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GI Problems: Diarrhea, Constipation, Heartburn, and Nausea

GI Problems: Diarrhea, Constipation, Heartburn, and Nausea. Rho Chi Review Series. Heartburn. Origins of Heartburn. What are some symptoms of heartburn? What is something you want to rule out before recommending treatment?

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GI Problems: Diarrhea, Constipation, Heartburn, and Nausea

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  1. GI Problems: Diarrhea, Constipation, Heartburn, and Nausea Rho Chi Review Series

  2. Heartburn

  3. Origins of Heartburn • What are some symptoms of heartburn? What is something you want to rule out before recommending treatment? • Is heartburn more frequent in men or women? Younger or older? Pregnancy? • What is the primary antireflux barrier? • Which cells secrete acid in the stomach? • What are some things that can cause heartburn? • _______ = when the pressure gradient between the LES and stomach is less than normal or non-existent

  4. Origins of Heartburn • What are some symptoms of heartburn? What is something you want to rule out before recommending treatment? • Burning in substernal area that is worse after eating and while lying down. Want to rule out heart attack • Is heartburn more frequent in men or women? Younger or older? Pregnancy? • More frequent in pregnancy. Equal in men and women and in all age groups • What is the primary antireflux barrier? • Lower esophageal sphincter stops regurgitation of food from the stomach • Which cells secrete acid in the stomach? • Parietal cells • What are some things that can cause heartburn? • Smoking, pregnancy, spicy foods, obesity, genetics, diseases, certain medications (ASA, NSAIDs), stress • Reduced sphincter tone = when the pressure gradient between the LES and stomach is less than normal or non-existent

  5. What are exclusions to self-care for heartburn? Alarm symptoms?

  6. Exclusions to Self-Care • Pregnancy • Nursing • Have to be 12 y/o or older to use H2RA or antacid • Have to be 18 y/o or older to use PPI • If heartburn persists after self-treating • Alarm symptoms: • If symptoms occur >2/3x a week or have lasted > 3 months • N/V/D • Chest pain, pain radiating from left arm to jaw, SOB • Wheezing, coughing, hoarseness, pain/difficulty swallowing • Signs of GI bleed • Family hx of ulcers

  7. Non-Pharmacologic Treatment

  8. Non-Pharmacologic Treatment

  9. Pharmacologic Treatment

  10. Classification of Heartburn • Fill in the chart with the phrases below • Word Bank: low dose H2RA, lifestyle/dietary modifications, longest duration, GERD (if > 3 months), antacid, high dose H2RA, PPI, fast onset, slow onset, long duration, short duration, slowest onset, duration episodic, 2 or more days a week, diet/lifestyle

  11. Classification of Heartburn • Word Bank: low dose H2RA, lifestyle/dietary modifications, longest duration, GERD (if > 3 months), antacid, high dose H2RA, PPI, fast onset, slow onset, long duration, short duration, slowest onset, duration episodic, 2 or more days a week, diet/lifestyle

  12. Antacids • What is the mechanism of action of antacids? • What is the onset and duration of action? Can these be used for heartburn prevention? • What are some common antacids? (ex. Sodium bicarbonate) • What is one counseling pt for chewable antacids? • What can happen with too much Mg/Al? Too much Ca/Al?

  13. Antacids • What is the mechanism of action of antacids? Reacts with acid in stomach to form neutralizing salt • What is the onset and duration of action? Can these be used for heartburn prevention? 5 min onset, lasts 20 min-3 hrs. Cannot be used to prevent heartburn; only treats • What are some common antacids? (ex. Sodium bicarbonate) • Calcium carbonate, aluminum hydroxide, aluminum phosphate, magnesium hydroxide, magnesium chloride • What is one counseling pt for chewable antacids? Drink full glass of water after • What can happen with too much Mg/Al? Too much Ca/Al? Diarrhea with Mg/Al and constipation with Ca/Al

  14. H2RAs • What is the mechanism of action of these drugs? • What is the onset? The duration of action? Can these be used for heartburn prevention? • What are the 3 H2RAs mentioned in class? How often are they dosed? • Which H2RA has the most drug interactions? • Can these be used in combination with an antacid? • What is one major drawback to this medication class?

  15. H2RAs • What is the mechanism of action of these drugs? Competitive (and reversible) inhibition of H2 receptors on parietal cells • Decreases acid production in stomach • What is the onset? The duration of action? Can these be used for heartburn prevention? Onset is 30-40 min, duration is 4-10 hours. Can be taken 15-60 min before meals for prevention • What are the 3 H2RAs mentioned in class? How often are they dosed? Ranitidine, famotidine, cimetidine. Dosed BID • Which H2RA has the most drug interactions? Cimetidine • Can these be used in combination with an antacid? Yes • What is one major drawback to this medication class? Can become tolerant to it

  16. PPIs • What is the mechanism of action of these drugs? • What is the onset? The duration of action? Can these be used for heartburn prevention? • What are the four PPIs mentioned in class? • Which PPI has the least drug interactions? • What are some common side effects for PPIs? • How are these dosed? Why? • What is the duration of therapy?

  17. PPIs • What is the mechanism of action of these drugs? Irreversible inhibition of H+/K+ ATPase pumps on parietal cells • Stops acid secretion • What is the onset? The duration of action? Can these be used for heartburn prevention? • Onset 2-3 hours w/ full effect seen in 1-4 days. Used almost exclusively for prevention. Need to be taken w/ or w/out symptoms • What are the four PPIs mentioned in class? Omeprazole, lansoprazole, esomeprazole, omeprazole sodium bicarbonate • Which PPI has the least drug interactions?Lansoprazole • What are some common side effects for PPIs? Constipation, diarrhea, headache • How are these dosed? Why? In the morning, 30-60 min before breakfast. If taken at night, too many proton pumps active and can’t work against them • What is the duration of therapy? 14 days. Can try again in 4 months

  18. Constipation

  19. Origins of Constipation • Is constipation more frequent in men or women? Younger or older? Pregnancy? • Name one cause of constipation in each of the following categories: • Disease-induced: • Drug-induced: • Special population: • Lifestyle: • What are some common symptoms of constipation? What is the important thing to note about number of bowel movements?

  20. Origins of Constipation • Is constipation more frequent in men or women? Younger or older? Pregnancy? More common in women and pregnancy, no difference in age groups • Name one cause of constipation in each of the following categories: • Disease-induced: ulcers of hemorrhoids, IBS (GI issues), diabetes, gallbladder disease • Drug-induced: OPIOIDS, hypertension meds, BZDs • Special population: children, older adults, women • Lifestyle: not enough fluids, low calorie intake, low fiber intake • What are some common symptoms of constipation? What is the important thing to note about number of bowel movements? • Abdominal distension, difficulty passing a stool, lower back pain, headache, decreased appetite • A decrease in the FREQUENCY of bowel movements is more important than the overall number of bowel movements

  21. What are exclusions to self-care for constipation?

  22. Exclusions to Self-Care for Constipation

  23. Non-Pharmacologic Treatment

  24. Pharmacologic Treatment

  25. Bulk Forming Laxatives • What are the three bulk-forming laxative drugs mentioned in class? • What is the mechanism of action? • What is the onset and duration of action of these drugs? • Can these be used for treatment, prevention, or both? • What are two important counseling points to mention with these drugs?

  26. Bulk Forming Laxatives • What are the three bulk-forming laxative drugs mentioned in class? Psyllium, methylcellulose, calcium polycarbophil • What is the mechanism of action? Forms an emollient gel around the poop • What is the onset and duration of action of these drugs? Onset 12-24 hrs. Duration 72 hours • Can these be used for treatment, prevention, or both? Both • What are two important counseling points to mention with these drugs? Take with full glass of water. Separate by 1-2 hours from other medications

  27. Emollient Laxatives • What is the emollient laxative drug mentioned in class? • What is the mechanism of action? • What is the onset of action of this drug? • Can this be used for treatment, prevention, or both? • What are some side effects of this drug? What is the youngest age this can be used in? • Which special population could this be a good option for? • What other laxative should this not be combined with?

  28. Emollient Laxatives • What is the emollient laxative drug mentioned in class? Docusate sodium • What is the mechanism of action? Acts as a surfactant to soften the poop mass • What is the onset of action of this drug? 1-3 days • Can this be used for treatment, prevention, or both? Prevention • What are some side effects of this drug? What is the youngest age this can be used in? diarrhea, GI pain, discomfort. 6 years old • Which special population could this be a good option for? Pregnancy • What other laxative should this not be combined with? Mineral oil

  29. Lubricant Laxative • What is the lubricant laxative drug mentioned in class? • What is the mechanism of action? • What is the onset of action of this drug? Which dosage form works faster? • Can this be used for treatment, prevention, or both? • What are some side effects of this drug? What is the youngest age this can be used in? • What is an important counseling point to let patients know?

  30. Lubricant Laxative • What is the lubricant laxative drug mentioned in class? Mineral oil • What is the mechanism of action? Coats and softens the poop • What is the onset of action of this drug? Which dosage form works faster? 6-8 hrs. Rectal form works in 5-15 minutes • Can this be used for treatment, prevention, or both? Treatment (short-term) • What are some side effects of this drug? What is the youngest age this can be used in? can be irritable or aspirated while swallowing (it’s thick). 6 years old • What is an important counseling point to let patients know? Take on an empty stomach

  31. Saline Laxative • What are the saline laxative drugs mentioned in class? • What is the mechanism of action? • What is the onset of action of this drug? What about the rectal dosage form? • Can this be used for treatment, prevention, or both? • What are some conditions that patients may have that would caution use of this drug?

  32. Saline Laxative • What are the saline laxative drugs mentioned in class? Milk of magnesia, mag citrate, fleet enema • What is the mechanism of action? Is an osmotic that draws in water and promotes motility • What is the onset of action of this drug? What about the rectal dosage form? 30min-3hrs. For rectal < 1 hr • Can this be used for treatment, prevention, or both? Treatment • What are some conditions that patients may have that would caution use of this drug? CHF, renal dysfunction, missing parts of the intestine, dehydration

  33. Stimulant Laxatives • What are the stimulant laxative drugs mentioned in class? • What is the mechanism of action? • What is the onset of action of this drug? What about the rectal dosage form? • Can this be used for treatment, prevention, or both? • What special population should these not be used in? Why? • These drugs should not be used for greater than ________ days. Why?

  34. Stimulant Laxatives • What are the stimulant laxative drugs mentioned in class? Bisacodyl, castor oil, sennosides • What is the mechanism of action? Promotes peristalsis in gut • What is the onset of action of this drug? What about the rectal dosage form? 6-12 hrs. 15-20 min rectal • Can this be used for treatment, prevention, or both? Treatment • What special population should these not be used in? Why? Pregnancy, can induce labor (esp. castor oil) • These drugs should not be used for greater than 7 days. Why? Abuse potential is high

  35. Hyperosmotic Laxatives • What are the hyperosmotic laxative drugs mentioned in class? • What is the mechanism of action? • What is the onset of action of this drug? What about the rectal dosage form? • Can this be used for treatment, prevention, or both? • What is the difference in dosing for adults vs children ? • Why is this a good medication recommendation for most adults? (hint, drug interactions)

  36. Hyperosmotic Laxatives • What are the hyperosmotic laxative drugs mentioned in class? Polyethylene glycol 3350 (PEG), glycerin • What is the mechanism of action? Acts as an osmotic, drawing water into rectum and promoting motility • What is the onset of action of this drug? What about the rectal dosage form? PEG takes 1-3 days, glycerin takes 30 min • Can this be used for treatment, prevention, or both? Both • What is the difference in dosing for adults vs children ? Children get half the adult dose. Adults and children >6 y/o get 3 g while children <6 y/o get 1.5 g • Why is this a good medication recommendation for most adults? (hint, drug interactions) Very few drug interactions, well tolerated

  37. Diarrhea

  38. Origins of Diarrhea • Which age groups is diarrhea most prominent in? • What are some causes of diarrhea? • Diarrhea is/isn’t (CHOOSE) self-limiting • What are some complications that can occur because of diarrhea?

  39. Origins of Diarrhea • Which age groups is diarrhea most prominent in? Children and adults > 65 y/o • What are some causes of diarrhea? Certain medications and disease states, food poisoning, bacteria/viruses • Diarrhea is self-limiting. Will stop eventually (usually in 24-36 hours) without any treatment • What are some complications that can occur because of diarrhea? Dehydration, electrolyte imbalances, worsening of other disease states

  40. What are exclusions to self-care for diarrhea?

  41. Exclusions to Self-Care for Diarrhea • Patients < 6 months old • Non-stop vomiting • Severe dehydration • Fever > 102 F • If there is severe abdominal pain or blood/mucus/pus in the stool • If patient is pregnant • If patient is unable to properly hydrate • If diarrhea becomes chronic • If several other disease states

  42. Fluid Replacement • For each of the following categories, when is it appropriate to initiate oral fluid replacement vs. IV? • Which vital signs should be normal? • What percent body wt loss is acceptable? • Other signs that pt is mild-moderately dehydrated? • Why are sugar and electrolyte oral replacement fluids helpful in preventing dehydration? • What is the fluid replacement regimen for children 1 month – 5 years ? • What is the fluid replacement regimen for children > 5 years and adults ? • What is the BRATT diet?

  43. Fluid Replacement • For each of the following categories, when is it appropriate to initiate oral fluid replacement vs. IV? • Which vital signs should be normal? BP, HR (can be slightly elevated) • What percent body wt loss is acceptable? 3-9% • Other signs that pt is mild-moderately dehydrated? Less urine output, less solid stools, thirsty, fatigued • Why are sugar and electrolyte oral replacement fluids helpful in preventing dehydration? Can still be absorbed by intestine when pt is having diarrhea. Can help with sodium and water absorption • What is the fluid replacement regimen for children 1 month – 5 years ? • 50-100 mL/kg over 3-4 hrs. • 1-2 teaspoon q 1-2 min for vomiting • Must replace losses initially • What is the fluid replacement regimen for children > 5 years and adults ? • 2-4 L over 3-4 hrs • Must replace losses initially • BRATT diet – banana, rice, applesauce, tea, toast

  44. Pharmacologic Treatment

  45. Loperamide • What is the mechanism of action of this drug? • What is the minimum age this drug should be used in? • What is the initial dose for this drug? How is it dosed thereafter? • What is the recommended length of therapy? What are some side-effects that can occur with longer use?

  46. Loperamide • What is the mechanism of action of this drug? opioid agonist, stimulates mu receptors on intestines and slows motility • What is the minimum age this drug should be used in? 6 y/o • What is the initial dose for this drug? How is it dosed thereafter? 4 mg followed by 2 mg with a max of 8mg/day • What is the recommended length of therapy? What are some side-effects that can occur with longer use? 48 hours max. Can get constipation and abdominal pain

  47. Bismuth Subsalicylate • What is the mechanism of action of this drug? • What is the minimum age this drug should be used in? • What is the initial dose for this drug? What is the maximum dose? • What is the recommended length of therapy? What is one important counseling point to tell patients about this drug? • Why is the use of this drug cautioned in children?

  48. Bismuth Subsalicylate • What is the mechanism of action of this drug? Reactswith acid in stomach to form salicylic acid, and insoluble bismuth oxychloride. This relieves nausea, cramping, vomiting and decreases loose stool formation • What is the minimum age this drug should be used in? 12 y/o • What is the initial dose for this drug? What is the maximum dose? 525 mg q 30 min – 1 hour. Max of 4200 mg/day • What is the recommended length of therapy? What is one important counseling point to tell patients about this drug? 48 hours. Stool and tongue might turn black • Why is the use of this drug cautioned in children? Formation of salicylic acid  Reye’s syndrome

  49. Lactose Intolerance and Probiotics • Which enzyme is non-functional in lactose intolerance? Which medication can be used to relieve symptoms after dairy consumption? • What is the purpose for using each of the following probiotics: • Lactobacillus – • Bifidobacterium – • Saccharmomyces –

  50. Lactose Intolerance and Probiotics • Which enzyme is non-functional in lactose intolerance? Which medication can be used to relieve symptoms after dairy consumption? Lactase is the deficient enzyme. Can use Lactaid • What is the purpose for using each of the following probiotics: • Lactobacillus – management/prevention of acute diarrhea or vaginal infection • Bifidobacterium – to regulate bowel movements, help with gas/bloating • Saccharmomyces – prevention/treatment of antibiotic associated and traveler’s diarrhea

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