Therapeutics - Gastrointestinal

Constipation

• condition of unsatisfactory defecation through passing stools less frequently than normal, difficulty passing stools or the feeling of incomplete emptying when opening the bowel

• what is normal varies

• classified as - spontaneous bowel movement occurring fewer than 3 times per week

constipated info

• affects all ages

• 2-3 times more common in women than men

• more common over 60 years

• question patients frequency and consistency

• risk factors - sedentary lifestyle, poor diet, avoiding going to the toilet when needed

• can be drug induced - opioid analgesics

bristol stool chart

constipation management - pharmacological

• managed with laxatives

  • bulk forming ispaghula

  • osmotic e.g. lactulose or macrogels

  • surface-wetting agents - docusate

  • stimulant - senna, sodium picosulphate

  • enemas and suppositories - phosphate enemas, glycerol suppositories

• Prucalopride - available on prescription

constipation - management - non pharmy

• increase physical activity

• increase fluid intake

• eat a balanced diet - regular eating pattern

• regular toilet routine

Diarrhoea overview

• WHO defines as passing or more loose or liquid stools per day

• Classified as acute, persistent or chronic

  • acute < 14 days

  • persistent >24 days

  • chronic > 4 weeks

• Chronic diarrhoea associated with IBS, IBD, coeliac disease, bowel cancer

diarrhoea causes

• viral

• bacterial

• side effect of meds

• anxiety

• food intolerance

diarrhoea diagnosis

• any triggers, duration, frequency, severity of symptoms

• is it normal for Pts

• any recent foreign travel

• stool sample taken in more severe cases

• need to rule out red flags-unexplained weight loss, blood in the stool, nocturnal symptoms

• important to asses dehydration - pinch test

diarrhoea treament

• Electrolyte imbalances and dehydration need to
  be addressed – rehydration salts (e.g.
  Dioralyte®) appropriate, particularly in children,
  pregnant women and the elderly

• Loperamide (e.g. Imodium®) can be given but
  should be avoided where the cause is
  infectious

• Opioid analgesics cause constipation as a side-
  effect and can be considered where
  appropriate – codeine is licensed to treat acute
  diarrhoea

Irritable bowel syndrome over view

• chronic, relapsing condition triggered by biological, psychological and social factors

• not IBD

• affects 5-20% of the globe but more common in young adults

IBS symptoms

• lower abdominal pain - spasmodic/sharp

• bloating

• bouts of constipation

• bouts of diarrhoea

IBS diagnosis

• presence of symptoms for 6 months

• symptoms made worse by eating but relieved by defecation

• Blood and stool tests used to rule out other causes IBD or cancer

IBS - management non pharmy

• dietary changes - more or less fibre increased fluid

• regular physical activity

• stress management - brain-gut link

IBS - management pharmy

• Loperamide for diarrhoea

• Laxatives for constipation

• Abdominal pain/spasms managed with
  antispasmodics such as hyoscine butylbromide,
  mebeverine, dicycloverine

• Tricyclic antidepressants (TCAs) or Selective
  Serotonin Reuptake Inhibitors (SSRIs) can be
  used where symptoms do not respond to
  antispasmodics – note: these are POMs

Indigestion

Indigestion / heartburn occurs when the acidic
contents of the stomach move back up into the
oesophagus due to the sphincter at the base of the
oesophagus being less effective

main symptom of indigestion

• The main symptom is a burning sensation in the
  middle of the chest – it is important to distinguish
  this from a heart attack!
  • Patients may visually describe the feeling by
  clenching their fist across the chest and moving it
  downwards

• Other symptoms include unpleasant taste in the
  mouth, a non-productive cough, bloating and
  nausea

Indigestion red flags

• unexplained weight loss

• blood in vomit/stool

• difficulty swallowing (dysphagia)

• Signs of a heart attack (myocardial infarction)

  • sweating

  • pain radiating to left arm, jaw, neck or back

  • feeling faint or dizziness

indigestion management - non pharmy

• avoid trigger foods

• eat smaller more frequent meals

• raise the head of the bed to bring chest above the level of waist

• reduce stress

• wear loose fitting clothing

• reduce alcohol intake

indigestion management - pharmy

• antacids - reduce pH of the stomach contents

• alginates - form raft on top of stomach contents to help protect oesophagus

• Proton-pump inhibitors - used to manage GORD, mostly POM but some P meds

• Histamine H2 antagonists - limited due to adverse effects with ranitide