Mod 3 Lecture 3 FULL Lower GI DX Flashcards
Exam 2
1
Q
What makes up the lower GI:
A
Small intestine
Large intestine (colon)
Nerve innervations
2
Q
What is the role of small intestine?
A
Completes digestion
Pancreatic & intestinal secretions
Mucus protects gut wall
Absorbs nutrients and most water
Peptidase digests protein
Sucrases digest sugar
Site of enzymatic activity
Bile emulsifies fat
3
Q
What is the role of the large intestine?
A
Reabsorbs some water and ions
Forms and stores feces
Bacteria break down remaining proteins
Facilitates passage of fecal contents out of the body.
4
Q
What are the nerve innervations of the lower GI tract?
A
- Parasympathetic
- Sympathetic
5
Q
lower GI tract: Parasympathetic
A
Increasing digestive activity
6
Q
Lower GI tract: Sympathetic
A
Slowing digestive activity
Vasoconstriction in mucosa
7
Q
Lower GI A&P:
What are the components of the small intestine?
A
Duodenum (upper), jejunum, ileum
8
Q
What is the longest section of the GI tract? How long?
A
Longest section of GI tract ~ 20ft
9
Q
How does peristalsis occur in small intestine?
A
Peristalsis via muscular rings
10
Q
What occurs in the small intestine?
A
Enzymatic degradation & nutrient absorption
11
Q
Where do the nutrients absorbed in the small intestine go?
A
Nutrients –> circulatory & lymphatic systems
12
Q
Lower GI A&P: Small Intestine
Plicae circulars
A
circular folds within wall
13
Q
Lower GI A&P: Small Intestine
What makes up the plicae circulars?
A
Villi & microvilli
Capillaries, nerves,lymphatic vessels
14
Q
Lower GI A&P: Small Intestine
What does the villi and microvilli do in the small intestine?
A
↑ surface area for absorption
absorb nutrients through finger-like, tiny projections
15
Q
Lower GI A&P: Small Intestine
What are protective features of the small intestine?
A
Pancreas ducts
Mucus production
16
Q
Lower GI A&P: Small Intestine
What do the pancreatic ducts do in the small intestine?
A
pH neutralizing fluid
produce fluid with a pH of around 7
17
Q
Lower GI A&P: Small Intestine
What does the pancreatic ducts do with digestive enzymes?
A
The pancreatic duct carries digestive enzymes from the pancreas to the small intestine
18
Q
Lower GI A&P: Large Intestine
How large is it?
A
shorter ~ 5ft long
19
Q
Lower GI A&P: Large Intestine
What happens to the chyme from the small intestine? How long is this process?
A
Chyme from small intestine –> large intestine ~ 3-5h
20
Q
Lower GI A&P: Large Intestine
What does the small intestine have that the large intestine does not?
A
⍉ villi
21
Q
Lower GI A&P: Large Intestine
What is the cecum
A
Cecum – beginning of large intestine, precedes colon
22
Q
Lower GI A&P: Large Intestine
What is the order of the large intestine?
A
Ascending –> transverse –> descending –> sigmoid –> rectum –> anus
23
Q
Lower GI A&P: Large Intestine
What occurs minimally in the colon?
A
Absorption of nutrients is minimal
24
Q
Lower GI A&P: Large Intestine
How much fluid enters the colon each day?
A
1500 mL of fluid enters colon each day
25
Lower GI A&P: Large Intestine
What is reabsorbed in the colon?
Reabsorption of fluids, electrolytes, acids & bases
26
Lower GI A&P: Large Intestine
What is stored/formed in the colon?
Forms and stores feces
27
Lower GI A&P: Large Intestine
What is attached to the cecum of the large intestine?
Appendix, attached to cecum
28
Lower GI A&P: Large Intestine
What is the purpose of the appendix?
Aids in immunity
No function, but potential harm
29
Lower GI A&P: Large Intestine
What is the appendix a reservoir for?
Reservoir for good bacteria
30
Lower GI A&P: Large Intestine
What does the rectum do?
Fecal formation &storage
31
How does the defecation reflex compare in adults and infants?
Consciously controlled (⍉ infants)
32
How is the defecation reflex activated?
Feces --> stretch receptors --> spinal cord --> signal
33
How do the muscles move during defecation?
Relaxation of internal & external anal sphincters
Contraction of rectum
34
What muscles assist in defecation when needed?
Abdominal muscles~ assistance when needed
35
What innervations are involved in defecation control?
Innervations: sympathetic & parasympathetic
36
What is required for defecation control?
Requires intact muscular & nervous function
37
What does prolonging urges of defecation control lead to?
H2O reabsorption ~ difficulty to pass bowel movement (BM)
38
What is used to ID underlying cause and complications of GI tract?
Poop
39
What type of patient medical history do you collect about poop?
Usual BM pattern
HX of weight loss, anorexia, fatigue
40
PE
Cramping, fever, chills, N/V: Acute ~ infectious
41
Stool analysis & cultures
Frank Blood
bright, red surface of the stool, lesions in the rectum or anal canal and has not been “digested”
42
Stool analysis & cultures include:
Frank blood:
Occult blood:
Melena:
Steatorrhea:
(+) blood, pus, mucus ~ exudative diarrhea
43
Stool analysis & cultures
Occult Blood
small hidden trace amounts not visible but detected on fecal testing;
44
Stool analysis & cultures
How does occult blood result?
result of small bleeding ulcers in the stomach or small intestine
45
Stool analysis & cultures
Melena:
dark, tarry stool often resulting from significant bleeding higher in the digestive tract;
46
Stool analysis & cultures
Why does the dark color occur in melena:
dark color is due to hemoglobin being broken down by intestinal bacteria ~ upper GI bleed
47
Stool analysis & cultures
What does (+) blood, pus, mucus indicate?
exudative diarrhea
48
Stool analysis & cultures:
Steatorrhea:
“Fatty” stools
Frequent bulky, loose stools that are greasy, often with a foul odor
49
According to the Bristol Stool Chart, how many types of poop are there?
7 Types (study if you have time slide 8)
50
What is diarrhea?
Change in bowel pattern characterized by an increased frequency, amount, and water content of stool
51
What causes diarrhea to occur?
Results because of increased fluid secretion, decreased fluid absorption, or an alteration in GI peristalsis
52
How is diarrhea viewed in relation to disease?
Symptom of GI disease not a disease per se
53
What are the two groups of diarrhea?
Acute diarrhea
Chronic diarrhea
54
What is Acute Diarrhea?
> 3 stools within 24hrs that last < 14 days
55
What usually causes acute diarrhea?
Often caused by viral or bacterial infections or certain medications (e.g., antibiotics, antacids, and laxatives)
56
How does acute diarrhea progress?
Usually self-limiting, depending on the cause
57
Acute diarrhea is generally what? What are the symptoms?
Generally infectious and accompanied by cramping, fever, chills, nausea, and vomiting.
58
What may be present in acute diarrhea?
Blood (may be frank, occult, or melena), pus, or mucus may be present.
59
How are bowel sounds in acute diarrhea?
Bowel sounds may be hyperactive.
60
What kind of imbalances occur in acute diarrhea? What does this lead to?
Fluid, electrolyte, and pH imbalances (met acidosis).
61
What is chronic diarrhea?
Lasts longer than 4 weeks
62
What are the causes of acute diarrhea?
Causes: inflammatory bowel diseases, malabsorption syndromes, endocrine disorders, chemotherapy, and radiation
63
Approach to Management of Diarrhea
Strategies vary depending on etiology
64
Approach to Management of Diarrhea: Acute Diarrhea?
Acute diarrhea usually self-limiting
65
Approach to Management of Diarrhea:
Maintenance and correction of BOTH Acute Diarrhea and Chronic include?
Hydration, electrolyte, acid-base
Non-severe ~ PO
Severe or hyponatremia IV
66
Approach to Management of Diarrhea:
What does dietary fiber do?
Absorbs excess H2O & ↑ stool bulk
Beneficial for chronic diarrhea
67
Approach to Management of Diarrhea:
Why is skin care important?
Issue in bowel incontinence
68
Approach to Management of Diarrhea:
What is needed for infectious diarrhea?
ABX, when needed
69
What kind of infectious diarrhea would antibiotics be needed for ?
Severe traveler’s
C diff
70
What should be avoided when experiencing infectious diarrhea?
Avoid antidiarrheals
71
What is used to treat non- infectious diarrhea?
Antidiarrheal agents
Anticholinergics
Antispasmodics
72
What is C.diff?
Gram + bacillus anaerobe
73
What is Clostridium Difficile-Associated Diarrhea (CDAD):
Bacteria-related damage to the intestinal mucosa and colon
74
What are mild signs and symptoms of Clostridium Difficile-Associated Diarrhea (CDAD):
Mild: abdominal discomfort, nausea, fever, diarrhea, leukocytosis
75
What are severe signs and symptoms of Clostridium Difficile-Associated Diarrhea (CDAD):
Severe: toxic megacolon, pseudomembranous colitis, colon perforation, sepsis
76
What is antibiotic induced CDAD?
Broad spectrum antibiotics that disrupt normal flora
77
What are examples of antibiotics that lead to antibiotic induced CDAD?
Clindamycin, 2nd & 3rd gen cephalosporins, FQs
78
What are predisposing factors that lead to CDAD?
Surgery of the gastrointestinal (GI) tract
Diseases of the bowel (inflammatory bowel disease, colon cancer)
Weakened immune system (eg chemo)
Advanced age
Kidney disease
Use of proton pump inhibitors
Prior C. diff infection
79
What are the two most important ways in managing CDAD?
Discontinue offending ABX
Obtain stool cx to r/o C diff
80
What else (other than the two most important ways) should CDAD be managed?
ABX for CDI
81
What antibiotics are used for MILD CDAD?
Metronidazole PO 500mg TID 10-14 days, Vancomycin PO 4x/day 10-14d
82
What antibiotic should be given for severe/complicated CDAD?
Severe/complicated: Metronidazole 500mg IV q8 + Vancomycin PO 4x/day 10-14d
83
What other medication can be given for CDAD management?
Fidaxomicin
84
How should medication be administered in CDAD management?
Start empirically if lab confirmation delay
85
Antidiarrheal Classification:
What are the two broad groups of antidiarrheals?
Non-specific antidiarrheals (diphenoxylate, loperamide)
Specific antidiarrheals
86
What are examples of non-specific antidiarrheals? (opioids)
Non-specific antidiarrheals (diphenoxylate, loperamide)
87
How do Non-specific antidiarrheals (diphenoxylate, loperamide) act?
Act on or within the bowel to provide symptomatic relief only!
88
What does Non-specific antidiarrheals (diphenoxylate, loperamide) have to do with the cause of diarrhea?
⍉ influence underlying cause
89
What are the two agents in Non-specific antidiarrheals?
Opioid-derived agents
Non-opioid agents
90
What does Specific antidiarrheals treat?
TX underlying causes (e.g. IBD)
91
What are specific antidiarrheals used for?
(Give examples)
Anti-infectives for C Diff, traveler’s diarrhea
Agents to correct malabsorption diagnosis
92
Nonspecific Antidiarrhea Agents: Opioids
What is the 2 groups of nonspecific antidiarrheal opioids
Diphenoxylate [Lomotil] &
Loperamide (Imodium)
93
Nonspecific Antidiarrhea Agents: Opioids
What do Diphenoxylate [Lomotil] & Loperamide (Imodium) both activate in the GI tract?
Activate opioid receptors in GI tract
94
Nonspecific Antidiarrhea Agents: Opioids
What do Diphenoxylate [Lomotil] & Loperamide (Imodium) both do in the GI tract?
Decrease intestinal motility, slows intestinal transit to allow more time to absorb F&E
95
Nonspecific Antidiarrhea Agents: Opioids
When Diphenoxylate [Lomotil] & Loperamide (Imodium) activate opioid receptors, what happens?
Activation of opioid receptors decreases secretion of fluid into SI & increases absorption of fluid & salt
96
What is the goal of Nonspecific Antidiarrhea Agents: Opioids?
Goal: less H2O in LI --> less fluidity & volume of stools & decreased stool frequency
97
Nonspecific Antidiarrhea Agents: Opioids
What can high doses of opioid receptors lead to?
High doses can elicit typical morphine-like subjective responses
98
Nonspecific Antidiarrhea Agents: Opioids
How would you treat a severe OD of Nonspecific Antidiarrhea Agents: Opioids?
Severe OD: tx with naloxone
99
Nonspecific Antidiarrhea Agents: Opioids
How can you get Diphenoxylate [Lomotil]? In what form do they come?
Rx only
Tablets & liquid
100
Nonspecific Antidiarrhea Agents: Opioids
What is Diphenoxylate [Lomotil] formulated with? Why?
Formulated with atropine to discourage abuse (5ml = 2.5mg diphenoxylate + 0.025mg atropine)
101
Nonspecific Antidiarrhea Agents: Opioids
What does atropine do in Diphenoxylate to discourage abuse?
Atropine to discourage abuse (unpleasant side effects from high dose of atropine)
102
Nonspecific Antidiarrhea Agents: Opioids
What is Diphenoxylate [Lomotil] only used for?
Opioid used only for diarrhea
103
Nonspecific Antidiarrhea Agents: Opioids
How can you get Loperamide (Imodium)? In what form do they come?
OTC, 2mg capsules
104
Nonspecific Antidiarrhea Agents: Opioids
What is Loperamide (Imodium) similar to?
Structural analog of meperidine
105
Nonspecific Antidiarrhea Agents: Opioids
What does Loperamide (Imodium) do?
Suppresses bowel motility & fluid secretion into intestinal lumen
106
Nonspecific Antidiarrhea Agents: Opioids
What is Loperamide (Imodium) used for?
Used to treat diarrhea and to reduce the volume of discharge
107
Nonspecific Antidiarrhea Agents: Opioids
How is absorption of Loperamide (Imodium)?
Poor absorption, does not readily cross BBB
108
Nonspecific Antidiarrhea Agents: Opioids
What is the potential of abuse of Loperamide (Imodium)?
What is the half life?
Little or no potential for abuse
Half-life: 9-14 hrs
109
Nonspecific Antidiarrhea Agents: Non-Opioids
What are the types of Other Nonspecific AD: Non-Opioids?
1. Bismuth Subsalicylate (Pepto-Bismol)
2. Bulk-Forming Agents
3. Anticholinergic Antispasmodics
110
Nonspecific Antidiarrhea Agents: Non-Opioids
What is the mode of action of Bismuth Subsalicylate (Pepto-Bismol)?
Coats wall of GI tract, adsorbing bacteria or toxins causing the diarrhea
Reduces prostaglandins
111
What do prostaglandins?
PGs induce inflammation & hypermotility
112
Nonspecific Antidiarrhea Agents: Non-Opioids
What is Bismuth Subsalicylate (Pepto-Bismol) used for?
Use in mild cases for prophylaxis & treatment of diarrhea & h pylori
113
Nonspecific Antidiarrhea Agents: Non-Opioids
What is the prophylaxis treatment dosages for Bismuth Subsalicylate (Pepto-Bismol)?
Px: 262mg tabs 4x/day x 3wks
114
Nonspecific Antidiarrhea Agents: Non-Opioids
What is the treatment dosages for Bismuth Subsalicylate (Pepto-Bismol)?
Tx: 2 tabs every 30 min x 8 doses
115
Nonspecific Antidiarrhea Agents: Non-Opioids
How is Bismuth Subsalicylate (Pepto-Bismol) administered?
Shake suspension well
Chewable tabs may be dissolved in mouth or chewed & swallowed
116
Nonspecific Antidiarrhea Agents: Non-Opioids:
What is a bulk forming agent?
Methylcellulose and Psyllium
117
Nonspecific Antidiarrhea Agents: Non-Opioids:
What does Methylcellulose do?
Paradoxical laxatives, refer to constipation
Makes stools more firms less watery
118
Nonspecific Antidiarrhea Agents: Non-Opioids:
What are examples of anticholinergic antispasmodics?
Atropine,
dicyclomine (bentyl)
119
Nonspecific Antidiarrhea Agents: Non-Opioids:
What is the mode of action of anticholinergic antispasmodics?
Muscarinic antagonists
Block vagal tone --> prolong gut transit time
120
Nonspecific Antidiarrhea Agents: Non-Opioids:
What should Anticholinergic Antispasmodics be used for?
Relief of cramping
121
Nonspecific Antidiarrhea Agents: Non-Opioids:
What should Anticholinergic Antispasmodics NOT be used for?
⍉ effect on fecal consistency/volume
122
Nonspecific Antidiarrhea Agents: Non-Opioids:
What are the adverse effects of Anticholinergic Antispasmodics?
Blurred vision, photophobia, dry mouth, urinary retention, tachycardia
123
Patho of Constipation:
What is constipation characterized by?
Change in bowel pattern characterized by infrequent passage of stool in reference to the individual’s typical bowel pattern.
124
Patho of Constipation:
How are stools and process of creating stool in constipation?
Hard & dry stools, excessive straining, prolonged effort, incomplete evacuation
125
Patho of Constipation:
How are stools IN the body during constipation? What does this lead to?
Stool remains in the large intestine longer than usual, increasing the amount of water reabsorbed by colon.
126
Patho of Constipation
What is constipation determined by?
Determined by stool consistency > number of BMs
127
Patho of Constipation
What are causes of constipation?
Causes: low-fiber diet,
inadequate physical activity,
insufficient fluid intake,
delaying the urge to defecate,
laxative abuse,
stress (SNS stimulation slows GI motility), travel,
bowel diseases,
certain meds (eg narcs, anticholinergics, fe supplements),
depression,
neurologic diseases (eg CVA, Parkinson’s, SCI) and
colon cancer.
128
Patho of Constipation
What are the benefits of fiber in constipation?
Absorbs water: Softens feces and increases size
Can be digested by colonic bacteria --> growth increases fecal mass
129
Clinical Presentation & Complications
What are symptoms of constipation?
Straining with defecation
Hard stools
Sensation of incomplete emptying
Manual maneuvers to facilitate stool evacuation
Fewer than three bowel movements per week
Infrequent stools
Prolonged effort
Unsuccessful defecation
130
Clinical Presentation & Complications
What are complications of stool?
anal bleeding, anal fissure, bowel incontinence (leakage of liquid stools), hemorrhoids, obstipation, intestinal obstruction, bowel perforation
131
Obstipation
a severe form of constipation that results in a person being unable to have a bowel movement.
132
How is constipation diagnosed?
H&P, Bristol Stool chart, digital exam, abd XR, UGI series, barium swallow, colonoscopy
133
What is the treatment of constipation?
Increasing dietary fiber with concomitant increase in hydration
134
Proper bowel functioning is dependent on whaat?
Proper bowel function is highly dependent on dietary fiber (bran is best source)
135
What is the best source of dietary fiber?
(bran is best source)
136
When fiber is given for constipation, what does it do?
Fiber absorbs water --> soft feces, increased mass
137
What do colonic bacteria do when fiber and hydration are given as treatment for constipation?
Digested by colonic bacteria --> increased fecal mass
138
What is something (other than bran) that is rich in fiber?
Flax seed
139
What are treatments for constipation (other than increasing fiber and hydration)?
increasing physical activity
defecating when initial urge is sensed
stool softeners & fiber supplements
limited use of laxatives and enemas
140
Laxatives have how many modes of actions?
What is the general goal of laxative?
Various MOA ~ stimulate defecation
141
What do stimulants do to stool? What does this do? Who is it good for?
Soften stool –prevents straining, esp good in cardiac pts to prevent elevation of BP & vasovagal
Increase fecal mass & volume
142
What do laxatives compensate for?
Compensates for loss of abdominal tone & perineal muscles in elderly
143
What do laxatives do to fecal transit?
Speed up fecal transit
144
How can laxatives be used for procedures?
Facilitate rectal evacuation – empty bowel before procedure
145
How does laxatives help with bedridden patients?
Prevent fecal impaction in bedridden patients
146
How do laxatives effect elimination?
Reduce painful elimination
147
What are contraindications and precautions for laxatives?
Acute surgical abdomen
Habitual use/abuse
Abd pain, cramps, appendicitis, inflamm bowel disease
Fecal impaction – increased peristalsis could cause bowel perforation
Caution in pregnancy – GI stimulate might induce labor
Not for habitual use
148
What are the classifications of laxatives?
Bulk-forming
Surfactant
Stimulant
Osmotic.
There is a graph on slide 25 to look at?
149
What is an example of a bulk forming laxative?
Psyllium [Metamucil]
150
Bulk forming laxative: Psyllium [Metamucil]
What does it do to food? Water? Waste?
Soften and increase bulk of digested food, so waste can more easily pass
Absorb water
Fecal swelling--> peristalsis
151
What is an example of a surfactant laxative?
Docusate sodium [Colace]
152
Surfactant laxatives: Docusate sodium [Colace]
What does it do?
Increase water in the stool, which helps soften it and makes it more comfortable to pass
153
What is an example of stimulant laxatives?
Bisacodyl [Dulcolax]
154
Stimulant laxatives: Bisacodyl [Dulcolax]
What does it do?
Stimulate intestinal walls, which causes the muscles’ contraction to clear the bowel
Soften feces by increasing water secretion & electrolytes into intestine
155
What is an example of Osmotic laxatives?
Milk of magnesia (MOM),
Polyethylene glycol (PEG),
lactulose
156
Osmotic laxatives: Milk of magnesia (MOM), Polyethylene glycol (PEG), lactulose
What do they do?
Draw water into the intestine
Osmotic action retains water soften feces, fecal swelling peristalsis
157
What does the osmotic action of osmotic laxatives allow them to do?
Osmotic action retains water --> soften feces, fecal swelling --> peristalsis
158
What are examples bulk forming laxatives?
Psyllium, Methylcellulose
159
What do bulk forming laxatives work similar to?
Function similarly to dietary fiber
160
How are bulk forming laxative absorbed and digested?
Nondigestible & nonabsorbable
161
How do bulk forming laxatives work?
Swell with water to form a gel that softens and increases fecal mass
162
What is the process of how bulk forming laxatives work?
Fecal mass swelling --> stretches intestinal wall --> speeds up transit time --> peristalsis
163
Where do bulk forming laxatives work?
Works in SI/LI
164
What do bulk forming laxatives do to food?
Soften and increase bulk of digested food, so waste can more easily travel through and leave the body
165
What kind of people are bulk forming laxatives good for?
Good for patients with ileostomy/colostomy
166
What are bulk forming laxatives preferred for?
Preferred temporary treatment of constipation
167
What do bulk forming laxatives do for diarrhea?
Can provide symptomatic relief of diarrhea
168
What do bulk forming laxatives do for ileostomy and colostomy?
Reduce discomfort/inconvenience with ileostomy/colostomy
169
How long does it take for bulk forming laxatives to form soft stool?
Produce soft stool 1-3 days
170
What is the dose for bulk forming laxatives?
1 heaping tsp/package in 8oz H2O 1-3x/day
171
What are the adverse effects of bulk forming laxatives?
Adverse effects are minimal
Esophageal obstruction
172
What should be done to avoid esophageal obstructions that can occur with bulk laxatives?
Give with plenty H2O or juice to prevent esophageal obstruction
173
How is the esophageal obstruction that occurs with bulk forming laxatives?
Obstruction or impaction forms a sticky substance when combined with water
174
What should you do if esophageal obstruction is suspected with bulk forming laxative use?
Avoid if suspected
Avoid if there’s narrowing of intestinal lumen or impeded passage to prevent obstruction
175
How are surfactant laxatives (like Docusate sodium (Colace)) taken?
PO: tablets, capsules, liquid, syrup
OTC
176
What is the mode of action of surfactant laxatives (like Docusate sodium (Colace))?
MOA “stool softener”
177
When does "stool softening" occur with surfactant laxative use?
Produce a soft stool several days after onset of treatment
178
What does surfactant laxatives promote?
What does this lead to?
Promotes incorporation of water into stool --> softer fecal mass
179
Why is it important that surfactant laxatives make stool softer?
Makes stool more comfortable to pass
180
Where does surfactant laxatives work?
Works in small intestine & colon
181
How is surfactant laxatives used?
(amount)
Soft, formed stool ~ 1-3d, can take 3-5 days
182
What is surfactant laxatives used for?
PX opioid-induced constipation, postop, pregnancy
183
What is the dose of surfactant laxatives?
Dose
Adults 50-500 mg/day
Usually given 3x/day
184
What is the example of Stimulant Laxatives?
Bisacodyl (Ducolax, Senna/Senekot)
185
What is the mode of action of Stimulant Laxatives like Bisacodyl (Ducolax, Senna/Senekot)?
What does it stimulate?
Stimulate intestinal motility causes the muscles’ contraction to clear the bowel
186
What is the mode of action of Stimulant Laxatives like Bisacodyl (Ducolax, Senna/Senekot)?
What does it do to water?
Increase amounts of water and lytes in intestinal lumen
187
Where does Stimulant Laxatives (Bisacodyl (Ducolax, Senna/Senekot)) work?
Works in the colon
188
What is Stimulant Laxatives Bisacodyl (Ducolax, Senna/Senekot) used for?
TX of constipation from slow intestinal transit & opioid-induced
189
How is Stimulant Laxatives Bisacodyl (Ducolax, Senna/Senekot) used? (abusable?)
Widely used & abused
190
What kind of stool does stimulant laxative bicacodyl create when given PO?
Produce semifluid stool with 6-12h
191
When is stimulant laxative bisacodyl given? (What time of day)
Given QHS to produce BM next day
192
How should stimulant laxative bicacodyl be given? How is the PO med taken?
EC to prevent gastric irritation
Swallow whole, no chewing, crushing
193
How do stimulant laxatives like bisacodyl act when they are in PR SUPP form?
Act rapidly – 15-60 min
194
What is the adverse reaction of stimulant laxative like Bisacodyl when they are given PR SUPP?
What should you avoid with this drug? Why?
ADE burning
Avoid long-term - proctitis
195
Proctitis
Proctitis is inflammation of the lining of the rectum.
196
Senna is derived from what?
What does it do to urine?
Plant-derived, stimulant actions (stimulates the bowels to move)
Yellow-brown/pink urine discoloration
197
What are ingredients in osmotic laxatives?
Sodium phosphate, Mg OH
198
What do osmotic laxatives do with fecal mass, what does this lead to?
softens and swells fecal mass, which stretches the intestinal wall to stimulate peristalsis
199
What does a low dose of osmotic laxatives do? What does a high dose of osmotic laxatives do?
Low dose – watery stool 6-12 hrs,
high dose 2-6 hrs (eg bowel cleanse prep)
200
Osmotic Laxatives:
Polyethylene Glycol-PEG (Miralax)
How is it administered?
How long may it take a BM to occur?
17gm (low dose) once a day dissolved in 4-8 oz of liquid
BM may not occur for 2-4 days
201
Osmotic Laxatives:
Where do they work?
Works in small intestine & colon
202
Osmotic Laxatives:
What are adverse effects?
Dehydration, nausea, bloating, cramping, flatulence
Acute renal failure
203
Osmotic Laxatives:
What are adverse effects that can occur because of renal failure?
Mg can accumulate to toxic levels
Sodium retention
204
Osmotic Laxatives:
What occurs with sodium retention in renal failure from osmotic laxative use?
Sodium retention: Exacerbated heart failure, hypertension, edema, can cause RF in kidney disease
205
ADEs of Osmotic Laxatives:
What drug interactions can occur?
Interactions with Ace-Is, ARBs, diuretics (drugs that alter renal, fxn)
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ADEs of Osmotic Laxatives:
Interactions with Ace-Is, ARBs, diuretics (drugs that alter renal, fxn)
What can these lead to?
Dehydration & precipitation of CaP in renal tubules
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Glycerin suppository:
What kind of agent is it?
Osmotic agent
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Glycerin suppository:
What does it do to stool? What may it stimulate?
Lubricates & softens hardened, impacted stool
May also stimulate rectal contraction
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Glycerin suppository:
How long does it take for effects to occur?
Evacuation occurs in about 30 min post-insertion
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Glycerin suppository
What are glycerin suppository useful for?
Useful for re-establishing normal bowel function following termination of chronic laxative use
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What are they used for?
Allow for good visualization of the bowel
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What are the types?
Sodium phosphate (OsmoPrep)
Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely)
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Sodium phosphate (OsmoPrep)
What is the dosages?
Dosage: 20 tabs evening, 20 tables AM with clear liquid
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Sodium phosphate (OsmoPrep)
What are the most common adverse effects?
Most common adverse effects are nausea, bloating, and abdominal discomfort.
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Sodium phosphate (OsmoPrep)
What can occur because of kidney disease and advanced age?
Can cause dehydration and electrolyte disturbance in kidney disease, advanced age
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What MUST patients do when consuming Sodium phosphate (OsmoPrep)?
Pts must drink large volume clear fluid before, during, after dosing
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What is a rare adverse effect of Sodium phosphate (OsmoPrep)?
Hyperphosphatemia rare - can cause renal damage if pre-existing conditions (eg kidney disease adv age)
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What does not occur with Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely)? Why?
Isoosmotic with body fluids, so dehydration & electrolyte balance does not occur
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely): Isoosmotic with body fluids, so dehydration & electrolyte balance does not occur
Who is Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely) safe for?
Safe for pts with lyte imbalances, HF, kidney, liver disease
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What is Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely) require?
Requires ingestion of large volume of bad-tasting liquid
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
How is the volume of Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely)?
Volume administered is huge, typically 4 L. Patients must ingest 250 to 300 mL every 10 min x 2 to 3hrs
Newer products: GaviLyte-H + bisacodyl + PEG-ELS – the volume is cut in half
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Bowel-Cleansing Products for Colonoscopy (Osmotic Lax):
What are the most common adverse effects of Polyethylene glycol (PEG) plus electrolytes (ELS) (Go-lytely)?
Most common adverse effects are nausea, bloating, and abdominal discomfort.
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Laxative Abuse: What is a misconception?
Misconception that bowel movements must occur daily
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Laxative Abuse: What is often mistaken for constipation?
Bowel replenishment after evacuation can take 2 to 5 days; often mistaken for constipation
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Laxative Abuse:
Consequences?
Diminished defecatory reflexes, leading to further reliance on laxatives
Electrolyte imbalance, dehydration, colitis
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Pathogenesis of Inflammatory Bowel Disease:
What is it?
Exaggerated immune response directed against normal bowel flora
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Pathogenesis of Inflammatory Bowel Disease:
What are initiating triggers that are genetic?
Antimicrobial peptides
Autophagy
Handling of bacteria
Chemokines
Cytokines
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Pathogenesis of Inflammatory Bowel Disease:
What are initiating triggers that are environmental?
Microorganisms
Diet
Infections
Stress
NSAIDs
Appendectomy
Smoking
Antibiotics
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Pathogenesis of Inflammatory Bowel Disease:
What are the four phases?
Phase I: Pre-disease stage
Phase II: Acute intestinal inflammation
Phase III: Chronicity or resolution
Phase IV: Tissue Destruction and complications
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Overview of Inflammatory Bowel Disease:
What are two major diseases?
Crohn’s Disease
Ulcerative colitis
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Overview of Inflammatory Bowel Disease:
Crohn’s Disease
What is it? When does it start?
Autoimmune disease
Starts in adolescence through early adulthood
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Overview of Inflammatory Bowel Disease:
Crohn’s Disease
What is common?
Abscesses, fissures, fistula & obstruction common
Mass of inflammatory tissue (granuloma) surrounded by ulceration
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Overview of Inflammatory Bowel Disease
Crohn's Disease:
What kind of inflammation occurs?
Mass of inflammatory tissue (granuloma) surrounded by ulceration
Transmural Inflammation:
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Overview of Inflammatory Bowel Disease
Crohn's Disease:
What is Transmural Inflammation?
Transmural Inflammation: involves deeper layers of bowel wall
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Overview of Inflammatory Bowel Disease:
Crohn's Disease:
What areas are affected? What area is most affected?
Any area of digestive tract may be affected, mouth ---> anus
Terminal ileum mostly affected
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Overview of Inflammatory Bowel Disease:
Crohn's Disease:
How does it affect areas of the body?
Affects all layers of the gastrointestinal tract in a “skip” pattern
Cobblestone lesions
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Overview of Inflammatory Bowel Disease:
Ulcerative colitis: What age does it occur?
Any age occurs
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Overview of Inflammatory Bowel Disease:
Ulcerative colitis: Where does it begin and extend?
Begins in rectum, may extend throughout colon
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Overview of Inflammatory Bowel Disease:
Ulcerative colitis: how is the mucosa?
Mucosa inflamed continuously confined to the mucosa
Friable mucosa
Crypt abscess formation, necrosis, ragged ulceration of mucosa
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Overview of Inflammatory Bowel Disease:
Ulcerative colitis:
What kind of lesions occur?
Small erosions --> superficial ulcers
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Overview of Inflammatory Bowel Disease:
What happens to the colon?
Edema & thickening of muscularis mucosa may narrow lumen of colon
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Overview of Inflammatory Bowel Disease:
Ulcerative colitis: What does crypt abscess formation, necrosis, ragged ulceration of mucosa lead to?
Accumulation of inflammatory & WBCs within the crypts of GIT
--> Tube-like glands in lining of GIT
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slide 40 read it
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Clinical manifestations of Crohn's disease?
Inflammation
Melena if lesions erode blood vessels
Malabsorption
Anemia & fatigue
Deep fissuring ulcers in intestines
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Clinical manifestations of Crohn's disease:
What symptoms does inflammation in Crohn's disease lead to?
Diarrhea/cramping/abd pain
Loose stool/semi-formed
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Clinical manifestations of Crohn's disease:
What does malabsorption in Crohn's lead to?
Anorexia; nausea; vomiting; weight loss--> malnutrition
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Clinical manifestations of Crohn's disease:
What causes Anemia and fatigue in Crohn's?
Lack of VitB12 absorbed in terminal ileum
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Clinical manifestations of Crohn's disease:
What can occur because of constipation in Crohn's?
Anal fissures from constipation, strictures, fistulas, and abscesses from transmural inflammation and micro perforation of diseased bowel
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Clinical manifestations:
What occurs in Ulcerative colitis due to inflammation?
Bloody, mucus diarrhea due to inflammation & damage to mucosa epithelium
- Up to 10-20x/day
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Clinical manifestations:
What occurs in Ulcerative colitis in addition to a need to defecate?
Spasms of the rectum along with a need to defecate
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Clinical manifestations:
What occurs in Ulcerative colitis from rectal bleeds?
Severe Iron Deficiency Anemia from rectal bleed
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Clinical manifestations:
What occurs in Ulcerative colitis from fludi loss?
Dehydration from fluid loss
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Drugs for IBD: What do drugs do in general?
Not curative; may control disease process
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Drugs for IBD: What are they?
5-Aminosalicylates - 5-ASAs (sulfasalazine; mesalamine)
Glucocorticoids
Immunosuppressants
Immunomodulators (infliximab – Remicade)
Antibiotics (metronidazole & ciprofloxacin) for Crohn’s
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Drugs for IBD: What are examples of 5-Aminosalicylates - 5-ASAs
(sulfasalazine; mesalamine)
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Drugs for IBD: What does 5-Aminosalicylates - 5-ASAs (sulfasalazine; mesalamine) do?
Reduces inflammation; suppresses prostaglandin synthesis and migration of inflammatory cells into affected region
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Drugs for IBD: What are immunosuppressants Azathioprine [Imuran], mercaptopurine [Purinethol], cyclosporine, methotrexate used for?
Used to maintain remission in both CD & UC
Used when pts not responding to traditional therapy
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Drugs for IBD: What are examples of Immunosuppressants?
Azathioprine [Imuran], mercaptopurine [Purinethol], cyclosporine, methotrexate
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Drugs for IBD: What are immunosuppressants Azathioprine [Imuran], mercaptopurine [Purinethol], cyclosporine, methotrexate:
What are adverse reactions
ADR: bone marrow suppression
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Drugs for IBD: What are examples of Immunomodulators
Immunomodulators (infliximab – Remicade)
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Drugs for IBD: What do Immunomodulators (infliximab – Remicade) what is most common reactions?
What is most concerning?
Infections & infusion reactions most common (chills, itching, cardiopulm sx, BP flucuations)
Tb & opportunistic infections, lymphoma most concerning
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Drugs for IBD: What do Immunomodulators (infliximab – Remicade) do?
Monoclonal antibody designed to neutralize tumor necrosis factor (TNF), a key immunoinflammatory modulator
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Drugs for IBD:
What are examples of antibiotics for Crohn's?
What are they for?
(metronidazole & ciprofloxacin)
Treatment for abscesses
