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
