Lower GI

Question 1

Contipation: Definition

Answer 1

• Abnormally slow movement of feces through colon (Note: What’s normal?)
• Usually hard, dry feces in descending colon
• Infrequent or difficult evacuation
• Sense of incomplete evacuation
  ​

Question 2

Constipation: LIfestyle Causes

Answer 2

• Put off urge
• Inactivity
• low fiber diet
• Low CHO diet
• inadequate fluid intake
• Cheese
• Post-op (fear of straining)
• Etc.
  ​

Question 3

Constipation: Medication Causes

Answer 3

• Opioids
• Al+ and Ca++ antacids
• Anticholinergics
• Anticholinergic actions:
  
  • Antidepressants
  • Antihistamines
  • Antihypertensives
  • Antipsychotics
• Bismuth salts
• Diuretics
• Iron salts
• Chronic irritant laxatives
• CCB’s (calcium channel blockers)
• Sulcralfate

Note that these are used in old people

Question 4

Constipation: Medical Conditions

Answer 4

• GI cancers
• DM (autonomic neuropathy)
  
  • nerve damage in gut
• Age (decreased neuro. stim)
• Diverticular Dz
  
  • pockets in gut
• Rectal stenosis, fissures, Hroids, etc.
• Stroke
• Adhesions
• Strictures
• Hernia
• Hypothyroid
• IBS (spastic colon)
• MS, PD (parkinsons)
• Pg
• E-lyte disturbances

Question 5

Constipation: Symptoms

Answer 5

• Dull headache
• Loss of appetite
• Lack of energy
• Feeling of fatigue
• Abdominal distension
• Bloating
• Lower abdominal discomfort or pain
• Lower back pain
  ​

Question 6

Constipation: The Essential Triad

Answer 6

• Bulk, Water, Exercise

Question 7

Constipation: When to Refer

Answer 7

• blood in feces
  
  • cancer
• nausea, vomiting
  
  • obstruction
• acute abdominal pain
• fever
• 7-10 days duration
• unresponsive to adequate laxative Rx
• quadriplegia, paraplegia
  
  • impaction risk
• Anorexia history

Question 8

Constipation: Non-Drug

Answer 8

• Alterations in diet (fiber, bulk)
• Increased fluid
• Exercise
• Stress management
• Avoidance of constipating drugs
  ​

Question 9

Constipation: Pharmacological

Answer 9

• Bulk Laxatives (12-72 hours)
  
  • Metamucil, Citrucel, Fibercon
  • Work by hanging onto water so that water won’t be suck out by colon
  • Stool stays softer
  • Safe and natural
  • Not acute, more of preventative agent
  • Have sugar, so be careful if diabetic
  • Need enough water
• •Stimulant laxatives (6-12 hours)
  
  • Ex-Lax, phenophaline
  • Irritant causes colon to contract
  • Senna, bisacodol (ducalax)
  • Enteric coated, can’t be ground up
• Saline laxative (30min-3 hours)
  
  • Sodium enema
  • Magnesium citrate, milk of magnesia
  • Can change electrolyte balance
  • Careful for renal patients, congestive heart failure
• Lubricant laxative (24-72 hr)
  
  • Mineral oil
  • Lubricates the hard stool to slide out
  • Not good for chronic use: seepage, if lay down can get into lungs, can waste fat soluble vitamins
• Surfactants (6-8 hrs)
  
  • Docusate
  • Not very effective by self (usually paired with stimulant)
  • Decrease water tension, supposedly let water into stool
  • 250 mg at LEAST, need quite a bit to be effect
  • Turn colon into secreting organ
  • Used prophylactically
• Hyperosmotic (15min-1 hour)
  
  • Glycerin (children), lactulose (chronic-lac), sorbitol, Miralax (PEG)
  • 17g mix with water

Question 10

Bulk Laxatives

Answer 10

• Polycarbophil (Konsyl Fiber)
• Psyllium (Metamucil, others)
• Methylcellulose (Citrucel, Maltsupex)
• Good initial choice: “approximate normal”
• Nonabsorbable; expand and take up water; stimulate distension reflex and intestinal motility
• Also for IBS diarrhea
• Contraindicated: intestinal stenosis, adhesions
• Careful:
  
  • Esophageal/intestinal obstruction (review mixing/dilution instructions)
  • Diabetes: sugar
• ADR:
  
  • Flatulance, borborygmi (rumbly tummy)
    ​

Question 11

Stimulant Laxatives

Answer 11

• Not first choice (except opiod)
• cascara sagrada
• •senna, sennasides (Senokot, Ex-Lax)
• •Castor oil (Purge, Neoloid)
• •bisacodyl (Dulcolax, Correctol)
• •Phenolphthalein – tumors, genetic damage – gone
• local irritation of intestinal tract, increase peristalsis, increase fluid secretion
• Warnings:
  
  • Casual use discouraged
  • Overuse/abuse: damages physiologic neurologic colon function – “cathartic colon”
  • melanosis coli: benign (stains colon)
  • Urine discoloration: senna
  • Bisacodyl: enteric coated (uncoated induces gastritis - don’t break, crush, etc,)

Question 12

Saline Laxative

Answer 12

• Phillips Milk of Magnesia
• Fleet Phospho-Soda
• Magnesium Citrate
• High concentration of electrolytes - hypertonic state - osmotic gradient - draws water into colon - increased colonic pressure - stimulates movement
• Single dose or short term use
• Warnings:
  
  • CHF, HTN (Na+)
  • Renal Failure (Mg+)

Question 13

Surfactant Laxatives

Answer 13

• “emoliants”
• Docusate (Colace, Surfak)
• Mild - increase fluid secretion, “wetting” agents; lowers surface tension, allowing water into fecal mass.
• Prevention rather than treatment
• 100 mg =placebo; use 250 mg dosage

Question 14

Lubricant Laxatives

Answer 14

• Mineral oil
• Oil - lubricates colon, rectum, anal canal allowing easier passage of hard stool.
• Limited utility - one time use
• Warnings: seepage, fat-soluable vitamin malabsorption
• only time to use is impaction
  ​

Question 15

Hyperosmotic Laxatives

Answer 15

• Glycerin
  
  • Short term, episodic use; pediatrics
  • Suppositories (Fleet Babylax, Sani-Supp)
• Sorbitol, lactulose
• Polyethylene glycol (PEG) +/- E-lytes

Question 16

Probiotics

Answer 16

• “Support” for bowel health
• No restrictions on length of use
• Dietary supplement
• May support growth of beneficial microfloral in intestinal tract.
  
  • Bifidus regularis
  • Lactobacillus acidophilus
  • Bifidobacterium longum

Question 17

Diarrhea: Definition

Answer 17

• Abnormal frequency or volume of semi-liquid or fluid fecal matter.
• Classification
  
  • Acute vs. Chronic
  • Infectious vs. Noninfectious
  • Physiologic
    
    • Osmotic (ex: lactose intolerance)
    • Secretory (ex: virus, bacterial)
    • Exudative (ulcerative colitis)
    • Motility Disorder (IBS)
      ​

Question 18

Diarrhea: 3 Types

Answer 18

• Acute
  
  • abrupt; < 2 weeks; abdomnal pain, malaise, flatulence, generally resolves in 3 days; causes dietary, infection, toxicity, drugs
• Chronic
  
  • frequent passage > 4 weeks; tough to diagnose; refer – requires medical evaluation
• Traveler’s Diarrhea
  
  • up to 10/day loose stools, w/nausea, abdominal cramps, +/- vomiting, fever; cause generally bacteria
    ​

Question 19

Diarrhea: Refer

Answer 19

• Temperature > 101
• Nighttime diarrhea
• Bloody diarrhea
• Severe abdominal cramps
• Symptoms of dehydration
• Failure to subside within 3-5 days
• Pediatrics, elderly, pregnant

Question 20

Diarrhea: Treatment

Answer 20

• Goals
  
  • Identify and treat cause
  • Prevent fluid/electrolyte loss
  • Relieve symptoms
• Nondrug
  
  • Clear liquids, then BRAT, slowly add milk/dairy
• Pharmacotherapy
  
  • Bulk forming agents (polycarbophil); Adsorbants
  • Loperamide
  • Antibiotics
    
    • C. dificil
  • ORS (oral rehydration solutions)
    
    • has more salt/sugar/bicarb than Gatorade
    • Old/young: Gatorade with pretzels and bannanas
  • Diet (BRAT, dairy)
  • Digestive enzymes (lactase, prevention)
  • Probiotics

Question 21

Diarrhea: Adsorbents/Protectants

Answer 21

• Attapulgite and Kaolin-pectin
  
  • Questionable efficacy – thus, GONE!
• Bismuth Subsalicylate
  
  • Antisecretory, adsorbent, antimicrobial, antiinflammatory
  • Prevention of TD
    
    • 60 mL (4 tab) every hour times 8, or until diarrhea done
  • Radiopaque
  • Salicylate
    
    • Aspirin allergy, kids

Question 22

Diarrhea: Loperamide (Imodium)

Answer 22

• Slows intestinal motility; inhibits peristalsis; tolerance doesn’t develop
• Don’t use in presence of bloody diarrhea, body temperature > 101; with organisms that penetrate the intestinal wall (enteroinvasive E. coli, Salmonella, Shigella, pseudomembranous colitis)
• Okay if know that bug cannot get out of tube
  ​

Question 23

Diarrhea: Polycarbophil, ORS

Answer 23

• Polycarbophil (Konsyl Fiber)
  
  • Good for diarrhea due to IBS
• ORS
  
  • Pedialyte, Gatorade + pretzels, crackers
  • Especially important for sick, pediatrics, elderly

Question 24

Gas: Etiology

Answer 24

• Normal
  
  • –average – 10 passages/day
  • –500-1500 mL/day)
• Affected by…
  
  • Malabsorption (e.g., lactose intolerance)
  • Gastric motility (e.g., IBS)
  • Dietary composition (lactose, legumes)
  • Drugs (antibiotics, acarbose)
  • Changes in colonic pH
• Gas formed by
  
  • Action of colonic bacteria on CHO’s
    
    • hydrogen sulfide​
  • Anaerobic fermentation
    
    • hydrogen
    • carbon dioxide
    • methane
  • Swallowed
    
    • Nitrogen
    • oxygen

Question 25

Gas: Signs/Symptoms

Answer 25

* “too much gas” * Abdominal cramping * Belching * Bloating * Discomfort * Audible bowel sounds

Question 26

Gas: Assesment

Answer 26

* more than 25 passages per day * Diet (legumes, starch, prunes, milk, cheese) * Meds (antibiotics, opiates, CCB’s, acarbose) * Surgical history (abdominal surgery) * Medical history (PUD, GERD, IBS) * Systemic disease (DM, hypothyroid)

Question 27

Gas: Treatment, Dietary

Answer 27

* Decrease sodas * Avoid whipped cream, milk shakes * Stop frequent sighing * Relax, Slow down * Chew thoroughly * Avoid washing solids down with liquid * Stop smoking * Stop gum chewing * Smaller meals *

Question 28

Gas: Drug Treatment

Answer 28

* Charcoal (Charcoal Plus DS)\* * Simethicone (Mylicon, Gas-X)\* * Lactase (Lactaid, Dairy Ease)@ * a - glactosidase (Beano)@ * Probiotics@ Key: @ is a preventer, \* is a reliever * relievers not very effective UNLESS lactose intolerant or alpha-glactosidase deficient

Question 29

Hemorrhoid: Definition

Answer 29

* varicose condition of hemorrhoidal veins. * pregnancy, straining at stool, constipation, prolonged sitting or standing, anal infection * Internal vs. external * above or below dentate line * above: no nerves, not feel

Question 30

Hemorrhoid: Symptoms

Answer 30

* Anal pain * Bleeding, anemia * Itching * Burning * Incontinence * Rectal protrusion, prolapse * Fissure, ulceration, infection

Question 31

Hemorrhoid: Treatment

Answer 31

* Nondrug: * Alterations in diet * Avoidance of prolonged sitting * Sitz bath * Anal hygeine * Drugs: * Limited benefit, lots of witch craft * Stool softeners, psyllium * Topical anorectal preps * Astringents, counterirritants, emollients, protectants, keratolytics, local anesthetics, wound-healing agents, vasoconstrictors, corticosteroids

Question 32

Hemorrhoid: Anorectal Preps

Answer 32

* Astsringents (Hamamelis water i.e., witch hazel) * good for cleaning * Counterirritants (camphor) * -\_- * **Emollients/protectants (mineral oil, petrolatum, zinc oxide)** * **​**helpful \<3 * Keratolytics (resourcinol) * NO * Local anesthetics (benzocaine, pramoxine) * NOOOO!!! * Wound healing (balsam Peru) * witchcraftery * Vasoconstrictors (ephedrine, phenylephrine) * witchcraftery * **Antiinflammatory - hydrocortisone** * **​**beat the itch * best is HC **ointment**

Question 33

Hemorrhoid: Rx

Answer 33

* Hydrocortisone 1% ointment * Two most rationale drug classes (protectant/emollient and steroid) * Avoids other witchcraft * Cheaper than Anusol HC or Prep H * Caution: HPA axis * **Go to the derm aisle**

Question 34

Pinworms: Pathophysiology

Answer 34

* eggs from perianal area * bedding/clothing * new host’s hands * mouth/swallowed * eggs hatch * larvae in small intestine * mature female migrates to perianal area * deposits eggs * itch, irritation * reinfestation

Question 35

Pinworms: Symptoms

Answer 35

* asymptomatic * itching * abdominal pain * weight loss * appendicitis * dermatitis * Tape test

Question 36

Pinworms: Rx

Answer 36

* Reverse tape on popsicle stick, squeeze cheeks, see eggs on slide * Personal hygiene * Launder bed clothes, bedding, etc. * Need to identify worm, because could be hookworm * **Pyrantel pamoate** (Antiminth, Reese’s Pinworm) Pinworms only * liquid by weight * Mebendazole (Vermox) Pinworms and other helminths; easy dosing; tablet, off the market now