Polycarbophil (Konsyl Fiber) Psyllium (Metamucil, others) Methylcellulose (Citrucel, Maltsupex) Good initial choice: “approximate normal” Nonabsorbable; expand and take up water; stimulate distension reflex and intestinal motility Also for IBS diarrhea Contraindicated: intestinal stenosis, adhesions Careful: Esophageal/intestinal obstruction (review mixing/dilution instructions) Diabetes: sugar ADR: Flatulance, borborygmi (rumbly tummy)

Not first choice (except opiod) cascara sagrada •senna, sennasides (Senokot, Ex-Lax) •Castor oil (Purge, Neoloid) •bisacodyl (Dulcolax, Correctol) •Phenolphthalein – tumors, genetic damage – gone local irritation of intestinal tract, increase peristalsis, increase fluid secretion Warnings: Casual use discouraged Overuse/abuse: damages physiologic neurologic colon function – “cathartic colon” melanosis coli: benign (stains colon) Urine discoloration: senna Bisacodyl: enteric coated (uncoated induces gastritis - don’t break, crush, etc,)

Phillips Milk of Magnesia Fleet Phospho-Soda Magnesium Citrate High concentration of electrolytes - hypertonic state - osmotic gradient - draws water into colon - increased colonic pressure - stimulates movement Single dose or short term use Warnings: CHF, HTN (Na+) Renal Failure (Mg+)

"emoliants" Docusate (Colace, Surfak) Mild - increase fluid secretion, “wetting” agents; lowers surface tension, allowing water into fecal mass. Prevention rather than treatment 100 mg =placebo; use 250 mg dosage

Mineral oil Oil - lubricates colon, rectum, anal canal allowing easier passage of hard stool. Limited utility - one time use Warnings: seepage, fat-soluable vitamin malabsorption only time to use is impaction

Lower GI Flashcards by Rachael Gerboth

Contipation: Definition

Abnormally slow movement of feces through colon (Note: What’s normal?)
Usually hard, dry feces in descending colon
Infrequent or difficult evacuation
Sense of incomplete evacuation

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Constipation: LIfestyle Causes

Put off urge
Inactivity
low fiber diet
Low CHO diet
inadequate fluid intake
Cheese
Post-op (fear of straining)
Etc.

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Constipation: Medication Causes

Opioids
Al+ and Ca++ antacids
Anticholinergics
Anticholinergic actions:
- Antidepressants
- Antihistamines
- Antihypertensives
- Antipsychotics
Bismuth salts
Diuretics
Iron salts
Chronic irritant laxatives
CCB’s (calcium channel blockers)
Sulcralfate

Note that these are used in old people

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Constipation: Medical Conditions

GI cancers
DM (autonomic neuropathy)
- nerve damage in gut
Age (decreased neuro. stim)
Diverticular Dz
- pockets in gut
Rectal stenosis, fissures, Hroids, etc.
Stroke
Adhesions
Strictures
Hernia
Hypothyroid
IBS (spastic colon)
MS, PD (parkinsons)
Pg
E-lyte disturbances

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Constipation: Symptoms

Dull headache
Loss of appetite
Lack of energy
Feeling of fatigue
Abdominal distension
Bloating
Lower abdominal discomfort or pain
Lower back pain

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Constipation: The Essential Triad

Bulk, Water, Exercise

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Constipation: When to Refer

blood in feces
- cancer
nausea, vomiting
- obstruction
acute abdominal pain
fever
7-10 days duration
unresponsive to adequate laxative Rx
quadriplegia, paraplegia
- impaction risk
Anorexia history

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Constipation: Non-Drug

Alterations in diet (fiber, bulk)
Increased fluid
Exercise
Stress management
Avoidance of constipating drugs

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Constipation: Pharmacological

Bulk Laxatives (12-72 hours)
- Metamucil, Citrucel, Fibercon
- Work by hanging onto water so that water won’t be suck out by colon
- Stool stays softer
- Safe and natural
- Not acute, more of preventative agent
- Have sugar, so be careful if diabetic
- Need enough water
•Stimulant laxatives (6-12 hours)
- Ex-Lax, phenophaline
- Irritant causes colon to contract
- Senna, bisacodol (ducalax)
- Enteric coated, can’t be ground up
Saline laxative (30min-3 hours)
- Sodium enema
- Magnesium citrate, milk of magnesia
- Can change electrolyte balance
- Careful for renal patients, congestive heart failure
Lubricant laxative (24-72 hr)
- Mineral oil
- Lubricates the hard stool to slide out
- Not good for chronic use: seepage, if lay down can get into lungs, can waste fat soluble vitamins
Surfactants (6-8 hrs)
- Docusate
- Not very effective by self (usually paired with stimulant)
- Decrease water tension, supposedly let water into stool
- 250 mg at LEAST, need quite a bit to be effect
- Turn colon into secreting organ
- Used prophylactically
Hyperosmotic (15min-1 hour)
- Glycerin (children), lactulose (chronic-lac), sorbitol, Miralax (PEG)
- 17g mix with water

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Bulk Laxatives

Polycarbophil (Konsyl Fiber)
Psyllium (Metamucil, others)
Methylcellulose (Citrucel, Maltsupex)
Good initial choice: “approximate normal”
Nonabsorbable; expand and take up water; stimulate distension reflex and intestinal motility
Also for IBS diarrhea
Contraindicated: intestinal stenosis, adhesions
Careful:
- Esophageal/intestinal obstruction (review mixing/dilution instructions)
- Diabetes: sugar
ADR:
- Flatulance, borborygmi (rumbly tummy)

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Stimulant Laxatives

Not first choice (except opiod)
cascara sagrada
•senna, sennasides (Senokot, Ex-Lax)
•Castor oil (Purge, Neoloid)
•bisacodyl (Dulcolax, Correctol)
•Phenolphthalein – tumors, genetic damage – gone
local irritation of intestinal tract, increase peristalsis, increase fluid secretion
Warnings:
- Casual use discouraged
- Overuse/abuse: damages physiologic neurologic colon function – “cathartic colon”
- melanosis coli: benign (stains colon)
- Urine discoloration: senna
- Bisacodyl: enteric coated (uncoated induces gastritis - don’t break, crush, etc,)

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Saline Laxative

Phillips Milk of Magnesia
Fleet Phospho-Soda
Magnesium Citrate
High concentration of electrolytes - hypertonic state - osmotic gradient - draws water into colon - increased colonic pressure - stimulates movement
Single dose or short term use
Warnings:
- CHF, HTN (Na+)
- Renal Failure (Mg+)

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Surfactant Laxatives

“emoliants”
Docusate (Colace, Surfak)
Mild - increase fluid secretion, “wetting” agents; lowers surface tension, allowing water into fecal mass.
Prevention rather than treatment
100 mg =placebo; use 250 mg dosage

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Lubricant Laxatives

Mineral oil
Oil - lubricates colon, rectum, anal canal allowing easier passage of hard stool.
Limited utility - one time use
Warnings: seepage, fat-soluable vitamin malabsorption
only time to use is impaction

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Hyperosmotic Laxatives

Glycerin
- Short term, episodic use; pediatrics
- Suppositories (Fleet Babylax, Sani-Supp)
Sorbitol, lactulose
Polyethylene glycol (PEG) +/- E-lytes

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Probiotics

“Support” for bowel health
No restrictions on length of use
Dietary supplement
May support growth of beneficial microfloral in intestinal tract.
- Bifidus regularis
- Lactobacillus acidophilus
- Bifidobacterium longum

Diarrhea: Definition

Abnormal frequency or volume of semi-liquid or fluid fecal matter.
Classification
- Acute vs. Chronic
- Infectious vs. Noninfectious
- Physiologic
  - Osmotic (ex: lactose intolerance)
  - Secretory (ex: virus, bacterial)
  - Exudative (ulcerative colitis)
  - Motility Disorder (IBS)

Diarrhea: 3 Types

Acute
- abrupt; < 2 weeks; abdomnal pain, malaise, flatulence, generally resolves in 3 days; causes dietary, infection, toxicity, drugs
Chronic
- frequent passage > 4 weeks; tough to diagnose; refer – requires medical evaluation
Traveler’s Diarrhea
- up to 10/day loose stools, w/nausea, abdominal cramps, +/- vomiting, fever; cause generally bacteria

Diarrhea: Refer

Temperature > 101
Nighttime diarrhea
Bloody diarrhea
Severe abdominal cramps
Symptoms of dehydration
Failure to subside within 3-5 days
Pediatrics, elderly, pregnant

Diarrhea: Treatment

Goals
- Identify and treat cause
- Prevent fluid/electrolyte loss
- Relieve symptoms
Nondrug
- Clear liquids, then BRAT, slowly add milk/dairy
Pharmacotherapy
- Bulk forming agents (polycarbophil); Adsorbants
- Loperamide
- Antibiotics
  - C. dificil
- ORS (oral rehydration solutions)
  - has more salt/sugar/bicarb than Gatorade
  - Old/young: Gatorade with pretzels and bannanas
- Diet (BRAT, dairy)
- Digestive enzymes (lactase, prevention)
- Probiotics

Diarrhea: Adsorbents/Protectants

Attapulgite and Kaolin-pectin
- Questionable efficacy – thus, GONE!
Bismuth Subsalicylate
- Antisecretory, adsorbent, antimicrobial, antiinflammatory
- Prevention of TD
  - 60 mL (4 tab) every hour times 8, or until diarrhea done
- Radiopaque
- Salicylate
  - Aspirin allergy, kids

Diarrhea: Loperamide (Imodium)

Slows intestinal motility; inhibits peristalsis; tolerance doesn’t develop
Don’t use in presence of bloody diarrhea, body temperature > 101; with organisms that penetrate the intestinal wall (enteroinvasive E. coli, Salmonella, Shigella, pseudomembranous colitis)
Okay if know that bug cannot get out of tube

Diarrhea: Polycarbophil, ORS

Polycarbophil (Konsyl Fiber)
- Good for diarrhea due to IBS
ORS
- Pedialyte, Gatorade + pretzels, crackers
- Especially important for sick, pediatrics, elderly

Gas: Etiology

Normal
- –average – 10 passages/day
- –500-1500 mL/day)
Affected by…
- Malabsorption (e.g., lactose intolerance)
- Gastric motility (e.g., IBS)
- Dietary composition (lactose, legumes)
- Drugs (antibiotics, acarbose)
- Changes in colonic pH
Gas formed by
- Action of colonic bacteria on CHO’s
  - hydrogen sulfide
- Anaerobic fermentation
  - hydrogen
  - carbon dioxide
  - methane
- Swallowed
  - Nitrogen
  - oxygen

Gas: Signs/Symptoms

* “too much gas” * Abdominal cramping * Belching * Bloating * Discomfort * Audible bowel sounds

Gas: Assesment

* more than 25 passages per day * Diet (legumes, starch, prunes, milk, cheese) * Meds (antibiotics, opiates, CCB’s, acarbose) * Surgical history (abdominal surgery) * Medical history (PUD, GERD, IBS) * Systemic disease (DM, hypothyroid)

Gas: Treatment, Dietary

* Decrease sodas * Avoid whipped cream, milk shakes * Stop frequent sighing * Relax, Slow down * Chew thoroughly * Avoid washing solids down with liquid * Stop smoking * Stop gum chewing * Smaller meals *

Gas: Drug Treatment

* Charcoal (Charcoal Plus DS)\* * Simethicone (Mylicon, Gas-X)\* * Lactase (Lactaid, Dairy Ease)@ * a - glactosidase (Beano)@ * Probiotics@ Key: @ is a preventer, \* is a reliever * relievers not very effective UNLESS lactose intolerant or alpha-glactosidase deficient

Hemorrhoid: Definition

* varicose condition of hemorrhoidal veins. * pregnancy, straining at stool, constipation, prolonged sitting or standing, anal infection * Internal vs. external * above or below dentate line * above: no nerves, not feel

Hemorrhoid: Symptoms

* Anal pain * Bleeding, anemia * Itching * Burning * Incontinence * Rectal protrusion, prolapse * Fissure, ulceration, infection

Hemorrhoid: Treatment

* Nondrug: * Alterations in diet * Avoidance of prolonged sitting * Sitz bath * Anal hygeine * Drugs: * Limited benefit, lots of witch craft * Stool softeners, psyllium * Topical anorectal preps * Astringents, counterirritants, emollients, protectants, keratolytics, local anesthetics, wound-healing agents, vasoconstrictors, corticosteroids

Hemorrhoid: Anorectal Preps

* Astsringents (Hamamelis water i.e., witch hazel) * good for cleaning * Counterirritants (camphor) * -\_- * **Emollients/protectants (mineral oil, petrolatum, zinc oxide)** * ****helpful \<3 * Keratolytics (resourcinol) * NO * Local anesthetics (benzocaine, pramoxine) * NOOOO!!! * Wound healing (balsam Peru) * witchcraftery * Vasoconstrictors (ephedrine, phenylephrine) * witchcraftery * **Antiinflammatory - hydrocortisone** * ****beat the itch * best is HC **ointment**

Hemorrhoid: Rx

* Hydrocortisone 1% ointment * Two most rationale drug classes (protectant/emollient and steroid) * Avoids other witchcraft * Cheaper than Anusol HC or Prep H * Caution: HPA axis * **Go to the derm aisle**

Pinworms: Pathophysiology

* eggs from perianal area * bedding/clothing * new host’s hands * mouth/swallowed * eggs hatch * larvae in small intestine * mature female migrates to perianal area * deposits eggs * itch, irritation * reinfestation

Pinworms: Symptoms

* asymptomatic * itching * abdominal pain * weight loss * appendicitis * dermatitis * Tape test

Pinworms: Rx

* Reverse tape on popsicle stick, squeeze cheeks, see eggs on slide * Personal hygiene * Launder bed clothes, bedding, etc. * Need to identify worm, because could be hookworm * **Pyrantel pamoate** (Antiminth, Reese’s Pinworm) Pinworms only * liquid by weight * Mebendazole (Vermox) Pinworms and other helminths; easy dosing; tablet, off the market now