NVD & Constipation Flashcards
(39 cards)
1
Q
- What is nausea?
- What is vomiting?
- What is regurgitation?
A
- Feeling sick
- Forceful expulsion of stomach contents up through the esophagus
- Non-forceful bubbling up of stomach contents into the esophagus
2
Q
- What are the differential diagnoses for N/V?
- How should you approach the diagnosis of N/V?
A
- Meds, Pregnancy, Food poisoning, Vertigo, Head trauma, Infection, Alcohol, Appendicitis, Gallbladder, Chemo, Diverticulitis, GERD, Psychiatric, MI, Inflammatory disorders (IBS etc.), Constipation
- Think through the intrinsic (GI related) causes first, ten move on to extrinsic (systemic) causes
3
Q
- What endoscopic/imaging studies would you perform on a patient complaining of N/V?
- Which laboratory studies would you do?
- What is a HIDA scan?
- What is an ERCP?
- Would you treat a patient for nausea and vomiting without knowing a definitive diagnosis?
A
- Abdominal X-ray, US, CT (gold standard), HIDA scan, EGD, ERCP
- CMP (electrolytes, LFTs), CBC (infection), Amylase/Lipase (looks at pancreas
- Hepatobiliary Imino-Diacetic Acid scan. Tracks the production and flow of bile from the liver to the small intestine. Dye is injected and teken up in the bile duct and gallbladder
- Endoscopic retrograde cholangiopancreatogram. combines the use of a flexible, lighted scope (endoscope) with X-ray pictures to examine the tubes that drain the liver, gallbladder, and pancreas
- Yes
4
Q
- What is the treatment for mild-moderate N/V?
- What is the treatment for moderate-sever N/V?
A
- Clear liquids, advance to small quantities of bland food, antiemetic meds
- Hospitalization with IV fluids, antiemetic meds, NG tube in some situations
5
Q
- What are the indications for Ondansetron?
- What class does ondansetron fall under?
- What are the dosage forms?
- What is the usual starting dose?
- Where is Ondansetron metabolized?
- Can this be used by pregnant women?
- What are the most common adverse effects?
A
- Acute onset N/V; Post-op N/V; Hyperemesis gravidum; Chemo
- IM, IV, ODT (generic only)
- 4-8 mg IV
- In the liver (caution with hepatic impairment)
- Yes, it is a pregnancy category B
- Visual disturbance; HA; diarrhea/constipation; urinary retention; dizziness; pruritis
6
Q
- Which anti-emetic ia a 1st gen antihistamine/anticholinergic?
- What are the indications for promethazine?
- What are the dosage forms for promethazine?
- What is the usual dosage for promethazine?
- Where is it metabolized?
A
- Promethazine
- Acute onset N/V
- IM, IV, oral solution, tablet, rectal suppository
- 12.5-25 mg q 4-6 hrs prn
- Liver (CYP 450)
7
Q
- What are possible serious adverse reactions to promethazine?
- What are the common adverse reactions to promethazine?
- What is the black box warning?
- What are the contraindications?
- When should caution be used (other than always)?
- What pregnancy category does promethazine fall under?
- Which labs should be obtained when using promethazine in a pregnant patient?
A
- Respiratory depression; hallucination; extrapyramidal side effects; seizures; leukopenia; thrombocytopenia; bradycardia
- Sedation; blurred vision; confusion; xerostomia; dermatitis; urinary retention
- Respiratory depression; tissue injury/necrosis
- Respiratory depresion
- Elderly; asthma/COPD; glaucoma; BPH; cardiac ds; hepatic ds; seizure ds
- Category C
- CBC, ophthoexam
8
Q
- If I wanted to prescribe a prokinetic antiemetic drug what would I give?
- What are its indications?
- Dosage forms?
- Usual dosage?
- Where is it metabolized and excreted?
A
- Metoclopramide
- N/V (as adjunctive therapy); gastroparesis; GERD
- IM, IV, oral tablet, oral liquid
- 10-20 mg BID
- Minimally by the liver, excreted renally
9
Q
- What are the possible adverse reactions to metoclopramide?
- What are the most common adverse reactions to metoclopramide?
- What is the black box warning?
- What are the contraindications?
- What pregnancy category does metoclopramide fall under?
- Which lab should be obtained as a baseline before giving metoclopramide to a pregnant patient?
- How should therapy in a pregnant patient be stopped?
- Cautions?
A
- Extrapyramidal; neuroleptic malignant syndrom; seizures; depression/suicidal ideations; leukopenia/agranulocytosis; HF; arrhythmias; HTN
- Diarrhea; drowsiness; restlessness; anxiety/insomnia/depression; HA/dizziness; hormonal disorders; HTN
- Tardive Dyskinesia
- Seizure ds; GI obstruction
- Category B
- CrCl
- By tapering
- HTN; parkinsons; HF; depression; DM; renal impairment
10
Q
-Which anti-emetic is a neurokinin-1 receptor antagonist?
A
-Aprepitant
11
Q
- What are the indications for aprepitant?
- Dosage forms?
- Where is it metabolized?
A
- Prevention of chemotherapy induced and post-op N/V; NOT for acute N/V
- Oral tablet
- Liver
12
Q
- How is diarrhea defined?
- What are the acute causes of diarrhea?
- What are the chronic causes of diarrhea?
- How long does it take for most cases of acute diarrhea to resolve?
- If it is within the 5 days, when is a diagnostic work-up needed?
- How long should you wait before really worrying about acute diarrhea?
A
- Increased stool frequency (>3 BMs/day); liquidity of feces
- Viral, protozoal, bacterial
- Osmotic; secretory (tumors, GB removal); inflammatory; medications; malabsorption syndromes; motility disorders (IBS); chronic infections; factitious (laxative abusers)
- 5 days
- When associated with warning signs
- When it has lasted longer than 7 days
13
Q
- What imaging/endoscopic procedures would you use in a diagnostic workup for diarrhea?
- Which lab studies would you use?
A
- Colonoscopy; sigmoidoscopy
- Fecal leukocytes; stool culture; O&P; Stool for C, diff
14
Q
- How do you manage acute diarrhea?
- How do you manage chronic diarrhea
A
- Supportive measures (fluids); antidiarrheals (loperamide, diphenozylate, bismuth), antibiotics (if bacterial or protozoal cause suspected)
- Diet; medications (antidiarrheals, octreotide, cholestyramine, antispasmodics like dicyclomine)
15
Q
- What type of drugs are Loperamide and diphenoxylate?
- What is its mechanism of action?
- How do you dose loperamide?
- Lomotil?
- What are the contraindications?
- What are possible serious adverse reactions?
- Non-serious?
A
- Antidiarrheals
- Inhibit peristalsis
- 4mg x 1 dose, then 2mg after each diarrheal stool
- 2.5mg 2 tablets po QID, reduce as symptoms improve
- Bloody diarrhea; C. diff
- Paralytic ileus; toxic megacolon
- Constipation; abdominal cramps; dizziness
16
Q
- What type of drug is bismuth?
- What is its MOA?
- How do you dose it?
- What are common adverse reactions?
A
- Antidiarrheal
- Reduces secretions, some antimicrobial effect
- OTC oral tablet and suspension
- Black stool; black tongue; constipation; tinnitus
17
Q
- Which type of antibiotics should you give as empiric treatment for diarrhea?
- FOR REVIEW-
- What is their MOA?
- What are the main quinolones?
- What is their spectrum of activity?
- What type of diarrhea are they first line for?
A
- Floroquinolones
- They inhibit bacterial DNA synthesis
- Ciprofloxacin; Levofloxacin; Moxifloxacin
- Better Gram (-) coverage than Gram (+) coverage
- Traveler’s and infectious
18
Q
- Which drug inhibits intestinal fluid secretion and stimulates absorption?
- What are the indications for this drug?
- How would you dose it?
- What are some possible adverse reactions to this drug?
- What cautions go along with this drug?
A
- Ocreotide
- Chronic secretory diarrhea (neuroendocrine tumors, AIDS-realted)
- 50-250 mcg SC TID
- Cholelithiasis/cholecystitis/biliary tract disease; edema; contipation
- With DM, thyroid, pancreas, kidney or lier disease, arrhythmias; inhibits production of multiple hormones (insulin, LH, TSH etc…)
19
Q
- If you had a patient with chronic secretory or malabsorptive diarrhea which medication would prescribe?
- What is this drugs MOA?
- How is it dosed?
- What are the adverse effects?
- What is the other potential use for this drug?
- What should you educate patients about when prescribing this med?
A
- Cholestyramine (post small bowel resections, post cholecystectomy)
- Binds intestinal bile acids
- Powder; 4gm packet - sprinkle into food up to QID
- Biliary/intestinal obstructruciton, fecal impaction, constipation, abdominal pain, flatulence
- To lower cholesterol
- Too much can cause impaction
20
Q
-What class of drugs to hyoscyamiine and dicyclomine fall under?
-What are the indications for these meds?
-What is their MOA?
-How do you dose them?
-What are the adverse effects?
-Contraindications?
-
A
- Antispasmodics
- Diarrhea associated with IBS; acute diarrhea (eases pain caused by intestinal spasms); bladder spasm (hyoscyamine only)
- Relaxed intestinal smooth muscle, inhibits spasms and contraction
- 20mg tablet QID (dicyclomine); 0,125mg ODT SL q4 hr PRN (hyoscyamine)
- Ileus, delirium, nervousness, constipation, palpitations, xerostomia, mydriasis
- Toxic megacolon, IBD
21
Q
- What are the common viral causes of acute diarrhea?
- How do patients typically present?
- How is it transmitted?
- What is the incubation period?
- How is the diagnosis made?
- How is acute diarrhea managed?
A
- Rotavirus (m/c cause in children); Norwalk virus (m/c cause)
- “Acute gastroenteritis,” sudden onset, N/V/D, non-inflammatory diarrhea (watery, non-bloody, moderate), myalgia, malaise, HA, +/- fever,
- Fecal/oreal, contaminated surfaces, food, or water, airborne droplets
- 24-48 hours
- Clinically; stool studies (to rule out other causes); fecal leukocytes negative, culture negative
- Self-limited; supportive measures; antiemetics and antidiarrheals, antibiotics not indicated
22
Q
-What are the bacterial causes of inflammatory acute diarrhea?
A
- Salmonella
- Campylobactor
- Shigella
- Hemorrhagic E. coli
- B. anthracis
- C. difficile
23
Q
-What are the bacterial causes of non-inflammatory acute diarrhea?
A
- E. coli
- Vibrio cholera
- Clostridium perfringins
- Bacillus cereus
- Staphylococcus aureus
24
Q
- What is the pathogenesis of bacterial inflammatory acute diarrhea?
- What are the signs/symptoms?
A
- Organism invades colon and causes colonic tissue damage
- Blood or pus with diarrhea, fever, LLQ abdominal pain and cramping, urgency, fecal leukocytes postive
25
- What is the pathogenesis of bacterial non-inflammatory acute diarrhea?
- What are the signs/symptoms?
- Oraganism invades the small intestine and disrupts normal absorption (no tissue invasion)
- Profuse, watery diarrhea; non-bloody; periumbilical cramping and bloating; often with N/V; fecal leukocytes negative
26
-What can give you a huge clue to what the causative agent of bacterial acute diarrhea might be?
-The incubation period, make sure you get a good history
27
- What other type of organism is a typical cause of acute diarrhea?
- How do you treat this type of diarrhea?
- Protazoans
| - Metronidazole
28
- What is a potential complication of N/V/D?
- Symptoms?
- Signs?
- Work-up?
- How do you make the diagnosis?
- Volume depletion
- Lassitude, postural dizziness, muscle cramps
- Decreased skin turgor, hypotension (postural), oliguria
- Serum electrolytes, UA (volume, sodium concentration, osmolality)
- --Can experience multiple electrolyte abnormalities: hyponatremia, hypo/hyperkalemia, metabolic acidosis/alkalosis, elevated BUN/cr
- Made with clinical picture and confirmed by low urine sodium concentration
29
- What is a major danger of volume depletion?
- What are the signs/symptoms?
- Management?
- Can lead to hypovolemic shock
- Confusion, lethargy, tachycardia, hypotension, cold/clammy skin, oliguria, coma
- Fluid replacement: Isotonic solution (normal saline or 1/2 normal saline), may use different solutions in the presence of electrolyte abnormalities; rate of infusion depends on degree of hypovolemia
30
- How is constipation defined?
- What are the potential causes of constipation?
- Which population is constipation most common in?
- Infrequent stools (<3/week), hard stool, excessive straining, sense of incomplete evacuation
- Diet, opiates, dehydration, other meds, over-use of laxatives obstruction/narrowing of bowels, systemic disorders (DM, thyroid)
- The elderly
31
- Important historical questions?
| - What should you do on the PE?
```
-Last BM?
Appearance of BM? Blood?
How is diet?
Prior issues?
Meds?
Does it hurt?
How long does it take to have a BM
Activity level?
Fam Hx of colon problems (esp if blood in stool)
-Complete abdominal exam, DRE (stool in vault, occult blood)
```
32
-When do you need to perform a diagnostic eval in a patient with constipation?
-Age>50, hematochezia, weight loss, hemoccult positive, family history of colon cancer, signs/symptoms of underlying systemic disease
33
- What endoscopic and imaging procedures can be done to eval constipation?
- Laboratory studies?
- Colonoscopy, colonic transit studies
| - TSH, glucose, electrolytes, calcium, CBC (all to rule out systemic disease)
34
- What diet and lifestyle modifications can be used to treat constipation?
- Which pharmacotherapeutics can be used to treat constipation?
- What other options are there?
- Proper toileting habits, dietary fiber, fluids, regular activity
- Fiber supplements, stool softeners, laxatives, enemas, bowel cleansers
- Manual disimpaction for fecal impaction; surgery may be indicated for structural causes
35
- What types of fiber/bulk forming laxatives are available?
- MOA?
- Contraindications?
- Side effects?
- What systemic effects do these have on the body?
- Psyllium, methycellulose, calcium polycarbophil, wheat dextran
- Promotes intestinal motility by increasing the bulk of the stool and draws more water into it
- GI obstruction
- GI obstruction, constipation, abdominal cramps and distention, flatulence
- No systemic absorption
36
- What type of medications are Ducosate and Mineral oil?
- What is their MOA:
- When should they not be used?
-Stool softeners/surfactants
-Emollient that covers stool and softens it allowing it to pass through the colon more easily
-Severe constipation
They are generally safe and well tolerated, but mineral oil can interfere with absorption
37
- What are the three osmotic laxatives we learned about?
- What is their MOA?
- What are their indications?
- Side effects
- When are they used as bowel cleansers?
- Magnesium hydroxide (MOM), Polyethylene glycol, Lactulose (they are also known as bowel cleansers)
- Pull water into stool and increases fluid inside intestines (increases transit)
- Opioid induced constipation and chronic constipation in the elderly
- Generally well tolerated; abdominal bloating and cramps, flatulence, diarrhea
- Prior to colonoscopy and bowel surgeries because they provide a more rapid and complete cleanse
38
- What are Bisacodyl, Senna, and Cascara?
- MOA?
- Side effects?
- Cautions?
- Stimulant laxatives
- Irritate intestinal wall causing fluid accumulations and increased contractions of the intestines which increases motility
- N/V/D, abdominal cramps
- Not for long-term or daily use and may cause electrolyte abnormalities and "cathartic colon"
39
- What are the ingredients of an enema?
| - What are they used for?
- Tap water, sodium phosphate, mineral oil
- Adjunct to bowel cleanse prior to surgical procedures/colonoscopy, common in hospital setting if oral laxatives not successful, mineral oil enema can be used to soften fecal impaction
