Lower GI: Gas, Constipation, Diarrhea

Fiber for Constipation

helps bulk stool, easier to signal, healthy for microbiome

Intestinal Gas

• excessive aerophagia (air swallowing)

• Eructation- belching of swallowed air

• Bloating- excessive gas esp after eating

• Flatulence- excessive passage of air from stomach/ intestines

• IBS- Rome III diagnostic criteria: Recurrent gas pains associated with diarrhea or constipation, can be related to stress, lactose intolerance or gluten intolerance

• Antiflatulent meds, digestive enzymes, probiotics, diet, lifestyle

Dietary Sugars

-substrates for H2 production

• Lactose in dairy & prepared foods

• Fructose in fruits, veggies, candies, drinks

• Sucrose from table sugar

• Glucose from breakdown of starches

Complex Carbs, Ingestible Oligosaccharides, Fatty Foods

substrates for bacterial fermentation & production of H2 & CO2

Fiber

mixed results for IBS, soluble semisynthetic fiber (calcium polycarbophil) may be better than psyllium

Celiac Disease

intolerance to gluten, protein present in wheat, rye, barley, oats. Gas results from inflammatory response in GI tract after gluten exposure

Diabetic Gastroparesis

potential complication of poorly controlled diabetes in which patient has delayed gastric emptying (bloating, fullness, uncomfortable)

Medications that may cause gas

-Meds that affect intestinal flora: lactulose, antibiotics

-Meds that affect metabolism of glucose, substrates: acarbose, miglitol, metformin

-GI lipase inhibitors: orlistat

-Meds that affect GI motility: narcotics, anticholinergics, calcium channel blockers, psyllium

-Release gas: effervescent agents like Alka-Seltzer

How many grams of fiber should males consume a day?

38 g

Females?

25g

Culprits of Gas

-swallowing air: smoking, chewing gum, whipped food, blended food, drinking through a straw

-medical conditions: lactase deficiency

-odors: odor may be worsened by ingestion of sulfate containing food (bread, bear, red meat)

How may times per day do you pass gas/belch?

How may times per day do you pass gas/belch?

gas: 10-20 x a day

belch: 10-30 x day

Treatment

• Reduce frequency, intensity, duration

• Reduce lifestyle consequences

• Assess sxs, diet, eating habits, med use, relevant med conditions

• Treat underlying cause!

Nonpharmacologic Therapy: Gas

• Eating habits & dietary modifications

• Reduce consumption of gas-producing foods

• Lactose intolerant?

Pharmacologic Therapy: Gas

• Simethicone & activated charcoal: after gas has formed

• Alpha-galactosidase & lactase enzymes: take with foods to prevent gas from forming

• Probiotics: Bifidobacterium, Lactobacillus, Saccharomyces, Streptococcusthermophilus

• Not prebiotics like oligofructose which is a nutrient used by normal intestinal bacterial flora and by probiotic organisms.

-Normal flora produces greater amounts of CO2, CH4, and H2 may increase gas

Simethicone

-allows one to pass gas, reduces bloating/uncomfortable

• Defoaming agent to relieve gas

• Reduce surface tension of gas bubbles embedded in mucus in GI tract

• Not absorbed from GI tract

Activated Charcoal

-not approved, not shown to be effective

-absorbent effects

-not recommended

Beno

-alpha-galactosidase

• Derived from mold Aspergillus niger

• Classified as a food

• Hydrolyzes oligosaccharides into component parts before they can be metabolized by colonic bacteria

• Patients with diabetes- extra 2-6 grams carbs / 100 grams food

• Allergies- PCN or mold- nothing in literature

• Galactosemia-speak with MD

Beano: How to Take

• Take before first bite of food

• Swallow or chew 2-3 tablets for a typical meal

• Do not cook with Beano®

• For 12 years of age and older

• Not studied in pets or pregnancy/ lactation

• Dose: 2-3 chewable tabs or 1 meltaway at a meal

Lactase Replacement Products

• Used for lactose intolerance

• Lactase breaks down lactose

• Aids in digestion of dairy products

• Treat intestinal gas & diarrhea

• Dose: take with first bite of food, if meal lasts longer than 30-45 min then take another

Lactase Products

• Lactase units vary

• Take with first bite of problem food

• If continuing to eat 30-45 minutes after first dose, take another tablet

• Children 4 years and older may take, if younger than 4, avoid dairy

Special Pops: Gas

• Peds: simethicone 40mg/0.6ml=colic?

• Pregnancy: no reports linking to congenital defects

• Nursing: safe (simethicone)

• Beano®: not for children; preg & nursing=consult

• Lactase replacement products: no special pop considerations

Complementary Therapies

• Probiotics • Bifidobacteriuminfantis

• Or multiple bacteria: lactobacillus acidophilus, Lactobacillus paracasei, Bifidobacteriu, & Streptococcus thermophilus

• Normal colonizers of GI

• Balance the digestive system

• Daily admin, 14 day trial

Patient Counseling; Gas

• Eating habits: relax, chew, no smoking/ gum

• Diet: keep diary, avoid whipped foods,soda

• Med use: anticholinergics, Alka-Seltzer, antiobiotics, metformin, orlistat

• Lifestyle Habits: avoid tight clothes, do not lie down after eating, regular exercise & rest

Exclusions: Gas

-Symptoms that last more than a few days or occur more than several times per month

-Severe debilitating symptoms

-Change in location of pain, increase in frequency/ severity, or onset in patients over 40 years

-symptoms plus sig abd discomfort or sudden change in bowel fxn

-Accompanying severe or persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, freq nocturnal sxs

Constipation

• Less than 3 bowel movements/ week characterized by strain, passage of hard, dry stools

• 2-28% of population

• Usually results from abnormally slow movement of feces through colon & accumulates in descending colon

• Untreated may lead to hemorrhoids, anal fissures, rectal prolapse, fecal impaction

-dont self treat over 7 days

Nonpharm Treatment of Constipation

-establish dietary (fiber and water) and exercise habits

Medications that may cause constipation

Analgesics (including NSAIDs) Antacids (e.g., calcium and aluminum compounds, bismuth) Anticholinergics (e.g., benztropine, glycopyrrolate) Anticonvulsants (e.g., carbamazepine, divalproate) Antidepressants (specifically, tricyclics such as amitriptyline, bupropion) Antihistamines (e.g., diphenhydramine, loratadine) Antimuscarinics (e.g., oxybutynin, tolterodine) Antineoplastics (e.g., vinca alkaloids) Benzodiazepines (especially alprazolam and estazolam) Calcium channel blockers (e.g., verapamil, diltiazem) Calcium supplements (e.g., calcium carbonate) Diuretics (e.g., hydrochlorothiazide, furosemide) Hematinics (especially iron) Hyperlipidemics (e.g., cholestyramine, pravastatin, simvastatin) Hypotensives (e.g., angiotensin converting enzyme inhibitors, beta blockers) Muscle relaxants (e.g., cyclobenzaprine, metaxalone) Opiates (e.g., morphine, codeine) Parkinsonism agents (e.g., bromocriptine) Polystyrene sodium sulfonate Psychotherapeutic drugs (e.g., phenothiazines, butyrophenones) Sedative hypnotics (e.g., zolpidem, benzodiazepines, phenobarbital) Serotonin agonists (e.g., ondansetron) Sucralfate

Pharmacologic Therapy

• Classified by MOA

• Bulk forming

• Hyperosmotic

• Emollient

• Lubricant

• Saline

• Stimulant

Bulk Forming Agents

-prevention and treatment, safe to take daily

• Methylcellulose, polycarbophil, psyllium

• Dietary supplements: inulin, guar gum, powdered cellulose, wheat dextrin

• Most closely approximate physiologic mech on promoting evacuation

• Dissolve or swell in intestinal fluid of intestines-stim peristalsis

• Not absorbed systemically & do not interfere with absorption of nutrients

• Onset: 12-24 hours, up to 72 hours

• CHOKING: dry powder, take with full glass of water

• Separate meds by 2 hours

• Not for children <6 years old

Hyperosmotic Agents

• Draw water into colon/ rectum thru osmosis to stimulate BM

• PEG 3350: 17 grams (capful start with 1/2) in 4-8 oz water once daily

• Onset 12-72 hours up to 96 hours

• 17 years and older

• First-line option

• Glycerin suppositories

• 15-30 minutes

• SUPP safe in all groups

• Side Effects: minimal

Emollient Agents

• Stool softeners

• Anionic surfactants act in intestines to increase wetting efficacy of intestinal fluid as well as facilitate a mix of aq and fatty substances to soften fecal matter= SLIPPERY

• Prevent straining & painful defecation

• Combo w/ stimulant for long term tx of opioid-induced constipation

• Onset: 12-72 hours up to 3-5 days

• 12years+: 1-3 caps daily

-good for patients who can't strain

Lubricant Agent

• Mineral oil

• Soften fecal contents in colon by coating stool & preventing colonic absorption of fecal water

• Onset: 6-8 hours after oral (5-15 min rectal)

• Safer agents, don't generally recommend

• Anal leakage of oil, lipid pneumonia

• Impair A, D, E, K absorption

Saline Laxative Agents

-not used much anymore: unsafe

• Mag citrate, mag hydroxide, mono-&dibasic sodium phosphate, mag sulfate

• Ions retained in intestinal wall & draw water in by osmosis increase intraluminal pressure & intestinal motility

• Oral onset: 30 min-3 hrs- 6 hrs

• Rectal: 2-15 min

• Electrolyte imbalances: hypermagnesemia (hypotension, muscle weakness, fatigue) & Sodium phosphate- hyperphosphatemia, hypocalcemia, hypernatremia

Stimulant Agents

• Anthraquinones-senna*, cascara sagrada, aloe extract

• Diphenylmethanes- bisacodyl*, phenolphthalein

• In colon, increase intestinal motility by local irritation of mucosa or intestinal smooth muscle & increase secretion of water and electrolytesin intestine

• Onset: 6-10 hrs up to 24 hrs oral; 15-60 min rectal

• Combination for opioid-induced constipation

• s/e: severe cramping, electrolyte and fluid def, enteric loss of protein, hypokalemia, malabsorption

• Senna may color urine pink-red-violet or brown

• Second line choice for simple constipation

Product Extension

-check AI

-600mgmagnesium hydroxide

• 30 min to 6 hours

• Saline laxative

-can lead to diarrhea and side effects

Special Pops

• Children: delay or difficulty of 2 weeks or longer!

• Fecal impaction=refer

• Dietary & behavior modifications

• 2-6yo: oral docusate sodium, magnesium hydroxide, senna (not first)

• 6-12yo: bulk-forming agents, docusate sodium, mag hydroxide, others

• Off label: PEG 3350

• NEVER Epsom salts or castor oil

Advanced Age

• MTM

• Lifestyle modifications

• Dehydration

• Bulk-forming lax or PEG 3350- firstline

• Stoolsofteners

• Plain water enemas or glycerin supp- acute episode

Constipation Counseling

• Identify cause

• Balanced diet, exercise, adequate fluids

• Regular pattern for toileting

• Squatty potty

• Limit lax use to 7 days unless PCP involved

• Abdominal pain, N, V, change in bowel habits x2 weeks, lax>7 days=refer

• Rectal bleeding=refer

• Space meds 2 hours apart

Diarrhea

• Abnormal frequency or volume of semi-liquid or fluid fecal matter, >3/day

• Classification: Acute, Persistent, Chronic

Acute Diarrhea

abrupt, <2weeks, abdominal pain, malaise, flatulence, generally resolves in 3 days, Causes: dietary, infection, toxicity, drugs

Persistent Diarrhea

2-4 weeks

Chronic Diarrhea

frequent passage>4 weeks; difficult to diagnose

Travelers' Diarrhea

3-8 water stools/ day, w/ nausea, abd cramps, +/- vomiting, fever, subsides over 3-5 days, usu bacterial

Food Induced Diarrhea

allergy, fatty, spicy, fiber, seeds, lactose intolerant

Viral Gastroenteritis

• Noroviruses- most common cause of diarrheal illness in adults & children

• Highest incidence in younger than 5 yo

• Responsible for 18% of acute gastroenteritis infections annually worldwide (685 million)

• US: 800 deaths, 71K hospitalizations, 400K ED visits, 1.9 million outpatient visits

• Year round, peak in Winter

• Transmitted by contaminated water or food, or person to person orsurfaces

• Rotavirus- most common cause of severe diarrhea in infants and young children; vaccine rate in US children over 70%, spread by oral- fecal route

• Often both result in osmotic diarrhea

Bacterial, Protozoal, Foodborne Gastroenteritis

• Bacterial pathogens cause 10% of acute diarrheal illness in US, most from foodborne transmission

• Risk factor for IBS development

• Protozoal- no OTC

• Foodborne- 47.8 million episodes, 3K deaths in US

• When identified, 59% caused by viruses (often noroviruses), 39% bacteria, 2% protozoa

• Poor sanitation

Exclusions for Self Treatment of Diarrhea

• <6months of age

• Severe dehydration

• > or = 6 months w/ high fever>102.2

• Blood, mucus, pus in stool

• Protracted vomiting

• Severe abdominal pain/distress

• Risk for sig complications

• Pregnancy

• Chronic/ persistent diarrhea

• Suboptimal response to ORS

Clinical Presentation for Diarrhea

• Thorough medical hx

• Pathophysiologic mech: Osmotic, Secretory, Inflammatory, Motor

-Black, tarry stool- upper GI bleed

• Red stools- lower bowel, hemorrhoids, red foods, drugs

• High in sodium-secretory diarrhea

• Yellowish- bilirubin- liver

• Whitish- fat- malabsorption dx

Goals of Diarrhea Tx

• Prevent and correct fluid & electrolyte loss and acid-base disturbance

• Control sxs

• ID & treat cause

• Prevent acute morbidity & mortality

Diarrhea Tx

• Often self-limiting

• Fluid and electrolyte replacement

• Specific dietary measures

• Maybe loperamide

• Uncomplicated- improve 24-48 hours

• Normal bowel in 24-72 hours

Fluid and Electrolyte Management

• Reduced osmolality ORS preferred tx for mild to moderate (75meq/L of sodium)

• Rehydration phase: over 3-4 hours quickly replaces water & electrolyte def

• Maintenance phase: ORS given to maintain normal body composition until adequate dietary intake is established

• Oral intake does not worsen diarrhea

-ORS 5 years and above

Dietary Diarrhea Management

• Early refeeding and ORS improves outcomes

• Most can tolerate breast milk & cow milk

• BRAT diet - not recommended unless short term because not nutritious

• Avoid fatty foods, spicy, simple sugars, caffeine

Loperamide (Imodium)

-OTC 8mg

• Popular, safe, effective

• Synthetic opioid agonist (can be abused)

• Stimulates micro-opioid receptors on intestinal muscles to slow intestinal motility

• >6yo indicated

• <6yo: risky due to ileus & toxic megacolon w/o clinically sig benefit

• S/E: dizziness, constipation, xerostomia

• Undergoes extensive first-pass metabolism by cytochrome P450 (CYP) 3A4 and CYP2C8

• Substrate for the efflux transporter P-glycoprotein (P-gP) • Resulting in limited bioavail to 0.3%

• P-gP limits distribution into CNS, minimizes risk of CNS adverse effects

• BUT at high doses or inhibition of CYP3A4, CYP2C8, or P-gP= CNS, cardiac conduction is disrupted and life-threatening

Bismuth Subsalicylate

• Acute & traveler's diarrhea

• Reacts w/ hydrochloric acid in stomach to form bismuth oxychloride & salicylic acid

• Bismuth has direct antimicrobial effects

• Salicylate moiety exerts antisecretory effects (reduce losses)

• Avoid use in AIDS patients

• Counsel?

• 525mg Q30-60min up to4200mg/day

Digestive Enzymes

• Lactase deficiency who are intolerant of milk products

• Lactase enzyme

• 5-15 drops placed in dairy or taken with

• 1-3 tabs or 1-2 caps with first bite

Special Pops- Diarrhea

• 5yo and under: treat dehydration w/ ORS, not antidiarrheal meds

• Elderly= REFER

• Pregnant= REFER

• BSS CI breastfeeding

• BSS DOC if vomiting w/ gastroenteritis

Probiotics

• Lactobacillus species, Bifidobacterium lactis, Saccharomyces bouladrii prevent & treat mild acute diarrhea even rotavirus & abx associated diarrhea

• Produce acids that lower intestinal pH and suppress growth of pathogenic bacteria, enhance immune response, produce antimicrobial substances, and compete bacteria for intestinal mucosal binding sites

Hemorrhoids

• Large, bulging, symptomatic conglomerates of hemorrhoidal vessels, supporting tissues, overlying mucous membranes in anorectal region

• Due to inflammation of vascular cushions

• Itching, discomfort, irritation, burning, inflammation, swelling

Treatment for Hemorrhoids

• Alleviate & maintain remission of anorectal sxs

• Prevent complications

• Maintain adequate fluid intake, well-balanced high fiber diet

• Good perianal hygiene

• Avoid prolonged sitting on toilet

Nonpharm Tx for Hemorrhoids

• Avoid lifting heavy objects

• D/C foods that irritate or aggravate sxs (caffeine, citrus, spicy)

• Increase fiber

• Avoid NSAIDs and ASA which may promote bleeding

• Listen to body

• Good hygiene

• Sitz bath 2-4 times per day x10-20minutes

Local Anesthetics for Hemorrhoids

• External anal sxs

• Temporary relief of itching, irritation, burning, discomfort, pain by reversibly blocking transmission of nerve impulses

• Allergic reactions

• Benzocaine, dibucaine, lidocaine, pramoxine

• Not on open sores

Vasoconstrictors for Hemorrhoids

• Structurally related to endogenous catecholamines, epinephrine, & norepinephrine

• Constriction of arterioles- ?

• Phenylephrine- external & intrarectal use

• Minimal CNS effect, cardiac rhythm

• Ephedrine & epinephrine: increased cardiac contractility,HR

Protectants for Hemorrhoids

• Prevent fecal matter from causing perianal irritation by forming a physical protective barrier over skin

• Soften dry anal canal by decreasing water loss

• Temporary relief of discomfort, itching, irritation, burning with ext and int (not glycerin)

• Mineral oil, petrolatum

Astringents for hemorrhoids

• Promote coagulation of skin cells- protect underlying tissue

• Witch hazel- external use only

• Calamine, zinc oxide- external & internal

Keratolytics for hemorrhoids

• Cause desquamation & debridement of epidermal surfacecells

• External use

• Resorcinol but...

• Risky: methemogloinemia, dermatitis, death in infants, myxedema in adults, tinnitus, ringing in ears, sweating, SOB

Analgesics/Anesthetics/Antipruritic for Hemorrhoids

• Counterirritants: menthol, juniper tar, camphor- external

• Relief of pain, itching, burning, discomfort by producing local sensation that distracts

Corticosteroids for hemorrhoids

• Vasoconstrictor & antipruritic

• Onset may take up to 12 hours, effect is longer than most

• Minor external anal itching

• Skin atrophy can be S/E

• Apply 3-4x/day

• Dr. Capoccia's #1 pick!

Special Pops for Hemerroids

• Pregnant & breastfeeding: external use except protectants(not glycerin containing ones) which may be used internally

• Increase fiber and fluid intake

• Cocoa butter, topical starch supp (TUCKS®)- not glycerin

• Under 12 years? REFER