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GI Exam 2
Long Diarrhea
| Question | Answer |
|---|---|
| Diarrhea has a variable definition: | INCREASED frequency and decreased consistency of fecal discharge vs the INDIVIDUAL’S NORMAL bowel pattern |
| Diarrhea: normal bowel patterns VARY and can be affected by diet patterns. Typically diarrhea can be? | mild, moderate, or severe |
| Mild diarrhea definition? | if </= to 3 loose stools in 24 hours |
| Moderate diarrhea definition? | if 4-5 loose stools/24 hours |
| Severe diarrhea definition? | if >/= 6 loose stools/24 hours |
| We can also define pt’s diarrhea by timing such as? | Acute/ Persistent/Chronic |
| Acute diarrhea is < ______ days. Main cause? Big player bugs? | 14 days; Infectious diarrhea (bacteria > viruses), or food diarrhea (gastric irritation); Shigella, Salmonella (raw chicken), Campylobacter, Staphylococcus, E. Coli, Norwalk virus, rotavirus; infections are often food-borne or hygiene/sanitization-related; food-induced: spicy/fatty foods, caffeine, artificial sweeteners, beans, nuts |
| Acute diarrhea is often _____-_______ and resolves within _____ hours | self-limited; 72 hours *wait for it to be over and be sure to hydrate |
| Persistent diarrhea (definition by duration) is > _____ days | 14 days (2 weeks on a regular basis) |
| Chronic diarrhea (definition by duration) is > ____ days | 30 days (at least a month and is a sign of IBS or IBD) |
| What are the DRUG-INDUCED causes of Diarrhea? (ONES IN RED TO REMEMBER) | Magnesium products; ABX; PPIs/H2RAs; Cholinergics Not red: Anti-neoplastic agents, colchicine, metoclooparmide, quinidine Digoxin, laxatives |
| What are the 4 main types of diarrhea? | Secretory, Osmotic, Exudative, Altered Intestinal Transit |
| Type of Diarrhea: Secretory is? | increased secretion or decreased absorption of water/electrolytes; unabsorbed dietary fat, laxatives, hormones, bacterial toxins, excessive bile salts; large stool volumes with normal ionic contents/osmolarity |
| Type of Diarrhea: Osmotic is? | Poorly absorbed substances retain intestinal fluids; ⭐️ STOPS WHEN FASTING; I,e: LACTOSE INTOLERANCE, MALABSORPTION SYNDROMES, MAGNESIUM |
| Type of Diarrhea: Exudative is? | Mucus, serum proteins, and blood are discharged into the gut; ⭐️ INFLAMMATORY GI DISEASE -Large stool volumes |
| Type of Diarrhea: Altered Intestinal Transit is? | decreased contact time in small intestine, premature colonic emptying, bacterial overgrowth; ⭐️ METOCLOPRAMIDE, ABX, COLCHICINE, MISOPROSTOL |
| Complications of Diarrhea include? | ⭐️ FLUID AND ELECTROLYTE IMBALANCES; DEHYDRATION; Acid-base disturbances; CV collapse/death |
| High risk populations for complications for diarrhea include? | infants, young children, elderly, debilitated adults |
| Treatment strategy for Diarrhea is? | 1. identify and treat causes (if possible) 2. Manage potential dietary causes/exacerbations 3. Relieve symptoms 4. *prevent/treat water, electrolyte, and acid-base imbalances* 5. Prevent morbidity and mortality Look at the Hx and physical of the pt—> are they acute/chronic—> if acute check for infectious source if systemic symptoms—> implement symptomatic therapy |
| Self-Treatment exclusions for Diarrhea include? | severe dehydration; ⭐️ BLOOD 🩸; mucus, or pus in stool; severe abdominal pain; protracted vomiting; ⭐️ PERSISTENT/CHRONIC diarrhea; < 6 months old or >/= 6 months old with persistent fever > 102.2; pregnancy; PMH sig. for DM, severe CVD; renal disease; transplantation; AIDS; immunosuppression; Suboptimal response to oral replacement therapy *Help by REFERRAL *less than 6 months old—> send to pediatric |
| Symptomatic Therapy for Diarrhea includes? | Repleate hydration +/- electrolytes; D/C medication causes if possible; adjust diet; Administer Loperamide, diphenoxylate, or absorbent *IF APPLICABLE |
| We have to decide… should this diarrhea be stopped? Or is it serving a purpose? Can you think of any type of diarrhea discussed that you would want them to continue having diarrhea until it’s done? | Food poisoning (or some kind of infection) so if there’s signs of infection your body is having diarrhea to remove the infecting issue, if you give lopermaide, diphenoxylate, or absorbent—> that is going to stop 🛑 the diarrhea and therefore keep the infection inside the body wrecking more havoc. |
| So if pt has C.Diff, we want the C.Diff to come out and we treat the C. Diff with? | Metronidazole, Fidaxomycin, or PO Vanco ⭐️ We do not give Loperamide if we suspect an infection (i.e. fever) |
| Fluid and Electrolyte Management—>Replace water/electrolyte losses—> If pt is volume depleted—> | FiRST replace water/electrolytes to normal body composition; use ENTERAL route if possible ⭐️; Extra important for pediatric and geriatric populations |
| Fluid and Electrolyte Management in diarrhea—> If acute and from a developing country where water supply is not great we give? For an American child? | Add ZINC 20 mg daily for 10 days to decrease severity/duration in developing countries -We do not give Zinc because there is sufficient Zinc in diet |
| Fluid and Electrolyte Management: ⭐️ What we recommend as an option over pedialyte or Gatorade is? | ⭐️ WHO Oral Rehydration Solution *Just know that this is the option over pedialyte or Gatorade because it has lower carbohydrates |
| When we are replenishing fluids/electrolytes, the OPTIMAL way to do so is? | ENTERALLY not PARENTERAL (*unless it’s very severe) use the gut if we can. |
| Dietary management for Diarrhea—> we do not recommend the ______ diet because its very restrictive | BRAT (Bananas, Rice, Applesauce, Toast) |
| Retention question Long: Which of the following medications is the most likely to cause metabolic syndrome? -Quetiapine -Haldol -Abilify -Thorazine | Quetiapine |
| Which of the following are CI in pregnancy? (Select all) -Paxil -Depakote -Sertraline -Prozac -Olanzapine | Paxil, Depakote, |
| 5 different pharmacologic therapy for Diarrhea include? | Anti-motility; Anti-secretory; Adsorbent; Digestive Enzymes; Probitics |
| Anti-motility agents include? | Loperamide (Imodium), Dipenoxylate-atropine; Difenoxin-atropine; Opium tincture |
| Anti-secretory agents include? | Bismuth subsalicylate |
| Adsorbent agents include? | Polycarbophil; Kaolin-pectin; Attapulgite |
| Digestive enzyme agents include? | Lactase |
| Probiotic agents include? | Lactobacillus; Bifidobacterium infantis (Align) |
| Anti-motility agents: Loperamide (Imodium) works by? *remember its an OTC | stimulating the mu opioid receptors in the intestines FYI (slows GI motility, decreases peristalsis; decreases GI secretions, increases water/electrolyte absorption; strengthens rectal sphincter tone) |
| Dosing for Loperamide (Adults): | 4 mg initially—> 2 mg after each stool (MAX: 16 mg/day) for 48 hours ⭐️ *takes 2 tabs initially and after each time they go to the bathroom take another tablet but no more than 2 days and no more than 16 mg/day. For calculation, remember they are take 2 tabs initially |
| Dosing for Loperamide (Children): | <12 yo: 2 mg initially—> 1 mg after each stool for 48 hours ⭐️ 9-11 yo: *MAX: 6 mg/day ⭐️ 6-8 yo: MAX: 4mg/day ⭐️ |
| Lopermaide is well tolerated. It has the ______ AE in anti-motility class | LEAST; has some constipation, dizziness, dry mouth, abdominal pain; No sig. medication interaction |
| T/F: Any pt can use Loperamdie if they have INFECTIOUS diarrhea | FASLE *As we discussed, sometimes we don’t want the diarrhea to stop temporarily and make sure any kind of infectious component comes out of the body (*so look for signs of infection: fever, food-poisoning?) |
| T/F: Loperamide is Addictive | True (be sure to tell them the max |
| Anti-motility agents: Diphenoxylate-Atropine (Lomotil) is a? | Schedule V controlled substance, NOT OTC |
| What are the components of Lomotil? | Opioid + subtherapeutic anticholinergic Diphenoxylate—> stimulates the mu opioid receptors in intestin -Atropine added to discourage drug abuse (*Atropine is not at a dose to provide anticholinergic effects, just added to discourage drug abuse) |
| Lomotil (don’t need to know actual dose, just the MAX dose for adults? | (MAX dose: 20 mg-0.2 mg/day for 10 days) UNTIL IMPROVEMENT then decrease the dose |
| Lomotil MAX dose in children 2-12 yo (LIQUID ONLY) is? | MAX: 10 mg-0.1 mg/day |
| Remember, do NOT USE Lomotil if pt has __________ diarrhea | infectious *stopping the stool from happening and not solving the problem at all |
| AE of Driphenoxylate-Atropine are? | AE of Diphenoxylate are rare at the recommended dose; Some Atropine effects are possible (Blurred vision, dry mouth, constipation, nausea, drowsiness, dizziness) |
| Caution for Lomotil use—> CI in? Avoid use with? | CI in GLAUCOMA ⭐️; cardiac disease, and obstructive uropathy (due to atropine component); AVOID use with Azelastine, Ipatropium, MAOIs, and Potassium |
| Anti-secretory Agents: Bismuth Subsalicylate—> | Anti-secretory and direct antimicrobial vs bacterial/viral pathogens FYI—> increased stool consistency, decreases frequency of unformed stools, decreases abdominal pain, nausea and vomiting |
| Dosing for Peptobismol Adults: | 524 mg Q30-60 min for 48 hours MAX: 4800 mg/day ⭐️ |
| AE of Peptobismol include? | Tinnitus, neurotoxicity in high doses, risk of REYE’S SYNDROME ⭐️ (salicylate) -Avoid in pediatric pts who have/recovering from chickenpox/flu; Avoid in pregnancy ⭐️ Blackened tongue +/- stools—> COUNSELING POINT *turns black due to enzymes in the body; stool is black because of blood if not from pepto? Do not treat—> refer. |
| Medication interactions with Peptobismol include? ⭐️ | Decreased protein binding of WARFARIN, Valproic Acid, Methotrexate—> increases toxicity; Binding of TCN and FQ ABX—> decreases efficacy; increases bleeding risk with anticoagulants |
| Precautions with Peptobismol include? ⭐️ | Pregnancy or breastfeeding; recent influenza or chickenpox or adolescents; concomitant anticoagulation; Hx or risk of GI bleed |
| LONG: “if you decrease the protein binding of a medication that is highly protein bound, is there more active drug or less active drug? | More active drug; so when a drug is bound to a protein, its not working; if you remove proteins —> increase toxicity |
| The following are considered miscellaneous agents are not considered effective which are? | Probioitcs, Digestive enzymes (i.e. lactase products), Adsorbents, Octreotide, and bile acid sequesterants (Cholesytramine, colestipol, colesevelam) |
| Probiotics are? | replace colonic microflora—> suppress growth of pathogenic flora; mixed reports of efficacy in the evidence; Major AE—> FLATUS; Guidelines only recommend use in the context of clinical trials |
| Digestive enzymes (i.e. Lactase products) are? | useful if lactose intolerance, in which dairy products cause osmotic diarrhea; taken with dairy at mealtimes *pt can take the lactase that will supplement the enzyme since they have low level of enzyme |
| Adsorbents are? | they ADSORB nutrients, toxins, medications, digestive juices; Lack of evidence of efficacy—> rarely used; Polycarbophil (hydrophilic, nonabsorbable) 1250 mg up to 4x daily |
| Octreotide is much more used in which kind of patient? | Cirrhotic |
| Octreotide is a _________ analog that blocks the release of 5-HT; inhibits intestinal secretion and stimulates intestinal absorption | Somatostatin |
| This agent is used for diarrhea from CARCINOID TUMORS AND/OR CHEMOTHERAPY | Octreotide *lack of evidence for superiority over loperamide or lomotil |
| Octreotide can cause what kind of adverse reactions? | abdominal pain, bradycardia, and/or hyperglycemia |
| T/F: Octreotide is an INJECTIBLE formulation | TRUE |
| Our Bile Acid Sequesterants (Cholestyramine, Colestipol, and Colesevelam) help to? | decrease fecal bile acids by forming a non-absorbable complex -more commonly used for other indications (i.e. dyslipidemia, purities) |
| For our bile acid sequesterants we want to MONITOR for ⭐️ | MEDICATION INTERACTIONS due to BINDING-ABILITIES (vitamins, NSAIDs, Amiodarone, oral contraceptives, diuretics) ⭐️ *Dr. Long Acronym: DAVON* |
| Who should you NOT give Loperamide to for the treatment of diarrhea? -Pt with laxative-induced diarrhea -Pt with lactose-intolerance -Pt with diarrhea from C. Diff | Pt with diarrhea from C. Diff |
| Ms. Appleberry comes to the counter and asks which product would be best for her 5 month old son, who has been having diarrhea. She explains she’s pretty sure he is lactose intolerant because there is only a little blood. What do you recommend? -Lactase -Probiotic -Loperamide -Pepto-Bismol -None of the above | None of the above *Blood and 5 months old—> referral |
| Constipation/Diarrhea Summary: Constipation and Diarrhea are fairly common and definitions may vary based on? | individual pt’s normal bowel |
| Constipation/Diarrhea Summary: Age, diet, chronic diseases, and medications may _______ the risk of developing constipation or diarrhea | increase |
| Constipation/Diarrhea Summary: Pts with alarm symptoms should NOT self-treat, but instead should be ________ for further diagnostic testing due to the risk of complications | Referred |
| Constipation/Diarrhea Summary: There are a variety of non-pharmacologic and pharmacologic therapeutic options, many of which are ______, available for the prevention and tx of constipation and diarrhea | OTC |
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Xander635
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