GI Tract

• What is a mouth ulcer? + what could the patient recall?

  • Usually a single, irregularly-shaped ulcer
  • Patient can often recall the cause
  • Burn – hot/cold/chemical
  • Biting lining of mouth
  • Sharp surface of tooth/denture
• What is the most common type of mouth ulcer?

  Recurrent aphthous stomatitis
• What are the types of aphthous stomatitis?

  *aphthous minor (80% of cases)*aphthous major (10% of cases)*herpetiform (10% of cases)
• Summarise what are the symptoms of aphthous minor

  • Often in groups of up to five
  • Small ulcers (<1cm)
  • “uncomfortable”
  • Heal within 10-14 days
• Summarise what are the symptoms of aphthous major

  Usually 1-3 ulcers* Larger than 1cm* Painful and may affect eating* Can take weeks to heal
• Summarise what are the symptoms of aphthous herpetiform

  • Groups of 10-50 small ulcers
  • Very painful
  • Heal within 10-14 days
• What could be the causes to mouth ulcers?

  Iron deficiency anaemia* Vegetarian/vegan diet often implicated* Heavy menstrual loss* Hypersensitivity* Preservatives in food (benzoic acid/benzoates)* Foods (chocolate, tomatoes)* Sodium lauryl sulfate* Psychological stress
• What are the treatment options for ulcers?

  *saline solution*antiseptic (chlorhexidine)*anti-inflammatory benzydamine *steroid hydrocortisone
• How is saline used to treat mouth ulcers?

  * Half a teaspoon of salt in a glass of warm water

  • Rinse frequently until ulcers subside
  • Any age
• How is antiseptic chlorhexidine used to treat mouth ulcers?

  • Rinse (or spray) twice a day
  • Not within 30 minutes of toothpaste
  • Can cause temporary yellow staining of teeth
  • Can be used OTC from age 12
• How is benztdamine used to treat mouth ulcers?

  Use every 1.5-3 hours* Can be used OTC from age 6
• How is hydrocortisone used to treat mouth ulcers?

  • One tablet dissolved on ulcer four times a day
  • Can be used OTC from age12
• When should you refer a patient suffering with a mouth ulcer?

  • Lasts longer than 3 weeks
  • Keeps coming back
  • Painless and persistent
  • Grows bigger than usual
  • At back of throat
  • Bleeds or gets red and painful
• What is dyspepsia?

  A complex of upper gastrointestinal tract symptoms typically present for 4 or more weeks
• What are the symptoms to dyspepsia?

  • Severity varies from patient to patient (most: mild + intermittent)
  • Upper abdominal pain or discomfort
  • Burning sensation starting in stomach, passing upwards to behind the breastbone
  • Gastric acid reflux
  • Nausea or vomiting
• What are the common causes to dyspepsia?

  • Gastro-oesophageal reflux disease (GORD)
  • Peptic ulcer disease (gastric or duodenal ulcers)
  • Functional dyspepsia
  • Epigastric Pain Syndrome
  • Post-prandial distress syndrome (fullness and early satiety)
  • Barrett’s oesophagus
  • A premalignant condition
  • Upper GI malignancy
• What is GORD? + causes?

  Gastric-oesophageal reflux disease (GORD)2. Increased intra-gastric pressure3. Delayed gastric emptying4. Impaired oesophageal clearance of acid

  1.Transient relaxation of lower oesophageal sphincter
• What are the trigger factors to GORD?

  • Smoking
  • Alcohol
  • Coffee
  • Chocolate
  • Fatty foods
  • Being overweight
  • Stress
  • Medicines (calcium channel blockers, nitrates, NSAIDs)
  • Tight clothing
  • Pregnancy
• What are the causes to peptic ulcers (stomach)?PUD

  • Helicobacter pylori infection
  • Medication, mainly NSAIDs (others can cause them)
  • Zollinger-Ellison syndrome (rare condition causing high acid secretion)
• How can you confirm and treat a peptic ulcer?

  • Can only confirm ulcers with endoscopy
  • H. pylori infection managed with eradication therapy (2 antibiotics and a PPI)
  • Therefore, wouldn’t be managed OTC
  • However, patients frequently present asking for symptomatic relief.
• What are the treatment options for dyspepsia?

  • Non-pharmacological
  • Antacids
  • Alginates
  • H2 receptor antagonists (block them)
  • Proton pump inhibitors
• Dyspepsia - non pharmacological treatment options?

  • Lose weight if overweight
  • Eating small, frequent meals rather than large meals
  • Eat several hours before bedtime
  • Cut down on tea/coffee/cola/alcohol
  • Avoid triggers, e.g. rich/spicy/fatty foods
  • If symptoms worse when lying down, raise head of bed (do not propup head with pillows)
  • Avoid tight waistbands and belts, or tight clothing
  • Stop smoking
• What is an antacid + alginate?

  antacid = compounds that neutralise stomach acid alginate = form a raft on top of stomach contents, creating a physical barrier to prevent reflux
• What are some examples of antacids + alginates?

  antacid: pepto-bismol, Rennie alginate: gaviscon advancedual product: gaviscon dual action, peptac
• What do PPIs do? + example + side effects?

  • PPIs block proton pumps in stomach wall to prevent gastric acidproduction
  • Takes 1-4 days to work fully, so may need to cover with antacids untilit kicks in
  • Esomeprazole:
  • Common s/e: GI disturbances, headache, abdo pain
  • Can increase risk of GI infections such as Campylobacte
• When to refer a patient with dyspepsia?

  • 55 years or over, especially with new onset
  • Dyspepsia hasn’t responded to treatment
  • Features including bleeding, dysphagia, recurrent vomiting orunintentional weight loss
• What are the associated symptoms with nausea and vomiting? + medication that can be used?

  diarrhoea – may be gastroenteritis, question about food intake, could be rotavirus inchildren* ?blood in vomit – differentiate fresh blood from that of gastric/duodenal origin* ?faecal smell – GI tract obstruction* Medication: opioids, NSAIDs/aspirin, antibiotics, oestrogens, steroids,digoxin, lithium, etc
• What are the symptoms of constipation?

  • abdominal discomfort
  • cramping
  • bloating
  • nausea
  • straining
• When to refer someone with constipation?

  • unexplained weight loss
  • rectal bleeding
  • family history of colon cancer or inflammatory bowel disease
  • signs of obstruction
  • co-existing diarrhoea
  • long-term laxative use
  • failed OTC > 1 week
• What medications can cause constipation?

  Opioid analgesics* Antacids – aluminium* Antimuscarinics (anticholinergics)* Anti-epileptics* Anti-depressants* Anti-histamines* Anti-psychotics* Parkinson’s medication* Calcium-channel blockers* Calcium supplements* Diuretics* Iron* Laxatives
• What are the pharmacological + non pharmalogical treatment options for constipation?

  non pharm:*increase fibre intake*increase fluid intake*increase exercise pharm:bulk forming, ispaghula + methylcelluloseosmotic e.g lactulose, macrogols faecal softenerstimulant e.g glycerin, Senna, bisacodyl
• Diarrhoea - causes + types?

  90% of acute cases associated with viral or bacterial infection* norovirus and campylobacter most common in the community* may be parasites such as giardiasis following travel to certain areas* Acute: symptoms less than 14 days* Persistent: symptoms more than 14 days* Chronic: symptoms more than 4 weeks
• What are the symptoms to diarrhoea?

  • Three or more lose, watery stools in 24 hours
  • Faecal urgency
  • Abdominal cramps
  • Abdominal pain
  • +/- nausea and vomiting
• What to treat diarrhoea with? + when to refer?

  * 1 day in < 1year old* 2 days in < 3 year old or in older adults* 3 days in older children and adults* Pregnancy* Severe vomiting* Fever* Blood or mucous in stools* Suspected reaction to prescribed medicine* Suspected outbreak of “food poisoning”* Recent foreign travel* Persistent diarrhoea following antibiotic treatmen
• What are haemorrhoids? + risk factors?

  • Haemorrhoids are clusters of vascular tissue,smooth muscle and connective tissue arranged inthree columns along the anal canal
  • Constipation and poor diet
  • Increased incidence between ages 45-65yrs
  • Pregnancy
  • Heavy lifting
  • Chronic cough
  • Certain toilet behaviours, such as straining or spending more time ona seated toilet than on a squat toilet
• What are the two types of haemorrhoids + their symptoms?

  • External haemorrhoids
  • lumps and bumps around the anus
  • itchy (irritation from faecal matter not being fully removed by wiping)
  • not usually painful unless severely swollen
  • Internal haemorrhoids
  • discomfort/pain
  • feeling of fullness in rectum
  • when prolapsed, itchy and irritating
  • not usually painful unless prolapsed and strangulated
  • Both may bleed (especially after passing stools)
• What are the treatment options for haemorrhoids?

  • Usually self-limiting and heal within a week or so
  • Life-style measure in relation to diet and fluid intake
  • Analgesia as needed
  • Topical preparation may contain astringents, local anaesthetics,corticosteroids or a combination
  • Can be internal (creams, suppositories) or external (creams, gels,ointments)
• When to refer a haemorrhoids patient to the gp?

  *patients can feel a mass*systemic symptoms*extreme pain on defecation*weight loss*persistent change in bowel habit *faecal incontinence *over 40 years old