Gastro-Intestinal System: What the GPhC Registration Assessment Tests

Scope and time budget

The area is practical. Dyspepsia, constipation, diarrhoea and nausea are everyday requests at the counter, and each has red flags that move the answer from sale to referral.

What is tested

• Acid-related conditions. Dyspepsia, GORD, proton pump inhibitors and H. pylori eradication.
• Inflammatory bowel disease. Treatment and monitoring.
• IBS and constipation. Management and laxative choice.
• Opioid-induced constipation. Prevention and treatment.
• Diarrhoea. Oral rehydration and gastroenteritis.
• Nausea and vomiting. Antiemetics and QT risk.
• Liver disease. Drug choice in hepatic impairment.
• Gallstones and pancreatitis. Pancreatic enzymes.
• Haemorrhoids and anal fissure. Topical treatments.
• GI bleeding risk. NSAIDs and antiplatelets.

UK guideline anchors

• NICE. Dyspepsia, IBS, IBD and constipation guidance, and antimicrobial guidance for H. pylori regimens.
• BNF. Doses, hepatic impairment advice and interactions.
• OTC rules. Which products pharmacists can sell and for whom.
• Red flags. Weight loss, blood, difficulty swallowing, persistent vomiting, anaemia or age-related alarm features mean referral.
• Children. Oral rehydration, and care with antidiarrhoeals and antiemetics in young children.

Acid suppression and H. pylori

Dyspepsia questions start with alarm features: unintended weight loss, difficulty swallowing, persistent vomiting, bleeding or anaemia, and age. Where present, the answer is referral. Otherwise, think lifestyle advice, a trial of a proton pump inhibitor or an antacid, and testing for Helicobacter pylori when indicated. Know the principle of eradication therapy, which combines a proton pump inhibitor with two antibiotics, and the interactions that matter, such as clarithromycin with statins and warfarin. Long-term proton pump inhibitor use is linked with low magnesium, bone and infection concerns, so review the need.

Bowel disorders and laxatives

For constipation, match the laxative class to the cause and the patient: bulk-forming, osmotic, stimulant and softening agents. Opioid-induced constipation needs a stimulant plus a softener, and bulk-forming agents are unsuitable because they need fluid and mobility. For diarrhoea, oral rehydration is first, with special caution in young children, older people and pregnancy, and with red flags for blood, severe pain, recent antibiotics or travel. For inflammatory bowel disease, know the treatment classes and the monitoring that goes with immunosuppressants. For irritable bowel syndrome, know the first-line dietary and symptomatic approach.

Nausea, liver disease and NSAID risk

Antiemetics vary in sedation, QT risk and suitability in Parkinson's disease, so read the patient's other medicines. In liver disease, know that many drugs need a lower dose or avoidance, and that paracetamol is used with caution and reduced doses at low body weight or in hepatic impairment. Gastro-intestinal bleeding risk with NSAIDs rises with age, steroids, anticoagulants, antiplatelets and SSRIs, which is why gastro-protection is often needed. These cross-links connect this area to the cardiovascular and clinical evaluation domains.

Counselling points that earn marks

• Proton pump inhibitors. Take before food, review the need for long-term use, and report alarm symptoms.
• Laxatives. Match the type to the person, drink enough fluid with bulk-forming agents, and avoid long-term stimulant use without review.
• Oral rehydration. Make up sachets exactly as directed, and seek help for babies, frail older people and signs of dehydration.
• Antiemetics. Check sedation, QT risk and interactions, and know that some are unsuitable in Parkinson's disease.
• Haemorrhoids and fissure. Increase fibre and fluid, treat constipation, and refer if there is bleeding that is unexplained or persistent.

Children

Gastroenteritis in babies and young children is a common scenario. Oral rehydration is first, antidiarrhoeal drugs are generally avoided, and red flags include blood in stools, persistent vomiting, drowsiness and signs of dehydration. Colic, constipation and reflux in infants have their own advice and age limits. Doses and cautions come from the BNFc.

Older people and polypharmacy

In older people, anticholinergic burden, constipation from other drugs and bleeding risk from combined antiplatelets and NSAIDs recur. A well-prepared candidate links the gastro-intestinal findings to the whole medicines list. This is the clinical evaluation skill from the clinical evaluation domain applied to a single organ system.

If you have only an hour

Spend 20 minutes on alarm features and the referral rules for dyspepsia, constipation, diarrhoea and nausea. Spend 15 minutes on the laxative table and oral rehydration. Spend 15 minutes on proton pump inhibitor, NSAID and H. pylori interactions. Spend 10 minutes on liver dosing. Then do fifteen questions. If a stem lists many medicines, read for the gastro-intestinal risk they add together, not one at a time.

Remember also that the area overlaps with other domains. Gastro-protection links to NSAIDs and anticoagulants, antiemetics link to QT-prolongation and Parkinson's disease, and liver disease links to paracetamol dosing. Revising those links once, in this domain, saves effort elsewhere.

Three typical traps

1. The alarm-feature trap. A patient asking for an antacid may have an alarm feature in the stem. Read for it before choosing.
2. The wrong-laxative trap. A bulk-forming laxative is wrong for opioid-induced constipation, where a stimulant is needed.
3. The interaction trap. Clarithromycin in an H. pylori regimen interacts with statins and warfarin.

How to revise it

1. Learn red flags first. One list per complaint.
2. Make a laxative table. Class, example, onset and cautions.
3. Pair NSAIDs with gastro-protection. Who needs it and why.
4. Revise liver dosing. Drugs to avoid or reduce in hepatic impairment.
5. Do short mixed sets. Fifteen items across the area.

Continue with blood, nutrition, immune system and malignant disease and the musculoskeletal and skin domain. Back to the hub.