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phrm 504 > Letcure 12: Hemorrhoids, Pinworms and Intestinal Gas > Flashcards

Letcure 12: Hemorrhoids, Pinworms and Intestinal Gas Flashcards

1
Q

Rectum

A

Semipermeable membrane

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2
Q

Dentate Line

A
  • Columnar cells
  • Squamous cells

Where you find Sensory pain fibers

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3
Q

Anal Canal

A

Connects rectum and outside of the body

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4
Q

Perianal area

A
  • Portion of skin surrounding the
    anus
  • Protective barrier
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5
Q

Internal Anal Sphincter is

A

voluntary

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6
Q

External Anal Sphincter is

A

involuntary

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7
Q

Anal (or perianal) abscess

A

Bacterial infection; pus and bacteria collect and obstruct the anal glands

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8
Q

Anal (or perianal) abscess - Signs/Symptoms

A 
- Pain (worsens with sitting and
defecation)
- perirectal swelling
- discharge
- fever
- chills
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9
Q

Anal fissure

A

Slit-like ulcer in anal canal from a traumatic tear (e.g passage of stool; anal intercourse)

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10
Q

Anal fissure -Signs and Symptoms

A

Severe or burning pain during/after defecation, lasting several minutes to hours; anal spasms; blood may be seen on toilet tissue

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11
Q

Anal fistula

A

Abnormal internal opening that connects with the external opening

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12
Q

Anal fistula- Signs and Symptoms

A

Chronic, persistent drainage; pain; possible bleeding on defecation; perianal itching; stool seeping through
external opening

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13
Q

Anal neoplasm

A

Anal cancers

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14
Q

Anal neoplasm- Signs and Symptoms

A
  • Rare and usually asymptomatic
  • bleeding
  • changes in bowel habits
  • anal discharge
  • anal mass
  • pain
  • pruritus
  • rash
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15
Q

Pathophysiology of Hemorrhoids

A
  • Defecation = downward pressure on blood vessels, smooth muscle, and connective tissue in anal canal
  • Weakening and displacement of tissues
  • Blood vessels become inflamed, bleed, and protrude
  • Ultimately leads to hemorrhoids
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16
Q

Causes/Risk Factors of Hemorrhoids

A
  • Age (45-65 years at greatest risk)
  • Anal intercourse
  • Chronic diarrhea or constipation
  • Lack of physical activity
  • Obesity
  • Poor bowel habits (i.e. prolonged sitting, straining during defecation)
  • Pregnancy
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17
Q

Clinical Presentation for Hemorrhoids

A 
Burning
Discomfort
Inflammation
Irritation
Pruritus
Swelling
Bleeding
Change in bowel pattern
Pain
Prolapse/Protrusion
Seepage
Thrombosis
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18
Q

Exclusions to Self-Care: Hemorrhoids

A
  • Age < 12 years
  • Diagnosed gastrointestinal diseases associated with
    colorectal bleeding
    • Crohn disease, ulcerative colitis
  • Family history of colon cancer
  • Potentially serious anorectal disorder
    • Abscess, fissure, fistula, malignancy/neoplasm
  • Severe associated signs/symptoms:
    • Black, tarry stools, bleeding, pain, prolapse, seepage, thrombosis
    • Burning, discomfort, inflammation, pruritus, swelling
  • Minor symptoms that do not respond to 7 days of self treatment
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19
Q

Hemorrhoids: Goals of Self-Treatment

A
  1. Maintain soft stools and preventing straining during
    defecation.
  2. Alleviate and maintain remission of anorectal symptoms.
  3. Prevent anorectal complications.
  4. Prevent and manage unwanted effects of medications
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20
Q

Hemorrhoids are:
A. Harmless growths
B. Infected tissue
C. Swollen Veins

A

C. Swollen Veins

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21
Q

_________ may promote hemorrhoidal bleeding?
A.acetaminophen B.diphenhydramine
C.guaifenesin
D.naproxen

A

D.naproxen

Aspirin and NSAIDs

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22
Q

Non-Pharmacologic Therapy: Hemorrhoids

A

Diet

  • Increase dietary fiber (25-40 grams per day)
  • Increase fluid intake
  • Proper Bowel Habits
  • Avoid “holding it”
  • Avoid sitting on toilet for long periods
  • Proper anal hygiene
  • Avoidance Measures
  • Avoid lifting heavy objects
  • Discontinue aggravating foods/beverages
  • Alcohol, caffeine, spicy foods
  • NSAIDs and Aspirin may promote bleeding
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23
Q

Pharmacologic Therapy

A 
Topical Products
§ Analgesics
§ Antipruritics
§ Astringents
§ Corticosteroids
§ Keratolytics
§ Local anesthetics
§ Protectants
§ Vasoconstrictors
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24
Q

Analgesics, Anesthetics, Antipruritics Products and Dosing

A

Camphor
Juniper Tar
Menthol

  • Up to 6times/day
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25
Q

Analgesics, Anesthetics, Antipruritics Purpose

A

Relief for itching and inflammation

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26
Q

Analgesics, Anesthetics, Antipruritics MOA

A

Provides a cool, warm, or tingling sensation

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27
Q

Analgesics, Anesthetics, Antipruritics Warnings/Precautions

A
  • Do not use internally

- Use sparingly/ not frequently- in small amounts

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28
Q

Astringents Products and Dosing

A

Calamine
Witch Hazel
Zinc Oxide

-Up to 6times/day or after each bowel movement

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29
Q

Astringents Purpose

A
  • Promoted coagulation of protein in skin cells to protect underlying tissue
  • Dries affected area
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30
Q

Astringents MOA

A
  • Decrease cell volume
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31
Q

Astringents Warnings/Precautions

A

Zinc oxide: systemic zinc toxicity potential with

overuse (nausea, vomiting, lethargy)

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32
Q

Astringents Adverse Effects

A
  • Witch hazel contains alcohol
    • May cause stinging
  • Contact dermatitis (rare)
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33
Q

Corticosteroids Product and Dosing

A

Hydrocortisone 1%

Up to 3-4 times/day

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34
Q

Corticosteroids Purpose

A

Relief of itching and irritation

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35
Q

Corticosteroids MOA

A

Vasoconstrictor and antipruritic (anti-itch)

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36
Q

Corticosteroids Warnings/Precautions

A

May mask symptoms of bacterial and fungal infections

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37
Q

Corticosteroids Adverse Effects

A

Skin atrophy and reactions (rare)

atrophy- wasting away or diminution (reduction)

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38
Q

Corticosteroids PK

A
  • Onset of action: up to 12 hours

- Duration of action: longer lasting than other agent

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39
Q

Keratolytics Product and Dosing

A

Alcloxa
Resorcinol

Up to 6 times/day

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40
Q

Keratolytics Purpose

A

Debridement of epidermal surface cells

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41
Q

Keratolytics MOA

A

Fosters cell turnover and loosens surface cells

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42
Q

Keratolytics Warnins/Precautions

A

Do not use internally

  • May expose underlying tissue
  • Systemic absorption
  • Exfoliative dermatitis, methemoglobinemia
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43
Q

Keratolytics Notes

A

Balance between benefits and adverse effects

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44
Q

Local Anesthetics Product and Dosing

A

Dibucaine-Up to 3/4 times/day

Pramoxine- Up to 5 times/day

Benzocaine, Lidocaine and Tetracaine- Up to 6 times/day

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45
Q

Local Anesthetics Purpose

A

Temporary relief of external anal symptoms

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46
Q

Local Anesthetics MOA

A

Inhibit conduction of nerve impulses

47
Q

Local Anesthetics Warnings/Precautions

A
  • May mask pain in more severe disorders
    -Do NOT place on open sores
  • Systemic absorption -> CV and CNS
    Cardiovascular and Central Nervous System
48
Q

Local Anesthetics Adverse Effects

A

Burning and stinging

49
Q

Protectants Products and Dosing

A 
Cocoa Butter
Glycerin
Lanolin
Mineral Oil
White petrolatum

Up to 6 times/day or after each bowel movement

50
Q

Protectants Purpose

A

Protective barrier and softening of anal canal

51
Q

Protectants Mechanism

A

Lubricant

52
Q

Protectants Warnings/Precautions

A

Lanolin: obtained from sheep
• High risk of allergies

  • Greasy feel with ointments
53
Q

Protectants Adverse Effects

A

Minimal

54
Q

Vasoconstrictors Products and Dosing

A

Ephedrine
Epinephrine
Phenylephrine

Up to 4 times/day

55
Q

Vasoconstrictors Purpose

A

Relief of itching, discomfort, irritation, swelling

56
Q

Vasoconstrictors Mechanism

A

Stimulation of alpha-adrenergic receptors in vascular beds to
constrict arterioles and reduce swelling

57
Q

Vasoconstrictors Adverse Effects

A
  • Increased cardiac rate/contractility
  • Increased blood pressure (if absorbed systemically)
  • Contact dermatitis
58
Q

Vasoconstrictors Do NOT use for Self-care: Contraindications

A

Antidepressants, cardiac medications, Diabetes Mellitus (DM), enlarged prostate, heart disease, HTN( Hypertension), thyroid disease

59
Q

Topical Considerations for Pharmacologic Therapy

A 
§ Applicators
§ Creams
§ Foams
§ Ointments
§ Suppositories- NOT first line – may migrate from affected anal region easily; slower onset of action

Combination products- Often a good choice

60
Q

Patient Education: Non-pharmacologic measures

A
  • Avoid constipating medications
  • Bowel habits
  • Maintain hydration and healthy diet
  • Proper anal hygiene
61
Q

Patient Education: Pharmacologic products

A
  • Select ingredients needed to relieve specific symptoms
  • Reduction or relief of symptoms should occur within a few days
  • Appropriate use of dosage form based on patient’s preference
62
Q

Hemorrhoids: Refer if

A

Presence of serious/severe symptoms and progressive
worsening of symptoms

Symptoms persist beyond 7 days of self treatment

63
Q

Pinworms are called

A

Enterobius vermicularis

64
Q

Enterobius vermicularis

A

Small, thin, white roundworm
- Intestinal helminth/nematode (roundworms) cause enterobiasis (pinworm infection)
- Parasite
- Most common worm infestation in the United States
- Mostly commonly affects children (5-14 years) and
household members
- High prevalence in day care settings and urban areas
- Transferable only among humans

65
Q

Pinworm Lifecycle

A
  1. Ingestion of pinworm eggs
  2. Adult female matures (1-2 months)
  3. Adult female migrate to colon at night
  4. Lays eggs around the anus and female dies
  5. Larvae in eggs develop in 4-6 hours
    * cycle continues*
66
Q

Pinworm Pathophysiology

A 
- Eggs can be transmitted via
fomites/contaminated hands
- Eggs are very small
• Can ingest while breathing
•Larvae may return to colon
through anus (retroinfection)
  • Reinfection is common
  • Eggs are viable for 20 days
    outside intestinal tract
67
Q

Clinical Presentation of pinworms

A
  • Often asymptomatic
    -Pruritus ani
    •Typically at night
    • Inflammatory reaction of pinworm on skin

-Major infestations
- Abdominal pain, anorexia, insomnia, intractable itching
- Psychosocial trauma
- Complications
- Bacterial infection secondary to scratching
•Female genital tract
•Perianal and perineal regions
•Urinary tract infections

68
Q

Diagnosis Options

A
  1. Tape test
    - Touch perianal skin with clear tape first thing in morning
    - Perform on 3 consecutive mornings before any washing/hygiene
    - Provider examines tape with microscope
69
Q

Diagnosis Options 2

A
  1. Visual inspection
    - Look for pinworms overnight at least 2-3 hours after infected
    person is asleep
    - Worms are 3-7 mm
70
Q

Diagnosis Options 3

A
  1. Fingernail examination

- Look at fingernails under microscope

71
Q

Exclusions to Self-Care: Pinworms

A
  • Age < 2 years or weight < 25 pounds unless PCP has
    approved OTC treatment
  • Breastfeeding/ Pregnancy
  • Helminthic infections other than pinworms
  • Hypersensitivity to pyrantel pamoate (option that treats this)
  • Liver disease
  • Need for repeat dosing
  • Vague symptoms and negative visual inspection
72
Q

Goals of Self-Treatment: Pinworms

A
  1. Relieve symptoms of pinworm infection.
  2. Eradicate pinworms from patient and household.
  3. Prevent and manage unwanted effects of medications.
  4. Prevent reinfection and transmission.
73
Q

Non-Pharmacologic Therapy: Pinworms

A 
Proper hygiene
§ Wash hands with soap and water
§ Keep fingernails short and clean
§ Discourage biting nails and scratching perianal area
§ Daily showers
  • Wash bedlinens, underwear, and towels
    § Use hot water for washing and hot drying cycle
    § Pinworm eggs are killed by temperatures > 131 ℉
    §Change underwear, clothes, and bedlinens daily for several days after treatment
74
Q

Pinworms are killed by temperatures

A

greater than 131 ˚F

75
Q

Pharmacologic Therapy: Pinworms

A

Pyrantel pamoate
§ May not reliably kill pinworms
§ Second dose often used to prevent reinfection
§ Variable efficacy due to effect on eggs and egg viability for up to
20 days

76
Q

Pyrantel Pamoate Brand Name

A

Pin-X,

Reese’s

77
Q

Pyrantel Pamoate MOA

A

Depolarizing neuromuscular agent
This paralyzes adult worms Which loosens worms’ hold on intestinal wall
Then results in worm passed in stool before eggs are laid

78
Q

Pyrantel Pamoate Contraindications

A

Hypersensitivity

79
Q

Pyrantel Pamoate Precautions

A

Hepatic impairment

80
Q

Pyrantel Pamoate Adverse effects

A

Common: abdominal cramps; diarrhea; nausea; vomiting

Less common: dizziness; headache; rash

81
Q

Pyrantel Pamoate Dosing

A

11 mg/kg by mouth as a single dose
§ Maximum single dose = 1 gram
§ Dose can be repeated in 2 weeks if symptoms do not resolve
(consult PCP)

82
Q

Pyrantel Pamoate Patient Education

A

Take with or without food at any time of day
• May mix with juice or milk

  • Treat ALL members of the household to ensure elimination of the
    infection
  • Administered as a SINGLE dose
  • Weight-based dosing is the same for all patients ≥ 2 years
83
Q

Evaluation of Patient Outcomes

A

Refer if Symptoms persist beyond 2 weeks after initial dose of pyrantel pamoate

-PCP may recommend a second dose

84
Q

Intestinal gas pathophysiology

A

Colonic fermentation is the primary process for intestinal gas generation

  • Influenced by type and quantity of food ingested
  • Amount of air entering the upper GIT with swallowing
  • Bacterial overgrowth of small intestine
  • Medical conditions and Medications can cause this
85
Q

Common gas-producing foods

A
  • Beans
    § Carbonated beverages
    § Complex carbohydrates
    § Dairy products
    § Fatty foods
    § Fruits: apricots, bananas, dried fruit, prunes
    § Vegetables: Brussels sprouts, cabbage, cauliflower, onions
86
Q

Things that cause larger amounts of air swallowed

A 
§ Chewing gum/hard candies
§ Drinking carbonated beverages
§ Hyperventilating
§ Poor eating habits
§ Poor-fitting dentures
§ Smoking
87
Q

Medical conditions that can cause Intestinal Gas

A 
Carbohydrate malabsorption
§ Lactase deficiency
§ Celiac disease
§ Diabetic gastroparesis
§ Irritable bowel syndrome (IBS)
§ Pancreatic insufficiency
88
Q

Medications that can cause Intestinal Gas can/are

A

§ Affect GI motility, intestinal flora, or metabolism of glucose and
other dietary substances
§ Are high in fiber
§ Contain or release gas

89
Q

Clinical Presentation: Intestinal Gas

A 
Common symptoms:
§ Abdominal discomfort or cramping
§ Bloating
§ Excessive belching
§ Flatulence

Associated Symptoms
§ Audible bowel sounds
§ Dyspepsia
§ Nausea

90
Q

Exclusions to Self-Care: Intestinal Gas

A
  • Symptoms that persist for more than several days or occur more often than occasionally (several times a month)
  • Severe debilitating symptoms
  • Sudden change in location of abdominal pain, significant
    increase in frequency/severity of symptoms
  • onset of
    symptoms in individuals > 40 years of age
  • Significant abdominal discomfort or a sudden change in
    bowel function
  • Presence of accompanying symptoms such as severe or
    persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, or frequent nocturnal symptoms
91
Q

Goals of Self-Treatment: INTESTINAL GAS

A
  1. Reduce frequency, intensity, and duration of intestinal gas
    symptoms.
  2. Reduce the impact of intestinal gas symptoms on the
    patient’s lifestyle.
  3. Prevent and manage unwanted effects of medications.
92
Q

Non-Pharmacologic Therapy:

A
  • Avoid tight-fitting clothing and belts
  • Chew food thoroughly
  • Do not attempt to induce belching or strain to pass gas
  • Do not lie down immediately after eating
  • Eat and drink slowly
  • Reduce consumption of gas-producing foods
  • Wear dentures with proper fit
93
Q

Pharmacologic Therapy:

A

Antiflatulent products

  • Limited supporting evidence
  • Relieve symptoms after intestinal gas has formed
  • Digestive enzymes
  • Symptoms associated with foods containing lactose or oligosaccharides
  • Prevent gas from forming
94
Q

Intestinal Gas Pharmacologic Agents

A

Simethicone
Alpha-Galactosidase
Lactase Replacement Products

95
Q

Simethicone Brand Name

A

Gas-X

Mylicon

96
Q

Simethicone MOA

A

Defoaming agent – reduces surface tension of gas bubbles embedded in GIT

97
Q

Simethicone Dosing

A

Adults: 40-125 mg by mouth after meals and at bedtime as needed
Children ≥ 12 years: 40-125 mg by mouth 4 times daily
Children 2 to < 12 years: 40-50 mg by mouth four times daily
Children < 2 years: 20 mg by mouth four times daily as needed

98
Q

Simethicone Contraindications

A

Hypersensitivity; suspected intestinal perforation and obstruction

99
Q

Simethicone Special Pops

A

Children/ infants and Breastfeeding: considered safe

Pregnancy: fetal risk is minimal

100
Q

Alpha-Galactosidase Brand Name

A

Beano

101
Q

Alpha-Galactosidase MOA

A

Hydrolyzes oligosaccharides before they can be metabolized by colonic bacteria

102
Q

Alpha-Galactosidase Dosing

A

Adults: 300-450 units by mouth per serving of food

103
Q

Alpha-Galactosidase Contraindications

A

Hypersensitivity

104
Q

Alpha-Galactosidase Precautions

A

Diabetes
galactosemia
mold allergies

105
Q

Alpha-Galactosidase- Special Pops

A

Children and infants: avoid use

Pregnancy and Breastfeeding: consult with provider

106
Q

Lactase Replacement Products Brand Name

A

Lactaid, Lactase, etc

107
Q

Lactase Replacement Products MOA

A

Break down lactose, a disaccharide, into the monosaccharides

glucose and galactose, which are absorbed

108
Q

Lactase Replacement Products Dosing

A

Adults ≥ 12 years: 3000-18,000 units by mouth at first bite of food or
drink containing lactose

109
Q

Lactase Replacement Products Special Pops

A

No considerations listed

110
Q

Simethicone

A

Used to treat intestinal gas AFTER it has occurred

111
Q

Alpha-Galactosidase

A

Should be taken with foods to PREVENT intestinal gas from forming

112
Q

Lactase Replacement Products

A

Should be taken with foods to PREVENT intestinal gas from forming
-Take at first bite of dairy or lactose-containing food

113
Q

Non-pharmacologic measures

A
  • Avoid activities known to introduce gas into GIT

- Avoid triggers

114
Q

Evaluation of Patient Outcomes

A
  • Symptoms generally self-limiting within 24 hours

- Follow-up after 1 week of self-care with dietary measures or pharmacologic therapies

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