gastrointestinal system minor conditions

GI anatomy?

• mouth

• pharynx

• oesophagus - upper and lower sphincters

• stomach

• liver, gallbladder, pancreas 

• small intestine (duodenum, jejunum, ileum)

• large intestine (ascending, transverse, descending, sigmoid)

• rectum

• anus 

what does the GI system do in depth?

A muscular tube that transports food/fluids from the mouth to the stomach. Peristalsis propels food/fluids along the oesophagus. Starts at the cricoid cartilage, runs behind the heart and trachea down through the diaphragm (hiatus) to the stomach. The upper gastro-oesophageal sphincter prevents entry of air into the oesophagus.  The lower gastro-oesophageal sphincter prevents gastric acid entering the oesophagus

what is pharmacy first?

NHS Pharmacy First Scotland is a service designed to make it easier for people to access healthcare for minor illnesses and common conditions directly through their local community pharmacy, without needing to see a GP.

what are symptoms arising from the upper GI tract which are typically present for four or more weeks?

• upper abdominal pain/discomfort, heartburn, acid reflux, nausea and/or vomiting

(it may be caused by non-ulcer dyspepsia, GORD, PUD or a hiatus hernia

what are red flag/ alarm symptoms with dyspepsia?

• age > 55yrs

• unexplained weight loss

• blood in vomit or stools

• dysphagia

• anaemia

• potential cardiac cause - pain related to exercise, sweating, breathlessness, grey pallor

what are non- pharmacological management options for dyspepsia?

• reduce weight if overweight or obese

• avoid trigger foods e.g. coffee, chocolate, tomatoes, fatty or spicy foods 

• eat smaller meals and last meal 3-4 hours before bed

• stop smoking

• reduce alcohol use to recommended limits 

• reduce stress

(review medications: aspirin, bisphosphonates, calcium-channel blockers, corticosteroids, nitrates, NSAIDs, nicorandil, theophylline)

before recommending OTC dyspepsia treatments, it is important to ask patients about ?

the frequency of their symptoms, and whether they have already tried OTC antacids and/or alginates

when are antacids and alginates best taken?

when symptoms occur or are expected, usually between meals and at bedtime

(some medicines contain both alginate and antacid)

are liquid or tablet products more effective in dyspepsia treatment?

liquid products are more effective

what should i do if heartburn occurs at least twice a week for at least four weeks?

try an over-the-counter proton pump inhibitor (PPI) for 14 days to help reduce the production of stomach acid

what do antacids do and how do they work?

• neutralise gastric acid, increasing gastric pH

• typically contain magnesium salts or aluminium salts

-magnesium can cause diarrhoea

-aluminium can cause constipation 

• therefore combined formulations are used to balance side effects 

examples of antacids?

• rennies

• tums 

• maalox/ maalox plus (contains simeticone, an antifoaming agent that helps relieve bloating)

what is the mechanism of action for alginate containing antacids?

• increase viscosity and adherence of gastric mucus

• form a ‘raft’ that floats on top of gastric contents

• this barrier prevents reflux into the oesophagus

examples of alginate- containing antacids?

• gaviscon Advance

• peptac

take after meals and at bedtime

why must you consider electrolyte content when giving antacids and alginates to certain patients?

sodium/potassium content may affect patients with: hypertension, heart failure, renal impairment 

why must you consider the effect on gastric pH when giving antacids and alginates to certain patients?

may alter absorption of other medications

why must you consider the chelation and interaction risks when giving antacids and alginates to certain patients?

antacids can bind to or reduce absorption of iron, levothyroxine, doxycycline, bisphosphonates, enteric-coated (EC) formulations, ACE inhibitors (less commonly affected but still worth noting)

how long should you space antacids treatment when taking other medications?

space antacids 2 hours apart from interacting medications to avoid reduced efficacy

what do proton pump inhibitors (ppi) do?

reduce stomach acid by blocking the H+/K+ ATPase enzyme in gastric parietal cells

what are PPIs used to treat?

• frequent heartburn, acid reflux and dyspepsia 

what are common OTC PPIs ?

• nexium control 20mg GR tablet/capsule (18yrs+, 1 daily, max 14 days)

• pyrocalm control 20mg GR tablet (Adults, 1 daily, max 14 days)

what are indications of PPIs?

• frequent heartburn ( 2 days/ week)

• mild to moderate GORD

• short term relief of acid related symptoms 

what safety and use advice should you give a patient when counselling PPIs?

gastric parietal cell secretes H+ into the stomach using a?

H/K/ATPase pump (proton pump)

(stimulating factors: histamine, acetylcholine, gastrin)

what are the medicines on gastrointestinal system (dyspepsia and gastro-oesophageal reflux) pharmacy first approved list?

what is dyspepsia ?

a medical condition that causes persistent pain or discomfort in the upper abdomen

what is GORD (gastro oesophageal reflux disease)?

is a medical condition that causes stomach contents to reflux up into the oesophagus towards the mouth

GORD vs dyspepsia?

GORD and dyspepsia are two common digestive conditions occurring in the GI tract

the term ‘dyspepsia’ indicates there is an underlying disease of the upper digestive tract rather than a specific diagnosis

underlying causes of dyspepsia include gastro-oesophageal reflux disease (GORD), peptic ulcer disease, Barrett’s oesophagus and upper gastrointestinal cancers

GORD vs dyspepsia table…

GORD is the chronic reflux of gastric contents (hydrochloric acid and pepsin) from the stomach into the oesophagus, this leads to?

oesophageal irritation and the symptoms of heartburn

GORD typical symptoms, atypical symptoms and alarm symptoms?

Typical symptoms:

•Heartburn/dyspepsia

•Epigastric/retrosternal burning sensation

•Regurgitation (water brash/acid brash/vomiting)

•Belching

•May be precipitated by bending over, eating too much or lying down

Atypical symptoms:

•Cough

•Laryngitis

•Severe chest pain – think cardiac!

Alarm symptoms 

• weight loss

• difficulty swallowing

• blood in vomit

• abdominal mass

• age 55 +

GORD

gastric acid exits the stomach entering the lower oesophagus causing?

• irritation

• inflammation

• erosion of the oesophageal mucosa 

GORD epidemiology?

• prevalence increases with age

• more common in women 

• 20% of those with dyspepsia symptoms who have endoscopy will have GORD

Aetiology ( causes and origins) of GORD?

• obesity- increased abdominal pressure 

• smoking

• diet (coffee, mints dietary fat, onion, citrus fruit, tomatoes, alcohol

• medication (calcium channel blockers theophylline nitrates, anticholinergics, bisphosphonates)

• pregnancy (up to 50% of pregnant women will experience GORD)

• structural: hiatus hernia, occurs in 30% of the population 50 years +

GORD treatment?

• normally PPI for 4-8 weeks- this is prescribed as a POM

• lifestyle advice 

whwhat is diarrhoea ?

Diarrhoea is passing three or more loose or watery stools per day, affecting hydration and health

what are the different classifications of diarrhoea?

• acute 

• persistent 

• chronic 

based on symptom duration

what are infectious agents that commonly cause diarrhoea?

• bacteria

• viruses

• parasites 

e.g. stomach bug r food poisoning 

what are non-infectious agents that commonly cause diarrhoea?

• medications

• IBS

• malabsorption 

• inflammatory bowel disease

what to do/ lifestyle advice when dealing with diarrhoea?

• stay at home and get plenty of rest

• drink lots of fluids such as water or squash - take small sips if you feel sick 

• carry on breast or bottle feeding your baby - if they’re being sick, try giving them small feeds more often than usual

• give babies on formula or solid foods small sips of water between feeds

• eat when you feel able to - it may help to avoid foods that are fatty or spicy

• take paracetamol for discomfort - (check the leaflet before giving it to a child)

what NOT to do/ lifestyle advice when dealing with diarrhoea?

• do not have fruit juice or fizzy drinks - they can make diarrhoea worse 

• do not make baby formula weaker - use it at its normal strength

• do not give children under 12 medicine to stop diarrhoea 

• do not give aspirin to children under 16

how to counsel for diarrhoea?

• in adults and children:

-diarrhoea usually stops within 5 -7 days

-vomiting usually stops in 1 or 2 days

• stay off school or work until you have not been sick or had diarrhoea for at least 2 days 

• hygiene measure are very important to stop spread 

• alarm symptoms: severe and frequent vomiting, diarrhoea > 7 days or vomiting > 2 days, dehydration signs in child younger than 5, bleeding from rectal area, coloured vomit, sudden and severe headache/ stomachache 

diarrhoea pharmacy first approve list treatment?

diarrhoea treatment ?

•Rehydration sachets e.g. Dioralyte^Ò

•Powder form, typically in sachets. Mix the contents with water to create a drink that helps replenish fluids and electrolytes lost during diarrhoea.

•Improves absorption of water and salts in the intestines thanks to the glucose and rice starch content

•Each sachet contains:

•Sodium chloride, Potassium chloride, Disodium hydrogen citrate, Glucose

•Some versions (like Dioralyte Relief) also include rice starch, which helps firm up stool

rehydration sachets?

•Adults and children over 3 months can safely use rehydration sachets.

•For infants under 1 year, medical advice is recommended before use.

•It's suitable for use during travel, illness, or after exercise when dehydration is a risk

•Mix one sachet with 200 ml of fresh drinking water (boiled and cooled for infants).Take after each loose stool.

•Use immediately after mixing. If refrigerated, it can be stored for up to 24 hours.

•Not a cure for diarrhoea – manages dehydration

diarrhoea treatment - loperamide (antimotility agent)?

• opiate receptor agonist that stimulates opiate receptors in the GI tract

• Reduction of motility. More water is absorbed from faeces

• Does not cross the blood-brain barrier (at normal doses)

• Extensive first pass metabolism

• Licensed OTC dose is up to a max of 6 capsules in 24 hours

• Licensed POM dose is higher

• Brand names e.g. Imodium

constipation symptoms?

• You have fewer than three bowel movements per week

• Your stools are hard, dry, lumpy, or unusually large/small

• You experience straining, pain, or a feeling of incomplete emptying

• You feel bloated, nauseous, or have stomach aches

common causes of constipation?

• Low fibre intake (not enough fruits, vegetables, or whole grains)

• Dehydration (not drinking enough fluids)

• Lack of physical activity

• Ignoring the urge to go to the toilet

• Changes in routine, diet, or travel

• Side effects of medications (e.g. opioids, iron supplements, antidepressants)

• Stress, anxiety, or depression

• Pregnancy or ageing

• Medical conditions like IBS, Parkinson’s disease, or diabetes

when to consult a GP if experiencing constipation?

• Constipation lasts more than 2 weeks

• You notice rectal bleeding

• You experience unexplained weight loss or fatigue

• You have persistent abdominal pain

• You suspect a medication is causing the issue

lifestyle treatment and prevention of constipation?

diet

• eat high fibre foods: whole grains, fruits (especially apples, apricots, grapes) vegetables, nuts and seed 

• drink 1.5-2 litres of fluid daily 

• avoid excessive caffeine and alcohol

toilet habits 

• respond promptly to the urge to go

• sit with knees above hips (use a footstool if needed)

physical activity

• regular movement like walking or light exercise helps stimulate bowel function

medication treatment and prevention?

• If lifestyle changes don’t help, laxatives may be recommended by a pharmacist. These include:

-Bulk-forming laxatives (e.g. ispaghula husk)

-Osmotic laxatives (e.g. lactulose)

-Stimulant laxatives (e.g. senna)

-Softening laxatives (e.g. docusate)

bulk forming laxatives?

•Bulk forming laxatives

• Contains soluble fibre ispaghula husk – Retains fluid in the faeces

• Important to have good fluid intake, otherwise can be constipating

• Not recommended in persons taking constipating medication – risk of further constipation

• Takes 2 or 3 days to have an effect

(fybogel, ispaghula husk orange)

osmotic laxatives?

•Draws water into the faeces due to osmosis – must be alongside a good fluid intake!

•Glycerol suppositories, also has a mild irritant effect on the bowel promoting peristalsis

•Can be used if there is an inadequate response to bulk forming laxatives

•Orally can takes 1 or 2 days to have an effect, glycerol suppositories have a rapid onset of action within 15 - 30 minutes

(laxido, movicol, glycerol suppositories, lactulose)

stimulant laxatives?

•Cause direct stimulation of the bowel leading to increased colonic motility

•Can cause cramping abdominal pain so potentially limited value in IBS

•Can be used in conjunction if inadequate response to bulk forming/osmotic laxatives or if constipation exacerbated by medication (e.g. opiates)

•Orally they can take 6 - 12 hours to have an effect, bisacodyl suppositories will take 10 to 45 minutes to have an effect.  

(senna , bisacodyl, dulcolax)

softening laxatives?

•Docusate has a lubricating/stool softening action in addition to being a stimulant

•Docusate is a wetting agent lowering the surface tension and allowing water and salt to penetrate accumulated hard dry faeces in the bowel

•Orally docusate can take 1-3 days to have an effect.

( docusate sodium)