GI Self Care Flashcards
What are common GI disorders?
- Gastroenteritis
- Gastroesophageal reflux disease (GERD)
- Peptic ulcer disease (PUD)
- Lactose intolerance
- Constipation
- Diarrhea
- Nausea and vomiting
Why is abdominal pain significant to GI issues?
- One of the most common GI complaints
- Many possible causes depending on the location and characteristics of the pain.
Identify common causes for abdominal pain based on location.
- RUQ: Acute cholecystitis, Duodenal ulcer, Hepatitis, Congestive hepatomegaly, Pyelonephritis, Appendicitis, Pneumonia
- Epigastrium: Myocardial infarct, Peptic ulcer, Acute cholecystitis, Perforated oesophagus
- LUQ: Ruptured spleen, Gastric ulceer, Aortic aneurysm, Perforated colon, Pyelonephritis, (L) Pneumonia
- LLQ: Intestinal obstruction, Acute pancreatitis, Early appendicitis, Mesentreric thrombosis, Aortic aneurysm, Diverticulitis, (lower region)–> Sigmoid diverticulitis, Salpingitis, Tubo-ovarian abscess, Ruptured ectopic pregnancy, Incarcerated hernia, Perforated colon, Crohn’s disease, Ulcerative colitis, Renal/ureteral stone
- RLQ: Appendictitis, Salpingitis, Tubo-ovarian abscess, Ruptured ectopic pregnancy, Renal/uretric stone, Incarcerated hernia, Mesenteric adenitis, Meckel’s diverticulitis, Crohn’s disease, Perforated caecum, Psoas abscess
- Epigastrium: Mycocardial infarct, Peptic ulcer, Acute cholecystitis, Perforated oesophagus.
What are the components of GI Objective Assessment?
- Physical examination (limited role)
- Laboratry testing (limited role)
- Diagnostic testing (major role)
Diagnostic tests are undergone by…
Endoscope
What does a colonscopy measure? What does the sigmoidoscopy measure?
Colonoscopy examines the entire length of the colon; sigmoidoscopy examines only the lower third
What questioning method do pharmacists use for GI assessments?
SCHOLAR-MAC
* Symptoms
* Characteristics
* History
* Onset
* Location
* Aggravating Factors
* Remitting Factors
* Medications
* Allergies
* Conditions
What questions are used to collect and assess for patients with GI complaints or disorders?
- What symptoms are you are experiencing? .
- Describe the symptoms (in detail) in your own words and location.
- Do you have a history of these symptoms in the past? If yes, how long ago?
- Describe the onset, duration, and progression of these symptoms.
- What makes the symptoms better?
- What makes the symptoms worse?
- What self care measures have you tried so far? Impactof these measures?
- What medications do you take on a regular basis?
What are the goals of self-care treatment?
- Eliminate and/or minimize pain, discomfort, or other troublesome symptoms.
- Maintain or enhance QOL of patient
- Maintain proper nutritional and fluid intake.
- Rule out serious conditions associated with presenting symptoms (bleeding, organ dysfunction, malignancies, systemic complications)
What characteristics would qualify for immediate referral for GI issues?
- Vomiting blood
- Blood stool
- High fever with GI Sx
- Vomiting more than 2 days without relief
- Diarrhea greater than 1 week without relief
- Odynophagia (painful swallowing)
- Dysphagia (difficult swallowing)
- Jaundice skin
What are common GI diseases and conditions?
- Gastroenteritis
- GERD
- PUD
- Diverticulitis
- Celiac disease
- Lactose Intolerance
- Constipation
- Diarrhea
- N/V
What causes NV?
- Gastroenteritis
- Overindulgence
- Motion Sickness
- Medications
- Secondary to pain
- Secondary to other GI disorders
What are some questions to ask patients dealing with NV?
- When did symptoms begin
- Frequency, consistency, and color of vomit?
- Have you had similar bouts in the past?
- Presence of fever, malaise?
- Presence of abdominal pain and/or cramping?
- Others with similar symptoms
- Recent travel outside of US?
What symptoms would qualify a patient for referral who is NV?
Immediately necessary if the following is reported:
1. Weight loss
2. Intractable vomiting
3. Blood in vomit (hematemesis)
4. Constant pain
5. Odynophagia
What are some routes for self-care when dealing with NV?
- BRAT
- Oral rehydration
What is gastroenteritis?
Inflammation of the stomach and intestines
What are the causes of Gastroenteritis?
- Infection (typically viral)
- Contaminated food or water
- Medications
What are the symptoms of Gastroenteritis?
- N/V
- Diarrhea
- Abdominal cramping
- Low-grade fever
What is Nausea?
Sickness of the stomach with the inclination to vomit
What is Vomiting?
the ejection of matter forcibly from the stomach through the esophagus and mouth
What are some self-care treatments for gastroenteritis and NV?
Change the diet!
* Rest the gut by avoiding solid foods in first 24 hours
* BRAT–> avoid fatty, fried, and spicy foods; cold or room temp foods
* Rehydration therapy
* OTC medication- antacids- most effective meds are Rx only
Drink up!
* Rehydration therapies
* Available products: electrolyte replacement products, gatorade, soft drinks.
* Use weight to determine replacement needs
* Replace loss over 4-6 hours
How might NV and motion sickness be related?
- Motion sickness is caused when there is a mismatch between what the eyes see, the inner ear senses, outer ear senses, and what the body feels.
- Differences in sensations confuses the brain and may lead to NV as part of the body’s protective response (due to unusual movement).
What is the prevalence for motion sickness?
VERY COMMON
* 1/3 of population very susceptible
* 1/3 susceptible with rough conditions
* 1/3 susceptible only with extreme conditions
* Peak age 12 y.o. to 21 y.o.
What are medications that can be used to prevent motion sickness?
Dimenhydrinate 50 mg
* AKA Dramamine
* Oral (30 to 60 mins before travel)
Meclizine
* Bonine
* Dramamine Less Drowsy
* Zentrip
* Oral (30 to 60 mins before travel)
Refer for Scopolamine patch Rx
* 72 hour duration
* Ideal for cruises and long car rides
What is Diarrhea?
Increase in the number or fluid content of bowel movement.
What would classify as acute diarrhea?
- Continues for less than 3 weeks
- typically 12-60 hours
What would classify as chronic diarrhea?
- Continues for greater than 3 weeks
- Indicative for an underlying cause
What are the symptoms of acute vs chronic diarrhea?
Acute
* Sudden Onset
* Cramping
* NV
* weakness
* Low grade fever
* headache
* malaise
* chills
* bloating flatulence
Chronic
* Skin break down
* dehydration
* weight loss
* malnutrition
What are questions to ask patients dealing with diarrhea?
- When did symptoms begin
- Frequency, consistency, and color of stool?
- Have you had similar bouts in the past?
- Presence of fever, NV, malaise
- Presence of abdominal pain and/or cramping?
- Others with similar symptoms
- Recent travel outside of US?
When do we refer for diarrhea?
Immediately neccesary for patients presenting with:
* Bloody stool
* Signs of dehydration
* Weight loss
* High fevre
* Prolonged diarrhea (greater than 1 week)
How to self-care for diarrhea?
Diet:
* Avoid solid foods and dairy products for 24 hours
* BRAT
* Rehydration therapy
* May determin fluid deficit
* 1 kg-1 L
* Replace deficit over 4-6 hours
What do we look for when evaluating a patient for dehydration?
Diarrhea- Induced Dehydration
- Dry mucous membranes
- Concentrated urine
- Skin tenting
- Dizziness when standing
- Orthostatic hypotension
How do we treat patients with acute diarrhea?
- Acute= symptoms lasting fewer than 3 days
- Most cases will resolve with 1-2 days even without tx
- Most cases can be treated OTC
- OTC treatments include: Loperamide, Pepto Bismol, etc.
What is the dosing for loperamide/imodium?
Dosing:
* MOA: Blocks mu opiod receptors in the GI tract decreasing peristalsis
* Rx: 4 mg initially, then 2 mg with each loose stool (max 16 mg)
* OTC: 4 mg initially, then 2 mg with each loose stool (max 8 mg)
What is the dosing for Bismuth Subsalicylate or Pepto Bismol?
Dosing
* MOA: reduces secretions in GI tract
* Bismuth subsalicylate has also shown to have antimicrobial and anti-inflammatory effects
* 2 tabs (30 ml) every 30 to 60 mins as needed; up to 8 doses/24 hours
* May potentiate anticoagulants
* Cause stools and tongue to turn black
List medications that induce diarrhea.
- Antibiotics (#1 op)
- Antacids (containing Mg)
- Diabetes meds, such as Acarbose and Metformin
- Bethanecol
- Colchicine
- Metoclopramide
- Quinidine
- Acid suppressants (PPIs, Histamine receptor blockers)
- NSAIDs
What is constipation?
- No single, agreed upon definition.
- Decreased or sporadic passage of stool compared to a person’s normal bowel habits.
- Excessive straining/effort required to defecate
What are the characteristics of acute constipation?
- A noticeable change in normal bowel movement pattern.
- Less than 3 bowel movements/week
Other Key Features:
* Stoolls are dry and hard
* BM is painful and stools are difficult to pass.
* Feeling that bowels have not been fully emptied.
Ususally brought about by change in condition or drug.
What are the characteristics of chronic constipation?
- Symptoms lasting greater than 6 weeks
- May respond to laxative tx but returns when laxative d/c
- Does not respond to dietart changes alone
- Chronic Idiopathic Constipation
- No identified cause
What is the clinical presentation of constipation?
- Less than 3 stools per week
- Bloating
- Cramping
- Straining or grunting
- Sensation of blockage
What are possible causes of constipation?
- Medications
- Lack of physical activity
- Inadequate fluid intake
- Inadequate fiber intake
- Underlying disease state
Which medications may induce constipation?
- Opioid analgesics
- Antacids (containing Al or Ca)
- Anticholinergics (Antihistamines, Anti-Parkisonian agents, Phenothiazines, Tricyclic antidepressants)
- Antihypertensives (calcium channel blockers, clonidine)
- Muscle blockers
- Diuretics
- Iron supplements
Questions to ask to patients dealing with constipation?
- When did symptoms begin
- Frequency, size, consistency, and color of stool?
- How often do you normally have a a bowel movement?
- Have you had similar bouts in the past?
- Presence of fever, NV, malaise
- Presence of abdominal pain?
- Presenceof constipation with diarrhea?
- Presence of gas?
- Do you have a family history of IBD or colon cancer?
- Have you had an appetite or weight change?
Briefly describe the Bristol Stool Scale.
- Type 1–> separate hard lumps, like nuts
- Type 2–> Sausage-like but lumpy
- Type 3–> Like a sausage but with cracks in the surface
- Type 4–> Like a sausage or snake, smooth and soft
- Type 5–> Soft blobs with clear-cut edges
- Type 6–> Fluffy pieces with ragged edges, a mushy stool
- Type 7–> Watery, no solid pieces
When do we refer patients for constipation?
- Symptoms have persisted (with appropriate interventions) for greater than 2 weeks w/o significant relief
- Who has black or tarry stools
- Who has marked abdominal pain
- Who has a fever
List OTC options for constipation treatment.
- Metamucil
- Miralax
- Citrucel
- Sennokot-S
- Colace
What are examples of bulk laxatives?
- Psyllium- Metamucil
- Methylcellulose- Citrucel
- Calcium polycarbophil- Fibercon
What is the mechanism of action (MOA) of bulk laxatives?
- Forms emollient gels which retain water, swells, and stimulates BM
- Dose once or twice daily
What are the advantages and disadvantages of bulk laxatives?
Advantages
* Soften stools better than docusate
* Well tolerated, few SE
Disadvantages
* Taste
* Must have adequate fluid intake
* Gas formation
* Impact on drug absorption
* Not ideal for bedridden pts
How is citucel prepared?
- Mix cirtucel with at least 8 oz of cold water or juice
- Drink immediately
- Produces less gas
What class is docusate?
Surfactant/Emollient
What is a common dosing frequency for docusate?
- 100 mg once or twice daily
What is the mechanism of action for docusate sodium?
- Decreases fecal surface tension
- Stool softener
What are the advantages and disadvantages of docusate?
Advantages
* Safe
* Helps prevent hard stools and hemorrhoids
Disadvantages
* ??? Efficacy
* Not effective for active constipation
What are examples of saline laxatives?
- MOM; Mg Citrate; mg hydroxide
- Fleets Saline Edema
What is the mechanism of action for saline laxatives?
- Draws fluid into colon which stimulates motility
- Dosed once daily
What are advantages and disadvantages of saline laxatives?
Advantages
* Used for acute management of constipation; quick onset (12-24 hours)
* Most economical
Disadvantages
* Taste +/-
* Avoid in renal pts (Na, Mg)
What are examples of hyperosmotic agents?
Polyethylene Glycol 3350 (MiraLAX):
* 17 g mixed in 4-8 oz H2O daily
* Well tolerated
* Softens while stimulating BM
* Excellent for chronic constipation
Glycerin Suppositories
* Quick onset: used prn
* Adult and pediatric size
What is the mechanism of action for hyperosmotic agents?
Draws fluid into the colon due to high concentration of PEG or glycerin
Which are stimulant laxatives?
- Senna (Senokot)–> 2 tabs 1-2 times daily
- Bisacodyl (Dulcolax)–> 1-2 daily (either 1) 5 mg enteric coated tabs, 2) 10 mg suppository for rapid relief of constipation)
What is the mechanism of action for stimulant laxatives?
- Locally stimulates enteric nerves which stimulates contractions and mobility; also increases fluid and Na secretion into the lumen.
- Quick onset–> 6 to 12 hours; risk of abd cramping
- Agents of choice for opioid-induced constipation
Describe GERD.
- Gastroesophageal Reflux Disease
- Most common disorder of the esophagus
- Affects 10-20% of American population
Pathophysiology
* Decreased lower esophageal sphincter pressure
* Increased gastric volume
* Impaired esophageal motility
What questions can we ask pts regarding their GERD?
- Describe your symptoms in your own words. When did your symptoms
begin? - Have you had similar bouts in the past?
- Describe the onset, location, and progression of the heartburn symptoms.
- Describe the relationship of symptoms to meals and bedtime.
- Are there any foods that bring on symptoms?
- What makes the symptoms better and what makes them worse?
- Do you drink alcohol or smoke cigarettes??
- What other medications do you take?
What dietary factors are classified as exacerbating factors for GERD?
- Large meals
- Eating before bedtime
- Dietary fat
- Lower LES tone: chocolate, alcohol, caffeine, peppermint, garlic, onion, chili pepper
- Direct irritants: coffee, orange, tomato, spicy foods
What miscellaneous factors are exacerbating factors for GERD?
- Tight clothing
- Pregnancy
What medications are exacerbating factors for GERD?
Lower LES tone
* Anticholinergics
* Barbiturates
* Benzodiazepines
* Beta blockers
* Calcium channel blockers
* Opioids
* Nicotine/Cigarette smoking
* Progesterone
* Tetracycline
* Theophylline
Direct irritants:
* Aspirin
* NSAIDs
* Iron
* Alendronate
What are typical symptoms for GERD?
- Heartburn
- Water brash (hypersalvation)
- Belching
- Regurgitation
Atypical Symptoms (extrasophageal):
* Non-allergic asthma
* Chronic cough
* Hoarseness
* Pharyngitis
* Chest pain
* Dental erosions
When do we refer for GERD?
Necessary for pts presenting with the following:
* Constant pain
* Dysphagia
* Ondynophagia
* Unexplained weight loss
* Choking
* Prevent esophageal erosions
What are non-pharm methods for GERD self-care?
- Avoid foods and meds that worsen GERD symptoms
- Elevate head of bed (wedge pillow)
- Consume small frequent meals
- Avoid eating within 3 hrs of bedtime
- Avoid alcohol
- Weight loss
- Smoking cessation
What are GERD signs and symptoms?
- Heartburn
- Water brash (hypersalivation)
- Belching
- Regurgitation
- Sx worsen after meals
What are PUD signs and symptoms?
Epigastric pain
* Vague discomfort or cramping
* Burning, gnawing or hunger-like
* Radiation to the back
* Pain that awakens patient at night
* Pain relief with anatacid use or meals
Sx improve after meals
Anorexia; weight loss
Belching; Bloating; Abd distention
Dark sticky stools
Coffee ground emesis
What are the three types of self-care treatment options for the treatment of GERD and PUD?
- Antacids
- Acid Suppressant (Histamine receptor blocker)
- Acid Suppressant (Proton pump inhibitor)
Describe antacids
- Fastest acting to relieve GERD and PUD sx
- 15-30 ml (1-2 tabs) up to 4x daily + prn
- Calcium carbonate (TUMs)
Combination
* Aluminum hydroxide, Mg hydroxide +/- simethicone (Mylanta, Maalox Advanced)
Alginic Acid + Al + Mg (Gaviscon)
Characterize histamine receptor blockers.
- Acid suppressant
- Famotidine/Pepcid (10 mg-20 mg 1-2x daily)
- Cimetidine/Tagamet HB (200 mg 1-2x daily)
Characterize proton pump inhibitors.
- Acid Suppressant
- Important to take prior to first meal
- Esomeprazole (Nexium): 20-40mg once daily for 4-8 wks
- Lansoprazole (Prevacid): 15-30 mg once daily for 4-8 weeks
- Omeprazole (Prilosec): 20-40 mg once daily for 4-8 weeks
What is lactose intolerance?
- Lactase deficiency
What causes a lactose intolerance?
- Increase in age
- Result of injury or illness
- Congenital
What are risk factors for lactose intolerance?
Age, ethnicity, diseases of the small intestine, premature birth, some cancer treatments
What are symptoms of lactose intolerance?
- Diarrhea
- NV
- Abd Cramping
- Bloating
- Flatus
What are self-care options for lactose intolerance?
- Lactase enzyme tabs or drops
- Reduced lactase dairy products
- Consuming dairy with meals
- Consuming lower lactose dairy products
What are the “overview” concepts for GI self-care?
- Many, but not all GI complaints can be addressed with OTC products
- Asking the ‘right’ questions is key for making appropriate decisions to treat versus refer
