Week 2 GI Flashcards
Which 2 classifications of stool, according to the Bristol stool chart, are indicative of constipation? What is the recommended action?
Type 1 - separate hard lumps, like nuts (hard to pass)
Type 2 - sausage shaped but lumpy
The recommendation is to commence or increase laxatives.
Constipation can be classified as _______ or ________.
Constipation can be classified as primary or secondary.
Name some primary causes of constipation.
Primary causes include: normal transit, slow transit and defecatory dysfunction.
Name some secondary causes of constipation.
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.
Why is fiber indicated in fecal incontinence?
Solid stool may be easier to retain in the rectum in patients with FI that is diarrhea predominant.
T or F, biofeedback is recommended for people with fecal incontinence.
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.
What are some medications that can help with fecal incontinence, and what are some special considerations when prescribing these to older adults?
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).
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
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.
When evaluating fecal incontinence, what specific questions should you ask in regards to their bowel movements?
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.
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?
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)
Name some med classes that can cause constipation.
As per RxFiles:
Analgesics
Anticholinergics
Anti-Parkinson
Anticonvulsants
Antidepressants
Antidiarrheals
Antiemetics
Antihistamines
Antihypertensives
Antispasmodics
Cation agents
Chemotherapy
Resins
What are the 3 F’s you can counsel on to promote bowel regularity?
Fibre, fluid, fitness (physical activity)
What is the recommended treatment for constipation when straining and incomplete evacuation are the s/s of concern?
Lifestyle and a bulk-forming agent such as psyllium (as long as the patient can drink 250ml or more with each dose.
What is the recommended treatment for constipation when infrequent bowel movements are the s/s of concern?
Osmotic laxative such as PEG 3350, MOM, lactulose.
What is the recommended treatment for constipation when your patient has a neurogenic bowel?
Stimulant such as senna or bisacodyl
What is the recommended treatment for constipation when slow transit or severe pelvic floor dysfunction are the culprits?
Avoid high fibre diets and fibre supplements.
What meds should you prescribe when you are also prescribing an opioid?
A stimulant laxative +/- stool softener.
What dose of PEG is recommended for older adults?
17 g/day.
What are the two types of dysphasia?
Oral
Esophageal
What are some DDX for dysphagia?
DDx: Neurologic (CVA, dementia, parkinsons), Structural
(diverticula, stricture, mass), Muscular, Inflammatory
(Esophagitis, infectious, radiation)
What are some diagnostics you could consider running if your patient presents with dysphagia?
Labs (not overly helpful, low Hb or Fe may suggest malignancy)
Imaging (barium swallow)
Endoscopy is the gold standard if appropriate
Alarm features of constipation in the older adult?
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
What are some medical conditions in an older adult that may contribute to dysphagia?
Stroke
Neurologic disorders
Dementia
Cancers
Respiratory disorders
Poor dentition
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
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
Fluid hydration: what is the total amount of ounces a person should be consuming/day (inclusive of all food and beverages)
91 ounces
What does fibre do for your stool?
Bulk it up baby!
Why increase fibre slowly and weekly?
To avoid increased bloating and flatuence
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
T/F: Taste buds decrease by 70% in older adults.
True
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.
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
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
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.
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
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?
How much unintentional weight needs to be lost to trigger a nutritional assessment?
more than 5% in 6 months or low BMI
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.
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
