Gastrointestinal Problems 2

Gastrointestinal Problems 2

Gastrointestinal Problems 2

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Constipation

  • Normal range of bowel movement is from 3 x daily to 3 x weekly
    • Consider what's normal for the patient
  • Main symptoms
    • Hard stools which are difficult to pass
    • Less frequent than usual
  • Associated symptoms
    • Abdominal discomfort
    • Bloating
    • Nausea
  • Other potential causes
    • Induced by medication
    • Misuse of laxatives
    • Behavioural, e.g. holding it in, especially in children
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When to Refer

  • Pain on defecation
  • Blood in stools - tarry stools (GI bleeding), fresh blood (lower in GI tract)
  • >40 years of age with sudden change, no obvious cause
  • Lasts longer than two weeks
  • Associated tiredness (prolonged), anaemia, thyroid dysfunction
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Constipation: Advice and Treatment

  • Increase dietary fibre - fruit and vegetables, wholegrain, wholewheat, wholemeal, seeds and oats
  • Ensure adequate fluid intake
  • Avoid sedentary lifestyle
  • Reduce caffeine intake - leads to dehydration
  • Bulk laxatives - ispaghula, methylcellulose, sterculia
  • Osmotic laxatives - lactulose, macrogol
  • Stimulant laxatives - sennosides and bisacodyl
  • Consider time, e.g. Glycerin suppositories work within an hour, Fybogel sachets work in several days
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Diarrhoea

  • Normally acute and self-limiting - lasts a few days
  • Rapid onset, watery stools passed more frequently, more than 3 times daily
  • Associated symptoms
    • Abdominal cramps
    • Flatulence
    • Weakness and malaise
  • Triggers
    • Recent trip abroad - tropical or subtropical region
    • Local minor outbreaks of gastroenteritis 
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Diarrhoea: Red Flags and When to Refer

  • Red flags
    • Blood/mucus in stools
    • Previous recent history
    • Prolonged change in bowel habit
    • Infants
    • Certain medications
    • Severe vomiting
    • Pregnancy
  • Refer: diarrhoea of greater than
    • 1 day in children under 1 year
    • 2 days in children under 3 years
    • 3 days in children over 3 and adults
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Diarrhoea: Treatment

  • Oral rehydration therapy - electrolytes
  • Loperamide - over 12 years 
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Irritable Bowel Syndrome

  • One of the most common gastrointestinal conditions
  • Chronic, relapsing and often lifelong
  • Adult prevalence 10-20% - twice as common in women
  • Most commonly affects 20-30 year olds
  • Associated symptoms
    • Abdominal pain and discomfort
    • Pain relieved by defecation/passing of wind
    • Altered defecation, change in stool form/frequency
    • Associated bloating
    • Stress can be a factor
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IBS: Red Flags and When to Refer

  • Red flags
    • Blood in stools
    • Fever
    • Prolonged change in bowel habit
    • Infants
    • Severe abdominal pain
  • Refer
    • Children under 16
    • Patients over 45 with recent bowel habit
    • Steatorrhoea (fat in faeces)
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IBS: Treatment Options

  • Antispasmodics - mebeverine, hyoscine butlylbromide, peppermint oil
  • If constipation is predominant - bulk forming/stimulant laxative
  • If diarrhoea is predominant - loperamide
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Haemorrhoids (Piles)

  • Abnormally swollen vascular cushion that are present in the anal canal
  • Estimated that one in two people will experience at least one episode at some point during their lives
  • Occur at any age - rare in anyone under 20
  • Affects both sexes equally
  • More common in patients between 45-65
  • High incidence in pregnancy
  • Constipation is a contributory factor
  • Symptoms often intermittent (last few days to a few weeks)
    • Bleeding, perianal itching, mucous discharge, pain
    • Any blood associated is bright red (spotting around the toilet, streaking on toilet paper or visible on surface of stools)
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Haemorrhoids: When to Refer

  • Persistent change in bowel habit in patients over 40 years
  • Unexplained rectal bleeding
  • Severe pain when defecating
  • Blood mixed in with the stool
  • Fever
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Haemorrhoids: Management

  • Lifestyle advice
    • advise on importance of correct anal hygiene
    • keep the region clean and dry to aid healing and reduce irritation and itching
    • use of baby wipes to cleanse, using patting not a rubbing motion
  • Treatment
    • Anaesthetics, e.g. lidocaine, benzocaine, cinchocaine
    • Astringents, e.g. bismuth, zinc
    • Anti-inflammatory drugs, e.g. hydrocortisone
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