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Flashcards in Lower GI Deck (37):
1

Contipation: Definition

  • 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

2

Constipation: LIfestyle Causes

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

3

Constipation: Medication Causes

 

  • 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

4

Constipation: Medical Conditions

  • 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

5

Constipation: Symptoms

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

6

Constipation: The Essential Triad

  • Bulk, Water, Exercise

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Constipation: When to Refer

  • 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
     

8

Constipation: Non-Drug

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

9

Constipation: Pharmacological 

  • 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
       

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Bulk Laxatives

  • 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)

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Stimulant Laxatives

  • 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,)
       

12

Saline Laxative

  • 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+)


 

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Surfactant Laxatives

  • "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
     

14

Lubricant Laxatives

  • 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

15

Hyperosmotic Laxatives

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

16

Probiotics

  • “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
       

17

Diarrhea: Definition

  • 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)

18

Diarrhea: 3 Types

  • 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

19

Diarrhea: Refer

 

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

 

20

Diarrhea: Treatment

  • 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
       

21

Diarrhea:  Adsorbents/Protectants

  • 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

22

Diarrhea: Loperamide (Imodium)

  • 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

23

Diarrhea: Polycarbophil, ORS

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

24

Gas: Etiology

  • 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
         

25

Gas: Signs/Symptoms

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

26

Gas: Assesment

  • 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)
     

27

Gas: Treatment, Dietary

  • 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

  •  

28

Gas: Drug Treatment

  • 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

29

Hemorrhoid: Definition

  • 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

30

Hemorrhoid: Symptoms

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

31

Hemorrhoid: Treatment

  • 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

32

Hemorrhoid: Anorectal Preps

  • 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
       

33

Hemorrhoid: Rx

  • 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
       

34

Pinworms: Pathophysiology

  • 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
     

35

Pinworms: Symptoms

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

36

Pinworms: Rx

  • 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
     

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