Teresa Lowery, MD, MPH, FAAFP, ABFM Regional 2/3 Health Specialist

1. Help! I Can’t Go and My Chest is Burning:Constipation and GERD Common Solutions to Common Problems Teresa Lowery, MD, MPH, FAAFP, ABFM Regional 2/3 Health Specialist

2. Objectives Participants of this webinar should be able to: • Identify the common causes of constipation. • Articulate how to diagnose constipation. • Describe ways to treat symptoms of constipation pharmacologically and through natural remedies. • Review the most common lifestyle, diet, and physiological causes of GERD. • Articulate how to recognize and diagnose the most common symptoms of GERD. • Describe treatment of GERD symptoms. • Determine when to refer to a specialist for care.

3. Disclosures • The author of this webinar has no professional connections to any pharmaceutical companies to disclose. For the purpose of familiarity, branded medications may be mentioned. The author has no ties or connections to any of the named products (both branded and generic).

4. Help, I cant go!! • How do you define constipation? • Constipation is traditionally defined as three or fewer bowel movements per week and is the most common chronic gastrointestinal disorders in adults. Having fewer bowel movements is associated with symptoms of lower abdominal discomfort, distention, or bloating. • Patients define it differently than physicians. • The Rome Criteria has been developed as a diagnostic criteria for Functional (Primary) Constipation in research and as an international working definition.

5. Rome III Diagnostic Criteria for Functional Constipation • Must include two or more of the following: • Straining during at least 25 percent of defecations • Lumpy or hard stools in at least 25 percent of defecations • Sensation of incomplete evacuation for at least 25 percent of defecations • Sensation of anorectal obstruction/blockage for at least 25 percent of defecations • Manual maneuvers to facilitate at least 25 percent of defecations (e.g., digital evacuation, support of the pelvic floor) • Fewer than three defecations per week • Loose stools are rarely present without the use of laxatives • There are insufficient criteria for irritable bowel syndrome

6. Transit Types • Normal stools move at a regular rate throughout the colon, based on patient self report. May have abdominal pain and bloating. This type has been associated with increased psychosocial stress. Usually responds to medical therapy (e.g., fiber, laxatives). • Slow is defined as prolonged transit time. Patients with this type have normal resting colonic motility but do not have the increase in peristaltic activity that should occur after meals. May not respond to fiber or laxatives. • Outlet Constipation, also known as pelvic floor dysfunction, is defined as the incoordination of the muscles of the pelvic floor during attempted evacuation. Stool is not expelled when it reaches the rectum. This type occurs with prolonged or excessive straining, soft stools that are difficult to pass and rectal discomfort. Doesn’t respond to traditional therapy.

7. Risk Factors • Female sex • Older age • Inactivity • Low caloric intake • Low fiber diet • Taking a large number of medications • Low income • Low educational level

8. Other Causes (Secondary Constipation) • Common Medications: antacids, especially with calcium, iron supplements, opioids • Less Common:anticholinergic agents, antidiarrheal agents, antihistimines, antiparkinsonian agents, antipsychotics, calcium channel blockers, calcium supplements, diuretics, NSAIDS, sympathomimetics, TCA’s • Common Medical Conditions: CVA, depression, diabetes mellitus, hypothryroidism, IBS (Irritable Bowel Syndrome) • Less Common Conditions: anal fissures, autonomic neuropathy, cognitive impairment, colon CA, hypercalcemia, hypokalemia, hypomagnesemia, immobility, MS, Parkinson's, spinal cord injury

9. Evaluation • Should include a history and physical exam • History: Inquire about which features the student finds most distressing. If the student feels pain, bloating or intestinal cramping between bowel movements, these could be symptoms of IBS. • Rome Criteria for IBS: recurrent abdominal pain or discomfort at least three days per month in the past three months associated with two or more of the following: improvement of pain with defecation, onset associated with a change in frequency of stool, onset associated with a change in form (appearance of the stool). • A history of prolonged and excessive straining, especially with soft stools or need for digital manipulation to pass stools suggests pelvic floor dysfunction.

10. Evaluation • The physical exam should include an abdominal exam and rectal examination, looking for signs of anemia, weight loss, abdominal masses, liver enlargement, or a palpable colon. The perineum should be inspected for hemorrhoids, skin tags, fissures, rectal prolapse or anal warts. • Ask the student to strain as if having a BM and look for leakage of stool secondary to fecal impaction, rectal prolapse or a patulous anus. Also check the anal wink and complete the exam with a digital rectal examination.

11. Diagnostic Testing • Blood tests, radiography endoscopy are not routinely recommended in the initial evaluation in the absence of alarm signs or symptoms • Red flags: Hematochezia, unintended weight loss of 10 lbs or more, a family history of colon CA, iron deficiency anemia, positive fecal occult blood tests

12. Indications for Endoscopy • Age older than 50 years with no previous colorectal CA screening • Before surgery for constipation • Heme-positive stools • Iron-deficiency anemia (in certain populations) • Obstructive symptoms • Recent onset of constipation • Rectal bleeding • Rectal prolapse • Weight loss

13. Initial Management and Empiric Therapy • Student education, high-fiber diet, exercise and increased water intake. Aim for 20-35 grams of fiber daily, at least 30 min of aerobic activity daily and 6-8 glasses of 8 ounces of water with reduced intake of diuretics such as colas and caffeinated products). Prune juice works great! It may be mixed with water and/or grape or other juice to enhance palatability. • Encourage defecation after meals to take advantage of the normal postprandial increases in colonic motility (especially in the morning). • Anecdotally, some people feel that probiotics which can be found in yogurts (e.g., Activia) also work. These can also be found in a concentrated pill or liquid form in some grocery stores and most health food stores.

14. Pharmacotherapy • Dietary fiber and bulking forming laxatives such as psyllium (Metamucil) or methylcellulose (Citrucel), polycarbophil (FiberCon), and wheat dextran (Benefiber) are the most physiologic and effective approach to therapy. They exert their laxative effect by absorbing water and increasing fecal mass. May be used alone or with dietary fiber. Objective evidence for efficacy is lacking for some of these. • Surfactants: There is little evidence to support the use of these agents. Stool softeners such as sodium docusate (Colace) lower the surface tension of the stool allowing water to more easily enter the stool. They are less effective than other laxatives and inferior to psyllium (Metamucil) for improvement in stool frequency. • Osmotic Agents: PEG (polyethylene glycol) is a poorly absorbed sugar and, like other types of saline laxatives, causes intestinal water secretion and thereby increases stool frequency. Examples include GoLYTELY and powdered prep (Miralax) which are used for chronic constipation.

15. Pharmacotherapy • Osmotic Agents • Synthetic disaccharide-Lactulose (enulose) is a synthetic disaccharide. It is not metabolized by intestinal enzymes thus water and electrolytes remain within the intestinal lumen due to the osmotic effect of the undigested sugars. Sorbitol is an equally effective and a less expensive alternative. Both may cause abdominal bloating and flatulence. (PEG is superior to lactulose.) • Saline laxatives such as Milk of Magnesium and Magnesium Citrate are poorly absorbed agents that act as hyperosmolar solutions. They are inexpensive and sold over the counter. • Stimulant laxatives such as bisacodyl (Dulcolax) and senna (Senekot) primarily exert their effects via alteration of electrolyte transport by the intestinal mucosa. They work by increasing intestinal motor activity. Diarrhea and abdominal pain are common with this medicine.

16. Management of Severe Constipation • These patients have generally failed the previously discussed measures and require a different approach to therapy. • Suppositories: An initial trial of glycerin suppositories can be effective in liquefying stool and thereby overcoming obstructive defecation for the treatment of defecation disorder. • Disimpaction: Patients with a fecal impaction (a solid immobile bulk of stool in the rectum) should be removed with manual fragmentation if necessary. After this is accomplished, an enema with mineral oil will help to soften the stool and provided lubrication. • Behavioral approaches: Habit training has been used successfully in children with severe constipation. A modified program may also be helpful in adults with neurogenic constipation, dementia, or those with physical impairments. • Other Meds: Amitiza (lubiprostone) is a locally acting chloride channel activator that enhances chloride-rich intestinal secretion. It is approved for chronic idiopathic constipation. • Surgical options for patients with problems requiring repair (e.g., rectoceles).

17. GERD: Help, My Chest is Burning • GERD stands for Gastroesophageal Reflux Disease • Some people use it interchangeably with terms for heartburn, dyspepsia, or upset stomach, duodenal or gastric ulcer, intestinal angina… • How is it really defined??? • It is defined as reflux of “gastroduodenal contents into the esophagus, causing symptoms sufficient to interfere with quality of life.” ACG defines it as “symptoms of mucosal damaged produced by the abnormal reflux of gastric contents into the esophagus.” • However defined, persons with GERD often have symptoms of heartburn and acid regurgitation.

18. Incidence • Surveys form Europe and US suggest that 20-25 percent of persons have symptoms of GERD and 7 percent have heartburn daily. In primary care settings, about 25 to 40 percent of persons with GERD have esophagitis on endoscopy but most have endoscopy-negative reflux disease (no changes in the mucosa). • Most people have likely experienced symptoms of heartburn at some point in their life, but it is the intermittent continued symptoms of heartburn that we want to alleviate.

19. Possible Risk Factors • Obesity • Smoking • Alcohol • Foods: coffee, colas, mints, dietary fats, onions, citrus foods (such as orange juice) and drinks, tomatoes (pizza and marinara sauce), chocolate (which may reduce lower esophageal sphincter pressure) • ?Stress

20. Lifestyle Modifications • Dietary modification: This may work well when the offending agent is avoided. • Raising the head of the bed (using 6-8 inch blocks under the legs of the head of the bed) may be important for students with nocturnal or laryngeal symptoms. • Refraining from assuming a supine position after meals and avoidance of meals before bedtime- both which can minimize reflux. • Avoidance of tight fitting garments (No Spanx!!) which can reduce reflux by decreasing the stress on a weak sphincter.

21. Lifestyle Modifications (cont’d) • Weight loss may improve symptoms especially if weight is loss from the abdomen (mid section). • Promotion of salivation by either chewing or use of oral lozenges may be helpful in mild heartburn. Salivation neutralizes refluxed acid, thereby increasing the rate of esophageal acid clearance. • Restriction of alcohol use and elimination of smoking is deleterious in part because it diminishes salivation. • Breathing exercises??—Abdominal breathing exercises have been suggested as a way to improve GERD with the rationale of strengthening the anti-reflux barrier of the LES.

22. Pharmacotherapy • Acid –Suppressive Medication • The most common and effective treatment of GERD is to reduce gastric acid secretion with either an H2 (Histimine type 2) blocker (receptor antagonists) or a PPI (Proton Pump Inhibitor). The medication dose is titrated to the severity of disease for each patient. These therapies do not PREVENT reflux, but they reduce the adicity of the refluxate. • H2 blockers such as zantac (ranitidine), pepcid (famotidine), offer a therapeutic gain of 10-24 percent to placebo for healing esophagitis. Note: They are ineffective for severe esophagitis and do not exhibit a dose response curve in the treatment of esophagitis.

23. Pharmacotherapy (cont’d) • PPIs such as prilosec (omeprazole), nexium, prevacid, and protonix are more effective in healing esophagitis than H2 blockers with a therapeutic gain of 54 to 74 percent relative to placebo. They lead to rapid healing and symptom relief overall. • Unlike the H2 blockers, they exhibit a dose-response curve for healing high-grade esophagitis as evidenced by higher healing rates with higher doses and/or more potent compounds. • A number or studies have compared the various PPI’s to one another. While some differences have been reported, the magnitude of the differences has been small and of uncertain clinical significance.

24. Helicobacter Pylori Infection (H. Pylori) • The link for H. Pylori and GERD is complex and incompletely defined. The main linkage is in the effect that H. Pylori has on gastric acid secretion. Hence, eradication of H. Pylori is associated with mild worsening of GERD in patients with pan-gastritis (hyposecretors) vs. the improvement in those with antral-predominant gastritis (hypersecretors).

25. NonerosiveGastroesophageal Reflux Disease (NERD) • People with typical symptoms of GERD but that do not have esophagitis; such people have normal levels of esophageal acid exposure as assessed by a 24-hour pH monitoring study.

26. Maintenance Therapy • PPIs at a standard dose or a lower dose were more effective than the H2 blockers in maintaining healing of esophagitis. • PPIs at a standard dose were more effective than a lower dose in preventing relapse of symptoms. • PPIs at a standard dose were more effective than PPIs at a lower dose in maintaining healing of esophagitis. • The need for maintenance therapy can be judged by the rapidity of recurrence when students are given a trial of anti-secretory medications. Recurrent symptoms in less than three months suggest disease best managed with continuous therapy, while remissions in excess of three months can be adequately managed by repeated courses of acute therapy as necessary.

27. Intermittent Therapy • Intermittent (on-demand) therapy with an H2 blocker or PPI may be successful in some students with mild to moderate heartburn without moderate-severe esophagitis. The optimal approach for prescribing intermittent therapy has not been established. • Pregnancy: The smooth muscle relaxation as well as the increased intraabdominal pressure that occur during pregnancy predisposes to GERD. Lifestyle modifications or antacids should be first-line therapy in symptomatic women. However, the greatest experience with acid suppressive therapy in this population is with ranitidine (zantac) and (Tagamet) cimetidine which appear to be safe during pregnancy. There is less experience with PPI’s during pregnancy, but they are probably safe as well.

28. Safety Profile • There have been concerns raised; however, no studies that have found sufficient evidence to recommend for or against bone density studies, calcium supplementation, H. Pylori screening, or any other routine precaution in people taking PPIs. • Studies subsequent to the above guideline continue to raise concerns about the possible infectious complications, electrolyte disturbances and metabolic bone disease associated with PPI use.

29. Referrals • Who should have an endoscopy or a referral to GI?? • The need for endoscopy in patients with GERD is unsettled. Some experts advocated for an endoscopy in patients who required maintenance medical therapy to rule out Barrett’s esophagus. • Thus a stepwise approach to therapies in patients with GERD is useful and performance of endoscopy is required if there is significant doubt regarding the diagnosis or in patients with alarm symptoms suggesting alternative diagnosis (e.g., dysphagia, bleeding, weight loss, odynophagia).

30. Help! I can’t go and my chest is burning!! • I hope that you have enjoyed our common approach to the common complaints of constipation and GERD! • Any questions, concerns, or discussion??????????????????????????????????????????

31. Resources • Up-to-date.com • American Family Physician (journal)