Week 3 - Endocrine, GI and Nutritional disorders Flashcards
Risk factors for constipation
- Female
- Physical inactivity
- Low education/income
- Polypharmacy
- Comorbidity
- Depression
- Poor dietary intake
Symptoms of constipation
- Pain, bloating, gas, infrequent defecation, straining, incomplete evacuation
- Functional constipation – (2+ symptoms of…): straining, lumpy hard stools, sensation of incomplete evacuation, digital maneuvers to relieve symptoms, sensation of obstruction or blockage with 25% of BMs, decrease in stool frequency (less than 3 per week). Should be present for 3+ months consecutively with symptom onset at least 6 months prior to diagnosis)
Primary causes of constipation
- Slow transit
- Difficulty expelling stool from rectum
- IBS-C (abdo pain and altered bowel habits)
Secondary causes of constipation
- Malignancy
- medications
- DM
- hypo/hyperthyroidism
- parkinsons
- stroke
- dementia
- malabsorption
- scleroderma
- depression
- eating disorder
- alcohol/substance abuse
- anatomical dysfunction
- decreased mobility
Diagnosing constipation
- Rectal exam, history, CBC, serum calcium, thyroid function test, fecal occult blood testing
- No evidence for routine lab testing without a change in symptoms
- Evaluation for fecal impaction with abdominal xray (iusually not able to assess with rectal exam)
- Xray also indicated for megacolon, volvulus, mass lesion
Endoscopy only for:
* Colonic lesions, mass, obstruction. Volvulus, megacolon, strictures or mucosal biopsy for inflammation or microscopic colitis
Specialized testing to diagnose constipation and fecal incontinence
* Motility or colonic transit studies
* Anorectal manometry – measures internal and external anal sphincter pressure at rest and during contraction.
* Rectal balloon – evaluate sensation and rectal capacity
* Endoanal ultrasound – evaluates for structural defects with internal/external anal sphincters
* Defecography – evaluates defectaory process after barium paste inserted rectally and patient defecates under fluoroscopy (assess rectal emptying and structural abnormalities of the pelvic floor
Non-pharmacological treatment for constipation
- Regular bowel pattern
- Exercise to increase motility
- Water/fluid intake (91 ounces fluid/food)
- Avoid excess straining
- Increase fiber intake slowing *(5g/day at 1-week intervals until 25-30g fiber daily
- Probiotics
- Dyssynergia defecation (muscles and nerves in pelvic floor fail to coordinate correctly to have BM) treated with biofeedback
- Bowel retraining
Pharmacological treatment for constipation
Bulk forming laxatives– expand with water to increase fecal mass and softer stools
Sufficient water to avoid worsening of constipation or creating impaction. May inhibit absorption of some drugs (1 hour before or 2 hours after other meds)
Stool softeners and emollients – deterrent effect on stool consistency Does not interfere with other medicat5ions. Used when bulking agents don’t work or are not preferred, can be used in combo with bulking agents
Osmotic laxatives – promote secretion of water into the intestinal lumen by iostmotic activity (miralax, lactulose -less effective than miralax)
* Use in caution with CHF and CKD due to the risk of fluid/electrolyte imbalance
Stimulants – increase peristaltic contractions (senna, bisacodyl)
Suppositories/enemas – used when oral agents are not effective
**Chloride channel activators **
* Lubiprostone – improve intestinal motility by increasing intestinal fluid secretion without altering serum electrolytes.
* Guanylate cyclase C receptor agonists – linaclotice/plecanatide – stimulate intestinal fluid secretion and transit
Fecal incontinence
Involuntary loss of liquid or solid stool that is a social or hygienic problem
o Fecal and urinary symptoms should always be evaluated together
Nonpharmacological treatments for fecal incontinence
- Avoid diet triggers for loose stool – lactose containing products,
- increase dietary fiber
- Bowel habit training and scheduled toileting w/ or w/o laxatives
Biofeedback – trained provider who uses an instrument with visual or auditor feedback on proper control of voluntary muscle contraction and relaxation of the external anal sphincter and recognition of anal sphincter sensation – improve sensation and muscle contraction
Types of fecal incontinence
- Urgency – strong urge and unable to hold stool in rectal vault
- Passive – bowel leakage without sensation to defecate, seepage after BM, inability to discriminate gas/stool
- Overflow – seepage around impaction, common in older immobile adults
Pharmacological treatments for fecal incontinence
- Loperamide – watch for constipation
- Cholestyramine when the above not effective
- Perianal injection of dextranomer microspheres and hyaluronic acid
- Sacral neuromodulation – percutaneous tibial nerve stimulation (PTENS) – stimulate defecation nerves 12 week sof treatment
- Surgery – anal sphincter repair, artificial sphincter, colostomy
Treatment for fecal impaction
- Results from lack of ability to sense and respond to stool in the rectum
- Abdominal xray will help identify, digital rectum exam can be used but not always effective
- Digital disimpaction to fragment a large amount of feces, should be followed by warm water enema with mineral oil to soften and assist with evacuation
- Local anesthesia to relax anal canal and abdominal massage
- Rare cases colonoscopy with snare to fragment fecal material
Sarcopenia
decreased muscle mass for age, sex, race
Frailty
age related decline in reserve and function across multiple physiological systems
Xerostomia
dry mouth – can be due to decreased saliva production (medications)
Dysphagia
difficulty chewing and swallowing. Increases the risk for malnutrition
Components of nutrition assessment
Mini-Nutrition assessment/DETERMINE checklist
Measurements
* BMI, weight, weight changes, skinfold measurements
Labs
* CBC, protein status, C-reactive protein, lipids, electrolytes, BUN/creatinine
* Low albumin or prealbumin may instead indicate illness and inflammation rather than nutritional status. Experts recommend interpreting albumin levels based on CRP. If CRP is normal and albumin is low, then the low albumin may suggest low protein status
Clinical eval
* PE, chronic conditions, health status, oral health, polypharmacy
Dietary history and current intake
* Preferences, culture, frequency, control over selection/choices, fluid/alcohol intake, special diet, vitamin use, functional problems (chewing, feeding, cognitive change)
Two of the following elements needed to diagnose malnutrition
- Insufficient energy intake
- Weight loss
- Loss of muscles mass
- Loss of SQ fat
- Localized/generalized fluid accumulation
- Diminished functional status by handgrip strength
Management of malnutrition
- Treat underlying cause of malnutrition
- Increase macronutrient (protein, carb, fat) intake
- Appetite stimulant may be considered
Cancer management
- Local treatment – surgery (safe into 90s) and radiation (used for palliation of pain and obstruction)
- Systemic treatment – chemo, hormonal therapy (aromatase inhibitors are now treatment of choice – can cause osteoporosis), targeted therapy
- Prostate cancer – gonadotropin-releasing hormone analogs
- SERM (selective estrogen receptor modulator)– tamoxifen and raloxifene – prevent osteoporosis but have a risk for VTE
- AI (aromatase inhibitors) anastrozole, letrozole, exemestane - can cause osteoporosis
Common side effects of chemo in older adults
- Alopecia
- Anemia
- Depression
- Delirium
- Diarrhea
- Cardiotoxicity
- Fatigue
Workup for colorectal cancer
- Colonoscopy
- CT chest, abdo, pelvis
- PET scan for mets
Prostate cancer
- Active surveillance for 70+ with a well differentiated tumor
- Hormonal treatment for metastatic disease
Staging for colon cancer
- Stage I, T1T2, is limited to mucosa and submucosa (resection)
- Stage IIA, invades muscularis propria (resection)
- stage IIB invades the outer layer of colon proper, the serosa (fluorouracil and leucovorin)
- Stage III is any lymph node involvement. (fluorouracil and leucovorin)
- Stage IV involves distant metastases, typically the liver, regional abdominal lymph nodes, or lung because of the lymphatic drainage of the large bowel’’
Causes of dysphagia
- Systemic disorders
- primary GI inflammatory/motility disorders
- medication side effects
Symptoms of oropharyngeal dysphagia
- Coughing, choking, nasopharyngeal regurgitation, aspiration, retained food in mouth
- Reduced tongue strength, reduced wall contraction, decreased saliva, impaired gag reflex, poor dentition, neurological disorders (parkinson’s, alzheimers, myesthenia gravis), malignancies, zenker diverticulum, prominent osteophytes
Symptoms of esophageal dysphagia
- Sensation of food getting stuck in the esophagus several seconds after swallowing
- Decreased saliva, altered motility, medications
- Structural disorders
- Motility disorders
- Inflammatory/infectious disease
Dysphagia that moves from solids and progresses to liquids OR rapid progression is concerning for…
Malignancy
Dysphagia with odynophagia (painful swallowing) is indicative of…
infection viral or fungal (candida)
Diagnosing dysphagia
- Barium esophagram to identify diverticula, strictures and motility abnormalities
- EGD
Treatment for GERD
Hiatal hernia repair and nissen fundoplication
Causes of peptic ulcer disease
Chronic NSAID us and H. pylori
Most commonly affected ethnicity for DM
Black and hispanic
Diagnostic criteria for DM
- A1C 6.5% or higher
- FBG 126mg/dL or greater–> 2 readings needed to diagnose
- 2-hour BG during OGTT 200mg/dl or greater
- Random BG 200mg/dL or greater
- When classic symptoms of hyperglycemia or hyperglycemic crisis are present
Lifestyle changes for DM diagnosis
- Weight loss with caution
- Exercise – resistance & aerobic – 150 min moderate exercise per week
Pharmacological treatment for DM
- Biguanides (metformin)
- Sulfonylureas (glipizide)
- GLP1 Agents (exenatide, liraglutide)
- Sodium glucose transport 2 inhibitors (canagliflozin, dapaglifzolin_
- DPP-4 inhibitor (Sitagliptin, linagliptin, saxagliptin)
Insulin for DM management
o Indicated for patients who have not responded to diet and exercise an oral agents
o Need good functionality to monitor levels and hypos indepdendently
o can be given in long acting form once daily
o glargine or detemir insulin (
o if transitioning from a sulfonylurea to insulin need clear plan for taper and DC of sulfonylurea
Biguanides
Metformin
Decreases hepatic production and intestinal absorption of glucose while improving insulin sensitivity
* Do not use with an eGFR of less than 30
Sulfonylureas
Glipizide
Enhance beta cell secretion of insulin from the pancreas causing decrease in glucose output from the liver and increase in insulin sensitivity
GLP1 Agents
Examples: exenatide, liraglutide
- Intestinal hormone that stimulates the release of insulin as glucose rises in the postprandial period
- Unlikely to cause hypoglycemia
- Adjunct for glucose control in older adults
Sodium glucose transport 2 inhibitors
Canagliflozin, dapaglifzolin
- Increase urinary elimination of glucose
- Can lower blood pressure and weight
- Can cause orthostatic hypotension, increase in yeast and UTIs. Lowers the risk of CV events
DPP-4 inhibitor
Sitagliptin, linagliptin, saxagliptin
* Block the breakdown of GLP1
* Does not cause hypoglydemia
Metformin side effects
- GI discomfort
- Diarrhea
- Decreased appetite
- Weight loss
Sulfonylureas side effects
Example: glipizide
- Hypoglycemia
- Weight gain
- Skin rash/photosensitivity
Side effects of DPP-4 inhibitors
Example: Saxagliptin
- Severe skin rash
- Angioedema if combined with ACE
Side effects of GLP-1 agents
Example: liraglutide
- N/V
- Tachycardia
- Acute pancreatitis
Diabetic treatment priorities for older adults
Managing hypertension goal of <140/80 reduce by 20mmHg at a time)
* ACE / ARB preferred as they slow progression of proteinemia and nephropathy
Smoking cessation
Eye care for diabetic retinopathy
* New onset patient should have an eye exam annually (high risk), biennial (low risk}
Nephropathy
* Annual screening and at diagnosis
* BP and glucose control to slow progression
* Ace inhibitors delay progression
-
Neuropathies
Foot exam yearly
Gabapentin and pregabalin
Falls/fractures
Gait abnormalities
Altersed sense of vibration
Neuropathy
Foot deformities
Orthostatic hypotension
Decreased ankle dorsiflextion
Muscle weakeness
Cognition
HbA1c goals for older adults
- A1c<7.5% for adults with good health (fasting BG 90-130—140/90)
- A1c 8-8.5% for multiple comorbidities and minimizes risk for hypoglycemia (fasting BG 90-150 –140/90)
- 8.5% for those with limited life expectancy and severe functional impairment (fasting BG 100-180—150/90)
Hypoglycemia risk factors
- Poor intake
- Changes in mental status
- Polypharmacy/medication non-compliance
- Dependence or isolation
- Impaired renal or hepatic metabolism
- Presence of comorbid conditions that can mask symptoms (dementia, delirium, depression, sleep abnormalities, seizures, MI, CVA)
- Other endocrine disorders (adrenal insufficiency)
Diabetes risk factors
- Age>65
- Hispanic
- BMI >25
- Hypertension
- Thiazide diuretic
How to minimize diabetic macrovascular complications
- BP management
- Lipid management
Microvascular complications
- Nephropathy – routine urinalysis – albumin and creatinine clearance
- Retinopathy- yearly eye exam
- Peripheral neuropathy
Annual checks for diabetics
- HbA1c
- lipid panel
- BP
- urine check
- diabetic foot exam
- flu shot
- eye exam
Diabetic checks done at every visit
- Weight
- BP
- review blood sugars
- review medications
Symptoms of hypothyroidism
- Fatigue
- Weakness
- Depression
- Dry skin
- Significantly less common in elders:
- Weight gain
- Cold intolerance
- Muscle cramps
- Paresthesia’s
- Libido
- Appetite
- Arthralgias
- Confusion
- Constipation
- Brittle nails
- Loss of hair
- Easy bruisability
- Low back discomfort
- Periorbital edema
- Lipid abnormalities
- general slowing of mental and physical function, cold intolerance, weight gain, constipation, effects on blood pressure, and anemia.
- Older adults have less symptoms
Diagnosing hypothyroidism
TSH (high), free T4 (low), free T3 (low)
* If acutely ill, test may be inaccurate – be sure to recheck 2-4 weeks after infection occurs
Treatment for hypothyroidism
If patient is symptomatic and labs indicate hypothyroidism start with:
* Initial dose – 12.5-25mcg daily, recheck 4-6 weeks and adjust dose
- If patient has CAD and will be on it long term then do cardiac stress test should be done
Overtreating can lead to osteoporosis in women
Signs and symptoms of hyperthyroidism
Younger patients
* tachycardia, goiter, eye symptomology, diarrhea, sweating, agitation, anxiety
Older patients
* tachycardia, weight loss, apathy, fatigue, constipation
Thyroid storm symptoms
- a rapid heartbeat.
a high temperature.
- high blood pressure (hypertension)
- yellowing of the skin and eyes (jaundice)
- severe agitation and confusion.
- loss of consciousness.
Diagnosing hyperthyroidism
TSH (low) T3 (high), T4 (high)
Treatment for hyperthyroidism
- Propylthiouracil OR methimazole
- Beta blocker
- Stabilize with above therapy, then radioactive iodine treatment (monitor for hypothyroidism)
Hashimoto’s disease
Hypothyroidism
Cell mediated autoimmune inflammatory process
Results from irradiation, surgical removal of thyroid, pituitary and hypothalamic disorders causing TSH deficiencies, iodine induced (amiodarone, lithium, contrast dye, antithyroid drugs)
Most common form of hypothyroidism
Grave’s disease
Autoimmune disorder resulting in hyperthyroidism.
Multinodular or unimodular goiter
Subclinical hypothyroidism
o Mildly elevated TSH, normal free T4,
o No guidelines for treatment without evidence of symptoms
