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Terms in this set (80)
What are the 4 main categories/pathophysiology of diarrhea?
Secretory, Osmotic, Exudative and Altered Intestinal Transit
In secretory diarrhea, there is a change in ______ ________ by either a decrease in __________ absorption or increase in ___________ secretion into the lumen
ion transport; sodium; chloride
Secretory diarrhea can be caused by...?
pancreatic tumors, unabsorbed fat, laxatives or bacterial toxins
Osmotic diarrhea is caused when poorly absorbed substances are ________ in intestinal fluids which results in an _________ of _________ and electrolytes into the lumen
retained; influx of water
Osmotic diarrhea can be caused by...?
Malabsorption syndromes, lactose intolerance, administration of divalent ions and consumption of poorly soluble CHOs
Osmotic diarrhea can be ___________ with fasting state
improved (no eating = no diarrhea)
Exudative diarrhea is a subset of __________ diarrhea; secondary to ____________ diseases of the bowel
Exudative diarrhea is characterized by...?
Large stool volumes
Altered Intestinal Transit is when there is ____________ time of exposure between intestinal epithelium and chyme leading to __________ absorption and secretion
Altered intestinal transit is characterized by...?
rapid, small, coupling burst of diarrhea
Altered intestinal transit is caused by _______________ or ____________
bowel resection or pro-motility meds
What are the different causes of diarrhea?
Bacterial, viral and drug induced
What is the clinical presentation of diarrhea?
nausea and vomiting, headache, abdominal pain, fever, chills and malaise; chronic diarrhea pt could have weight loss, anorexia and weakness
What are the complications of excessive diarrhea?
dehydration (important in pediatrics!) and electrolyte imbalance (Na, K, Ca, Mg)
What are some non-pharmacologic treatments for diarrhea?
Diet management and fluid/electrolyte replacement
What is the best treatment for acute diarrhea with no fever or systemic symptoms?
1. Fluid/electrolyte replacement
2. Loperamide, diphenoxylate or absorbent
What is the first step in treating acute diarrhea with fever or systemic symptoms?
Check feces for WBC/RBC/ova and parasites
If it tests negative...
use symptomatic therapy
If it tests positive...
use antibiotics and symptomatic therapy
What should you do if experiencing diarrhea for > 14 days (chronic diarrhea)?
Always refer to physician
How do you treat chronic diarrhea if there is no diagnosis?
1. replete hydration
2. discontinue potential drug inducer
3. adjust diet
4. loperamide or absorbent
What is the treatment for chemo-induced diarrhea?
2. rotate loperamide and lomotil
3. extensive GI workup
What is the mechanism of anti motility drugs?
activation of the mu opioid receptors on the smooth muscle of the bowel to reduce peristalsis and increase segmentation; thus, delaying transit of intraluminal contents
What is the mechanism of absorbents?
absorb nutrients, toxins, drugs and digestive juices
What is the mechanism of anti secretory drugs?
act by reducing secretions in the gut
What occurs during normal defecation?
contraction of diaphragm, abdomen, and rectal muscles; relaxation of EAS and puborectalis muscle; decreased sphincter pressure
What occurs during abnormal/dyssynergic defecation?
prolonged colonic transit time; discoordination of abdomen, rectoanal and pelvic floor muscles; rectal hyposensitivity; increase in sphincter pressure
In acute constipation, there are less than __ bowel movements/week
In acute constipation, stools are _____ and ______; bowel movements are _______ and there is feelings that bowels have not been ____________
dry and hard; painful; emptied fully
Chronic constipation symptoms last ______ weeks
In chronic constipation, there may be response to _______ but returns when they are ___________
What are some common causes of constipation?
Dietary changes (poor fluid intake, decreased calorie intake), failure to heed defecation reflex, impaired physical mobility, lack of privacy, increased psychological distress and disease states that slow down GI motility (Diabetes, Parkinson's, CNS injury or MS)
What are some common medication causes of constipation?
Analgesics/opioids, antacids (Al, Ca), antihistamines, antimuscarinics, amitriptyline, verapamil, clonidine, calcium channel blockers, iron, diuretics and chronic use of laxatives
A patient with constipation should be referred if they have symptoms for _______ weeks, __________ stools, ________, severe ______ and _______ history
>2; black; fever; nausea and vomiting; family
What are some non-pharmacologic treatment options for constipation?
Adequate fluid and fiber in diet, prunes, power pudding, do not ignore urge to defecate, establish a regular time for bowel movements and encourage patient to defecate when colonic activity is greatest (first thing in morning, ~30 min of eating)
What is the mechanism of action of bulk laxatives?
Forms emollient gels which retain water, swells and stimulates bowel movement
What are some examples of bulk laxatives?
Psyllium, Methylcellulose and calcium polycarbophil
What are the advantages of bulk laxatives?
soften stools better than docusate (surfactant/emollient); well tolerated and few side effects
What are the disadvantages of bulk laxatives?
taste, must have adequate fluid intake, gas formation, impact on drug absorption and not ideal for bedridden patients
What is the mechanism of action of surfactants/emollients?
Decreases fecal surface tension and stool softener
What is an example of a surfactant/emollient?
What are the advantages of surfactants/emollients?
safe, helps prevent hard stools
What are the disadvantages of surfactants/emollients?
not effective for active constipation
What is the mechanism of action of lubricants?
lubricates lumen of colon
What is an example of a lubricant?
What are the advantages of lubricants?
What are the disadvantages of lubricants?
poor patient acceptance, oily, only effective as prevention and may decrease absorption of fat-soluble vitamins
What is the mechanism of action of saline laxatives?
Draws fluid into colon which stimulates motility
What are the advantages of saline laxatives?
used for acute management of constipation, quick onset
What are the disadvantages of saline laxatives?
taste and avoid in renal patients
What is the mechanism of action of hyperosmotic agents?
Draws fluid into colon due to high concentration of sugar, PEG or glycerin
What are examples of hyperosmotic agents?
PEG, sorbitol, lactulose, glycerin suppositories, MiraLAX and Kara corn syrup
What are the advantages of hyperosmotic agents?
well tolerated, softens while stimulating bowel movement and excellent for chronic constipation
What are the disadvantages of hyperosmotic agents?
1-3 day onset and minor nausea, cramping
What is the mechanism of action of stimulant laxatives?
locally stimulates enteric nerves which stimulates contractions and mobility; also increases fluid and Na secretion into the lumen
What are some examples of stimulant laxatives?
Senna, Bisacodyl and castor oil
What are the advantages of stimulant laxatives?
6-12 hours onset, works in patients with mobility disorders and drug of choice for opioid induced constipation
What are the disadvantages of stimulant laxatives?
risk of nausea and cramping, avoid long term continuous use in patients with normal GI motility
What is the mechanism of action of chloride channel activators?
activates chlorine channels in small intestine resulting in Na influx which increases fluid movement into intestinal lumen
What is an example of a chloride channel activator?
What is the mechanism of action of Guanylate Cyclase-C receptor activators?
increases chloride and bicarbonate secretions into the intestinal lumen and also inhibits sodium absorption
What is an example of a Guanylate Cyclase-C receptor activator?
What is the mechanism of action of 5-HT4 receptor agonists?
Activates 5-HT4 receptors which facilitates the release of ACH resulting in enhanced colonic peristalsis
What is an example of a 5-HT4 receptor agonist?
What are some ADRs of Prucalopride?
headache, abdominal pain, nausea and diarrhea
What are pharmacologic treatment options for acute constipation for patients seeking 6-24 hours symptomatic relief?
MOM, standard doses of PEG and bisacodyl or Senna tablets
What are pharmacologic treatment options for acute constipation for patients seeking RAPID symptomatic relief?
Magnesium citrate, large doses of PEG
What are pharmacologic treatment options for acute constipation for patients seeking VERY RAPID symptomatic relief?
Enemas and suppositories (bisacodyl, glycerin)
What is the first step in treating chronic constipation?
What is the second step in treating chronic constipation?
Bulk-forming laxative and adequate fluid intake
What is the third step in treating chronic constipation?
sorbitol/lactulose/PEG (hyperosmotic agents)
What is the fourth step in treating chronic constipation?
What is the last step in treating chronic constipation?
lubiprostone, linaclotide or prucalopride
How should spinal cord injury patients be treated for constipation?
routine use of bowel stimulants
How should pregnant women be treated for constipation?
diet, fiber, docusate
How should children be treated for constipation?
glycerin suppositories, karo syrup or PEG
How should diabetics be treated for constipation?
How should patients on opioids be treated for constipation?
stimulants; then add docusate, lactulose, sorbitol or PEG as needed
Avoid bulk laxatives
How should post-op patients be treated for constipation?
start with MOM or PEG, then stimulants if needed
How should preps for GI procedure patients treated for constipation?
hyperosmotics or saline laxatives
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