DYSPEPSIA, GERD, IBS AND DIVERTICULAR DISEASE

Indigestion (dyspepsia) is a mild discomfort in the upper belly or abdomen,it occurs during or right after eating. It may feel like:

-A feeling of heat, burning, or pain in the area between the navel and the lower part of the breastbone.

-An unpleasant feeling of fullness that comes on soon after a meal begins or when the meal is over.

Antacids and simeticone, indicated for dyspepsia.

1. Aluminium and magnesium-containing antacids:

-Aluminium hydroxide (Alu-Cap, Maalox, Mucogel).

-Magnesium carbonate

-Magnesium trisilicate

2. Aluminium-magnesium complexes:

-Hydrotalcite

3. Antacid preparations containing simeticone (Altacite Plus, Asilone, Maalox Plus).

4. Simeticone alone (Dentinox, Infacol).

Gastroesophageal reflux disease

Your esophagus is the tube that carries food from your mouth to your stomach. Gastroesophageal reflux disease (GERD) happens when a muscle at the end of your esophagus does not close properly. This allows stomach contents to leak back, or reflux, into the esophagus and irritate it.

You may feel a burning in the chest or throat called heartburn. Sometimes, you can taste stomach fluid in the back of the mouth. If you have these symptoms more than twice a week, you may have GERD. You can also have GERD without having heartburn. Your symptoms could include a dry cough, asthma symptoms, or trouble swallowing.

Compound alginates and proprietary indigestion preparations

Alginate taken in combination with an antacid increases the viscosity of stomach contents and can protect the oesophageal mucosa from acid reflux. Some alginate-containing preparations form a viscous gel (raft) that floats on the surface of the stomach contents, thereby reducing symptoms of reflux. 

1. Alginate raft-forming oral suspensions: Acidex, Peptac.

2. Other compound alginate preparations: Gastrocote, Gaviscon Advance, Gaviscon Infant, Rennie Duo, Topal.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a problem that affects the large intestine. It can cause abdominal cramping, bloating, and a change in bowel habits. Some people with the disorder have constipation. Some have diarrhea. Others go back and forth between the two. 

Diverticular disease

Diverticula are small pouches that bulge outward through the colon, or large intestine. If you have these pouches, you have a condition called diverticulosis. It becomes more common as people age. About half of all people over age 60 have it. Doctors believe the main cause is a low-fiber diet.

Most people with diverticulosis don't have symptoms. Sometimes it causes mild cramps, bloating or constipation.

Antispasmodics and other drugs altering gut motility

The smooth muscle relaxant properties of antimuscarinic and other antispasmodic drugs may be useful in irritable bowel syndrome and in diverticular disease.

1. Antimuscarinics:

-Atropine sulphate: Atropine.

-Dicycloverine hydrochloride: Merbentyl, Kolanticon.

-Hyoscine butylbromide: Buscopan.

-Propantheline bromide: Pro-banthine.

2. Other antispasmodics:

-Alverine citrate: Spasmonal.

-Mebeverine hydrochloride: Mebeverine, Colofac, Fybogel Mebeverine.

-Peppermint oil: Colpermin, Mintec.

Sources:

http://www.nlm.nih.gov/medlineplus

BNF 57 March 2009

FIRST AID

What to do in an emergency:

Priorities:

-assess the situation - do not put yourself in danger.

-make the area safe.

-assess all casualties and attend first to any unconscious casualties.

-send for help - do not delay.

Check for a response

Gently shake the casualty´s shoulders and ask loudly, "are you all right?" If there is no response, your priorities are to:

-shout for help

-open the airway

-check for normal breathing

-take appropiate action.

A- Airway

To open the airway:

-place your hand on the casualty´s forehead and gently tilt the head back;

-tilt the chin with two fingertips.

B- Breathing

Look, listen and feel for normal breathing for no more than 10 seconds:

-look for chest movement

-listen to the casualty´s mouth for breath sounds

-feel for air on your cheek.

If the casualty is breathing normally:

-place in the recovery position

- get help

-check for continued breathing.

If the casualty is not breathing normally:

-get help

-start chest compressions

C- CPR

-lean over the casualty and with your arms straight, press down on the centre of the breastbone 5-6cm, then release the pressure

-.repeat at a rate of about 100-120 times a minute

-after 30 compressions open the airway again

-pinch the casualty´s nose closed and allow the mouth to open, 

-take a normal breath and place your mouth around the casualty´s mouth, making a good seal

-blow steadily into the mouth while watching for the chest rising

-remove your mouth from the casualty and watch for the chest falling

-give a second breath and then start 30 compressions again without delay

-continue with chest compressions and rescue breaths in a ratio of 30:2 until qualified help takes over or the casualty starts breathing normally.

Severe bleeding
The aim will be to control the bleeding and prevent infection.
-apply direct pressure to the wound
-raise and support the injured part (unless broken)
-apply a dressing and bandage firmly in place

Broken bones and spinal injuries

If a broken bone or spinal injury is suspected, obtain expert help. Do not move casualties unless they are in inmediate danger.

Burns

Burns can be serious so if in doubt, seek medical help. Cool the affected part of the body with cold water until pain is relieved. Throrough cooling may take 10 minutes or more, but this must not delay taking the casualty to hospital.

Certain chemicals may seriously irritate or damage the skin. Avoid contaminating yourself with the chemical. Treat in the same way as for other burns but flood the affected area with water for 20 minutes. Continue treatment even on the way to hospital, if necessary. Remove any contaminated clothing which is not stuck to the skin.

Eye injuries

All eye injuries are potentially serious. If there is something in the eye, wash out the eye with clean water or sterile fluid from a sealed container, to remove loose material. Do not attempt to remove anything that is embedded in the eye.

If chemicals are involved, flush the eye with water or sterile fluid for at least 10 minutes, while gently holding the eyelids open. Ask the casualty to hold a pad over the injuried eye and send them to hospital.

Record keeping

It is good practice to use a book for recording any incidents involving injuries or illness which you have attended. Include the following information in your entry:

-the date, time and place of the incident

-the name and job of the injured or ill person

-details of the injury/illness and any first aid given

-what happened to the casualty immediatly afterwards

-the name and signature of the person dealing with the incident. 

Source:

Health and Safety Executive, Basic advice on first aid at work

SUBCUTANEOUS FLUIDS

The management of unwell older people who have poor venous access, or who are unable to tolerate intravenous cannulation, presents a common and difficult challenge for clinicians in many specialities. Whilst the use of subcutaneous infusions (hypodermoclysis) is commonplace in a palliative care environment and elderly medical ward, its use, particularly outside of hospice and acute hospital (medical centre) settings, remains rather variable. 

Hypodermoclysis has been an alternative option to the traditional intravenous route for over 50 years. This method involves the insertion of a 21 or 23 gauge butterfly cannula under aseptic conditions into subcutaneous tissue. As subcutaneous tissue tends to diminish peripherally and increase in central areas as part of the ageing process, the abdomen, scapula or thighs are all prime sites for administration of subcutaneous fluids. Once the cannula is inserted, it is attached to a giving set and connected to a bag of parenteral fluids, commonly infused over a 24 h period. The standard practice is to use Saline 0.9%.

Indications:

-Mild dehydration, used as a supplement as the amount of fluid per 24 hours is restricted.

-Acute episode: mild infection, vomiting, diaorrhea, temporary confusion, prevention of pressure sores or/and an adequate fluid intake cannot be maintained.

Contraindications:

-Existing fluid restrictions.

-Diuretic therapy.

Fluids must be gravity fed by drip stand giving set (like Sof-set or Graseby) and calculate drip rate, not infused using a pump.

Sof-set

Equipment needed:

-Fluids for infusion

-Standard administration set

-Drip stand

-Transparent adhesive dressing (opsite, tegaderm)

-Sharp bin

-Sterile field

-Gloves and apron

-Anti-microbial swabs

-Butterfly needle/Sof-set

-Signed direction to administrate and all recorded on the kardex

-Fluid balance chart

Palliative Care

Portable infusion pumps are used in palliative care to deliver a continuous subcutaneous infusion of medication over 24 hours in order to maintain symptom control.
A patient is unable to take medication orally due to:
-Persistent nausea and/ or vomiting.
-Dysphagia.
-Bowel obstruction or malabsorption.
-Reduced level of consciousness, such as in the last days of life.

The McKinley syringe driver is one of the most used, instructions of use can be found in this webpage: http://www.mckinleymed.co.uk/training/t34/index.php

Source: 

http://qjmed.oxfordjournals.org/content/97/11/765.full

Subcutaneous fluids training, provided by Belfast Health and Social Care Trust

http://www.palliativecareguidelines.scot.nhs.uk/

COPD (Chronic Obstructive Pulmonary Disease)

COPD is a disabling condition affecting the lungs and involving irreversible lung damage, so that the lungs can no longer function at full capacity.

COPD comprises two related lung diseases:

-Chronic bronchitis: results from inflammation and irritation of the airways in the lung. This causes airway narrowing, which can cause shortness of breath or wheezing. It is characterised by the presence of cough and phlegm production for more than three months in two consecutive years.

-Emphysema; air sacs deep within the lungs, where oxygen is absorbed into the bloodstream, are prone to damage from toxins such as tobacco smoke. Emphysema develops when the air sacs enlarge and are no longer able to function properly. This results in poor oxygen delivery to the blood circulation.

The chest muscles that are involved in breathing in people with emphysema have to work harder in order to sustain an adequate oxygen level in the blood. This contributes to breathlessness, which is made worse by the associated collapse in the surrounding airways caused by the loss of the lungs natural elasticity as a consequence of lung tissue destruction. Air gets trapped in the lungs when the airways collapse during exhalation and this leads to hyperinflation of the lungs where the volume of the lungs becomes larger than normal.

There is ongoing inflammation in the airways in COPD. The onset of breathlessness is gradual over time.

Symptoms of COPD

-Many people get used to their COPD without realising it, especially in the early stages of the condition.

-You may find that you become tired easily when gardening or get out of breath when walking on an incline.

-People with COPD also tend to produce phlegm, particularly in the mornings.

-You may find that you always need to bring up phlegm by constantly coughing.

-You may also find it hard sometimes to shift phlegm from your lungs.

-The phlegm is usually clear in colour. Green or brown discoloration of thickened phlegm usually indicates an infection. Chest infection is common in people with COPD, especially during winter months. It is important to recognise infection early and to seek medical treatment.

Causes of COPD

-Smoking is the main cause of COPD.

-Other causes of COPD: alpha-1-antitrypsin deficiency, chest infections, bronchiectasis, chronic asthma and occupational exposures.

Other complications from COPD

-Breathlessness, is a frequently occuring symptom of heart failure.

-Swollen ankles, can be also a symptom of heart failure.

COPD can be very disabling; there is currently no known cure but appropriate treatment and support will help.

Treatment

The main aim of treatment is to relieve breathlessness. It does not reverse or cure the underlying condition but may improve symptoms and reduce flare-ups.

There are several forms of treatment available divided into two categories:

• Inhaled therapy: reliever (when the need arises) and preventer (they need to be taken regularly) medication.

Class of medication:

-Corticosteroids (preventer, usually twice daily): beclometasone (AeroBec), budesonide (Pulmicort) and fluticasone (Flixotide).

-Beta-2 agonists short acting like salbutamol (Ventolin) and terbutaline (Bricanyl), they are taken when the need arises and their effects last for around 2 hours.

-Beta-2 agonists long acting like formoterol (Oxis) and salmeterol (Serevent), they keep the airways opened for up to 12 hours, used as a preventer medication usually twice a day.

-Anticholinergics short acting; can relieve breathlessness for up to 6 hours, usually used four times daily like ipratropium (Atrovent).

-Anticholinergics long acting: can keep the airway open for up to 24 hours, used once daily like tiotropium (Spiriva).

Examples of combination inhalers are:

-Combivent (ipratropium plus salbutamol).

-Seretide (fluticasone plus salmeterol).

-Symbicort (budesonide plus formoterol).

Types of inhaler devices:

-Pressurised metered-dose inhalers.

-Dry powder inhalers.

-Nebulisers.

-Using a spacer.

• Oral therapy:

-Corticosteroids: are used mainly during a flare-up. They control inflammation of the lungs and may help in hastening recovery.

-Methylxanthines: may be used in addition to inhaler medication. They inhibit enzymes (phosphodiesterases) involved in the inflammatory process in the body and by doing so help reduce inflammation in the airways. They need to be taken daily and regular blood tests will be required. An example is theophylline (Phyllocontin).

-Mucolytics: they loosen the phlegm in the lungs making it easier to cough up. Carbocisteine (Mucodyne) and mecysteine (Visclair) are mucolytics.

-Antibiotics: may be used during a flare-up because they kill bacteria and prevent it from multiplying. They should not be used routinely to prevent infections as this may cause antibiotic resistance. Some antibiotics used are amoxicillin and clarithromycin.

-Antidepressants: may be prescribed to help with anxiety and depression related to COPD. Usually taken once daily like citalopram and paroxetine.

-Anti-phosphodiesterases: they reduce inflammation in the airways and may help with breathlessness, roflumilast and cilomilast are some examples.

• Oxygen therapy: can be used either continuously or qhen the need arises but it may not be suitable for everyone with COPD.

Source: COPD Chronic Obstructive Pulmonary Disease, Dr Daniel Lee, Family Doctor Publications 2008.