

Answer 29

Active ingredients: - Omperazole - Pantoprazle OTC brands- Zanprol, Pantoloc Control Mechanism of action: - Reduce stomach acid production. Counselling points: May take 2-4 days to gain maximum effect.