Nurs 723: Gi Disoders

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Rome III Criteria for Constipation

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*Sx for ≥6 months & ≥2 of the following symptoms for more than 1/4 of defecations during the past 3 months:
-Straining
-Lumpy or hard stool
-Sensation of incomplete evacuation
-Sensation of anorectal obstruction/blockade
-Manual maneuvers to facilitate defecations; <3 defecations/wk.
-Loose stools are not present, and there are insufficient criteria for IBS

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Rome III Criteria for IBS

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*Recurrent abdominal pain or discomfort @ least 3 days/month in the past 3 months associated with ≥ 2 of the following:
-Improvement with defecation
-Onset associated with change in frequency of stool
-Onset associated with change in form (appearance) of stool
-<25% of bowel movements were loose stools

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Once secondary causes of constipation are eliminated, consider _______________________ constipation or a ___________________ disorder.

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Once secondary causes of constipation are eliminated, consider idiopathic constipation or a functional disorder.

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5 Causes of Constipation

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1) Insufficient fiber, fluid, &/or exercise
2)Neurogenic: peripheral or central
3) IBS
4) Medications
5) Non-neurogenic

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Peripheral Neurogenic Causes of Constipation

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-DM
-autonomic neuropathy
-Hirshsprung's
-Pseudo-obstruction

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Central Neurogenic Causes of Constipation

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-multiple sclerosis
-spinal cord injury
-Parkinson's

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Medications that can Commonly Cause Constipation

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-narcotics
-antidepressants
-antipsychotics

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Non-neurogenic Causes of Constipation

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-hypothyroidism
-hypokalemia
-pregnancy
-AN

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5 Classes of Laxatives

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1) Bulk-forming
2) Osmotic
3) Stimulants
4) Stool softeners (surfactants/lubricants)
5) Chloride channel secretion

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MOA of Bulk Forming or Fiber Laxatives

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*absorb water & increase fecal mass and distention → increased peristalsis
*natural and semisynthetic polysaccharides and cellulose

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Considerations with Bulk Forming or Fiber Laxatives

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-start low to avoid bloating and distention
-encourage adequate hydration
-low cost and easy

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Dietary Fiber Recommendations

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25-50 grams/day

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Benefits of Bulk-Forming or Fiber Laxatives

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-safe, can be used long term
-do not affect absorption of nutrients

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Limitation with Bulk-Forming or Fiber Laxatives

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*poor patient compliance

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Examples of Bulk-Forming or Fiber Laxatives

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*Bran 1 cup a day
*Carboxymethylcellulose(Citracel®)
*Pysllium(Metamucil®, Konysl®)
*Polycarbophil (Fibercon®)
*Wheat Dextran (Benefiber®)

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Dosage of Pysllium(Metamucil®, Konysl®)

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1-3 T/day

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Dosage of Polycarbophil (Fibercon®)

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*2-4 tablets per day
**patients prefer tablets over solutions

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Dosage of Dextran (Benefiber)

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*1-3 caplets or 2 tsp. up to tid
**odorless/colorless

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Osmotic Laxative Agents

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*Polyethylene glycol (Golytely®, Miralax®)
*Synthetic disaccharides: Lactulose (Enulose®), Sorbitol
*Magnesium Sulfate
*Magnesium Citrate (Citrate of Magnesia®)
*NaPhosphate (Fleets®)
*Glycerin

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Initial Dose of Polyethylene glycol (Golytely®, Miralax®)

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*17gms in 8oz of water daily
**titrate to effect

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MOA of Osmotic Laxatives

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*draws water into intestinal lumen via osmosis resulting in softer/liquid stools & distention induced peristalsis

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MOA of Synthetic disaccharides: Lactulose (Enulose®), Sorbitol

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*synthetic disaccharide is NOT metabolized by intestinal enzymes
*water and electrolytes remain in intestinal lumen
*exert osmotic effect secondary to sugars

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Why is Sorbitol poorly tolerated?

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*cheap, but no well-tolerated
**very sweet**

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Concerns with Mg Sulfate, Mg Citrate, & NaPhosphate Administration

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*poorly absorbed; hyperosmolar
*hyper-magnesemia: use cautiously in renal patients & patients with heart failure

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Adverse Effect with Glycerin Administration

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*rectal irritation

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Examples of Stimulant Laxatives

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*Bisocodyl (Dulcolax®)
*Senna (Senokot®) 2-4 tabs
*Cascara
*Phenolphthalein (Ex-Lax®)

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Bisocodyl (Dulcolax) Dosage

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*10-30mg PR daily or
*10mg PR daily

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MOA of Stimulant Laxatives

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*stimulates colonic smooth muscle and causes water accumulation in lumen
*exact mechanism not known

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2 Adverse Effects of Cascara & Phenolphthalein (Ex-Lax)

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*habituation
*urine discoloration

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Adverse Side Effects of Stimulant Laxatives

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*Protein-losing enteropathy: abnormal loss of protein from the digestive tract or the inability of the digestive tract to absorb proteins
*Salt overload
**used cautiously

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True or False. Long term use of stimulant laxatives is recommended.

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False. Stimulant laxatives are used when prompt response is warranted, but should not be used long-term.

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2 Classes of Stool Softeners

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*Surfactants
*Lubricant

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Example of Surfactant Stool Softener

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*Ducosate (Colace)

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MOA of Surfactant Stool Softener (Ducosate/Colace)

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*lowers surface tension of stool, allows water to more easily enter, softens stool
**softens stool, but does NOT impact mobility**

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Recommended Dosage of Ducosate (Colace)

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*100 mg bid

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2 Examples of Lubricant Stool Softeners

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*Mineral Oil
*Glycerin

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MOA of Mineral Oil

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*softens stool, prevents water absorption
**can inhibit absorption of fat-soluble vitamins

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MOA of Glycerin

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*draws water into the colon by osmotic pressure

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Examples of Chloride Channel Activator

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*Lupiprostone (Amitiza®)
*Linaclotide (Linzess®)

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MOA of Lupiprostone (Amitiza®)

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*activates chloride channel which causes chloride secretion
*sodium follows to maintain isoelectric equilibrium *water follows sodium; water accumulates, increasing stool bulk
**work well initially, but decreased effectiveness over time**

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Indications/Recommended Dosages for Lupiprostone (Amitiza®)

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*chronic idiopathic constipation = 24mcg bid
*IBS constipation = 8mcg bid

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MOA of Linaclotide (Linzess®)

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*stimulates intestinal fluid secretion and transit

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Indications/Recommended Dosages for Linaclotide (Linzess®)

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*Chronic idiopathic constipation = 145 mcg daily
*IBS-Constipation = 290 mcg daily

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Special Considerations for Linaclotide (Linzess®)

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*give 30” minutes before breakfast
*NOIT for use in those <17

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Most Common Side Effect with Linaclotide (Linzess®)

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*diarrhea

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Warning with Antidiarrheal Agents

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*do NOT give antidiarrheal agents in the setting of bacterial infection or inflammation

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Examples of Antidiarrheal Agents

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*Attagpulgite (Kaopectate)
*Bismuth subsalicylate (Pepto-Bismol)
*Cholestyramine (Questran®)
*Diphenoxylate and atropine (Lomotil®)
*Loperimide (Imodium®)
*Tincture of Opium (Paragoric®, DTO®)

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MOA of Attagpulgite (Kaopectate)

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*absorption of toxins produced by bacteria and gastrointestional irritants
*decreases gastric motility & stool water content
**same as Pepto-Bismol in the U.S.**

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Common Adverse Effect with Attagpulgite (Kaopectate) Administration

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*hypokalemia
*interference with absorption of other medications

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MOA of Bismuth subsalicylate (Pepto-Bismol)

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*slows motility & antimicrobial activity GI microbes
*prophylaxis for traveler's diarrhea

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Adverse Effect associated with Bismuth Subsalicylate (Pepto-Bismol) Administration

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*tongue discoloration
*dark stools
**both can turn black

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Bismuth subsalicylate (Pepto-Bismol) should be used cautiously with which patient populations?

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*Patients on ASA or anticoagulation
*Reye syndrome
**Remember "salicylate" in Bismuth Subsalicylate (Pepto-Bismol)

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MOA of Cholestyramine (Questran®)

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*absorbs bile salts which can cause diarrhea
**used in patients s/p cholecystectomy
*absorbs Clostrium difficle toxin

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Administration of Cholestyramine (Questran®)

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*separate Cholestyramine (Questran®) administration from other medications by @ least 2 hours

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Dosing for Diphenoxylate and atropine (Lomotil®)

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*2.5 / 0.25 mg QID

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True or False. Diphenoxylate and atropine (Lomotil®)
is a controlled substance.

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True

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Common Side Effects with Diphenoxylate and atropine (Lomotil®) Administration

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*tachycardia
*lethargy
*HA
*urinary retention

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MOA of Loperimide (Imodium®)

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*binds to opioid receptors in intestine to slow intestinal motility
*increases bulk
*slows intestinal motility, including peristalsis

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Dosing for Loperimide (Imodium®)

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*4mg, followed by 2mg after each loose stool
*Max dose = 16mg/day

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Indications for Loperimide (Imodium®)

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*acute & chronic diarrhea
*traveler's diarrhea

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Common Side Effects with Loperimide (Imodium®) Administration

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*dizziness
*constipation
*abdominal cramping
*nausea

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MOA of Tincture of Opium (Paragoric®, DTO®)

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*decrease in GI motility & peristalsis
*decrease in digestive secretions
**difficult to dose...comes in drops

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Common Adverse Effects with Tincture of Opium (Paragoric®, DTO®) Administration

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*drowsiness
*lightheadedness
*bradycardia

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What 2 antidiarrheal agents must be used cautiously with other CNS depressants?

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* Tincture of Opium (Paragoric®, DTO®)
*Loperimide (Imodium®)

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Initial Therapy recommended for mild-to-moderate c. diff associated diarrhea

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Metronidazole (Flagyl)

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Initial Therapy recommended for severe c. diff associated diarrhea

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Vancomycin
*WBC > 15,000
*Creatinine > 1.5x pre-morbid level

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Consult surgery early with c. diff associated diarrhea if you suspect ______________ ____________________.

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*fulminant colitis
*diarrhea may be decreased or absent with this condition

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True or False. Treatment is necessary for asymptomatic patients with positive toxin assays.

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False

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sensation of needing to vomit

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nausea

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forceful evacuation of stomach contents in a retrograde fashion

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vomiting

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Treatment Modalities for Nausea & Vomiting

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*correct underlying cause
*correct electrolyte abnormalities
*eliminate symptoms
*drug therapy
*anti-emetics
*pro-kinetics

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Different Drug Classifications for Anti-Emetics

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*anticholinergics
*antihistamines
*dopamine-antagonists
*5-HT3 antagonists
*Cannabinoid
*Neurokinin antagonists

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Example of Anticholinergic Anti-Emetic

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Scopolamine

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MOA of Anticholinergic Anti-Emetics

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*blocks action of acetylcholine at muscarinic receptor
*decreases salivary & lacrimal secretions

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Indications for Scopolamine

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*effective for preventing motion sickness, but not treating it
*preventing chemotherapy induced nausea

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Application of Transdermal Scopolamine Patch

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*q 72 hrs.

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Anticholinergic Side Effects with Scopolamine Administration

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*dry mouth
*sedation
*blurred vision
*confusion & urinary retention in the elderly

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Examples of Antihistamine Anti-Emetics

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*Meclizine (Antivert®) 25-50mg PO q 24hrs.
*Diphenhydramine(Benadryl®) 25-50mg PO q6 hrs. or 10-50mg IV or IM
*Dimenhydrinate (Dramamine®) 50mg PO q 4hrs.

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Indications for Antihistamine Anti-emetics

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*motion sickness
*vertigo
*migraines

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Formularies for Antihistamine Anti-emetics

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*tablet
*oral suspension
*IM or IV Benadryl

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Adverse Effects with Antihistamine Administration

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*anticholinergic effects
*drowsiness
*hypotension
*urinary retention
**meclizine may be less sedating than Benadryl**

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Examples of Dopamine Receptor Blockers

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*Promethazine (Phenergan®) + some anticholinergic effects
*Prochlorperazine (Compazine®) 5-10mg q 6-8hrs., 25mg IV q 4 hrs., or 25mg PR q 12 hrs.

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Available Formularies for Dopamine Receptor Blockers

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*Oral tablet or suspension
*Rectal suppository
*IM & IV

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Indications for Dopamine Receptor Blockers

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*vertigo
*motion sickness
*chemotherapy
*toxic & metabolic induced nausea
*pre-operative prophylaxis/post-operative n/v

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Adverse Effects with Dopamine Receptor Blockers

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*Extrapyramidal Sx:
-pseudo-parkinsonism
-acute dystonic reaction
-tardive dyskinesia
*QT prolongation
*anticholinergic side effects

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MOA of Butyrophenones in N/V

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*blocks dopamine effects

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Examples of Butyrophenones Used for N/V

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*Haloperidol (Haldol)
*Droperidol

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Indications for Butyrophenones

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*chemotherapy-related n/v
*post-operative n/v

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Adverse Effects of Butyrophenones

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*QT prolongation
*movement disorders
*sedation
*hypotension

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MOA of 5-HT3 Antagonists

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*receptor antagonists at the 5-HT3 receptor
- a subtype of serotonin receptor found in terminals of the vagus nerve & chemoreceptor trigger zone

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Examples of 5-HT3 Antagonists

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*Ondansetron (Zofran®)
*Dolasetron (Anzemet®)
*granisetron

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Indications for 5-HT3 Antagonists

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*chemo-therapy induced n/v
*postoperative n/v
*gastric irritants
*hyperemesis gravidarum

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Adverse Effects of 5-HT3 Antagonists

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*QT prolongation
*HA
**FDA recently eliminated 32 mg IV dose that was administered prior to chemotherapy

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Example of Cannabinoid used for N/V

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*Dronbinol (Marinal®)

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MOA of Cannabinoids in N/V

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*unknown
*made with sesame oil

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Indications for Cannabinoids

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*chemotherapy-induced n/v

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Adverse Effects of Cannabinoid Administration

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*sedation
*tachycardia
*confusion
**euphoria
**appetite stimulant

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Indications for Aprepitant (Emend) Substance P Antagonist Administration for N/V

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*acute & delayed:
-post-operative n/v
-chemotherapy induced n/v

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Indications for Dexamethasone & Benzodiazepines for N/V

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*unknown MOA
*adjunct therapy for chemotherapy-induced n/v

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Indications for Pro-Kinetic Agents

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*Gastroparesis
*GERD

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2 Pro-Kinetic Agents used for N/V

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*Erythromycin (rarely used)
*Bethanechol

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MOA of Erythromycin

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*direct effect on gut motility

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Adverse Effects with Erythromycin Administration

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*QT prolongation
*rash
*abdominal pain

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MOA of Bethanechol

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*muscarinic receptor agonist

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Adverse Effects wit Bethanechol Administration

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*hypotension
*tachycardia
*bronchial constriction