Advanced Gastroenterology

Where will enemas reach?

The splenic flexure

Where will foams reach?

Sigmoid colon

Where do suppositories reach?

Rectum and 15cm beyond anal verge

Define ulcerative colitis?

a chronic inflammatory bowel disease (IBD) that causes inflammation and sores (ulcers) in the inner lining of the large intestine (colon) and rectum

What are the symptoms of ulcerative colitis?

Limited to large intestine
Inflamed areas are continuous
Lower left abdo
Ulcer in inner lining
Blood common in stool

What is the first step when managing acute severe ulcerative colitis?

IV hydrocortisone 100mg QDS

What is the second step when managing acute severe ulcerative colitis?

After 72 hours or deterioration
Ciclosporin IV → monitor continuously for 30 minutes then every 4 hours
Interacts with IV tube need to be reset every 6 hrs

Why may infliximab be given?

If Ciclosporin contradicted
Red drug
Need to check patient eligibility

What is Mesalazine (Salofalk)?

a medication used to treat inflammatory bowel disease, including ulcerative colitis and Crohn's disease

How does Mesalazine (Salofalk) work?

n anti-inflammatory drug is diverse. It appears to act locally on colonic mucosa and reduces inflammation through a variety of anti-inflammatory processes

What can spoking do to symptoms?

can reduce symptoms so this may have changed symptoms

Define Post Operative Ileus?

• partial or complete non-mechanical blockage of the bowel → means peristalsis is not working nothing is passing through

A complication in 10-30% of abdominal surgeries

What are the symptoms of Post Operative Ileus?

• Abdominal distension (swelling)

• Nausea

• Vomiting

• Absence of flatus and passing stool

• Unable to tolerate oral or enteral diet

What are the 3 possible management strategies for Post Operative Ileus?

Prokinetics
Antiemetics
Non pharmaceutical

What are the prokinetic treatments for Post Operative Ileus?

Metoclopramide: acts as a cholinergic agonist and dopamine antagonist
Erythromycin: motilin receptor agonist, stimulating the release of migrating motor complexes → expensive

IV → short term 2-3 days

What antiemetics are used in Post Operative Ileus?

• No data to support one antiemetic over another

• Be cautious of ondansetron (constipating)

What non pharmaceutics management options for Post Operative Ileus?

Chewing gum
Appropriate venting NG tube

• Parenteral nutrition

• Fluid management

• Electrolyte replacement

Where are the 3 main places a stoma can go?

Colostomy
Urostomy
Ileostomy

What can happen when POI is resolved?

most medications have been switched to oral by the doctor

What needs to be considered before using enteral tubes for med?

Function of enteral tube
Size of lumen and length of tube
Multi lumen tubes
Confirmation of position
Tip position of the tube

Why is the function of enteral tube important?

Aspiration or on free drainage – do not use for drug administration

Why is the size of lumen of enteral tube important?

Narrow or long tubes are more likely to become blocked

Why is multi lumen tubes in enteral tubes important?

• Simultaneous gastric aspiration and jejunal feeding

• Need to use the correct lumen

How is the Confirmation of position of enteral tube checked?

NG tubes should have the position checked regularly by measuring pH

Why is the Tip position of the tube of enteral tube important?

• Site of drug absorption

• Disintegration and dissolution of the drug

• Solubility in different pH

• Time in contact with the GI tract

• First pass metabolism

How can jejunal tubes change absorption?

Bypasses first pass metabolism

Why are suspension not used in tubes?

• so can be small granules and not be fully soluble

• granules could block tube and settling of granules could affect accuracy of dosing.

How can sorbitol affect patients

• sweetener in many liquids

• laxative effect

What needs to be considered with soluble tablets

Effervescent tablets produce a gas when water is added
Caution mixing in syringe
can have a high sodium content.
Some can leave particules

What can be issue with Oro-dispersible tablets and tubes?

swallowed with saliva and they are not absorbed sublingually
Can contain granules so restricts size of lumen

What can be issue with sublingual tablets and tubes?

ok if patient has enough saliva.

Why are normal tablets/capsules fine in tubes?

Tablets disperse well in water
Can open capsules and disperse

What can be issue with MR tablets and tubes?

• designed to release drug slowly over a given period

• crushing will change the characteristics and result in excess dosage

What can be issue with EC tablets and tubes?

• stop drug degrading in stomach acid or reduce GI S/E –

• Crushing can lead to tube blockage

Examples of injections suitable for tube admin?

Vancomycin, hyoscine

How to limit drug drug interactions with tubes?

Intervals between drugs
Flush well

Admin 1 at a time

Never mix drugs
Check interactions

How to limit drug feed interactions with tubes?

Drugs during feed breaks
Flush well
Medicines after food should be taken immediately after feed stops

What types of drugs used in a high output stoma?

Antimotility
Antisecretory
Others

Which drugs are antimotility for high out put stoma

Loperamide (high dose)
Codeine

Which drugs are antisecretory for high output stoma?

PPIs
H2r antagonists
Octreotide

What other non motility drugs are there for high out put stoma

Teduglutide
ORS → St Marks solution, Double strength dioralyte

Why are isotonic fluids used?

similar solute concentration to blood. At least 90mmol/L sodium is needed to maximise water and sodium absorption – rehydration energy drinks are not useful