L18: Minor Ailments - Responding to GI Queries in Community

• Common GI queries

  • Dyspepsia/indigestion
  • Gastro-oesophageal reflux disease (GORD)
  • Constipation
  • Diarrhoea
  • Nausea and vomiting
  • Piles
  • Irritable bowel syndrome (IBS)
• Dyspepsia/indigestion

  A group of symptoms linked to eating and drinking, associated with excess acid. Symptoms include bloating, burping, stomach cramps and flatulence. Causes include certain foods, timing of eating, caffeine, medication or GI tract problems (ulcer, cancer, infection)
• GORD - Gastro-oesophageal Reflux Disease

  Reflux of gastric content into the oesophagus. Symptoms include gastric pain, discomfort and wind, nausea, acidity at the back of the throat and abdominal pain. Causes include diet, lifestyle, overeating, drinking, obesity, pregnancy, incompetence of oesophageal sphincter (hernia or drug-induced)
• Indigestion, heartburn, acid reflux, GORD

  Terms often used interchangeably by patients. Heartburn (acid reflux) occurs when sphincter muscle between stomach and oesophagus allows stomach acid to leak back up. Indigestion (dyspepsia) occurs when acid from the stomach comes into contact with lining of the digestive system. GORD is a more chronic severe form of acid reflux.
• Lifestyle Advice

  Avoid large meals, fatty/hot spicy food, reduce alcohol, stop smoking, raise head of bed, don't lie down within 3 hours of meal, lose weight if overweight
• Antacids

  Raise pH, neutralize excess acid, provide rapid relief. Sodium bicarbonate causes belching, aluminium causes constipation, magnesium causes diarrhoea. Alginates form a raft/viscous foam to protect oesophagus during reflux.
• H2 - receptor antagonist

  Competitive antagonists of H2 receptor, inhibit induced acid secretion, most effective at night. OTC medicines like Ranitidine (Zantac) are no longer available OTC due to recall.
• Proton pump inhibitors (PPIs)

  Inhibit hydrogen-potassium adenosine triphosphatase enzyme system (proton pump). Converted to active drugs at acid pH, have preventative role, inhibit certain drugs metabolism.
• When to refer

  • Dysphagia
  • Hematemesis
  • Weight loss
  • Vomiting
  • Upper abdominal masses
  • Repetitive request for OTC supple
  • Onset of new symptoms
  • Upper epigastric pain
  • Hunger pain
  • Night pain relieved by eating
  • Drug induced
• Diarrhoea

  Passing of soft or watery stool at an increased frequency (> 3 times a day). Symptoms include crampy stomach pains, fever, loss of appetite, nausea and vomiting. Causes include bacterial/viral infection, antibiotics, medications, change in climate/country, anxiety, excessive alcohol.
• Diarrhoea management

  Drink plenty of fluid, eat high carbohydrate food, oral rehydration therapy, antibiotics, antimotility drugs. Review medication if drug-induced.
• Oral rehydration therapy

  Dioralyte/rehydration salts - specific mixture of electrolytes and glucose to correct electrolyte disturbances
• Antimotility agents

  Reduce motility to allow reabsorption of water and minerals, control diarrhoea. Loperamide is widely used.
• Antibiotics

  Used only if bacterial infection confirmed by stool culture, as most diarrhoea is viral
• When to refer for diarrhoea

  • Length exceeds 3 days
  • Blood in stool
  • Moderate to severe dehydration not self-managed
  • Drug-induced
  • Recent travel history
  • Regular purchase of codeine based products
• Constipation

  Altered bowel habits with reduced frequency and hardened faeces. Rome IV criteria: spontaneous bowel movements < 3 times a week. Regularity, not frequency, is important.
• Constipation management

  Lifestyle changes: balanced high-fibre diet, high fluid intake, increased exercise. Laxatives: osmotic, stimulant, bulk-forming, softeners.
• When to consider laxatives

  Straining affecting other conditions, temporary illness causing constipation, elderly with low mobility or drug-induced, before colonoscopy
• Bulk forming agents

  Swell in gut to increase faecal mass and stimulate peristalsis. Takes a few days to work, should be taken with plenty of water.
• Stimulant laxatives

  Stimulate nerve endings in gut, cause muscle contraction and faster peristalsis. Rapid relief but short-term, risk of nerve damage, can cause cramps.
• Osmotic laxatives

  Increase flow of water into intestines for softer stools. Variable onset, can cause abdominal cramps and wind.
• Faecal softeners

  Lubricate and soften faeces. Should be used in small quantities due to serious side effects like paraffin seepage and interference with fat-soluble vitamin absorption.
• When to refer for constipation

  • Drug-induced requiring regular laxatives
  • Sudden onset with no apparent reason, especially in elderly
  • Blood in faeces
  • Overuse of slimming substances
  • Severe abdominal pain
• Nausea and vomiting

  Common, can indicate serious underlying pathology. Causes include alcohol, infection, motion sickness, medications, peptic ulceration, migraine, pregnancy, head trauma, Meniere's disease, renal failure.
• When to refer for nausea and vomiting

  • Blood in vomit
  • Occurs more than two days
  • Weight loss
  • Severe abdominal pain
• Nausea and vomiting management

  Manage symptoms, oral rehydration therapy, preventative measures (diet) - dioralyte, Pepto-Bismol
• Haemorrhoids (Piles)

  Swollen veins in lining of anus and rectum, can be external or internal. Symptoms include bleeding, itching, irritation, sense of incomplete emptying, fullness around anus. Causes include increased pressure, straining, constipation, pregnancy.
• Haemorrhoids management

  High-fibre diet, plenty of water, avoid straining, treat constipation, use fibre supplements, topical corticosteroids for inflammation and itching.
• Irritable bowel syndrome (IBS)

  Common bowel disorder, abnormal contractions of large intestine muscles, increased sensitivity to gas and movement. Causes poorly understood, may relate to anxiety, depression, certain foods. Symptoms include gripy, colicky pain, wind, bloating, fatigue, disturbed bowel habits (diarrhoea, constipation).
• IBS management

  Keep diet/activity diary to identify aggravating factors, manage diarrhoea and constipation, non-medical treatments like CBT, hypnotherapy, acupuncture. Antispasmodics like hyoscine, mebeverine, peppermint oil, alverine to relax intestine.