Hemorrhoids, Diarrhea, Gas Flashcards
Hemorrhoids: Definition & Symptoms
• Enlargement or inflammation of normal structures • Mild symptoms: – Itching – Irritation – Burning – Swelling – Inflammation • Severe symptoms: - Pain - Bleeding - Seepage - Thrombosis - Prolapse
Diarrhea: Definition & Symptoms
• Stool frequency or liquidity greater than normal
– “Normal” varies from patient to patient
– May be associated with urgency, pain, flatulence
• Patient reports:
– The runs
– The trots
– La turista
Gas: Symptoms
• Belching • Flatus • Cramping or distension • Excessive quantity, foul odor, or causing pain – Excessive flatus: >20 passages/day
Hemorrhoids: Activities & Conditions
• From pressure, irritation, or weakness of anal tissue – Behaviors & activities • Heavy lifting • Prolonged standing • Erect posture • Straining - Other conditions • Advanced age • Heredity • Diarrhea • Constipation • Pregnancy
Diarrhea: Infections & Medications
• From increased gut motility, secretion, or osmolarity – Infections • Viral (most common) • Bacterial • Protozoal • Toxins – Food intolerance • Enzyme deficiency - Medications • Antibiotics • Laxatives • Stimulants
Gas: Belching & Flatus
• Belching: Mostly from swallowed air
– Carbonated drinks
– Chewing gum
– Smoking
– Other (psychiatric)
• Flatus: Mostly from gut bacterial metabolism
– Maldigestion of certain foods (lactose, fiber, etc)
– Bacterial overgrowth (caused by certain drugs or diseases)
Hemorrhoids: Referral Criteria
Severe symptoms
- Pain
- Bleeding
- Prolapse
- Seepage
- Thrombosis
- OTC treatment failure (> 7 days)
High risk patients
- Children < 12 yo
- History of GI disease
- Family history of colon cancer
Diarrhea: Referral Criteria
Severe dehydration
- Dizziness
- Lethargy
- Confusion
- Low blood pressure
- Tachycardia
- Decreased urination
Systemic illness
- Fever
- Severe pain
- Blood or pus in stool
- Prolonged vomiting
- OTC treatment failure (> 2 days)
High risk patients
- Infants < 6 months
- Pregnancy
- Diabetes
- Kidney disease
- Heart disease
- Immunosuppression
Gas: Referral Criteria
Severe symptoms
- Pain
- Frequency
- Duration
Signs of another problem
- Other accompanying symptoms: fatigue, weight loss, bleeding
- Sudden changes in symptoms: bowel habits, pain location, frequency or duration, new onset if age > 40 yo
Hemorrhoids: Non-Pharmacologic Treatment
• Bowel modifications
– Act on the urge (don’t hold it in)
– Limit sitting time, don’t strain – Anal hygiene
• Dietary modifications
– Increase fiber
– Increase fluids
• Non-pharmacologic treatments
– Sitz baths
– Surgery (laser, banding, sclerosis, etc)
Diarrhea: Non-Pharmacologic Treatment
• Maintain healthy diet
– Complex carbs & Protein
– Avoid: High fat, sugar, spice, or caffeine content
– Not recommended: “BRAT diet” (bananas, rice, applesauce, toast), bowel rest
• Prevention
– Sanitation (hand washing, food handling)
– Avoid sick contacts
• Fluid & electrolyte replacement
Diarrhea: Oral Rehydration
• Solutions of sodium and glucose are most effective (Pedialyte)
- NaCl = 2.6 g/L
- Glucose = 13.5 g/L
- KCl = 1.5 g/L
- Sodium citrate = 2.9 g/L
• Immediate treatment: 2-4 L over 4 hours
– Children ≤ 5yo: 50-100 mL/kg over 4 hours
• Maintenance: As needed to replace ongoing losses
– Children ≤ 5yo: 10 mL/kg or 1⁄2 - 1 cup per loose stool
Gas: Non-Pharmacologic Treatment
• Behavioral modifications
– Eat slowly, don’t gulp air
– Mild exercise after meals
• Dietary modifications
– Avoid carbonated drinks, gum
– Decrease carbohydrates (beans, starch, lactose, fiber)
• Bowel modifications
– Avoid constipation
Hemorrhoids: OTC, external vs. internal use
- Local anesthetics (Lidocaine, pramoxine): External only
- Astringents: External only
- Keratolytics: External only
- Analgesics (Witch hazel): External only
- Corticosteroids (Hydrocortisone): Both
- Vasoconstrictors (Phenylephrine): Both
- Protectants (Glycerin, petrolatum, mineral oil, cocoa butter): Both
Hemorrhoids: OTC MOA
- Local anesthetics
Block nerve transmission, ↓ all sensation - Vasoconstrictors
Less blood flow, ↓ swelling - Protectants
Protective barrier, ↓ irritation from stool - Astringents
Dries skin, ↓ itch, gives some protection - Keratolytics
Removal of epidermal surface cells - Analgesics
Heat / cold / tingling, soothing sensations - Corticosteroids
Decrease itch & inflammation
Hemorrhoids: OTC Adverse Effects
- Local anesthetics
Allergy, contact dermatitis - Vasoconstrictors
HTN, heart disease, urinary retention - Protectants
Rare, poorly absorbed - Astringents
Irritation, contact dermatitis - Keratolytics
Resorcinol: circulatory failure - Analgesics
Irritation, central nervous effects - Corticosteroids
Skin atrophy, ↑ risk of infecon
Hemorrhoids: OTC Max Dosing
- Local anesthetics: 6x (pramoxine: 5x) (dibucaine: 4x)
- Vasoconstrictors: 4x
- Protectants: 6x, or after each bowel movement
- Astringents: 6x, or after each bowel movement
- Keratolytics: 6x
- Analgesics: 6x
- Corticosteroids: 3-4x
Diarrhea: MOA
Loperamide
- Decreases intestinal motility and secretion
Bismuth subsalicylate
- Bismuth -> Antibacterial
- Salicylate -> Antisecretory
Loperamide: Use & AEs
• Use: Acute treatment of diarrhea in adults & children
– Decreases stool frequency, volume, and liquidity
• AE’s: Rare (low systemic absorption)
– Abdominal pain, constipation, paralytic ileus
– Risk of arrhythmias if max doses are exceeded (abuse)
– May worsen underlying infections
• Practical issues:
– Adults: 4mg x1, then 2mg q loose stool (Max 8 mg/day OTC)
– 9-11yo: 2mg x1, then 1mg q loose stool (Max 6 mg/day)
– 6-8yo: (Max 4mg/day)
Bismuth Subsalicylate
• Uses: Acute treatment of diarrhea in adults > 12 yo
– Treatment of nausea or upset stomach
– Prevention of travelers’ diarrhea
• AE’s:
– Black stained stools & tongue (harmless)
– Salicylate toxicity: tinnitus, Reye’s syndrome in children
– Bismuth toxicity: encephalopathy
• Practical issues:
– Decreased absorption of some antibiotics
– Available in tablets, capsules, and liquid formulations
– Dosing: 525mg q1h prn (Max 4200 mg/day = 8 doses/day)
Diarrhea: Other Options
• Enzyme supplementation (Lactase)
– For diarrhea associated with dairy foods
• Adsorbents (kaolin, pectin, attapulgite)
– Used once upon a time
– Most are no longer recommended or available in the USA
Gas: MOA
- Simethicone: Decreases gas bubble surface tension
- Lactase: Breaks down lactose into simpler sugars
- α-galactosidase: Breaks down some 3-5 saccharides into simpler sugars
Simethicone: Use & AEs
• Use: Relief of gas pain or bloating
• AE’s: Rare (not absorbed systemically)
– May increase flatus or belching
• Practical issues:
– Available as tablet, suspension, & combo products
– Adult dosing: 40 – 360 mg QID prn (Max 500mg/day)
Lactase: Use & AEs
- Use: Prevention of gas from dairy foods
- AE’s: Rare (not systemically absorbed)
• Practical issues:
– Adult dosing: 3000-9000 units with 1st bite of lactose- containing food (Max 18,000 units/day)
α-galactosidase: Use & AEs
• Use: Prevention of gas from high-fiber foods
• AE’s: Rare (not systemically absorbed)
– Mold allergy (enzyme is derived from mold)
– Diabetes (enzyme may increase sugar absorption)
• Practical Issues:
– Chewtab: 2-3 tabs/meal (based on number of food items)
– Solutab: 1 tab/meal
Gas: Other Options
• Probiotics
– May help some patients if used long-term
– Slowest onset and weakest efficacy data
– Many products, usual dose is 1 capsule daily
• Activated charcoal
– Used once upon a time. No longer recommended due to very poor tolerability and side effects.
