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NUNP547 Older Adult Theory > Week 2 GI > Flashcards

Week 2 GI Flashcards

1
Q

Which 2 classifications of stool, according to the Bristol stool chart, are indicative of constipation? What is the recommended action?

A

Type 1 - separate hard lumps, like nuts (hard to pass)

Type 2 - sausage shaped but lumpy

The recommendation is to commence or increase laxatives.

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2
Q

Constipation can be classified as _______ or ________.

A

Constipation can be classified as primary or secondary.

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3
Q

Name some primary causes of constipation.

A

Primary causes include: normal transit, slow transit and defecatory dysfunction.

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4
Q

Name some secondary causes of constipation.

A

Secondary causes include:
medical conditions (endocrine or metabolic, neurologic, nutritional, rheumatic)
medications,
malignancy,
gut motility,
mobility, and
psychological or anatomic dysfunction such as strictures, fissures or hemorrhoids.

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5
Q

Why is fiber indicated in fecal incontinence?

A

Solid stool may be easier to retain in the rectum in patients with FI that is diarrhea predominant.

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6
Q

T or F, biofeedback is recommended for people with fecal incontinence.

A

FALSE
People with impaired cognition and spinal cord injury may not be good candidates as it requires awareness of their defecation symptoms and the ability to participate in the program and exercise actively. For those with mobility or cognitive impairment, bowel habit training and scheduled toileting can be helpful.

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7
Q

What are some medications that can help with fecal incontinence, and what are some special considerations when prescribing these to older adults?

A

For diarrhea, prominent antidiarrheals are helpful. Loperamide is a preferred agent for older adults, as other medications have more anticholinergic properties. Cholestyramine is a second line-but limited data in older adults.

In constipation predominant-laxatives, PEG are helpful. Watch for electrolyte imbalance (hypokalemia).

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8
Q

Peter has been trying all conservative measures to manage fecal incontinence without success. What is your next step?
a) Tell him there is nothing else we can do.
b) Suggest a procedure that will stimulate his sacral nerves with a neuromodulator device.
c) Recommend biofeedback

A

B-
Percutaneous tibial nerve stimulation (PTNS) and a surgically implanted device involve the treatment of FI by “stimulating” the nerves that help control defecation. Improvement may be seen in 12 weeks.

Biofeedback is a conservative measure.

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9
Q

When evaluating fecal incontinence, what specific questions should you ask in regards to their bowel movements?

A

Some people report:
- rectal urgency
- loss of stool with straining or valsava
- seepage of stool after bowel movements
- incomplete evacuation
- loss of stool without any sensory awareness.

A focused history on stool frequency and consistency, and other bowel symptoms, helps identify types of FI.

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10
Q

ROME IV diagnostic criteria for constipation in adults:

25% of BMs are associated with 2 or more of the following symptoms, occurring in the previous 3 months with an onset of s/s >6 months and does not meet the criteria for IBS.

What are the symptoms?

A

Straining

Hard or lumpy stools

A sense of incomplete evacuation

A sense of anorectal obstruction or blockage

The need for manual maneuvers

Less than 3 spontaneous BMs per week (I’m going to start saying I am heading off for a spontaneous BM)

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11
Q

Name some med classes that can cause constipation.

A

As per RxFiles:

Analgesics
Anticholinergics
Anti-Parkinson
Anticonvulsants
Antidepressants
Antidiarrheals
Antiemetics
Antihistamines
Antihypertensives
Antispasmodics
Cation agents
Chemotherapy
Resins

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12
Q

What are the 3 F’s you can counsel on to promote bowel regularity?

A

Fibre, fluid, fitness (physical activity)

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13
Q

What is the recommended treatment for constipation when straining and incomplete evacuation are the s/s of concern?

A

Lifestyle and a bulk-forming agent such as psyllium (as long as the patient can drink 250ml or more with each dose.

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14
Q

What is the recommended treatment for constipation when infrequent bowel movements are the s/s of concern?

A

Osmotic laxative such as PEG 3350, MOM, lactulose.

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15
Q

What is the recommended treatment for constipation when your patient has a neurogenic bowel?

A

Stimulant such as senna or bisacodyl

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16
Q

What is the recommended treatment for constipation when slow transit or severe pelvic floor dysfunction are the culprits?

A

Avoid high fibre diets and fibre supplements.

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17
Q

What meds should you prescribe when you are also prescribing an opioid?

A

A stimulant laxative +/- stool softener.

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18
Q

What dose of PEG is recommended for older adults?

A

17 g/day.

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19
Q
A
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20
Q

What are the two types of dysphasia?

A

Oral
Esophageal

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21
Q

What are some DDX for dysphagia?

A

DDx: Neurologic (CVA, dementia, parkinsons), Structural
(diverticula, stricture, mass), Muscular, Inflammatory
(Esophagitis, infectious, radiation)

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22
Q

What are some diagnostics you could consider running if your patient presents with dysphagia?

A

Labs (not overly helpful, low Hb or Fe may suggest malignancy)

Imaging (barium swallow)

Endoscopy is the gold standard if appropriate

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23
Q

Alarm features of constipation in the older adult?

A

Hematochezia
Positive fecal occult blood test
Obstructive bowel symptoms
Acute onset of constipation
Severe persistent constipation that is unresponsive to treatment
Weight loss of 10 pounds or more
Change in stool caliber
Family history of colon ca or IBD
Iron deficiency anemia

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24
Q

What are some medical conditions in an older adult that may contribute to dysphagia?

A

Stroke
Neurologic disorders
Dementia
Cancers
Respiratory disorders
Poor dentition

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25
What are some management options for dysphagia?
Regular oral care Physical activity as tolerated Referrals to SLP/dietician/OT/PT Dietary modifications Aspiration precautions Supervised hand feeding Inspect oral cavity for residual food after feeding Elevate HOB to at least 30 degrees for at leawst 1 hour after eating
26
For someone who is chronically constipated, you advise them to increase their fibre intake. What would be an appropriate "daily fibre" schedule to start someone on, to help with constipation.
5g of fibre/day, slowly increase weekly, until maximum intake is 25-30g/day On average, the daily consumer has only 5-10g fibre/day To get an idea of what 10g fibre looks like: Whole Grains: 1 cup of cooked quinoa: ~5g of fiber 1 slice of whole-grain bread: ~2g of fiber Legumes: 1/2 cup of cooked lentils: ~8g of fiber 1/2 cup of black beans: ~7g of fiber Fruits: 1 medium-sized pear: ~6g of fiber 1 medium-sized apple: ~4g of fiber Vegetables: 1 cup of broccoli (cooked): ~5g of fiber 1 medium-sized carrot: ~2g of fiber Nuts and Seeds: 2 tablespoons of chia seeds: ~10g of fiber 30g of almonds: ~4g of fiber Cereal: 1 cup of bran flakes: ~7g of fiber
27
Fluid hydration: what is the total amount of ounces a person should be consuming/day (inclusive of all food and beverages)
91 ounces
28
What does fibre do for your stool?
Bulk it up baby!
29
Why increase fibre slowly and weekly?
To avoid increased bloating and flatuence
30
A good mnemonic to use when doing a nutritional health check.
DETERMINE D isease, illness or chronic condition E ating poorly T ooth/loss or mouth pain E conomic Hardship R educed social contact M ultiple Medicines I nvoluntary Weight Loss/Gain N eeds assistance in self care E lder years >80yrs https://acl.gov/sites/default/files/nutrition/NSI_checklist_508%20with%20citation.pdf
31
T/F: Taste buds decrease by 70% in older adults.
True
32
Do older adults have an increased tolerance to salty and sweet foods. If so, why?
Yes, physiological signs of aging in sensory receptors causing a reduced perception and an increased appeal to stronger flavors.
33
What aging influences impact nutrition?
*Alterations in oral health-no teeth, xerosthema (dy mouth), chemosensory changes (cause poor appetite). *Changes in gastric muscular tone and decreased motility that slows gastric emptying resulting in constipation and early satiety. *Decreased metabolism due to loss lean body mass *hormonal changes in gut mediators
34
What psychosocial and environmental influences impact nutrition?
*Being recently widowed, lonely, or depressed *Alzheimers/Dementia d/t neuropathic alterations that impact feeding behaviour and memory, disturbed appetite signalling, volitional swallowing, and alterations to taste and smell. *Poverty and food insecurity *Housing, transportation, accessibility to local resources
35
What Chronic and Comorbid conditions impact nutrition?
*Chronic diseases due to decreased appetite, restrictive diets (low cholesterol, heart healthy, no/low salt), limitations in ADLS (immobility, tremors). *Inflammation diminish physiologic reserve. *Medications (side effects). Most common-changes in taste and smell, xerostoma, GI discomfort, slow gastric motility, early satiety, thirst, anorexia, and weight loss/gain.
36
What feeding / swallowing condition can impact nutrition?
Dysphagia (difficulty swallowing and chewing) affect 7-13% <65yrs. Caused by many disorders-stroke, neurologic dx, dementia, cancers, and resp dx). Dysphagia: coughing, choking, (food/drink sticking throat), pocketing of food, changes in voice quality, persistent throat clearing, upper airway sounds, change breathing pattern. Geriatric Syndrome - major cause of anorexia and weight loss
37
If a senior arrives to your office, presenting with weight loss, what questions should be asked?
Ask about difficulty with chewing and swallowing food (ill-fitting dentures, dry mouth)? Ask if patient is eating with someone or alone? Ask who does the cooking and grocery shopping at home? Who has traditionally done these tasks if it has changed? Ask about use of community services, such as Food Bank, Meals on Wheels, church-delivered food?
38
How much unintentional weight needs to be lost to trigger a nutritional assessment?
more than 5% in 6 months or low BMI
39
What is sarcopenia?
Sarcopenia, a physiological change of aging, and can cause significant morbidity (aspiration pneumonia) and mortality. *progressive loss of muscle mass and strength *primary symptom: muscle weakness - caused by poor nutrition and low activity/sedentary lifestyle.
40
Name a few chronic conditions/diseases that can impact nutrition?
Cardiac and pulmonary diseases Cancers, Infections/AIDS RA H-pylori, Gallbladder Malabsorption Alcoholism Hyper / Hypothyroidism Parkinsons pressure ulcers
41
What does malnutrition mean?
Inadequate intake of proteins and/or low intake of energy (protein-calorie malnutrition) *undernutrition
42
What are the 3 types of malnutrition?
1. Starvation-related malnutrition (pure starvation or anorexia nervosa) is caused by energy deficit, without any underlying inflammation. 2. Chronic disease-related malnutrition is characterized by mild to moderate inflammation in the setting of chronic disease (disease or condition lasting >3 months). 3. Acute disease or injury-related malnutrition is characterized by severe inflammation in the setting of acute illness (e.g., severe sepsis or trauma).
43
During nutritional assessment, can a calf circumference can be used in place of BMI?
Yes
44
What are the physical signs of malnutrition?
*Loss of subcutaneous fat (orbital, triceps over rib cage) *Muscle loss (wasting of the temples, clavicles, shoulders, interosseous muscles, scapula, and calf) *Fluid accumulation (extremities, vulvar/scrotal edema, or ascites)
45
Out of the 6 criteria: - insufficient energy intake, - weight loss, - loss of muscle mass, - loss of subcutaneous fat, - localized/generalized fluid accumulation, - diminished functional status (diminished hand-grip strength) How many need to be present to be diagnosed with malnutrition?
Malnutrition can be diagnosed when 2 of 6 criteria are present.
46
Is weight considered an important vital sign?
yes - height and weight should be measured regularly as self-report may not be reliable.
47
How do you interpret low protein status?
If CRP is normal and albumin is low, then the low albumin may suggest low protein status.
48
What normal changes of aging predispose someone to GERD?
-Reduced lower esophageal sphincter tone -Hiatal hernia (tightening around fundus, impairs LES, contributes to GERD) -Medication related effects (I would argue this is not a "normal change of aging" but Don has it on his PPT slide)
49
What is GERD?
Reflux of acid and pepsin from the stomach to the esophagus that causes esophagitis
50
Briefly describe the pathophysiology of GERD
Resting tone of LES tends to be lower than normal Conditions that increase abdominal pressure or delay gastric empyting can contribute to development of reflux esophagitis
51
Manifestations of GERD?
Most reliable indicators: Heartburn Acid regurg Others: Dysphagia Chronic cough Asthma attacks Laryngitis Upper abdominal pain within 1 hour of eating
52
What is the agent of choice in GERD? Why?
PPI are agents of choice for controlling symptoms and healing esophagitis
53
A topic Don seems to always bring up: How do we help differentiate from GERD and ACS in the ED (if there is low suspicion for ACS) ?
Pink lady (viscous lidocaine and almagel)- if symptoms resolve, indicates symptoms are likely of esophageal source
54
Janet presents with dyspepsia at age 72. She has never had these symptoms before. Are we concerned?
RxFiles says yes- increased age puts patients at increased risk of organic causes (i.e., cancer, ulcers). Consider endoscopy.
55
What are alarm features we need to consider when investigating dyspepsia/ GERD?
VBAD Vomiting (persistent, >7 days) Bleeding, anemia, melena Abdominal mass or unexplained weigh loss (>3kg or 10% of body weight) Dysphagia (warrants prompt endoscopy) Others: Jaundice, family history of gastric or ovarian cancer, prior ulcer, multiple risk factors for Barretts
56
How to proceed if alarm features present?
Consider endoscopy
57
True or false: A patient is having GERD symptoms twice a week. They can be managed with lifestyle, diet changes, OTC antacids.
True (RxFiles)
58
What is initial therapy for GERD (3+ times/ week)
Standard dose once daily PPI x8 weeks Lifestyle- diet (reduce foods that worsen sx, eat lighter meals, chew well), avoid lying down within 2-3 hours after eating, avoid tight clothes, elevate HOB, sleep in L lateral position, exercise and weight loss, moderate etoh, smoking cessation
59
You have started George, 61 on a PPI. He has been taking it for 8 weeks. He states his symptoms are resolved! What do you do next?
STOP/ TAPER Can consider on demand PPI
60
You have starting Susan, 68, on a PPI. She has been taking it for 8 weeks. She says her symptoms are a bit better, but she still gets reflux at least twice a week. What do you do next?
-Confirm adherance -Ensure PPI taken 30 min before meal -Augment therapy: BID PPI therapy for 4-8 weeks
61
Susan's symptoms are still not controlled despite the steps you took above. What now?
Refractory GERD is uncommon when lifestyle and PPI used together. Refer to GI.
62
Scott has newly diagnosed Barrett's esophagus and has been placed on a PPI. He tells you he is very happy he only needs to take this medication for 4-8 weeks, because until now, he didnt have to take any meds! What do you say?
Sorry Scott but Barret's esophagus requires long term therapy (as does erosive esophagitis, increased GI bleed risk, etc.)
63
What are the long term AE of PPIs?
PNA Gastric Ca OP related fractures CKD Vitamin/ mineral deficiencies Stroke (?) (RxFiles)
64
Diverticulosis vs diverticulitis. What are they?
presence of small pouches (diverticula) in the wall of the colon that form when the inner layers of the colon protrude through weak areas of the outer muscular layers. Diverticulitis occurs when one or more diverticula becomes inflamed
65
Is diverticulosis common in older adults?
Extremely! >50% of North American population over age 60 have diverticulosis. With increased age, the colonic wall loses elasticity increasing risk of mucosal outpouching. Diverticulitis develops in 10-20% of those with diverticulosis. 10-20% of those with diverticulitis will develop an abscess.
66
Risk factors for diverticulosis/itis
Low fibre diet (slow transit time) NSAIDS (direct topical injury to colon and reduced prostaglandins which compromise mucosal integrity, increase permeability, and enable the growth of bacteria/toxins) Immunosuppression (increased risk of infection) Smoking (mucosal barrier and healing) Obesity (increased colonic pressure) Caucasian
67
How does diverticulitis occur?
one or more diverticula becomes inflamed due to fecal material collecting within, causing diverticula pressure/obstruction, bacterial overgrowth, or micro/macroperforation.
68
Possible complications of diverticulitis?
abscess, fistula, bowel perforation, obstruction, peritonitis, or sepsis.
69
S&S of diverticulOSIS
80-85% of those with diverticulosis are asymptomatic. LLQ pain (less commonly RLQ pain), crampy Change in bowel habits
70
S&S of diverticulITIS
Abd pain (LLQ most common) Nausea, Vomiting Constipation Fever Flatulence Bloating Tachycardia, tachypnea Localized abd tenderness Abd distension Tympanic abd on percussion Tender mass (abscess) Hypo/Hyperactive bowel sounds Urinary tract findings in the case of fistula (suprapubic/flank pain, Hematochezia Absent bowel sounds (perforation) Generalized abd pain with guarding and rebound tenderness (perforation/peritonitis) CVA tenderness, fecaluria (oh dear), purulent vaginal discharge
71
How might S&S of diverticulitis be different for elderly/those taking corticosteroids?
In elderly patients or those taking corticosteroids, exam findings may be unremarkable or blunted even in severe diverticulitis
72
What is the most useful DI tool for diagnosing diverticular disease? Is endoscopy recommended?
CT Abd (best imaging method to confirm diagnosis. Sensitivity 94% and Specificity 99%) Contrast enema in uncomplicated cases Abd xray can indicate bowel obstruction, ileus, or perforation Endoscopy is NOT recommended during acute diverticulitis given risk of worsening inflammation or perforating bowel. In diverticulosis, colonoscopy effective evaluation of diverticula and to R/O malignancy
73
There is a clinical prediction rule for diverticulitis with 3 criteria. What are these?
CRP > 50mg/L Absence of vomiting Tenderness limited to LLQ When all three criteria are present, positive predictive value is 97% and negative predictive value is 47%. Sensitivity 36% and Specificity 98%.
74
T/F Diverticulosis doesn't require treatment
True
75
Treatment of complicated diverticulitis
First step is to determine whether diverticulitis is complicated (abscess, fistula, obstruction, bleeding, perforation, sepsis) or uncomplicated (localized inflammation) based on symptom severity, exam, and CT Abd results Complicated diverticulitis will require hospital admission, surgical/GI consult
76
Treatment of uncomplicated diverticulitis? Diet What meds
Clear liquid diet x 2-3 days Slowly introduce high fibre diet (35-40g/day) in conjunction with increased fluid intake. Some evidence for vegetarian diet and limiting red meat. Selective use of broad spectrum PO abx only if risk factors (multiple/significant co-morbidities, symptom duration > 5 days, vomiting, CRP > 140mg/L, WBC > 15x109/L, fluid collection, inflammation on CT scan > 86mm) (Bugs & Drugs, 2021) Antispasmotics Reassess in 6-8 weeks and consider colonoscopy to evaluate for malignancy, stricture, extent of diverticula
77
What lifestyle counselling can we offer patients for diverticulitis?
Do NOT need to avoid seeds, nuts, popcorn Avoid NSAIDs Treat constipation as appropriate Physical activity and weight loss (when applicable) Smoking cessation
78
Which liver tests are liver FUNCTION tests?
INR, Bilirubin, albumin, platelets (to a lesser extent)
79
Checking INR can help rule out a ______ deficiency
Vitamin K
80
What is bilirubin?
A waste product AND digestive emulsifier Bilirubin is a brownish yellow substance found in bile. It is produced when the liver breaks down old red blood cells. Bilirubin is then removed from the body through the stool (feces) and gives stool its normal colour. - Usually increased in bile duct injury, cholestasis, and severe hemolysis - An increased bilirubin due to hepatic cause usually indicates advanced liver disease
81
Which tests are liver ENZYMES?
AST ALT ALP GGT
82
Which liver tests are hepatocellular and which are cholestatic
Hepatocellular (suggesting liver injury) = ALT, AST Cholestatic (suggesting blockage of biliary tree or common bile duct, sometimes from stones) = ALP, GGT
83
What is don's handy dandy way of remembering what can cause an elevation in AST? is AST very sensitive or specific for liver disease?
AST = "alcohol, statins, tylenol" Less sensitive and specific than ALT. Can be used as screening test to determine AST/ALT ratio (as per Edmonton manual)
84
What situation causes elevation of ALT?
ALT is the most sensitive and specific marker of liver injury/inflm high levels of ALT may be a sign of liver damage from hepatitis, infection, cirrhosis, liver cancer, or other liver diseases - Think the "L" in the middle stands for "liver" causes **Don emphasized this can be an indication of fatty liver d/t to persistent inflammation in the liver tissue
85
What procedure can be done to to remove gallstones?
ERCP An ERCP (endoscopic retrograde cholangiopancreatography) combines an endoscope and x-rays to examine and treat diseases of the bile and pancreatic ducts.
86
Is ALP very specific to cholestasis? What else might cause it to be elevated?
No, it is elevated in all forms of cholestatic disease but can also be high in pregnancy, bone disease, renal disease
87
How is GGT helpful?
Useful to confirm that high ALP reflections hepatobiliary disease (order GGT when ALP is elevated) Can also be elevated with recent EtOH, antiseizure meds, renal disease, pancreatitis, DM, CAD, prostate CA
88
What can cause a low albumin?
Liver disease Malnutrition Diarrhea Iron deficiency infection
89
What is a hemorrhoid and what is the usual patho behind them?
Dilated vessels (internal/external) - often from valve failure , usually due to increased pressure
90
What are risk factors for hemorrhoids?
Increased abdominal pressure from things like obesity, pregnancy, chronic constipation/straining, portal HTN and heavy lifting. Low libre diet, sedentary job, loss of muscle tone due to advanced age.
91
Which type of hemorrhoids tend to cause more symptoms – internal or external?
External are often more symptomatic with itching and pain. Internal hemorrhoids are viscerally innervated and therefore painless
92
Outline the four degrees of internal hemorrhoids
1st degree: bleed, do not prolapse 2nd degree: bleed, prolapse with straining, spontaneous reduction 3rd degree: bleed, prolapse, require manual reduction 4th degree: bleed, permanently prolapsed, cannot be manually reduced
93
What might a very painful hemorrhoid indicate?
Thrombosis
94
What are some important differentials to consider when symptoms related to hemorrhoids are present?
Anal cancer Anal condylomata Anal fissure Colorectal ca IBD Perianal abscess Skin tags
95
Hemorrhoid management: nonpharm
Adequate fluid and fiber intake Fiber supplementation (i.e., psyllium) Avoid straining Sitz baths (no evidence for benefit though) Regular physical exercise, avoid prolonged sitting, sleep on side if pregnant (prevent compression of inferior vena cava.)
96
Hemorrhoid management: pharm
Topical ointments (short term ~7days) : Anesthetics (e.g. Dibucaine 1% ointment) Astringents (e.g. witch hazel pads) Steroids (e.g. Hydrocortisone 1% cream) Combination products available *No evidence for long term use Bulk-forming agents (ex. psyllium), stool softeners Oral NSAIDs or acetaminophen for discomfort ***Highlights provided in Don’s notes: High fibre, stool softeners, topical analgesics
97
T/F: The management of fissures is similar to that of hemorrhoids.
True
98
Anal fissure is a tear in the lining of the anal canal, distal to the dentate line. What are common causes of anal fissures?
Primary anal fissure: usually from trauma – constipation, diarrhea, vaginal delivery, anal sex Secondary anal fissure: from underlying medical condition – Crohn's, malignancy (squamous cell anal carcinoma), infections (HIV, syphillis)
99
Management of anal fissures
Avoid diarrhea/constipation - high fibre diet with adequate fluids Warm sitz bath TID Topical analgesic jelly/cream (2% lidocaine jelly) Bulk forming agents/stool softeners/laxatives Topical vasodilators: nifedipine or nitroglycerine **Do all this for one month, then reassess and repeat for a second month if needed.
100

NUNP547 Older Adult Theory (10 decks)

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