WEEK 9: Alimentary system - History
Abdominal pain: qus about pain itself
HPC
Rationale
Site
Where, local/ diffuse, "show me where it is worst"; can give an idea about which organ affected
Onset
Timescale: Single/multiple bout? Acute/gradual?(hours, weeks, months, years).
Character
Vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing
‘Colicky-like’ – a squeezing pain that builds up and then eases off; comes in waves; indicates a
blockage in a duct/hollow organ and represents the body’s attempt to overcome this
• Gallstones/biliary colic: RUQ radiating to tip of scapula
Radiation
• Peptic ulcers: Epigastric pain, often burning/gnawing, radiating to back
• Pancreatitis: Severe epigastric/central pain, radiating to back
• Irritable bowel syndrome: Colicky lower pain, relieved by defecation
Associated sym
Pallor, sweating?
Timing
When last felt well, chronic: why came now? How long did it last? Secs, mins hours
Pattern: chronic intermittent condition with exacerbation of same symptoms? Chronic intermittent
condition with new symptoms? New presentation? When did symptoms begin?
Exacerbating /
"What are you doing when it comes on?". "What do you do after it comes on?" ,
• Gallstones: pain increased by fatty food intake; relieved by low fat diet
relieving factors
• Peptic ulcers: pain increased by aspirin/NSAID and spicy foods; relieved by Antacids/H2
receptor antagonists/PPIs/milk
• Pancreatitis: if chronic, pain increased by eating/alcohol; relieved by not eating
• Irritable Bowel Syndrome: pain increased by stress; pain better when on holiday
• Oesophagitis: made worse by hot tea, relief by antacids or milk
Severity
Acute abdo pain can be very severe; the pt will roll around the floor with renal colic; the pt won’t
want to move if a perforated ulcer; there may be pallor and sweating in each case
• Impact of symptoms on life – FIFE: ‘does it interrupt your life?’
Questions about potential causes of pain
Area
Common
Description of cause
cause
Oesophagus Oesophagitis Inflammation of oesophagus caused by gastric reflux.
Retrosternal burning pain made worse by citrus fruits and spicy foods and eased by
milk and antacids(and maybe GTN – reduces spasm). Lasts a few mins-hours;
recurrent.
Ass symptoms: nausea, vomiting, abdo pain. RF = smoking, alcohol
GastroDue to reflux of gastric acid/stomach contents into oesophagus
oesophageal Symptoms vary: heartburn; acid reflux; regurgitation; vomiting; chest pain;
reflux
endoscopy normal in 30-50% of cases so good history needed.
disease
Worrying symptoms: if not helped by acid-suppressive therapy; if associated
(GORD)
dysphagia (may be due to oesophagitis, but never assume this); if weight loss; if
associated haematemesis (again, may be due to oesophagitis, but never assume
this); new symptoms in older age group
Stomach/
Gastritis
Inflammation of stomach mucosa, which can be due to bile reflux, H. pylori bacteria,
duodenum
NSAIDs, AD(pernicious anaemia)
Peptic ulcer
Deficit that penetrates the muscularis mucosae.
Burning/gnawing pain located in epigastrum; pain of gastrc ulcer increases after a
meal whilst a duodenal ulcer is eased – sometimes! Complication of peptic ulcer is
perforation leading to peritonitis – pt can only lie still.
Ass symptoms: anorexia, nausea, vomiting, belching, waterbrash. RF = H. pylori,
NSAIDs, smoking, alcohol
Hepatobiliary Biliary colic/
Precipitates of cholesterol form gall stones which can occur in gallbladder or bile
tract
stones or
ducts. Stones in duct or gallbladder can act as source of infection and cause
Cholecystitis ascending cholangitis or cholecystitis, respectively.
Acute pain in RUQ/epigastrum that radiates around scapula and lasts ~hours. Pt
rolls around in agony; pain rarely fluctuates despite ‘colic’
Ass symptoms: Anorexia, nausea, vomiting, belching, jaundice, fever(with
cholecystitis/cholangitis) . RF = high cholesterol, >40yo
Pancreas
Pancreatitis
Inflammation of pancreas for which alcohol and gallstones are major risk factors
Often acute pain in epigastrum that radiates through to the back. Should be
considered with any acute abdo pain.
Ass symptoms: anorexia, nausea, vomiting, fever, hypotension, weight loss(chronic
pancreatitis). RF = gallstones, alcohol, viral infections, drugs – steroids
Kidneys
Renal
Calcium oxalate precipitates to form kidney stones that can block the ureter/renal
colic/stones
pelvis.
Pain felt in loins and can also cause pt to roll around in agony; pain radiates down
abdo into testes/labia(loin to groin)
Ass symptoms: anorexia, nausea, vomiting, urinary frequency, haematuria. RF =
dehydration, immobility, hypercalcaemia, stagnant infected urine,
hyperuricaemia(eg after chemotherapy)
Large bowel
Constipation
Bowel frequency < 3x/week of having to strain for >1/4 time of defaecation
Usually in elderly pt; pain may be dull or sharp, constant or colicky, tends to be
diffuse and diff to point to; pain may also move site.
Ass symptoms: anorexia, nausea, vomiting, flatulence, spurious diarrhoea. RF =
dehydration, lack of dietary fibre, drugs
Diverticulitis
Outpuchings of the large bowel due to an increased pressure in the lumen; common
and asymptomatic usually.
Pain may be severe and acute; may originate in umbilical region and radiate to lt
iliac fossa(ie mirror image of appendicitis).
Ass symptoms: anorexia, nausea, vomiting, diarrhoea/constitpation, bleeding per
rectum(PR), fever. RF = poor dietary fibre, increasing age
Irritable
Can cause constipation, diarrhoea, abdo pain.
bowel
Variable pain in terms of onset and character; rarely severe
syndrome
Ass symptoms: nausea, diarrhoea/constitipation, belching, heartburn, flatulence. RF
= anxiety, depression
Appendix
Appendicitis
Inflammation of appendix. Most common predisposing cause is a faecolith within
the lumen of the appendix.
Colicky, umbilical pain that radiates to rt iliac fossa(McBurney’s point)
Ass symptoms: anorexia, nausea, vomiting, urinary frequency,
diarrhoea/constipation. RF = poor dietary fibre
Less likely DD: bowel obstruction, mesenteric ischemia, diabetic ketoacidosis, acute intermittent porphyria,
hypercalcaemia
Other presenting complaints:
Presenting Complaint
Rationale
Abdominal distension
Ascites in liver disease; 6Fs(fat, fetus, faeces, flatus, fluid, flipping tumour!)
Nausea
Often non-specific symptom alone
Possible diagnoses: Gastroenteritis(diarrhoea); Obstruction(abdo pain, bloating);
PUD(abdo pain); Pancreatitis(abdo pain); Gastric outflow obstruction(weight loss)
Qus about vomit itself:
Vomiting
Gastrointestinal
How long for(acute/chronic)? Is it preceeded by nausea/retching? How long after eating
Peptic ulcer; pancreatitis;
does vomiting occur? Immediate (often psychogenic); Within 1 hour (gastric cause); 2-3
cholecystitis
Bowel obstruction
hours later (small bowel cause) How much? What do they vomit? undigested
Non-GI
food(pharyngeal pouch); digested+projectile vomiting(pyloric stenosis); dark+smell
Psychogenic; sepsis; severe
pain(MI, aortic dissection);
faeculent(bowel obstruction); blood(coffee grounds – see later)
endocrine(DM, Addison’s,
Qus about potential causes:
hyperparathyroidism);
Pregnant? Any precipitating factors – food?(6h – Bacillus cereus; 12-24h – salmonella);
CNS(meningigits, SOM);
drugs(opiates, NSAIDS, digoxin,
ask about chest pain(MI) or epigastric pain(MI, pancreatitis, cholecystitis, peptic ulcer);
cytotoxic drugs)
colicky pain+vomit(?intestinal obstruction)
From here do a review of GI system.
Dysphagia
Sensation of obstruction during the passage of liquid or solid through the pharynx or
Difficulty in swallowing oesophagus, i.e. within 15 seconds of food leaving the mouth.
‘difficulty in getting
Continuous or intermittent? How long? Where does food stick? Solids, liquids or both?
food down’
Acid reflux or dyspepsia? Consider risk factors for Ca.
Disease of mouth and tongue
Characteristics of oesophageal disorder: exclude local problems/pain on swallowing 1st
(e.g. tonsillitis)
?Regurgitation: ?mistaken for vomit but absence of retching/presence of undigested food
Neuromuscular disorders
Pharyngeal disorders
Local factors in the mouth: apthous ulcers, herpes simplex, candida, lack of
Bulbar palsy (e.g. motor neurone
dentures(causes pain when chewing food), tonsillitis
disease); stroke, PD, MS
Myasthenia gravis
Odynophagia is pain during the act of swallowing(suggests oesophagitis). Causes
Oesophageal motility
include tonsillitis, reflux, infection(candida), chemical oesophagitis due to drugs such as
disorders
bisphosphonates or slow-release potassium, or associated with oesophageal stenosis.
Achalasia; Scleroderma;
Diffuse oesophageal spasm;
Substernal discomfort, heartburn: when severe can be difficult to distinguish from the
Presbyoesophagus; Diabetes
pain of IHD; often worst lying down at night as gravity inc reflux, or on bending or stooping.
mellitus; Chagas' disease
Extrinsic pressure
High dysphagia: Do they have a sensation of a lump in their throat? Do they swallow
Mediastinal glands; Goitre;
food, then regurgitate? Do they have progressive difficulty in getting food down?
Enlarged left atrium
Intrinsic lesion
Causes: Globus hystericus(lump in throat at level of the larynx); Pharyngeal pouch(food
Foreign body
down then regurg ½hr later); High stricture(very diff to get food down at all – ?liquid diet;
Stricture:
intermittent slow progression with a history of heartburn(benign peptic stricture)
benign - peptic, corrosive
malignant - carcinoma
Low dysphagia: All foods? Solids>liquids? How long? Progressive? Continuous or
Lower oesophageal ring
intermittent? Associated with reflux symptoms?
Oesophageal web
Pharyngeal pouch
Causes: relentless progression over a few weeks(malignant stricture); slow onset of
dysphagia for solids and liquids simultaneously(motility disorder: achalasia); oesophagitis;
Dyspepsia/’indigestion’
Haemetemesis
Oesophageal causes:
severe oesophagitis,
Mallory-Weiss tear, varices,
cancer
Stomach causes: gastric
ulcer, erosions, varices,
cancer
Duodenum causes:
duodenitis, duodenal ulcer
Recent change in
bowel habit
Cause of constipation:
Idiopathic; diet;
drugs(opiates, anticholinergics); colon/rectum
cancer; diverticular disease;
acute bowel obstruction;
spinal cord disease; PD;
hypothyroidism;
hypercalcaemia
Cause of diarrhoea:
Diet(curry, malnutrition);
stress(tests, IBS);
infection(viral
gastroenteritis, food
poisoning, traveller’s
diarrhoea);
chronic inflamm(UC,
Crohn’s, ischaemic colitis,
radiation colitis);
endocrine(hyperthyroidism,
carcinoid syndrome,
Zollinger-Ellison syndrome);
malabsorption(celiac
disease, bacterial
overgrowth, iliac resection);
pancreatic disease;
drugs(laxative abuse,
antibiotics, digoxin,
theophylline, Mg
compounds);
spurious diarrhoea
Rectal bleeding
Anal causes:
haemarrhoids, anal fissure,
carcinoma of rectum
Colon causes: ulcerative
colitis, Crohn’sdisease,
ischaemic colitis, carcinoma
of colon, polyps,
angiodysplasia
Rarely used term by pts. Inexact term – collective range of symptoms – epigastric pain,
heartburn, nausea, upper abdo bloating, belching,wind, fullness; indicates upper GI
pathology – often caused by peptic ulcer – confirm with endoscopy.
Red flags suggest cancer = anorexia, weight loss, dysphagia, protracted vomiting,
haematemesis/melaena, constant abdominal pain
Ask what the patient means: Covers ‘coffee-ground’ if blood kept in stomach for long time
to vomiting up fresh blood and clots(signifies upper GI bleed)
Appearance: check if ribena/wine has not just been drunk(dark vomit can often be
misleading as dark blood)
Is pt haemodynamically stable or hypovolaemic? If blood loss is severe enough, the pt
may complain of dizziness; pale/clammy, tachycardia(>100 = serious), BP(hypotension =
serious) – signs of circulatory shock
Is there nausea or retching? If the pt has retched repeatedly before blood finally
appears(Mallory-Weiss tear of oesophagus; if blood/coffee grounds in early vomit(eg
peptic ulcer); effortless vomiting of large bright red blood(bleeding oesophageal varices –
emergency, esp in pt with alcohol, chronic liver disease, past varices); if pain(PUD,
gastritis, duodenitis)
How much did they vomit?
Associated symptoms: anaemia; anorexia, dysphagia, weight loss(underlying malignancy)
Constipation = <3x/week or straining > ¼ time of defaecation
How long has the pt suffered constipation? Symptoms >1year unlikely to be sinister
pathology(?normal variant) – check why their complaining now
Ask about pt’s diet and what they eat in a typical day. May not eat enough/v little fibre;
~1.5L fluid required along with exercise for regular bowel habit. Maybe check Ca 2+ and
thyroid levels to rule out hypercalcaemia or hypothyroidism.
Ask about occupation – lorry drivers may get used to ‘hanging on’ a bit longer
If pt flipping between diarrhoea/constipation or recently developed constipation – further
investigation - ?bowel cancer, diverticulitis, IBD
Pt with absolute constipation(even flatus) together with colicky abdo pain and faeculent
vomiting - ?acute bowel obstruction
Any other abdo symptoms, esp tenesmus(carcinoma of rectum, IBD)
Be aware it may occur in spinal injury, PD, stroke – these can have a huge impact on pt
Drugs may cause constipation(opiates, anti-cholinergics and those drugs with anticholinergic side effects: anti-depressants or oxybutinin, Al-containing antacids: aludrox,
algicon)
Diarrhoea +/- vomiting – Onset? Contacts? Travel?
Normal bowel habit varies from once a week to several times per day: be clear what the
patient means – what is normal for them?; may mean loose stool 1-10x/day. True
definition is greater than 300g/day of stool but this has no practical relevance
What does the stool look like? (formed, semi-formed, watery) – Bristol stool chart
Number of times/day
Any blood in stool(infective colitis, diverticular disease, IBD, malignancy)
Any mucus in stool(ass with inflammatory conditions)
Are stools loose, pale, bulky and float in water(steatorrhea caused by malabsorption)
Ask about parties, restaurants(food poisoning: campylobacter may cause chronic
diarrhoea)
Recent travel abroad
Occupation(counselling rather than a clue to cause) – should not work until clear of risk if
work in a ‘sensitive’ job – cooks, Drs...
Drugs(antibiotics – kill off commensual bacteria, C. Diff = diarrhoea/’pseudomembranous
collitis’); laxatives
Review of systems: hyperthyroidism, carcinoid syndrome, Zollinger-Ellison
syndrome(Zollinger-Ellison syndrome is caused by tumors, usually found in the head of
the pancreas and the upper small intestine; produce gastrin(gastrinomas); cause
production of too much stomach acid)
Acute causes: Gastroenteritis;
Chronic causes: Inflammatory bowel disease; Colonic cancer (classically L-sided presents
with increasing constipation, right sided with anaemia);
Two forms: melaena or frank bleeding
Is the pt haemodynamically stable? Use same criteria as for haematemesis
Is blood bright red or dark red? The more proximal the lesion, the darker the blood.
Is the blood mixed in with the motion?(note that most pt will finish toileting and see a
mixture of blood and faeces, and claim it is mixed in) – ask if blood dripped in the toilet
after defaecation or was on the toilet paper?(both suggest haemorrhoids/anal fissure)
Pain on defaecation?(painless = haemorrohoids; painful = anal fissure); any other abdo
Upper GI cause: torrential
bleed
Change in appearance
of stool: Melaena
Weight
change/anorexia
Jaundice
symptoms – further investigation may be due
Any diarrhoea(IBD) or constipation(anal fissure)?
Any mucus passed?(suggests an inflamm cause of diarrhoea/bleeding)
Ask about recent travel as some infective conditions can cause PR bleeding(shigella,
amoebic dysentery, schistosomiasis)
Ask about abdo pain(colicky/cramp-like prior to defaecation suggests UC)
Black, sticky stool; results from degradation of blood; can occur with 50-100ml of blood
loss; proximal colonic lesions may also cause; if very fresh, can appear to be fresh PR
bleeding
Pt may describe black stools if on iron tablets/bismuth compounds
Due to bleeding in upper GI tract or right sided colonic lesions; ask about duration and
amount; change in bowels, tenesmus(incomplete evacuation following defeacation – pt
needs to return to toilet constantly), abdo pain(PUD), weight loss(malignancy)
Drugs: aspirin, clopidogrel/prasugrel = anti-platelet drugs; dipyridamole; NSAID;
warfarin/heparin = inc bleeding
Verify change in wt: How much over how long? If problems thinking about this, ‘Are your
clothes loose and ill fitting these days?
Establish the cause: ask about food intake; loss of appetite or interest in food(anorexia)?
Dieting? Depression? – check by asking about sleep patterns, anhedonia, observing pt’s
demeanour; if young girl – suspect anorexia nervosa; weight loss despite normal/inc
appetite can occur in thyrotoxicosis(an overactive thyroid), diabetes mellitus, malignancy;
nights sweats and weight loss may be due to TB or lymphoma; if asymptomatic always
look for coeliac disease and check review of systems. Remember thyroid dysfunction
(hyperthyroidism), high calcium, drug side-effects.
Weight gain uncommon complaint but may be a sign of depression, hypothyrpoidism,
rarely – lesion of hypothalamus(leading to hypopituitarism), fluid retention(congestive
cardiac failure/ascites) if rapid weight gain and drugs(NSAID/steroids inc appeptite).
Associated symptoms are important because there are lots of possible diagnoses
(not just GI) and so has to be seen in the context of other symptoms.
Yellow discolouration of the skin and sclera due to the deposition of bile pigment bilirubin.
Bilirubin is a breakdown product of Hb+is conjugated in the liver before excretion in bile.
PC:
How long has the pt had jaundice?
Ask about colour of stools/urine. In obstructive jaundice, bilirubin in bile does not reach
intestine where it contributes to colour of stools(faeces therefore pale/clay coloured);
excess bilirubin is excreted in urine(hence dark urine)
Ask about itching as bilirubin deposited in skin is an irritant.
Ask about pain(biliary colic suggests gallstones; dull epigastric/rt hypochondrum pain
suggests hepatitis; painless, progressive jaundice suggests carcinoma of head of
pancreas)
Ask about fever(sweating and rigor suggest ascending cholangitis – infection of bile
ducts); Charcot’s triad =jaundice, RUQ pain, fever
PMH: Blood transfusions(pre-1991: Hep B/C risk); previous ops esp around biliary
tree(bile duct stricture); autoimmune disease(SLE ass autoimmune hepatitis/IBD);
previous gallstones? Even if cholecystectomy, can get gallstones in CBD; recent RUQ
pain?; any history of cholangitis? Triad of RUQ pain, jaundice and fevers and recent
weight loss? Recent central abdo pain radiating to back?
Drugs may cause liver damage – check BNF; alcohol = chronic liver disease; paracetamol
O/D; metformin inc wind and changes bowel
FH: Some haemolytic diseases are hereditary(hereditary spherocytosis = autosomal
dominant)
SH: IVDU; unprotected sex with multiple partners(inc risk of hep B/C and HIV); piercing;
tattoos; travel abroad?(exotic infections, Hep A can be acquired through seafood; hydatid
amongst sheep in Wales); occupation(sewage workers: leptospirosis; sheep farmers:
hydatid disease; Drs: hep B/C)
Review of systems
Causes:
 Pre-hepatic: Dark urine and dark stools; Gilbert’s Syndrome(inborn error of
metabolism=familial hyperbilirubinaemia as low activity of UDP-glucoronyl transferase);
Dubin-Johnson(inborn error of metab; low activity of excretion of bilirubin glucoronide);
haemolysis of RBC
 Hepatic: Dark urine and dark stools; drugs, Hepatitis infection(high AST/ALT, low ALP)
 Cholestatic/Post-hepatic: Dark urine and pale stools: (high ALP, low AST/ALT);
 note – sometimes causes are based on obstructive versus non-obstructive
 Obstructive: gallstones; pancreatic cancer (head of pancreas blocking CBD); lymph
nodes at porta hepatis
Pruritis
Lethargy
`Heartburn'
Hernia: protrusion of a
viscus through its
containing sac
 Non-obstructive: drugs; fluid; infiltration
Bilirubin deposited in skin is an irritant – early jaundice?
Malabsorption?
Common symptom; retrosternal burning pain; may radiate to neck. Normally due to GORD
or peptic ulcer disease, but may be due to cardiac ischaemia or infarction(check ?angina).
Ass symptoms: nausea, waterbrash(fluid inc in mouth); suggests GI cause if exacerbated
by spicy food, citris fruits, lying flat and relieved by antacids/PPIs.
Types of hernia: incisional ; inguinal; femoral; hiatus (causing GORD);
Classical history: bulge in groin or previous scar; comes and goes; usually on coughing or
straining; able to push it back in; may be painful; always need to examine groins abdo pain
Past Medical History
Any similar problems in the past?
Any hospital admissions?
Any investigations / operations?
Rationale
Blood transfusions(pre-’91)
Last menstrual period
Carcinoma
Peptic ulcer / H.Pylori
Hepatitis
JADE, TAB, MARCH, thyroid function
Drug History
ALLERGIES (response?)
Steroids
Antibiotics
NSAIDs
Contraceptive pill
Opiates
Diuretics
Supplements (ferrous sulphate,
vitamins, calcium, phosphates)
OTC / homeopathic remedies
Warfain
Changed GI motions
Vomiting
?Cholecystectomy causing diarrhoea; ?Obstetric / gynaecological; previous
ops can cause adhesions in the abdomen leading to bowel obstruction
Hep B/C risk
Pregnancy can cause early morning vomiting
?Metastases
Common cause of peptic ulcer
Rationale
Inc risk of bleeding, esp if combined with NSAIDs
Cause jaundice, diarrhoea
Potentiate peptic ulceration
Constipation
Fe tablets: usually constipation
SSRIs: diarrhoea
May contain aspirin
Exacerbates bleeding
Iron tablets, laxatives, opiates, NSAIDs, antibiotics, anticoagulants and SSRIs;
metformin increases wind and change in bowel habit
Any drug, esp antibiotics, cytotoxic drugs, and NSAIDs, or drugs in overdose.
Some drugs have a small therapeutic range(digoxin, aminophylline, phenytoin);
alcohol too. Emotions can also induce vomiting.
Social History
Rationale
Smoking (pack years)
Crohn’s disease: smoking bad
Alcohol (units/week)
UC: alcohol bad; smoking not so; % x L=units e.g. 1L 40% vodka = 40 units
Diet
IBD risk if poor fibre; foods may affect pain
Exercise
Housing
Recreational drugs (IV)
Hep risk (A – recover or die; B/C – can be carriers)
Occupational exposure
Pub landlord
Overseas travel
Hep and TB risk
Contact with jaundiced person
Sexual orientation?
Hep risk
Hepatitis RF: alcohol, sex, drugs, piercings, tattoos, transfusions pre-’91, infection
Family History
Inflammatory Bowel Disease (IBD)
Irritable Bowel Syndrome (IBS)
Peptic ulceration
Familial Polyps
Cancer
Jaundice
Rationale
Chron’s = 10% risk
Gilbert’s syndrome
List 4 risk factors for alimentary disorders (if necessary indicating for which
condition risk applies):
1
2
3
4
CLD: ascites, muscle wasting, bruising, gynaecomastia, spider naevi, caput medusa due to portal
hypertension
WEEK 10: Alimentary system - Examination
‘Do you mind if examine your tummy and hands?’
Ask pt to strip to underwear – ‘nipples to knees’, keeping groin/breasts covered until necessary – make sure check for
telangiectasia – dilated capillaries/small arterioles that look like thin streaks or blobs which blanch if pressed.
Lie pt flat on one pillow, or two if they have kyphosis. May have to examine them upright if they suffer orthopnoea.
General features (give 3):
face
hands
nutritional state
General Inspection
Examine
Is the patient breathing comfortably? GCS?
Is the patient in any pain?
Colour?
Is abdomen distended?
Evidence of muscle wasting, scratch marks?
Venflon or any equipment?
Rationale
Anaemia, jaundice, Grey-Turner’s, Cullen’s
See below – 6Fs
Pts may be itchy if on carbamizole or have jaundice - CLD
Analgesia as pt in severe pain(pancreatitis)/infection requiring
AB(cholecystitis)
Hands Those in bold = chronic(>6 months) liver disease(CLD) signs ColourContractureClubbingKoilonychia
Examine
Leukconychia
Koilonychia
Clubbing
Rationale
White nail due to liver cirrhosis+nephritic syndrome(due to low albumin)
Spoon-shaped depression on nail;due to chronic anaemia = iron deficiency:find cause!
Mainly a sign for resp disease, but also liver cirrhosis, achalasia, UC, Crohn’s and
celiac disease
Capillary refill
Perfusion
Palmer creases (anaemia)
Palmer erythema
(+anemia/jaundice)
Spider-naevus
May be present in alcoholic liver disease via malnutrition
Red thenar/hypothenar eminences/finger pulps due to CLD(gonadal atrophy),
pregnancy, contraceptive pill, rheumatoid arthritis(due to inc circulating oestrogens)
These are telangiectasia with a specific appearance; central arteriole with tiny vessels
radiating from it; must demonstrate by blanching; due to CLD, pregnancy,
thyrotoxicosis or a normal finding if <5!
Dupuytren’s contracture
Thickening+contracture of palmar aponeurosis(esp digits 3-5) due to alcoholism, CLD,
diabetes mellitus, heavy manual labour
Flapping tremor/liver
Hepatic encepthalopathy due to liver failure. Same as for resp disease(CO2 retention);
flap/asterixis
pt should flex hand at wrists and spread fingers.
Purpura
Due to spontaneous bleeding into the skin; if <3mm = petechiae; if >10mm =
ecchymoses. CLD will reduce clotting factors 2,7,9,10 leading to inc bleeding. Lesions
do not blanch with pressure.
Important! Acute liver failure(paracetamol O/D) may not present with any of these signs as it happens so quickly.
Liver failure = decreasing conscious level, asterixis, foeter hepaticus
Arms & Neck PulsePressurePerspiration(in axillae)Palpable lymph nodes
Examine
Pulse check
Blood pressure
JVP
Rationale
May be raised if portal hypertension?
Face
Examine
Eyes
Lips
Rationale/ Technique
Jaundice, anaemia(oesophageal varices; colonic polyps; malabsorption of iron, folate, B12)
Exopthalmos(thyroid may cause GI problems: hyper: diarrhoea; hypothyroid: constipation)
Brown freckly pigmentation around mouth/lips could signify Peutz-Jehger’s syndrome(hereditary
intestinal polyposis syndrome); indicative of bowel polyps(can bleed/cause obstruction). Also
look for telangiectasia(indicates HHT)
Xanthelasmata
Telangiectasia,
as well as
spider naevi
Mouth, tongue
and dentition –
use a light to
look inside!
Fluid status:
Stomatitis
Smooth tongue
Salivary glands
Oral mucosa
Yellowish papules(fatty deposits) around the eye that signify hyperlipidaemia; suggesting
prolonged cholestasis(obstruction of bile drainage: in 1° biliary cirrhosis)
Hereditary haemorrhagic telangiectasia(HHT)(Osler-Weber-Rondu syndrome): diff sized red blobs
around the face, lips, buccal mucosa, both sides of tongue. These are imp as they can be found in
nose, gut and lungs and are prone to bleeding and cause epistaxis(nosebleed), GI bleeding and
haemoptysis respectively.
Telangiectasia – confirm HHT
Brown freckly pigmentation – confirm Peutz-Jehger’s syndrome
Dentition – poor dentition+gingivitis(inflamed gums) – self-neglect/malnutrition
Apthous ulcers – deter pt from eating; have a yellow base and red rim; pt may have
neutropenia(low neutrophils)
Herpetic ulcers also occur in painful crops(if painless suspect carcinoma)
Ulcers also in IBD and celiac disease
Angular stomatitis – painful cracks in the corner of the mouth; candidal infection, chronic
anaemia, vitamin deficiency
Candidiasis – trauma, moist areas, antibiotics, DM, steroids(+ other immunosupression) –
resembles someone after drinking milk
Tongue – black and furry after antibiotics(overgrowth of papillae and Candida nigricans infection).
Wasted tongue – neurological disease. Large tongue – hypothyroidism, acromegaly, 1°
amyloidosis; smooth(atrophic glossitis) – anaemia?
Tonsils – pt should say ‘aaaah!’ Enlarged? Pus? Uvula raise midline?
Odour - hepatic fetor(sweet and musty) in CLD; acetone smell in ketoacidosis; halitosis may be
due to poor dental hygiene, nasopharynx pathology, bronchiectasis
Lichen planus or pemphigus vulgaris
If find pale conjunctiva, look for koilonychia, angular stomatitis(painful cracks in the corner of the mouth) and atrophic
glossitis(a smooth, painful tongue) – all indicate chronic anaemia!
Palpate the neck for cervical lymph nodes, esp the left supraclavicular fossa(Virchow’s node which is called Troisier’s
sign): lymph drains from the gut to this area. Indicative of metastasised intra-abdominal cancer; spread by thoracic
duct.
Inspection of chest
Inspect for
Asymmetry & Shape
Obvious lumps or swellings
Dilated veins
Spider naevi
Gynaecomastia
Rationale
Should move outwards on inspiration; peritonitis/abdo rigidity = no movement
Ascites in CLD
Portal hypertension leads to Caput Medusae – radiate out from the umbilicus
Inferior vena caval obstruction – see below
Inspect and blanche as before
Enlargement of breast tissue in men/loss of axillary hair; usually in CLD(inc
circulating oestrogens or dec testosterone). Also in puberty; thyrotoxicosis;
Klinefelter’s; testicular disease; pituitary disease; hypothalamic disease;
drugs(cimetidine, digoxin, cytotoxic drugs, methyldopa, anti-androgens)
Inspection of abdomen – previous should take only 1 minute! Map abnormal
findings to a quadrant/region distension discolouration down below(groins, genitals)
Inspect for
Pulsation / peristalsis
Colour striations(striae); scratch
marks; bruising; erythema;
pigmentation; distentded veins
Rationale
May see pulsatile AAA – emergency
Striae: indicate a recent rapid inc/dec in girth of the abdomen/thigh/bum/arms,
and can occur after pregnancy(striae gravidarum) or following drainage of
ascites. Can also occur in Cushing’s syndrome(look reddy purple though).
Pulsations: normally the abdominal aorta in thin pts; suspect an aneurysm in
obese pts and palpate gently.
Peristalsis: may be seen in thin pts, but if seen otherwise indicate gut
obstruction(epigastric region = SI obstruction; lt hypochondrium = pyloric
stenosis)
Distended veins: if seen indicate two conditions – portal hypertension in
CLD(caput medusa; radiate outwards in a star; blood flow away from the
umbilicus) or inferior vena caval obstruction(IVCO; radiate vertically up the abdo;
blood flow is upwards); occur as blood diverts through collateral vessels in order
to return to the rt atrium. To determine the blood flow, you need to press the vein
with the index finger of one hand, and then with the other ‘milk’ the vein –
determine which way blood flows by whether the vein refills or not(in the
direction of milking if it does not refill).
Grey-turner’s: subtle discolouration of the flanks that looks like a faint bruise
Abdominal distention
Fat, faetus, faeces, fluid, flatus,
flipping tumour!
Hernia
a protrusion of an abdominal
organ through an abdominal
opening: can be internal(hiatus
hernia) or external. Tend to be
labeled according to site. Bulging
inc with an inc intra-abdo
pressure(hence get there pt to
cough). If hernia can be pushed
back in or goes back in when pt
lies flat, it is reducable. A hernia
with a narrow neck is can
constrict blood, strangulating the
hernia causing necrosis
Scars
May be concealed in skin crease
Purply-red(new within ~a year)
Silvery-white(old scar)
caused by bleeding into the abdo cavity with blood tracking into the
subcutaneous layer of skin. Causes: haemorrhagic pancreatitis; ruptured AAA;
ruptured ectopic pregnancy
Cullen’s: as Grey-Turner’s but around umbilicus
Murphy’s sign: sudden pain when palpating near the gallbladder(suggests
cholecystitis); location = intersection of rectus abdominus with rt costal margin;
ask pt to take a deep breath and slip fingers under costal margin; sign is positive
if pt cries out/freezes in pain
Distended epigastrium – gastric cancer, enlarged left lobe of liver, pancreatic
cyst
Distended suprapubic – urine retention or ovarian cyst
Epigastric: protrusion through linea alba(lin-ee-a alba)(the central part of the
rectus) abdominus muscle; usually above umbilicus
Umbilical: swelling localized to the navel; common in babies
Paraumbilical: occurs just above/below the umbilicus in obese pts or women
who have had multiple childbirths; narrow neck and prone to strangulation
Divarication of recti: occurs in obese pts or women who have had multiple
childbirths; abdominal musculature is weak and linea alba bulges between
rectus abdominus muscle
Incisional: any surgical incision is a site of weakness; develops along a scar
Direct inguinal:
Indirect inguinal:
Femoral:
Median: gives access to most intra-abdominal organs; used in emergency if
cause of surgical emergency unclear: ‘incision of indicision’
Paramedian: traditional incision of choice for a laparotomy
Kocher’s: below and parallel to costal margin;access to liver/gallbladder/spleen
Transverse: exposure of upper abdominal organs; not often used nowadays
Gridiron: incision used to access appendix
Rutherford-Morrison: access to kidneys
Pfannenstiel: transverse incision inferior to pubic hairline: access to uterus for
c-sections or hysterectomy
Umbilical: laparoscopy (scars can be found anywhere mind as technology inc)
Palpation – ask if pt is in pain; or if they feel pain when you palpate
Light Palpation: start in opposite corner to pain
Demonstrate 9 zones
Peritonitis
Inflammation of the perineum; usually from bacterial infection or irritation from bowel
contents leaking into the abdo cavity(perforated gastric ulcer; penetrating injuries)
Guarding
Instantaneous contraction of muscles overlying an inflamed organ or peritoneum
Rebound tenderness
Another sign of inflamed peritoneum; pain is experienced after quickly lifting your hand off
the affected area; DO NOT DO
Rigidity
Severe peritonitis can lead to rigidity of the whole abdomen; breathing can cause pain
Watch the pt’s face for tenderness. Flex fingers at MCP joints. Note which regions display masses, tenderness or
guarding. Localized tenderness suggests problem in that area alone; generalized tenderness(general peritonitis)
Deep Palpation
If there is marked tenderness, guarding, rebound tenderness or rigidity this is unnecessary and unkind.
Site:
Masses –
vascular or Size: measured with a tape measure
Border: hard? Irregular? (cancer)
inflamm
Consistency: hard? irregular?(cancer); nodular?(cancer; cirrhosis if in liver)
cause?
Tenderness: suggests inflam process or distended capsule of an organ
Mobility: parts of the bowel are attached to the mesentery and are mobile; bowel tumours may become
fixed if they spread and invade adjacent organs or skin. Some organs are permanently fixed(pancreas)
Movement with respiration: see pg 166
Percussion note: see pg 167
Pulsality: suggests vascular cause
Overlying temperature: warm?(underlying inflammation such as an abscess or infected cyst)
Bruit: suggests a vascular cause
Stomach: cancer, pyloric stenosis
Epigastric
Liver: enlarged left lobe
mass
Rt iliac
fossa mass
Lt iliac
fossa mass
Suprapubic
mass
Aortic
aneurysm
Gallbladder
Pancreas: pancreatic cysts, pseudocysts(fluid in lesser sac), cancer at head of pancreas
Gallbladder(distended): mucocoele/empyaema
Caecum: carcinoma; Crohn’s disease, TB
Appendix: appendic abscess
Ovary: cyst, carcinoma
Psoas muscle: psoas abscess
External iliac artery: aneurysm
Pelvic kidney
Sigmoid colon: cancer, diverticular abscess
Ovary: cyst, carcinoma
Psoas muscle: psoas abscess
External iliac artery: aneurysm
Pelvic kidney
Enlarged bladder(can extend upwards as far as umbilicus); ovarian cyst; uterine fibroids/pregnancy;
tumour of sigmoid colon
Placing hands on either side of the pulsatile mass, they will be pushed up and outwards
In the presence of jaundice, a palpable GB is unlikely to be due to gall stones – more likely to be cancer
of the head of the pancreas
Specific Organs
Liver
Not normally palpable; commence in the rt iliac fossa and move towards to rt costal margin; palpate as
pt inspires(liver moves inferiorly on inspiration), move hand further superiorly when pt expires; note
whether smooth or irregular, tender or not, size
Enlarged liver:
Cardiac: congestive cardiac failure, tricuspid incompetence, hepatic vein thrombosis
Infective: viral(hep A,B,C, glandular fever); bacterial(brucellosis); parasite(hydatid disease);
Protozoal(amoebic disease)
Haematological: lymphoma; leukaemia; myelofibrosis; haemolytic anaemia
Infiltrative: Gaucher’s disease; amyloidosis
Kidneys
Not normally palpable; bimanual palpation(balloting); to examine the rt kidney, place lt hand under rt
loin(renal angle), place rt hand on rt lumbar region; press down with rt hand whilst flexing lt fingers
Enlarged kidney: polycystic kidneys(irregular too); tumours, hydronephrosis; amyloidosis
Spleen
Not normally palpable; commence in the rt iliac fossa and move towards lt costal margin; palpate as pt
inspires(spleen moves inferiorly on inspiration), move hand further superiorly when pt expires; note
whether smooth or irregular, tender or not, size; may ‘tip the spleen’ if it is only just palpable by rolling
the pt onto their rt, ask the pt to put their lt arm on your lt shoulder
Enlarged spleen:
Infective: viral(hep A,B,C, glandular fever); bacterial(sub-acute bacterial endocarditis);
protozoal(malaria); parasite(hydatid disease)
Haematological: lymphoma; leukaemia (CML); myelofibrosis; haemolytic anaemia
Liver cirrhosis
Infiltrative: Gaucher’s disease, amyloidosis
Aorta
Felt midline; mostly easily felt in umbilical area; pulsatile and expands as it pulses
McBurney’s Between anterior superior iliac spine(ASIS) and umbilicus; 1/3 way from ASIS; pt will guard; appendicitis
Difference between kidney and spleen?
 Can not get above spleen
 Overlying percussion note is dull over spleen
 It moves downwards and forwards on inspiration
 It can have a palpable notch on medial surface
Percussion
Any solid-filled organ(liver, spleen) will be dull; any gas-filled structure(bowel) will be resonant. If the solid organ lies
beneath bowel, it will sound resonant(kidney).
Ascites: abnormal collection of free fluid in the abdominal cavity – transudate(low protein) or exudates(high protein)
Percuss the centre of the abdomen. Should sound resonant. Then percuss out to the flanks. If abdominal distension is
due to flatus, it will remain resonant. If it is ascites, the percussion note is dull. Check this by testing for shifting
dullness. Ask the pt to roll over onto their rt side towards you, whilst keeping your hands where they were when the
dullness was first heard. Wait 20s and percuss. If it is ascites then should now be resonant.
Can also test for a fluid thrill. Have the pt place their arm on their abdomen midline. Tap a flank with a finger and
watch/feel the impulse conducted through the fluid onto the other side.
Cause of ascites:
Transudate: congestive cardiac failure, chronic liver disease, nephrotic syndrome, constrictive pericarditis,
hypoproteinaemia
Exudates: intra-abdominal malignancy, bacterial peritonitis, tuberculous peritonitis
Auscultation
Auscultate
Bowel sounds
Aortic/ Renal /
Hepatic /Splenic
artery
Rationale/ Technique
Gurgling sounds heard approximately every 10-20s. auscultate for 2 mins. Louder after a
meal/in diarrhoea (audible bowel sounds = borborygmi)
Absent sounds: abnormal(paralytic ileus; peritonitis)
Tinkling sounds: abnormal(mechanical obstruction of the bowel)
Renal artery bruits: superiolateral (2.5cm) to umbilicus either side = stenosis = ?hypertension
Hepatic bruits: heard over an enlarged liver(alcoholic hepatitis)
Loss of pubic hair in CLD(or change in distribution/testicular atrophy).
Feel along inguinal ligament. A small amount of irregularity is normal, as are small lymph nodes <1cm in diameter.
Large nodes are suspicious
Completing The Examination
Examine
Hernial orifices
Femoral pulses
External genitalia
Rectal Examination
Lymphadenopathy
Rationale
Urine testing, stool examination and rectal exam are unforgettable!
Specific examination features for you to practise:
examine mouth
inspect abdomen & palpate generally for tenderness
palpate liver & spleen
palpate kidneys
palpate masses
auscult abdomen
hernial orifices/femoral pulses
rectal examination (only under direct supervision)
inspect abdominal X-rays
seen
read
give one common symptom and sign
read
give one common cause
gastro-oesophageal reflex
peptic ulcer
gallstones
appendicitis
Diverticulitis
haemorrhoids
gastric carcinoma
colorectal carcinoma
pancreatic carcinoma
bowel obstruction
bowel perforation
hernia (simple/ acute)
inflammatory bowel disease
irritable bowel syndrome
seen
Dysphagia
epigastric pain
nausea/vomiting
Haematemesis
Melaena
Jaundice
weight loss
change of bowel habit
rectal bleeding
abdominal organomegaly
acute abdominal pain
AXR: small bowel obstruction
AXR: large bowel obstruction
AXR: sigmoid volvulus
AXR: bowel perforation
NUTRITION AND ENERGY Y1T3
Drug Name CARBAMAZEPINE
Class ANTI-EPILEPTIC
Conditions for which this drug is prescribed
- Epilepsy, trigeminal neuralgia (headache)
Mechanism of action
- Use dependent block of sodium channels reducing neuronal excitability in CNS.
Major unwanted actions - Toxic effects (overdose), interactions
- Dizziness, blurring of vision, unsteadiness, sedation are dose related and may be dose limiting.
- Careful timing of dose(s) or use of sustained release preparations can reduce severity of side effects.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Induces P450 microsomal enzymes and therefore interacts with many drugs biotransformed in the liver and
increases its own rate of metabolism, leading to tolerance and break through seizures
- Oxycarbazepine produces less hepatic enzyme induction but has similar therapeutic actions.
Drug Name CIMETIDINE (tagamet), RANITIDINE, FAMITIDINE, WS1
Class HISTAMINE H2-RECEPTOR ANTAGONIST
Conditions for which this drug is prescribed
- Benign gastric/duodenal ulcers, reflux oesophagitis, Zollinger-Ellison syndrome (G cell Tumor)
Mechanism of action
- Acts by inhibiting production of gastric acid by blocking histamine (histamine, Ach and gastrin all potentiate GA
secretion therefore K/O of 1 has a big effect)
- Reduces inflammation of gastric mucosa + promotes healing of duodenal ulcers
Major unwanted actions - Toxic effects (overdose), interactions
- Inhibits many isozymes of the of the cytochrome P450 enzyme system
- Can result in drug-drug interactions, e.g. affecting the actions of the hormonal contraceptive pill as well as
inhibiting the metabolism of warfarin leading to the increased risk of haemorrhage
- Side effects: diarrhoea, gastro-intestinal disturbance, headache, rash, rarely acute pancreatitis
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Use with caution in renal impairment, pregnancy and breast-feeding
- Also known as Tagamet (industry name)
Drug Name OMEPRAZOLE, RABEPRAZOLE, LANSOPRAZOLE
WS1Class PPIs (Proton Pump Inhibitors)
Conditions for which this drug is prescribed
- Peptic/gastric ulcers
Mechanism of action
- Inhibits the proton (H+) pumps in the gastric mucosa
- Reduces the volume of gastric acid secreted into the stomach lumen
- Blocks the H+/K+ ATPase pump on apical membrane of parietal cells therefore decreasing GA secretion
- Used to reduce inflammation in ulcers in conjunction with antibiotic treatments for H.Pylori infection.
Major unwanted actions - Toxic effects (overdose), interactions
- Lack of stomach acid may cause hypochlorhydria (lack of sufficient HCl in the stomach)
- Can result in impaired digestive transit
- Headache/nausea/diarrhoea/abdominal pain.
Drug Name ASPIRIN/IBUPROFEN WS1
Class NSAIDs (Non Steroidal Anti- Inflammatory Drugs)
Conditions for which this drug is prescribed
- Minor analgesic; reduces pain, fever and irritation.
Mechanism of action
- Analgesic, antipyretic and anti-inflammatory actions
- Irreversibly inhibits cyclo-oxygenase pathway, by inhibiting COX-1 (responsible for gastrin protection) and
COX-2
- Causes reduction in prostaglandin (PGE2) and thromboxane (TXA2) formation (and therefore can promote
haemorrhage as it blocks COX in platelets which have no DNA so can not repair themselves – have to be
replaced)
- So less inflammation
Major unwanted actions - Toxic effects (overdose), interactions
- Gastrointestinal; irritation to gastric mucosa (removal of the protective actions of prostaglandins via blocking of
COX-1) – VERY dangerous to stomach ulcer patients
- Renal; alters renal haemo-dynamics (vasomotor actions).
- Also increases [unbound] warfarin therefore increasing anti-coagulant effects
- Note rofecoxib (vioxx)/celecoxib = COX-2 selective inhibitors = reduce inflammation w/o increase in GA (but
increased risk of CHD instead!)
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Allows treatment without use of steroids.
Drug Name MISOPROSTOL WS1
Class SYNTHETIC PROSTAGLANDIN (PGE) ANALOGUE
Conditions for which this drug is prescribed
- Peptic/gastric ulcers; associated with NSAID use.
Mechanism of action
- Binds to the prostaglandin receptor on basal membrane of parietal cells; activates Gi, turning adenyl cyclase off
and decrease GA
- Causes increases in mucous production (HCO3-) and blood flow to the stomach (protective)
- Decreases secretion of histamine
Major unwanted actions - Toxic effects (overdose), interactions
- Diarrhoea
- Abdominal pain
- Nausea
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Risk for pre-menopausal women, as promotes uterine contractions, possibly causing spontaneous abortion
during pregnancy. Therefore they need to take a contraceptive too to avoid risk of pregnancy
- Often combined with an NSAID; Arthrotec = misoprostal + diclofenae (COX-2 inhib)
Drug Name LOPERAMIDE WS3
Class OPIOID RECEPTOR AGONIST
Conditions for which this drug is prescribed
- ‘travellers’’ diarrhoea (arising from IBD/gastro-enteritis)
- Active ingredient in Imodium
Mechanism of action
- Anti-inflammatory drug
- Acts on opioid receptors (it is an opiate) in myenteric plexuses of the colon (specific for GIT), without the CNS
effects of other opioids (can’t cross BBB)
- Causes decreased motility of the muscular walls of the colon, allowing more time for water to be re-absorbed
from faecal matter.
- Undergoes several rounds of enterohepatic circulation
- Decreases frequency, cramps and duration of illness
Major unwanted actions - Toxic effects (overdose), interactions
- Drowsiness, rebound constipation, abdominal pain.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Cannot cross the Blood-Brain-Barrier, unless administered with other pharmaceuticals.
- Should not be administered if patient is feverish, or has bloody stools.
- Purgative abuse (laxatives) = melanosis coli
Drug Name MESALAZINE
WS3
Class ANTI-INFLAMMATORY
Conditions for which this drug is prescribed
- Crohn’s Disease, ulcerative colitis. Inflammatory bowel disease (IBD)
Mechanism of action
- Anti-inflammatory actions (derived from 5’-salicylic acid e.g. aspirin related)
Major unwanted actions - Toxic effects (overdose), interactions
- Diarrhoea, nausea, cramping etc.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Administered rectally; usually acts specifically in the G.I. Tract (as it is metabolized here) – resulting in minimal
systemic side-effects.
Drug Name PREDNISOLONE& HYDROCORTISONE WS3
Class CORTICOSTEROIDS
Conditions for which this drug is prescribed
- Inflammatory Bowel Disease (IBD) / ulcerative colitis etc (PRED.)
- Anaphylaxis (HYD.) = decreases influx of leucocytes and therefore buys time
Mechanism of action
- Thought to act by the induction of phospholipase A2 inhibitory proteins, collectively called lipocortins
- Therefore reduce inflammation – preventing scarring etc. by reduced lymphocyte/histamine aggregation at the
inflamed site.
Major unwanted actions - Toxic effects (overdose), interactions
- Diarrhoea, nausea etc.
- Swelling of the face
- Black/tarry stools
- Fever and insomnia (following lengthy administration/high doses)
- Suppression of I.S. = opportunistic pathogens
- MAJOR = Cushing syndrome
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Prednisolone is banned under WADA rules (inhibited for athletics and other competitive sports).
- Hydrocortisone also for Addison’s disease (WS9)
Drug Name 6-MERCAPTOPURINE
WS3 Class IMMUNO-SUPPRESSIVE
Conditions for which this drug is prescribed
- Inflammatory Bowel Disease (IBD) – Crohn’s/Ulcerative colitis.
Mechanism of action
- Inhibits purine nucleotide synthesis and metabolism
- This alters the synthesis and function of RNA and DNA
- Therefore, cell proliferation is inhibited – notably in lymphocytes.
Major unwanted actions - Toxic effects (overdose), interactions
- Diarrhoea/nausea etc.
- Can be administered as azathioprine (a pro-drug) which has been widely acknowledged as having carcinogenic
properties.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Reduced ability of the body to combat infections; contraindicative for patients with impaired immunity (e.g. HIV+
patients).
Drug Name INFLIXIMAB WS3
Class IMMUNOSUPPRESSANT
Conditions for which this drug is prescribed
- Inflammatory Bowel Disease (IBD) – Ulcerative Colitis/Crohn’s etc.
Mechanism of action
- Chimeric monoclonal antibody (produced artificially; mAB)
- Blocks action of TNF-alpha by binding to it; prevents this cytokine from triggering the inflammatory response via
IL-1 and IL-6.
Major unwanted actions - Toxic effects (overdose), interactions
- Suppression of the immune system.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Can be used in conjunction with other drugs to treat various auto-immune/inflammatory disorders.
Drug Name ADRENALINE
WS3
Class CATECHOLAMINE
Conditions for which this drug is prescribed
- Anaphylaxis (food-allergy)
Mechanism of action
- Rapidly prepares the body for action in emergency situations
- Increases heart rate and stroke volume via β1-adrenoreceptor(increase in cAMP)
- Bronchodilator via β2-adrenoreceptor (increase in cAMP)
- Constricts arterioles in the skin via α1-adrenoreceptors (PLC and Ca2+) and gut while dilating arterioles in
skeletal muscles
- Elevates the blood sugar level by increasing catalysis of glycogen to glucose in the liver
- Immuno-suppressive actions
Major unwanted actions - Toxic effects (overdose), interactions
- Palpations, anxiety, tachycardia etc (CNS effects).
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc.)
- Can be administered by ‘epipen’ or via subcutaneous injection.
Drug Name ANTIHISTAMINES WS3
Class HISTAMINE ANTAGONIST
Conditions for which this drug is prescribed
- Anaphylaxis (allergic reactions)
Mechanism of action
- Antagonist of H1-histamine receptors
- Reduces histamine secretion (a pre-formed mediator released from mast cells in IgE-dependent anaphylaxis –
decrease in wheel and flare response) )etc; thereby reducing inflammation and limiting the immune response to
an allergen.
Major unwanted actions - Toxic effects (overdose), interactions
- Sedation (drowsiness)
- Nausea/diarrhoea/vomiting etc.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- These drugs have now been refined to produce 2 nd generation antihistamines, which have far fewer side-effects
and more specific actions.
Drug Name ETHANOL WS5
Class ALCOHOL
Conditions for which this drug is prescribed
- Drug/alcohol overdose
Mechanism of action
- Competes with other alcohols (e.g. methanol) for the alcohol dehydrogenase enzyme
- This prevents metabolism of the toxic alcohols into toxic products such as aldehydes.
Major unwanted actions - Toxic effects (overdose), interactions
- Addiction
- Cirrhosis of liver etc (all of the effects associated with alcohol comsumption and abuse).
- Induces CYP(2E1) and therefore increases paracetamol toxicity (hepatotoxicity)
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Serious cognitive effects; acts as a CNS depressant.
Drug Name BENZODIAZEPINES, DIAZEPAM WS5
Class PSYCHOACTIVE
Conditions for which this drug is prescribed
- Drug treatment of symptoms of alcohol dependence, anxiety, epilepsy, muscular disorders, acute mania.
Mechanism of action
- Management of alcohol withdrawal; ameliorates alcohol withdrawal syndrome and delirum tremens (DTs;
shakes/tremor)
- Blocks the oxidation of alcohol at the stage it is converted to aldehyde
Major unwanted actions - Toxic effects (overdose), interactions
- Drowsiness, dizziness, blurred vision, headache
- Various CNS effects
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Well-tolerated drugs
- Relatively safe and effective in the short term for a wide range of conditions.
Drug Name DISULPHIRAM
WS5
Class ANTI-ALCOHOLIC
Conditions for which this drug is prescribed
- Chronic alcoholism/prevention of alcohol dependence
Mechanism of action
- Blocks oxidation of alcohol at the stage it is converted to aldehyde
- Achieves this by blocking enzyme acetaldehyde dehydrogenase
- Causes acetaldehyde accumulation leading to nausea, vomiting, flushing, tachycardia, palpitations with small
amounts of alcohol
- Large amounts alcohol can lead to arrhythmias, hypotension and collapse
Major unwanted actions - Toxic effects (overdose), interactions
- Initial drowsiness and fatigue, nausea and vomitting
- Interacts with certain stimulants and anti-depressants
- Can result in lengthy insomnia and paranoia
- Interferes with the dopamine/nor-adrenaline system
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Medical ethics dictate the patient must be fully informed of the consequences of the Disulphiram-alcohol reaction
prior to prescription/administration.
- Contraindications: cardiac failure, coronary artery disease, hypertension
- Reacts with alcohol to cause unpleasant acetaldehyde intoxication
Drug Name NALTREXONE
WS5
Class OPIOID RECEPTOR ANTAGONIST
Conditions for which this drug is prescribed
- Alcohol and opioid dependency
Mechanism of action
- Reduces frequent/severe relapses into alcoholism
- Alcohol cravings are reduced by agonism of the related “addiction” receptors by the drug
Major unwanted actions - Toxic effects (overdose), interactions
- Few; of no use in overdose cases
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Relatively safe medication; patient may be susceptible to increased risk of overdose following cessation of the
treatment
Drug Name ACAMPROSATE WS5
Conditions for which this drug is prescribed
Class SEVERAL RECEPTORS INC GABA, 5-HT, ADR
- Alcohol dependency
Mechanism of action
- Exact mechanism unknown
- Thought to activate GABA receptors in the brain, whilst blocking glutaminergic N-methyl-D-aspartate receptors
(NMDARs) decreasing frequency of drinking
Major unwanted actions - Toxic effects (overdose), interactions
- Headache, diarrhoea etc.
- High blood pressure, irregular heart-beats
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Reports indicate it is only successful when used in conjunction with social therapy and support groups
- Depression ass with alcohol: fluoxetine
Drug Name INSULIN WS10
Class HORMONE
Conditions for which this drug is prescribed
- Diabetes mellitus
Mechanism of action
- Causes increased glucose storage in muscle/liver cells by increasing glycogen synthesis.
- Binds to receptors on the cell-surface, resulting in opening of glucose channels in the cell membrane.
- Circulating glucose levels are therefore lowered (works in complementary fashion with glucagon to maintain
glucose homeostasis).
Major unwanted actions - Toxic effects (overdose), interactions
- Hypoglycaemia; severe acute lack of blood glucose can result in irreparable damage to the CNS.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Produced using recombinant DNA technology.
Drug Name GLICAZIDE WS10
Class SULPHONYLUREA
Conditions for which this drug is prescribed
- Type 2 diabetes
Mechanism of action
- binds to SUR channel associated to k+ efflux channel
- closes k+ potassium channels- depol- Stimulates insulin secretion by the Beta-cells in the pancreas
Major unwanted actions - Toxic effects (overdose), interactions
- Hypoglycaemia
- G.I. disturbances
- Overdose can result in hypoglycaemic shock and require hospitalisation
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Contra-indicative to Type 1 diabetes.
Drug Name METFORMIN
ẀS10
Class BIGUANIDE
Conditions for which this drug is prescribed
- Type 2 diabetes
Mechanism of action
- Uncertain
- Appears to act mainly by reducing hepatic gluconeogenesis
- Decreases absorption of glucose from G.I. tract
- Increases peripheral utilisation of glucose
- AMPK?
Major unwanted actions - Toxic effects (overdose), interactions
- Diarrhoea
- Lactic acidosis
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- First-line treatment choice
- Used especially when Type 2 diabetes accompanies obesity and insulin-resistance
- Does not induce hypoglycaemia (unlike sulphonylureas)
Drug Name α-GLYCOSIDASE INHIBITORS WS10
Class
Conditions for which this drug is prescribed
- Type 2 diabetes
Mechanism of action
- Slow the breakdown of complex sugars into glucose
- Inhibit glycogen hydrolysis
- Delays glucose absorption
Major unwanted actions - Toxic effects (overdose), interactions
- Unknown
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Unknown
Drug Name GLITAZONES
WS10
Class THIAZOLIDENEDIONES
Conditions for which this drug is prescribed
- Type 2 diabetes
Mechanism of action
- Helps body to use existing insulin more effectively
- Increases insulin-sensitivity in the peripheral cells of the body
Major unwanted actions - Toxic effects (overdose), interactions
- Hypoglycaemia
- Mild-anaemia
- Nausea/vomiting
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Administered in combination with metformin
- Contraindicative for Type 1 diabetes, heart failure and acute liver disease
Drug Name STATINS WS8
Class HYPOLIPIDAEMIC
Conditions for which this drug is prescribed
- Hypercholesteraemia / Cardiovascular disease
Mechanism of action
- Inhibit HMG-CoA reductase; this causes stimulation of LDL-receptors in hepatocytes; resulting in an increased
clearance of LDL-cholesterol from the bloodstream.
Major unwanted actions - Toxic effects (overdose), interactions
- Myalgias/muscle cramps
- Complications may lead to acute renal-failure (complex and rare)
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Consumption of some citrus fruits (e.g. grapefruits) can result in degradation of statins in the body.
- Should not be administered in conjunction with fibrates (other lipid-lowering drugs).
Drug Name ORLISTAT WS6
Class LIPSTATIN
Conditions for which this drug is prescribed
- Obesity
Mechanism of action
- Prevents fat absorption from digested food
- Inhibits pancreatic lipase, which is used to breakdown triglycerides in the lower G.I. tract
- More fat is excreted than absorbed
Major unwanted actions - Toxic effects (overdose), interactions
- Steathorroea (fatty/oily stools)
- Faecal incontinence and flatulence
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Absorption of fat-soluble vitamins is inhibited (includes Vits. A, D, E and K).
- Contraindicated in malabsorption, reduced gallbladder function and should not be used during
pregnancy/lactation.
Drug Name CARBIMAZOLE
WS9
Class ANTI-THYROID
Conditions for which this drug is prescribed
- Hyperthyroidism (Grave’s disease)
Mechanism of action
- Carbimazole is a pro-drug; converted to methimazole in vivo.
- Prevents peroxidise enzyme from coupling the tyrosine residues on thyroglobulin; thereby reducing the
production of thyroxine (both hormones T3 and T4 which are produced by the thyroid gland).
Major unwanted actions - Toxic effects (overdose), interactions
- Rashes and pruritis (itchiness)
- Bone marrow suppression (and resulting complications involving the immune system etc.) is serious but rare.
Special features (e.g. low therapeutic index, contraindications, ethnic differences etc)
- Can be administered in conjunction with anti-histamines (which treat the rashers/inflammation caused).
- Rapid onset, but slow reaction due to a store of T3 and T4 in the thyroid.
antacids
diarrhoea
constipation
bowel
preparation/
cleansing
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Magnesium salts such as MgOH or Mg trisilicate (s/e = diarrhoea)
Aluminium salts such as Al2OH3 gel (s/e = constipation)
Alginates/simethicone
Gaviscon infant sachets
Gaviscon Advance For children aged 2-6yrs only
Antacids are the simplest of all the therapies for treating the symptoms of excessive gastric acid
secretion. They directly neutralise acid, thus raising the gastric pH; this also has the effect of
inhibiting the activity of peptic enzymes, which practically ceases at pH 5. Given in sufficient
quantity for long enough, they can produce healing of duodenal ulcers but are less effective for
gastric ulcers. Used in dyspepsia and symptomatic relief in peptic ulcer or oesophageal reflux
Antidiarrhoeal drugs
CODEINE PHOSPHATE
Loperamide
Macrogols - Movicol
Bowel cleansing solutions
Citrafleet (Picolax equivalent)
Citramag
Fleet phospho-soda solution
Klean-prep