GALLSTONES AND DRUGS AFFECTING INTESTINAL SECRETIONS

Your gallbladder is a pear-shaped organ under your liver. It stores bile, a fluid made by your liver to digest fat. There is a very useful tool to know more about its location and functions:

http://www.healthline.com/human-body-maps/gallbladder

Gallstones are hard, pebble-like deposits that form inside the gallbladder. Gallstones may be as small as a grain of sand or as large as a golf ball.

The cause of gallstones varies. There are two main types of gallstones:

-Stones made of cholesterol, which are by far the most common type. Cholesterol gallstones have nothing to do with cholesterol levels in the blood.

-Stones made of bilirubin, which can occur when red blood cells are being destroyed (hemolysis). This leads to too much bilirubin in the bile. These stones are called pigment stones.

Symptoms

Many people with gallstones have never had any symptoms. The gallstones are often found during a routine x-ray, abdominal surgery, or other medical procedure.

However, if a large stone blocks either the cystic duct or common bile duct (called choledocholithiasis), you may have a cramping pain in the middle to right upper abdomen. This is known as biliary colic. The pain goes away if the stone passes into the first part of the small intestine (the duodenum).

Symptoms that may occur include:

-Pain in the right upper or middle upper abdomen: may be constant, may be sharp, cramping, or dull and it may spread to the back or below the right shoulder blade.

-Fever

-Yellowing of skin and whites of the eyes (jaundice)

Other symptoms that may occur with this disease include:

-Clay-colored stools

-Nausea and vomiting

Treatment

-Surgery: some people have gallstones and have never had any symptoms. The gallstones may not be found until an ultrasound is done for another reason. Surgery is usually not needed unless symptoms begin. One exception is in patients who have weight-loss surgery.

In general, patients who have symptoms will need surgery either right away, or after a short period of time.

-A technique called laparoscopic cholecystectomy is most commonly used now. This procedure uses smaller surgical cuts, which allow for a faster recovery. Patients are often sent home from the hospital on the same day as surgery, or the next morning.

-In the past, open cholecystectomy (gallbladder removal) was the usual procedure for uncomplicated cases. However, this is done less often now.

Endoscopic retrograde cholangiopancreatography (ERCP) and a procedure called a sphincterotomy may be done to find or treat gallstones in the common bile duct.

-Medication: medicines called chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be given in pill form to dissolve cholesterol gallstones. However, they may take 2 years or longer to work, and the stones may return after treatment ends.

-Lithotripsy: electrohydraulic shock wave lithotripsy (ESWL) of the gallbladder has also been used for certain patients who cannot have surgery. Because gallstones often come back in many patients, this treatment is not used very often anymore

DRUGS AFFECTING INTESTINAL SECRETIONS

1. Drugs affecting biliary composition and flow, used in gallstone disease and primary biliary cirrhosis:

-Ursodeoxycholic acid (Destolit, Urdox, Ursofalk, Ursogal):

2. Bile acid sequestrants: relieves pruritus and diarrhoea, used also in hypercholesterolaemia:

-Colestyramine. 

3. Aprotinin: no longer used for treatment of acute pancreatitis.

4. Pancreatin supplements are given by mouth to compensate for reduced or absent exocrine secretion in cystic fibrosis and following pancreatectomy, gastrectomy or chronic pancreatitis.

Source:

-BNF 57 March 2009

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

HAEMORRHOIDS, FISTULAS AND PROCTITIS

HAEMORRHOIDS

Hemorrhoids are swollen, inflamed veins around the anus or lower rectum. They are either inside the anus or under the skin around the anus. They often result from straining to have a bowel movement. Other factors include pregnancy, aging and chronic constipation or diarrhea.

Hemorrhoids are very common in both men and women. About half of all people have hemorrhoids by age 50. The most common symptom of hemorrhoids inside the anus is bright red blood covering the stool, on toilet paper or in the toilet bowl. Symptoms usually go away within a few days.

Treatment may include warm baths and a cream or other medicine. If you have large hemorrhoids, you may need surgery and other treatments.

FISTULAS

A fistula is an abnormal connection between an organ, vessel, or intestine and another structure. Fistulas are usually the result of injury or surgery. It can also result from infection or inflammation.

Inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, is an example of a disease that leads to fistulas between one loop of intestine and another. Injury can lead to fistulas between arteries and veins.

Fistulas may occur in many parts of the body. Some of these are:

-Arteriovenous (between an artery and vein)

-Biliary (created during gallbladder surgery, connecting bile ducts to the surface of the skin)

-Cervical (either an abnormal opening into the cervix or in the neck)

-Craniosinus (between the space inside the skull and a nasal sinus)

-Enterovaginal (between the bowel and vagina)

-Fecal or anal (the feces is discharged through an opening other than the anus)

-Gastric (from the stomach to the surface of the skin)

-Metroperitoneal (between the uterus and peritoneal cavity)

-Pulmonary arteriovenous (in a lung, the pulmonary artery and vein are connected, allowing the blood to bypass the oxygenation process in the lung (pulmonary areriovenous fistula).

-Umbilical (connection between the navel and gut)

Types of fistulas include:

-Blind (open on one end only, but connects to two structures)

-Complete (has both external and internal openings)

-Horseshoe (connecting the anus to the surface of the skin after going around the rectum)

-Incomplete (a tube from the skin that is closed on the inside and does not connect to any internal structure)

PROCTITIS

Proctitis is an inflammation of the rectum. It can cause discomfort, bleeding, and the discharge of mucus or pus. There are many causes of proctitis. They can be grouped as follows:

-Autoimmune disease

-Harmful substances

-Non-sexually transmitted infection

-Sexually transmitted disease (STD)

Proctitis caused by STD is common in people who have anal intercourse. STDs that can cause proctitis include gonorrhea, herpes, chlamydia, and lymphogranuloma venereum.

Infections that are not sexually transmitted are less common than STD proctitis. One type of proctitis not from an STD is an infection in children that is caused by the same bacteria as strep throat.

Autoimmune proctitis is linked to diseases such as ulcerative colitis or Crohn´s disease. If the inflammation is in the rectum only, it may come and go or move upward into the large intestine.

Proctitis may also be caused by some medicines, radiotherapy or inserting harmful substances into the rectum.

Risk factors include:

-Autoinmune disorders

-High-risk sexual practices such as anal sex

-Symptoms

-Bloody stools

-Constipation

-Rectal bleeding

-Rectal discharge, pus

-Rectal pain or discomfort

-Tenesmus (pain with bowel movement)

Most of the time, proctitis will go away when the cause of the problem is treated. Antibiotics are used is an infection is causing the problem.

Corticosteroids or mesalamine suppositories may relieve symptoms for some people. The outcome is good with treatment.

Possible Complications: anal fistula, anemia, recto-vaginal fistula in women and severe bleeding.

LOCAL PREPARATIONS FOR ANAL AND RECTAL DISORDERS

1. Soothing haemorrhoidal preparations containing mild astringents such as bismuth subgallate, zinc oxide and hamamelis may give symptomatic relief. Preparations with local anaesthetics should be used for short periods only since they may cause sensitisation of the anal skin.

2. Compound haemorrhoidal preparations with corticosteroids:
-Anugesic-HC
-Anusol-HC
-Perinal
-Proctofoam HC
-Proctosedyl
-Scheriproct
-Ultraproct
-Uniroid-HC
-Xyloproct

3. Rectal sclerosants:
-Phenol (oily phenol injection is used to inject haemorrhoids particularly when unprolapsed).

4. Management of anal fissures:
-Glyceril trinitrate (Rectogesic).

Source:

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

-BNF 57 March 2009

ACUTE DIARRHOEA AND CHRONIC BOWEL DISORDERS

ACUTE DIARRHOEA

The priority in acute diarrhoea, as in gastro-enteritis, is the prevention or reversal of fluid and electrolyte depletion.

Antimotility drugs relieve symptoms of acute diarrhoea. They are used in the management of uncomplicated acute diarrhoea in adults, fluid and electrolyte replacement may be necessary in case of dehydration.

1. Absorbents and bulk-forming drugs:

- Kaolin, light.

2. Antimotility drugs:

- Codeine phosphate

- Co-phenotrope

- Loperamide Hydrochloride (Loperamide, Imodium).

CHRONIC BOWEL DISORDERS

Inflammatory bowel disease (Ulcerative colitis and Crohn´s disease):

-Ulcerative colitis (UC) is a disease that causes inflammation and sores, called ulcers, in the lining of the rectum and colon. It is one of a group of diseases called inflammatory bowel disease.

UC can happen at any age, but it usually starts between the ages of 15 and 30. It tends to run in families. The most common symptoms are pain in the abdomen and blood or pus in diarrhea. Other symptoms may include:

-Anemia

-Severe tiredness

-Weight loss

-Loss of appetite

-Bleeding from the rectum

-Sores on the skin

-Joint pain

-Growth failure in children

About half of people with UC have mild symptoms.

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-Crohn's disease causes inflammation of the digestive system. Crohn's can affect any area from the mouth to the anus. It often affects the lower part of the small intestine called the ileum.

The cause of Crohn's disease is unknown. It may be due to an abnormal reaction by the body's immune system. It also seems to run in some families. It most commonly starts between the ages of 13 and 30.

The most common symptoms are pain in the abdomen and diarrhea. Other symptoms include

-Bleeding from the rectum

-Weight loss

-Fever

Crohn's can cause complications, such as intestinal blockages, ulcers in the intestine, and problems getting enough nutrients. People with Crohn's can also have joint pain and skin problems. Children with the disease may have growth problems.

There is no cure for Crohn's. Treatment can help control symptoms, and may include medicines, nutrition supplements, and/or surgery. Some people have long periods of remission, when they are free of symptoms.

Other disorders:

-Clostridium difficile infection.

-Malabsorption syndromes.

PHARMACOLOGY

1. Aminosalicylates:

- Balsalazide sodium (Colazide), indicated for treatment of mild to moderate ulcerative colitis and maintenance of remission.

- Mesalazine (Asacol, Ipocol, Mesren, Mezavant, Pentasa, Salofalk), indicated for treatment of mild to moderate ulcerative colitis and maintenance of remission.

- Olsalazine sodium (Dipentum), indicated for treatment of mild ulcerative colitis and maintenance of remission.

- Sulfasalazine (Salazopyrin), indicated for treatment of mild to moderate and severe ulcerative colitis and maintenance of remission and active Crohn´s disease.

2. Corticosteroids:

-Beclometasone dipropionate (Clipper)

-Budesonide (Budenofalk, Entocort)

-Hydrocortidone (Colifoam)

-Prednisolone (Predenema, Predfoam, Predsol)

3. Drugs affecting the immune response, may benefit patients with unresponsive or chronically active Crohn´s disease.

-Azathioprine

-Ciclosporin

-Mercaptopurine

-Methotrexate

*Cytokine modulators, they should be used under specialist supervision:

-Adalimumab

-Infliximab, it is licensed for the management of severe active Crohn´s disease and moderate to severe ulcerative colitis in patients whose condition has not responded adequately to treatment  with a corticosteroid and a conventional immunosuppressant or who are intolerant of them.

4. Food allergy, allergy with classical symptoms of vomiting, colic and diarrhoea caused by specific foods, such as shellfish, should be managed by strict avoidance. Sodium cromoglicate (Nalcrom) may be helpful as an adjunct to dietary avoidance.

Sources:

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

-BNF 57 March 2009

PEPTIC ULCER

PEPTIC ULCER

A peptic ulcer is a defect in the lining of the stomach or the first part of the small intestine, an area called the duodenum.

A peptic ulcer in the stomach is called a gastric ulcer. An ulcer in the duodenum is called a duodenal ulcer.

Normally, the lining of the stomach and small intestines is protected against the irritating acids produced in your stomach. If this protective lining stops working correctly and the lining breaks down, it results in inflammation (gastritis) or an ulcer.

Most ulcers occur in the first layer of the inner lining. A hole that goes all the way through the stomach or duodenum is called a perforation. A perforation is a medical emergency.

The most common cause of such damage is infection of the stomach by bacteria called Helicobacter pylori(H.pylori). Most people with peptic ulcers have these bacteria living in their gastrointestinal (GI) tract. Yet, many people who have these bacteria in their stomach do not develop an ulcer.

The following also raise your risk for peptic ulcers:

-Drinking too much alcohol

-Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-inflammatory drugs (NSAIDs). 

-Smoking cigarettes or chewing tobacco

-Being very ill, such as being on a breathing machine

-Having radiation treatments

A rare condition called Zollinger-Ellison syndrome causes stomach and duodenal ulcers. Persons with this disease have a tumor in the pancreas. This tumor releases high levels of a hormone that increases stomach acid.

Many people believe that stress causes ulcers. It is not clear if this is true, at least for everyday stress at home.

Symptoms

Small ulcers may not cause any symptoms. Some ulcers can cause serious bleeding.

Abdominal pain is a common symptom, but it doesn't always occur. The pain can differ from person to person.

Other symptoms include:

-Feeling of fullness -- unable to drink as much fluid

-Hunger and an empty feeling in the stomach, often 1 - 3 hours after a meal

-Mild nausea (vomiting may relieve this symptom)

-Pain or discomfort in the upper abdomen

-Upper abdominal pain that wakes you up at night

Other possible symptoms include: bloody or dark tarry stools, chest pain, fatigue, vomiting, possibly bloody and weight loss.

Treatment

Treatment involves a combination of medications to kill the H. pylori bacteria (if present), and reduce acid levels in the stomach. This strategy allows your ulcer to heal and reduces the chance it will come back.

Antisecretory drugs and mucosal protectants

1. H2 receptor antagonists: Histamine H-receptor antagonists heal gastric and duodenal ulcers by reducing gastric acid, they are also used to relieve symptoms of gastro-oesophageal reflux disease.

-Cimetidine (Cimetidine, Tagamet)

-Famotidine (Famotidine, Pepcid)

-Nizatidine (Nizatidine, Axid)

-Ranitidine (Ranitidine, Zantac)

2. Chelates and complexes:

-Tripotassium Dicitratobismuthate (De-Noltab)

-Sucralfate (Antepsin)

3. Prostaglandin analogues:

-Misoprostol (Citotec)

4. Proton pump inhibitors:

-Esomeprazole (Nexium)

-Lansoprazole (Zoton)

-Omeprazole (Losec)

-Pantoprazole (Protium)

-Rabeprazole sodium (Pariet)

Sources:

-http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm

-BNF 57 March 2009