GI- adults Flashcards
Bilirubin- pathophysiology
Inc unconjugated bile:
- Inc production - hemolytic anemia
- Dec uptake by liver - CH, Gilbert syndrome
- Dec conjugation - Crigler-Najjar syndrome, Gilbert syndrome
Inc conjugated bile:
- Liver doesn’t secrete - damage to liver, Dubin-Johnson syndrome, Rotor syndrome
- Biliary tree is obstructed - intrahepatic (cirrhosis, Ca, granuloma), extrahepatic (stones, stricture, Ca)
Bilirubin- cause
Clay-colored stools
Dark tea-colored urine
Pruritis
Bilirubin- S/S & PE
Jaundice - inc of unconjugated or conjugated bilirubin
Cholelithiasis- pathophysiology
Cholesterol - 90% In Gallbladder Pigment stones: - Black - formed in sterile bile - heme - Brown - bacterial metabolism in biliary infection
Cholelithiasis- cause
Cholesterol stones - 4Fs
- Fat
- Forty
- Female
- Fertile
Cholelithiasis- epidemiology
> 40
F>M
Western Countries
Cholelithiasis- S/S & PE
Asymptomatic
- 80% stay this way
Symptomatic - intermittent blockage of cystic duct by a stone
Biliary Colic - intense, dull discomfort, RUQ radiates to back -> R shoulder blade
- N/V and diaphoresis
- Last 30min ->60min then subsides
- triggered - eating fatty meal
No positive PE signs
Incidental findings
Cholelithiasis- diagnosis
U/S - echogenic foci that cast an acoustic shadow
- gravitationally dependent - will move w/ movement
- may look like sludge, but is not
Cholelithiasis- labs & imaging
Labs - Nl, even during biliary colic
Cholelithiasis- treatment
Asymptomatic - do NOT perform cholecystectomy
Typical biliary symptoms + gallstones
- acute pain - NSAIDs or opioids
- Cholecystectomy or medical dissolution of stones
Atypical symptoms + gallstones
- Cholecystectomy - lower relief rates then w/ typical symptoms
Typical symptoms, but no stones visualized
- May have function gallbladder disorder
Cholelithiasis- prognosis
Symptom relief post-surgery
Complications - bile leak, bleeding, abscess formation, biliary injury, bowel injury
> 12% develop diarrhea - can’t digest food as well
Acute Cholecystitis- pathophysiology
Acute inflammation of the gallbladder
Calculous - gallstones
- Cystic duct become obstructed by a stone -> leads to inflammation
- Bacterial inflammation? - eColi, klebsiella, streptococcus, clostridium
Acalculous - no gallstones
- unknown
- some may have biliary sludge in cystic duct, vasculitis, obstructing adenocarcinoma of the gb, unusual infection, or systemic disease - TB, sarcoidosis, TB, syphilis
- Underlying SEVERE illness - burn, postpartum, postop, TPN
Acute Cholecystitis- epidemiology
Calculous:
- F>M
- 40-60y
Acalculous
- critically ill, bedridden, on TPN
- 5-10% w/ cholecystitis
- M>F
Acute Cholecystitis- S/S & PE
RUQ pain, Fever, Leukocytosis
Diarrhea
N/V
Hx of fatty food
Lasts - several hours >4-6
Hx of previous spontaneous resolving attacks
Ill appearing
Fever
Tachy
Voluntary/involuntary guarding on abdominal exam
Rebound tenderness in RUQ
Tender to Palpation RUQ
Pos Murphys Sign - when pressed -> inspiratory arrest and inc discomfort
Able to palpate an enlarged, tender gallbladder?
Acute Cholecystitis- diagnosis
U/S:
- cholelithiasis - supports, but doesn’t diagnosis
- Gallbladder wall thickened or edema
- sonographic Murphy’s sign
- Pericholecystic fluid & dilation of bile duct
HIDA scan - done if still not confirmed diag
- Technetium labeled HIDA injected IV -> taken by hepatocytes -> excreted into bile
- Neg = can visualize gallbladder
- Pos = can’t visualize gallbladder
Acute Cholecystitis- labs & imaging
Leukocytosis - Left shift (Inc bands)
LFTs - inc
Acute Cholecystitis- treatment
ADMIT!
Pain - NSAIDs or opioids
Abx - given for acute until resolution or chole
- Comm acquired acute - Cefazolin, cefuroxime, or ceftriaxone
Cholecystectomy or cholecystostomy
- Emergent for: progressive s/s - fever, hemodynamic instable, intractable pain; suspicion or gallbladder gangrene or perforation
- Low risk: chole during initial hosp - laparoscopic
- Risk>benefits, but not emergent: gallbladder drainage w/ percutaneous cholecystostomy; once acute episode resolved -> assess for risk, maybe schedule surgery
Acute Cholecystitis- prognosis
If not treated:
- can get better in 7-10 days
- Gangrenous cholecystitis
- Perforation - abscess or peritonitis
- Cholecystoenteric fistula
- Gallstone ileus
- Emphysematous cholecystitis
Chronic Cholecystitis- pathophysiology
Chronic inflammation of gallbladder wall
With gallstones
Chronic Cholecystitis- cause
Episodes of acute/subacute cholecystitis or gallstones -> persistent irritation to gallbladder wall -> fibrosis & thickening of gallbladder
Chronic Cholecystitis- S/S & PE
Multi episodes of biliary colic
Chronic Cholecystitis- labs & imaging
U/S - cholelithiasis, wall thickening from scarring
Chronic Cholecystitis- treatment
Cholecystectomy
Porcelain Gallbladder- pathophysiology
Calcification of gallbladder wall
Porcelain Gallbladder- cause
Chronic cholecystitis?
Porcelain Gallbladder- S/S & PE
Asymptomatic
Porcelain Gallbladder- diagnosis
Incidentally - Xray
- US or CT to confirm
Porcelain Gallbladder- treatment
Inc RISK FOR CARCINOMA
Resection
Choledocholithiasis- pathophysiology
Stones within the common bile duct
Choledocholithiasis- S/S & PE
RUQ /epigastric pain - prolonged then typical biliary colic Nausea Vomiting Jaundice?
Choledocholithiasis- diagnosis
U/S - 1st
Choledocholithiasis- labs & imaging
AST/ALT - inc early
Bili, ALP, GGT - inc later
Choledocholithiasis- treatment
If high risk for CBD stone -> ERCP w/ stone removal + cholecystectomy
Acute Cholangitis (Ascending Cholangitis)- pathophysiology
Statis and infection in biliatry tract
Biliary obstruction + bacterial infection
Obstruction:
- calculi, stenosis, malignancy
- > inc intrabiliary pressure -> permeability of bile ductulus -> easier for bacteria to transfer from portal circulation to biliary tract
-> easier for bacteria to g from bile to circulation -> septicemia
Bacteria - Ecoli, Klebsilella, Enterobacter
Acute Cholangitis (Ascending Cholangitis)- S/S & PE
Charcot triad - Fever, abdominal pain (RUQ), jaundice
Reynolds Pentad - Confusion, hypotension, fever, abdominal pain, jaundice
- suppurative cholangitis
Fever & abdominal pain - most common - RUQ, diffuse Jaundice - less common Older pts and immunosuppressed - atypical presentation - HTN only?
Acute Cholangitis (Ascending Cholangitis)- diagnosis
Suspect: 1 from each
- fever, shaking/chills, lab evidence of inflammatory response (WBC or inc CRP)
- Jaundice, abnormal LFTs
Definite: above and also has
- Biliary dilation on imaging
- evidence of an etiology on imaging - stricture, stone, stent
Acute Cholangitis (Ascending Cholangitis)- labs & imaging
Leukocytosis - neutrophil predominance
LFTs - Cholestatic patter -> Inc ALP, GGT and Bili
Blood cultures - pos?
- all should have done
- if ERCP - culture bile or stent
Acute Cholangitis (Ascending Cholangitis)- treatment
Charcots Triad + abn LFTs:
- ERCP - diagnose and drain
NO Charcots Triad:
- Transabdominal U/S - look for CBD dilation or stone
- Sene -> ERCP w/in 24 hrs for drainage/stone removal
- nl -> MRCP - only use if not 100% sure
Admit to hosp Watch for sepsis Abx - Ampicillin-sulbactam - Unasyn - Piperacillin-tazobactam - Zosyn - Ticarcillin-clavulanate - Ceftiazone + Metronidzaole - modify w/ culture results - 7-10 days Biliary drainage - ASAP - ERCP - TOC - Percutaneous transhepatic cholangiography or open surgical decompression
Acute Cholangitis (Ascending Cholangitis)- prognosis
11-20% mortality
At risk for recurrence - Cholecystectomy recom
Benign stenosis - surgery or endoscopic therapy
Malignant stenosis - recurrent obstruction common - stent?
Mirizzi Syndrome- pathophysiology
Hepatic duct obstruction from extrinsic compression
- from impacted stone in cystic duct
Mirizzi Syndrome- cause
Alcohol abuse
Chronic viral Hep
Hemochromatosis
Nonalcoholic fatty liver disease
Autoimmune hep Prim and sec biliary cirrhosis Prim sclerosing cholangitis Meds Polycystic liver dis RS heart failure Wilson dis Celiac dis Alpha-1 antitrypsin def
Mirizzi Syndrome- S/S & PE
Jaundice
Fever
RUQ pain
Mirizzi Syndrome- diagnosis
U/S - 1st
ERCP - 2nd
Mirizzi Syndrome- labs & imaging
ALP - inc
Bili -inc
Mirizzi Syndrome- treatment
Surgery - cholecystectomy
- poor candidate - lithotripsy
Mirizzi Syndrome- prognosis
High frequency of bladder Ca
Cirrhosis- pathophysiology
Progressive hepatic fibrosis
- fibrosis & regenerative nodes in live
Fibrosis -> Architectual distortion -> disruptt nl portal blood flow -> inc BP and impairs liver function
Cirrhosis- cause
Most Common: Alcohol abuse Chronic viral Hep Hemochromatosis Nonalcoholic fatty liver disease
Autoimmune hep Prim and sec biliary cirrhosis Prim sclerosing cholangitis Meds Polycystic liver dis RS heart failure Wilson dis Celiac dis
Cirrhosis- S/S & PE
Nonspecific symptoms - fatigue, anorexia, weakness, weight loss/wasting
Specific hepatic dysfunction:
Skin
- Jaundice - yellow of skin, eyes, membranes, >2-3 mg/dl
- Spinder angioma - vascular lesions; trunk, face, upper limbs
- Palmar erythema - palm w/ central pallor
Chest/Feminization
- Gynecomastia - 2/3 of pt
- Men - loss of chest/axillary hair, inversion of normal male public hair pattern; testicular atrophy
Abdominal findings
- Ascites - distended, fluid wave, flank dull to percussion
- Liver palpation - enlarged, nl, or small; can feel - firm and nodular
- Splenomegaly
- Capute medusa
- Cruveilhier-Baumgarten murmur - venous hum heard w/ portal HTN, over epigastrium
- Umbilical hernia
Neurologic
- cognitive deficits & impaired neuromuscular fnt
- Disturbances in sleep pattern often initial changes, mood changes, inappropriate behavior, disorientation, somnolence, confusion, unconsciousness, bradykinesia
- Asterixis - flapping of outstretched, dorsiflexed hand
- Hyperactive or hypoactive, slurred speech, nystagmus, ataxia, focal neuro deficit, coma
Hepatic Encephalopathy
- Ammonia neruotoxin - don’t need to be elevated
- Not specific - DO NOT use to screen
Extremity Changes
- Muehrcke nails - paired whitte horizontal bands separated by normal color
- Terry nails - proximal 2/3 of nail plate white, distal 1/3 is red, clubbing, Dupuytren’s contracture
Cirrhosis- diagnosis
Live biopsy - gold
- not needed dif clinical, lab and radiologic data strongly support presence
U/S - liver may be small & nodular, inc echogenicity w/ irregular appearing areas
Fibroscan - noninvasive test of hepatic fibrosis
- staging of fibrosis -> helps determine treatment
Child-Pugh score - severity of liver disease
5-6 = A - well compensated -> 100-85% survival
7-9 = B - signif functional compromise -> 80-60% survival
10-15 = C = decompensated -> 45-35% survival
MELD score - used to prioritize liver transplant
- > 10 - refer
- > 15 - candidate for transplant
- Predicts outcomes
- Bili, Creatinine, INR, Na
- The higher the score - the worse the outcome
Cirrhosis- labs & imaging
AST/ALT - inc ALP - inc GGT - much higher Bili - inc w/ progression Albumin - dec w/ progression PT - inc w/ progression Hyponatremia Serum Cr - inc Cytopenia - thrombocytopenia, leukopenia, anemai
Cirrhosis- treatment
NO Alcohol!
Vaccinate - hep
Med adjust for hepatic impairment
Treat chronic hep
Compensated - >12y survival
Decompensated
- <6m w/ a Child-Pugh score >12 or MELD >21
- <6m - hosp w/ acute liver illness
- lower mean arterial pressure - worse the survival
Transplant: Indications - Acute liver failure - highest priority - Cirrhosis w/ complication - neoplasm - liver based metabolic conditions - wilson dis, CF, hemochromatosis Contraindications - uncorrectable cardiopulm dis - AIDs - Ca outside of liver - uncontrolled sepsis - persistent nonadherence w/ medical care - lack of adequate social support Alcoholic liver dis - min of 6m none!
Cirrhosis- complications
Complications:
Variceal hemorrhage
- varices from portal HTN
- high mortality rates from bleeding episodes
- Asymptomatic -> hematemesis, melena
- everyone w/ cirrhosis needs to be screened - EGD
- if found - variceal band ligation
- Prevent - BB - low portal pressure and Dec risk of bleeding
Ascites
- Most common
- accumulation of fluid in peritoneal cavity
- Treated - diuretics, Na restriction - alcohol abstinence
- Diuretic therapy - spironolactone + furosemide 100:40 mg/day
- Paracentesis - tense ascites, need to rapidly decompress abdomen
-> remove 4-5L - anything more and albumin needs to be given
- TIPS - transjugular intrahepatic portosysttemic shunts - w/ refractory ascites
Spontaneous Bacterial Peritonitis
- infection of ascetic fluid
- Fever, abdominal pain, abdominal tenderness, AMS
- Diagnosis - fluid cultures or inc polymorphonuclear leukocyte count (>250) on eval of ascetic fluid
- High morality - start empiric abx ASAP - cefotaxime 2g IV Q8h
- if had it before - need to take daily abx forever - Norfloxacin or Bactrim
Hepatic Hydrothorax
- pleural effusion - w/ no other cause
- R sided - movement of ascites into pleural space from defects in diaphragm
- Treat - diuretics and Na restriction, thoracentesis if needed
Hepatopulmonary syndrome
- abnormal arterial O2 - intrapulmonary vascular dilatations
- Dyspnea, platypnea (better when laying down), impaired O2
- imaging - nonspecific
- PFTs - nl
- progressive
- therapy - liver transplant, O2 therapy - no meds work
Hepatorenal syndrome
- Renal failure
- Renal perfusion dec by hepatic dysfunction
- Diag - exclusion of other renal issues
Hepatic Encephalopathy
- Lactulose - dec ammonia from GI tract, titrate until having 2-3 stools a day, enema or PO
- nonabsorbable abx - rifaximin - added to lactulose or cant tolerate lactulose
- if combined - may have mortality benefit
- recurrent - need to be on forever
Hepatocellular carcinoma
- inc risk of developing
- think if - decomp in a previously stable pt
- asymptomatic - upper abdominal pain, weight loss, early satiety, palpable abdominal mass
- labs - nonspecific, maybe inc AFP
- only effective screening - U/S x 6m
- Treat - surgery, liver transplant
Portopulmonary HTN
- pulmonary htn in pts w/ portal htn
- Fatigue, dyspnea, peripheral edema, chest pain, syncope
- Diagnosis - echo - confirmed w/ R heart cath
- very hard to treat
- high mortality during liver transplant
Inflammatory Bowel Disease- cause
Crohn
Ulcerative Colitis
Inflammatory Bowel Disease- epidemiology
15-40yo
Jewish decent
1st deg relative w/ IBD
Smoking - inc risk of Crohn’s
- protective against UC
Western diet - inc risk
Ulcerative Colitis- pathophysiology
Idiopathic inflammatory condition
- involves mucosal surface of colon -> diffuse friable areas and erosions w/ bleeding
Starts distally -> progresses proximally
Continuous - no skip areas
Ulcerative Colitis- S/S & PE
Bloody diarrhea - BM frequent and small volume
Tenemesmus - straining, feeling like you have to poop all the time
Mainly distal - constipation + frequent blood and mucus discharge
Incontinence
Colicky abdominal pain
Onset of symptoms - gradual and progressive
Systemic symptoms - fever, weight loss, fatigue
Arthritis - nondestructive, peripheral large joints
- ankylosing spondylitis
Uveitis/episclertitis
Erythema nodosum
Pyoderma gangrenosum
VTE
Arterial thromboembolism
Autoimmune hemolytic anemia
Primary sclerosing cholangitis - liver and gallbladder disease
PE - usually nl
- abdominal pain w/ palpation
- fever
- hypotension
- tachy
- pallor
- blood on rectal exam
Ulcerative Colitis- diagnosis
Chronic diarrhea >4w
Evidence of active inflammation on endoscopy
- loss of vascular markings from swelling of mucosa -> looks erythematous
- Petechiae, exudates, edema, erosions, friability to touch, spontaneous bleeding
Chronic changes on biopsy
- Crypt abscesses
- Crypt branching
- Shortening and disarray
- Crypt atrophy
- Epithelial cell abnormalizes - mucin depletion, Paneth cell metaplasia
- Inflammatory features - inc lamina propria cellularity, basal plasmacytosis, lymphoid aggregates, lamina propria eosinophils
Exclude all other causes
Pattern:
- involves rectum
- extends proximally in continuous, circumferential
- No normal areas of mucosa
Ulcerative Colitis- labs & imaging
Anemia ESR/CRP - inc Electrolyte abnormalities - diarrhea/dehydration Fecal calprotectin - inc - differentiate b/t UC and IBS
Xray
- proximal constipation
- mucosal thickening - thumbprinting from edema
- colonic dilation - severe
Double contrast barium enema
- diffusely reticulated pattern w/ punctate collections of barium in microulcerations
- collar button ulcers
- shortening of colon
- loss of haustra
- polyps or pseudopolyps
- avoid in those severely ill -> can cause toxic megacolon
CT and MRI
- lower sensitivity than barium enema at detecting subtle early disease
- Thickening of bowel wall
Ulcerative Colitis - treatment
Ulcerative Proctitis or Proctosigmoiditis
Topical 5-aminosalicylic acid (5-ASA) - 1st line
- Suppositories - dis just distal to part of rectum
- Mesalamine 1 PR BID
- Enema + suppository - dis extends furth
- Enema BID + suppository BID
- symptomatic relief and dec bleeding - w/in few days
- complete healing >4-6w -> continue for 8 weeks - then taper
- 1st episode + proctitis -> disc, no maintenance therapy
- Proctosigmoiditis or >1relapse /year -> maintenance therapy
Alternatives - topical steroids, PO 5-ASA
Left sided colitis, extenside colitis, pancolitis
- combo therapy - PO 5-ASA, suppositories 5-ASA or steroid, and enemas 5-ASA or steroid
Refractory
- Refer
- further oral immunosuppressants
Ulcerative Colitis- severity
Severity: Mild - <4 stools/day - nl ESR - no severe abdominal pain, fever, wt loss, profuse bleeding
Mod
- > 4 loose, bloody stools/day
- mild anemia - no trans
- mod abdominal pain
- Minimal signs of systemic toxicity - low grade fever
- No wt loss
Severe
- Frequent loose bloody stools >6/day
- Severe abdominal pain
- Systemic symptoms - fever, tachy, anemia, Inc ESR
- May have rapid weight loss
Ulcerative Colitis- prognosis
Prognosis:
- w/ treatment - exacerbations/flares alternating w/ long periods of symptomatic remission - some won’t be able to get remission
- Dis extension
- Colectomy - 20-30% - acute complications or intractable disease
- slightly higher mortality - then rest of population
Chrohn Disease- pathophysiology
Transmural inflammation of GI tract - throughout whole GI tract
- ilium & R colon - most common
Skip areas - classic
Cause - Uknown
Chrohn Disease - epidemiology
15-35
Chrohn Disease - S/S & PE
Crampy abdominal pain Strictures - lead to repeated obstruction Diarrhea - fluctuating over time - gross bleeding - less common than UC Fistulas - entervesical, enterocutaneous, enteroenteric, enterovaginal Malabsorption Abscess formulation Aphthous ulcers
Fatigue, wt loss Arthritis Eye - uveitis, iritis, episcleritis Skin - erythema nodosum, pyodermo gangrenosum Primary sclerosing cholangitis VTE & arterial thromboembolism Nephrolithiasis Vit B12 def Pulm involvement Sec amyloidosis
PE - nl
- Perianal skin tags, sinus tracts, abdominal tenderness, wt loss, pallor
Chrohn Disease- diagnosis
Colonoscopy
- focal ulcerations next to nl areas
- polypoid mucosal changes - give cobblestone appearance
- Skip areas
- Rectal sparing
Wireless capsule Endoscopy
- no radiation
- don’t do - w/ suspected stricture
Crohn’s Disease Activity Index - CDAI
- stool patterns, abdominal pain rating, general wellbeing, complications, abdominal mass, anemia, weight change
Harvey-Bradshaw Index (HBI)
- general wellbeing, abdominal pain, number of liquid stools, abdominal mass, complications
Chrohn Disease- labs & imaging
CBC CMP ESR/CRP - CRP higher than in UC Serum Iron Vit D Vit B12 Fecal calprotection - diff b/t IBS Antibody test - pANC and ASCA pos - diff b/t CD and US
Barium Swallow - upper GI series
- narrowing o lumen w/ nodularity & ulceration
- Sring sign
- Cobblestone appearance
- Fistulas/abscess formation
- Bowel wall thickening
- Stricturing
CT - w/ ingestion of a neutral contrast agent to distend small bowel
- best study if abscess suspected
MRI
- mural thickening, high mural signal intensity (edema), layered patter of enhancement = acute small bowel inflammation
Chrohn Disease- treatment
Mild - Mod Disease
Ileum or proximal colon involvement
- Budesonide 9mg QD x 4-8 weeks -> taper Q2-4 w = 8-12 w total
- Corticosteroid
- AE - HA, acne, adrenal suppression, osteoporosis, immunosuppression, edema, psychiatric distrubances, exacerbation of CV dis, hyperglycemia
- Alternatives - budesonide - prednisone, oral 5-ASA - controversial
Diffuse Colitis or Left colonic involvement
- PO prednisone 40mg QD x 1w -> taper
- Atlern - Sulfasalazine
Oral lesionx
- topical meds - triamcinolone acetonide
Severe Disease
- Top Down
- Refer
- Bioloigic + immunomodulatory for induction
- TNFinhibitor - infliximab (remicade), adalimumab (Humaria), certolizumab (Cimizia)
- + azathioprine, 6-mercaptopurine, or methotrexate
- Glucocorticoid - immediate symptom relief - <8w
- Maintenance - long term w/ biologic
Relapse - begin sec course of glucocorticoid
Surgery - for complications or persistent symptoms
- perf, abscess, fistula, hemorrhage, stricture, neoplasm
Chrohn Disease- prognosis
Step Therapy - start w/ less potent meds - but fewer side effect
- use more potent meds if initial not effective
Top-down therapy - start w/ more potent therapies early in the course of disease before they become glucocorticoid- dependent
Goal - remission - endoscopic, histologic, clinical
- demonstrating complete mucosal healing
Intermittent exacterbat -> periods of remission
>1/2 develop structuring or penetrating disease
Will require surgery
80% require hosp
Predictors of severe course
- <40, perianal or rectal disease, smoking, low education level, initial need for glucocorticoids
Constipation- cause
Inadequate fiber & water consumption
Meds - opiates, anticholinergic, CCBs, antacids, Fe, Ca
Neurologic conditions - MS, Parkinson disease, dementia, stroke
Prolonged immobility - SCI, complete bed rest
Metabolic - DM, hypothyroidism, uremia, hypercalcemia, hypokalemia
Functional fecal retention - chronic stool-withholding
- common in kids
Anatomic abnormalities - neoplasms, anal fissures, lesions, proctitis, perirectal abscess, anorectal stenosis
Functional - inc rectal compliance, Pelvic floor dysfunction
Constipation - S/S & PE
Hard or lumpy stools Feeling of incomplete voiding Straining Abdominal discomfort or bloating Manual maneuvers <3 defecation x week Loose stools rare w/out laxative use
Constipation - treatment
Fiber - psyllium, methylcellulose, calcium polycarbophil
Hyperosmolar agent - sorbitol, lactulose, PEG (miralax)
Stimulant - glycerin suppository, bisacodyl, senna, senna/colace
Enema - mineral oil, tap water enema, Na phosphate
Opioid antagonist - methylnaltrexone, naloxegol
