from 3. Lower GI Disorders Flashcards
common GI probs
flatus, constipation, diarrhea
inflammatory bowel diseases
Crohn’s disease & UC
Lower GI Dx tests
barium enema (BE) & x-ray.
CT, MRI, ultrasound.
stool tests.
colonoscopy/endoscopy
stool tests
bacteria, malabsorption, blood, etc
colonoscopy/endoscopy
direct visual exam of colon, ileocecal valve, and portions of terminal ileum w/fiberoptic endoscope
virtual colonoscopy
small tube inserted in anus to inflate colon w/air. a CT is then used to take hundreds of pics of inside of colon
wireless capsule endoscopy
pt swallows tiny imaging capsule that takes pictures
flatus: cause
bacterial fermentation of fiber and nondigestible CHO (stachyose and raffinose in beans) in GI tract and most is reabsorbed.
also can be produced from undigested starch/sugars as in pancreatic enzyme insufficiency or lactose/disaccharide intolerance
flatus : Tx
beano (enzyme that digests CHO likes raffinose).
Gas X
gas forming foods
beans, peas, legumes broccoli/cabbage onion cucumber corn turnip, rutabaga, radish melon raw apple, pear any high fiber food (carbonated beverages, chewing gum, sorbitol, sugar alcohols, FOS)
constipation
less than 2 stools/wk or difficulty, pain, bloating.
constipation: common in
women, whites, elderly.
not caused by any certain foods.
constipation: contributing factors
low fiber/fluid/exercise, med side effects, ignoring need to defecate/not allowing adequate time, AN/bulimia, pg, laxative dependency, large intestinal obstruction, lack of peristalsis, cancer
constipation: contribution disorders
neuromuscular/autoimmune disorders: MS, Parkinson’s, scleroderma, lupus, spinal cord injury.
endocrine disorders: hypothyroidism,
diabetic gastroparesis
constipation: Management
first rule our serious medical causes. consult MD before taking OTC fiber supps as some fibers decrease absorption of some meds and risk of bezoars in pts w/intestinal strictures/poor peristalsis.
constipation: fiber
25-35 g/day
8 cups of fluid
wheat bran - effective stool bulking agent which holds water and increases stool bulk.
volatile short chain FAa produced by bacterial acting on the fiber may stimulate colon.
constipation: other foods to help
prunes contain high fiber and dihydroxyphenyl isatin which stimulates GI motility.
constipation: prebiotics
fiber, resistant starches, sugar alcohols, FOS promote growth of lactobacillus and bifidobacteria. gas may be produced.
constipation: probiotics
food/sup like culturelle w/live bacteria may normalize bowel fcn
constipation: fiber laxatives
some may decrease absorption of some meds. do not swallow dry form (except perdiem), drink w/16oz water to avoid blockage in esophagus.
constipation: fiber laxative side effects
difficulty breathing and swallowing, intestinal blockage, skin rash.
constipation: kidney failure pts avoid
avoid Haley MO, milk of magnesia, and any Mg laxatives.
constipation: stool softeners
MiraLAX, Colace, Dialose, Surfak
constipation: stimulant laxatives
senna, Correctol, Dulcolax, Purge, Feen-A-Mint, Senokot.
some herbal laxatives are stimulants.
constipation: osmotic agents
milk of Magnesia, Citrate of Magnesia, Haley’s M-O also has mineral oil.
constipation: other laxatives
targeted chloride channel activation to regulate intestinal fluid balance (Amitiza).
chronic enema use may cause bowel probs & dependency
constipation: mineral (Agora1)
slight decrease in fat sol vit absorption but no major change has been reported, best to not take w/meals.
acute diarrhea
often severe w/rapid onset caused by GI infection. rehydrate, electolytes (IV, equalyte, ricelyte, pedialyte) and maybe antibiotics
acute diarrhea: early refeeding
may help gut recover and 60% of intake may be absorbed. lactose intolerance may occur after acute episode.
acute diarrhea: meds
lomitil, Imodium, kaopectate
acute diarrhea: severe infection
like Clostridium difficile (c. diff) may need decal transplant
acute diarrhea: avoid
milk products, greasy food, high-fiber, very sweet
acute diarrhea: BRAT diet
bananas, rice, applesauce, toast
chronic diarrhea
requires workup & eval such as endoscopic exam/stool test for malabsorption, bac, etc.
Tx varies w/cause
- osmotic diarrhea: example
lactose intolerance
dumping syndrome
- osmotic diarrhea: cause
poor digestion/absorption resulting in osmotically active solutes pulling water into GI tract
- osmotic diarrhea: relieved by
fasting/avoidance of the indigestible substance
- exudative diarrhea: examples
radiation enteritis
UC
c. diff
- exudative diarrhea: cause
gut inflammation results in excretion of blood, mucus, plasma proteins, electrolytes
- steatorrhea/SI disorders/lack of enzymes diarrhea: examples
lack of pancreatic/biliary excretions, pancreatitis, CF, enterohepatic recirculation probs, bac overgrowth
- steatorrhea/SI disorders/lack of enzymes diarrhea: cause
inadequate exposure of chymeoo to intestinal epithelium, lack/inactivation of pancreatic enzymes, damage to DI, post-gastrectomy
Crohn’s disease: area
usually in terminal ileum (ileitis), may occur in any area of GI tract.
there is
transmural (thru the wall) inflammation w/granulomatous areas that lead to scarring, obstruction, fistulas
Crohn’s: onset
cause is immune related.
age 15-35 yrs, not inherited but higher risk in some families
Crohn’s: s/s
ab pain, fever, wt loss, N&V, GI bleed, chronic dia, poor child growth, nutr def.
Instestinal obstruction, GI sores/ulcers, fistulas.
Arthritis, skin probs, infla in eye/mouth, kidney stones, gallstones, other liver/biliary diseases.
crohn’s: nutr defs
marasmus, hypoalbuminemia, anemia (iron or B12 & folate def), Ca, Mg, Zn, Cu, K, vit A, C, D, K
crohn’s: management
decrease s/s (causes disease remission) and correct any nutr defs.
med to decrease inflamm or infections, surgery is often needed.
crohn’s: meds
Sulfasalazine.
Mesalamine (Asacol®, Mesalazine, Pentasa®, Rowasa®, Lialda)
crohn’s: supps
sup folate 800-1000 ug/day.
drink 8-10 c fluid/day.
Fe and PABA may lessen effect.
crohn’s: corticosteroids
long term high dose use - pro catabolism, wt gain, glucose intolerance hypertension, Na & water retention, K excretion, osteomalacia, Ca def.
eat more protein, take Ca sup
crohn’s: other meds
6-mercaptopurine (immunosuppressive).
azathioprine (Imuran).
Anti- TNF- Cimzia® (certolizumab pegol), Enbrel® (etanercept), Humira® (adalimumab), Remicade® (infliximab), and Simponi® (golimumab).
Natalizumab (Tysabri).
methotrexate.
cyclosporine.
cholestyramine.
crohn’s: methotrexate
need folate supp
crohn’s: cholesyramine
fat sol vit & folate sup are needed
crohn’s MNT: remission/nonacute periods Kcal needs
use normal food & sups to maintain (+300-500 kcal to gain wt, 1.5g pro/kg).
Kcal & pro based on acceptable wt for ht, not current wt, may add extra for malabsorption.
may need G tube or NG each night for wt maintenance/children
crohn’s MNT: insoluble fiber
cause distress & obstruction risk in pts w/int lumen narrowing or partial obstruction. avoid popcorn, seeds, nut, fruit peel, broccoli, dried beans
crohn’s MNT: fat
some pt need to restrict fat, but be liberal as possible. steatorrhea pts 50-70g fat per day and can use MCT oil. if less fat is tolerated, have a low fat oral sup/nocturnal TF.
crohn’s MNT: when to do fecal fat study
wt loss/poor growth w/adequate diet. frothy, oil, fatty stools. oxalate crystal in urine/kidney stones. low serum Ca/Mg/cholesterol. Hx of ileal resection
crohn’s MNT: TPN
may cause short term remission. expensive, needed in severe malabsorption.
crohn’s MNT: elemental formulas
may decrease stool freq, reduce immune stimulation, rest the bowel and decrease motility & secretions, alter gut flora& permeability, improve nutr absorption, provide nutr for gut such as glutamine
crohn’s MNT: fistulas
complication of crohn’s - often at site of obstruction, inflam, or surgery. bowel rest & TPN may heal 30% fistulas, but surgery may be needed. high output (over 500 mLs) esp SI, TPN or elemental formulas may be needed as tolerated.
module IBD
contains Transforming Growth Factor-Beta 2 (TGF-B2).
low in proinflammatory O-6 FAs.
TGF- B2
naturally present in human and cow milk protein. mechanism - may down regulate inflammation
crohn’s MNT: children formula
peptide-based elemental diet for nutr support of GI-impaired children ages 1-10. may help reverse growth failure secondary to crohn’s.
UC: areas
usually in colon, but may be in terminal ileum. inflamm in the colonic mucosa w/sores
UC: onset
age 15-35 years. immune-mediated inflammatory response, cause unknown. increased risk of colon cancer.
UC: s/s
rectal bleed. Fe def. dia & ab cramps. wt loss if severe. uric acid renal stones. mild fever. tachycardia. dehydration. malnutrition. ab tenderness.
UC: meds
same as crohn’s:
sulfasalazine, mesalamine, corticosteroids, methotrexate, cyclosporine, Anti-TNF
UC: uceris med
Uceris (Santarus) contains budesonide a corticosteroid that is in a matric that is reported to reach the entire colon
UC: psyllium
taking 20 g of psyllium (Plantago ovate) seeds w/mesalamine for 12 mo may improve maintaining of UC remission
UC: MNT during remission
no specific diet, avoid dia/discomfort foods, small freq meals.
UC: MNT during acute exacerbations
may have 20+ stools per day w/mucous, blood (iron loss), pus & loss of protein, iron, water, electrolytes, and trace minerals in stool
UC: colectomy
to cure UC. removal of colon followed by an ileostomy and often an ileoanal reservoir.
Small bowel length
10-28 ft or 650-800 cm
duodenum length
10 in long
jejunum length
6-8 ft/200-300 cm long
ileum length
up to 13 ft long
short bowel syndrome (SBS): causes for removing SI
thrombosis/bowel necrosis strangulated hernias crohn's trauma cancer radiation enteritis necrotizing enterocolitis/infection
SBS: s/s
30-50% resections cause diarrhea, steatorrhea, bloating, fatigue, malnutr
SBS: steatorrhea
does not develop unless >100 cm (3.3 ft) of terminal ileum has been removed
SBS: TPN
may be needed is >2/3 of SI is removed
jejunal resection
ileum will adapt and take over if entire jejunum is removed. maybe lactose intolerance. most absorption takes place in proximal jejunum.
jejunal resection: MNT
initially ileum undergoes hypertrophy & hyperplasia.
take MVT daily
jejunal resection: avoid
lactose, hyperosmotic liquids (gas, bloating, dia). may have mild fat & nitrogen malabsorption, trouble w/sorbital/sugar alcohol in prunes, pears, berries, sugar free foods.
jejunal resection MNT: hyperoxaluria
lead to kidney stones due to: FAs in bowel bind to Ca leaving less Ca to bind w/oxalate, so more oxalate s absorbed. also, the FA may make gut more permeable which increases oxalate absorption.
decrease high oxalate foods. increase Ca and fluid.
ileal resection
where cobalamine, chloride, Na, K is absorbed. distal 100 cm most critical. 90% bile salts are reabsorbed here after a meal. bile salts that are not reabsorbed may cause diarrhea. this causes poor fat absorption which also result in dia.
ileal resection: risks
rapid transit time & less digestion in proximal gut.
hyperoxaluria and oxalate kidney stones.
ileal resection: loss of ileocecal valve
probs w/malabsorption, diarrhea, bac overgrowth.
ileal resection: malabsorption of
CHO, N, fat, Ca, iron, zinc, Mg, fat sol vit
ileal resection: B12
terminal ileum is only site where cobalamin is absorbed w/gastric intrinsic factor. need IM B12 injections to prevent megaloblastic anemia & neuropathy
ileal resection: MNT
TPN is needed initially after surgery. wean to elemental high N, low fat formula (may have MCT oil). glutamine in formula is beneficial. give IM B12.
Massive small bowel resection
if >2/3 SI is removed, pt may need PN for life.
gastric hypersecretion makes enzymes less active. PUD risk is high. try to wean to elemental formula
SBS: teduglutide (Gattex)
Tx for adults w/ SBS. less TPN needed and may be able to wean off it.
ileostomy: malabsorption of
fat, protein, cobalamin if part of the ileum was removed during colectomy. since no colon, ensure intake of fluid and electrolytes.
ileoanal reservoir/pouch
4-8 liquid/soft bowels/day. Imodium can be taken to decrease diarrhea
ileoanal reservoir/pouch: MNT
eat slow, small, freq meals. increased fluid & electr.
limit simple sugars and caffeine.
soluble fiber (psyllium, guar gum) may help stools be more solid.
ileoanal reservoir/pouch: avoid
insoluble fiber (fruit peel, mushroom, corn, celery, lettuce, bean sprout, coleslaw, coconut, pineapple, nut, seed, tough meat, shrimp/lobster which may cuase mechanical bowel obstruction
ileoanal reservoir/pouch: gas/odor causing foods
asparagus, dried bean/pea, mustard, cabbage, onion, carbonated bev, egg, radish, pickle, beer, fish, cucumber, strong cheeses, melon, spices, fatty food, whips & meringues
ileoanal reservoir/pouch: anal irritating foods
certain raw F&V, popcorn, oriental vegs, nut ,coconut, dried fruit, seeds, spicy food
ileoanal reservoir/pouch: pouch output decreasing foods
applesauce, banana, boiled rice, pasta, cheese, creamy PB, tapioca pudding, skinless potato.
ileostomy MNT: malabsorption of
fat, bile acids, cobalamin, water, sodium, K, protein as the stoma is higher in the ileum (more ileum removed). take MVT supp
diverticulosis: cause
chronic constipation, low fiber diet. may be asymptomatic or cause abdominal distress
diverticulosis: MNT
high fiber diet to soften & increase stool volume.
stool softener meds like colase. wheat bran as a laxative. fiber laxatives
diverticulitis: s/s
ab pain and spasms, distension, N&V, constipation/diarrhea, chills, fever, bleeding, fistula, obstruction
diverticulitis: MNT
bowel rest w/IV hydration, antibiotics, NPO, low residue/elemental diet. may need surgery to remove part of colon
irritable bowel syndrome =
spastic colon
IBS: possible causes
bac overgrowth in SI, hypermotility/abnormal brain guy connection from stress, rarely due to endometriosis w/uterine lining cells growing on the bowel.
bacterial IBS: med
antibiotics like Xifaxan (Refaximin)
IBS: s/s
gas, bloating, ab pain, cramps, spastic contractions, constipation/diarrhea, fecal incontinence, anxiety, back pain, mucous in stool
IBS: irritant foods
keep diary, some are sensitive to caffeine, polyols, beef, wheat, citrus, corn, milk, lactose, equal, MSG, sulfites, alcohol.
IBS: Management
high fiber (psyllium) may help. regular exercise, relaxation, less stress
IBS: restrict FODMAP’s
high fructan wheat rye onion garlic excess fructose mango high polyol apricot plum sugar-free gums & sugar-free mints high GOS baked beans kidney beans lentils high lactose cow & goat's milk
IBS: Tx
aloe, ginger, chamomile, enteric coated peppermint tablets may help?
pre & probiotics?
IBS: meds
antibiotics.
antidepressants.
anticholinergic like Bentyl to decrease spasms.
Alosetron (Lotronex) - associated w/7 deaths.
Linzess (linaclotide) to tx both IBS w/constipation (IBS-C) and chronic idiopathic constipation (CIC).
antidiarrheals/laxatives.
Gluten Sensitive Enteropathy: s/s
steatorrhea w/foul, floating, clay-colored, light tan/gray, highly rancid & frothy stools
dia, fatigue, cramping, weakness, bloating, flatus, dehydration, electrolyte depletion/acidosis, rectal prolapse, clubbed fingers. failure to grow, wt loss, irritability & inability to concentrate. refractory iron def anemia, PEM, rickets, back pain as result of a collapsed lumbar vertebrae, osteopenic bone disease, hyperparathyroidism, amenorrhea, fat sol vit def.
GSE: risks
dermatitis herpetiformis - skin rash.
stomatitis and recurrent aphthous ulcers.
increased cancer risk (lymphomas & GI tract)
GSE: more common in
ppl w/autoimmune disorders (Grave’s disease, T1DM, Sjögren’s syndrome, collagen diseases, RA, IgA deficiency.
GSE: may cause
osteoporosis, nervous system disorders, pancreatic/liver probs, internal bleeding
GSE: conclusion of studies
“the greater freq of thyroid disease among celia pts justifies a thyroid functional assessment. In distinct cases, gluten withdrawal may singlehandedly reverse the abnormality”
GSE: avoid all
wheat (gliadin), spelt, triticale, kamut, rye (secalin), barley (hordein), maybe oats
gluten sensitivity: s/s
6% of population. s/s: ab pain similar to IBS, fatigue, headaches, brain dog, tingling in extremities.
