GI: Self-Care Approach

heartburn

a burning pain in the stomach or lower part of chest that rises toward the neck and occasionally to the back.

- occurs when stomach acid backs up into the tube that carries food from the mouth to the stomach (esophagus).

dyspepsia

Also known as indigestion is a pain or an uncomfortable feeling in the upper middle part of your stomach area.

- wide range of digestive issues. Heartburn, on the other hand, occurs when stomach acid escapes into your esophagus. It's one type of indigestion.

GERD

Heartburn occurs when stomach acid backs up into your esophagus due to a weak or relaxed lower esophageal sphincter. It may also be a symptom of a chronic condition called _____

lower esophageal sphincter

Normally, when swallowing occurs, a band of muscle around the bottom of your esophagus, the _____, relaxes to allow food and liquid to flow down into your stomach. Then, the muscle tightens again.

- If this relaxes abnormally or weakens, stomach acid can flow back up into the esophagus (acid reflux) and cause heartburn

- Delayed gastric emptying

- Impaired gastric accommodation to a meal

- Hypersensitivity to gastric distention

- H. pylori infection

- Altered response to duodenal lipids or acid

- Abnormal duodenojejunal motility

- Central nervous system dysfunction

Dyspepsia can be organic (has an identifiable cause) and functional (has no identifiable organic, systemic, or metabolic disease). Several pathophysiologic mechanisms have been suggested to underline dyspeptic symptoms. These include:

1. Aspirin/NSAIDs

2. Barbiturates

3. Beta2-adrenergic agonists

4. Calcium channel blockers

5. Antibiotics: clindamycin, doxycycline, tetracycline

6. Nitrates

7. Iron

8. Chemotherapy

9. Anticholinergic

10. Progesterone

11. Prostaglandins

12. Potassium

13. TCAs

14. Estrogen

15. Quinidine

16. Zidovudine

Medications that may contribute to heartburn and GERD

1. alcohol

2. caffeinated beverages

3. carbonated beverages

4. chocolate

5. citrus fruit

6. fatty foods

7. garlic or onions

8. mint

9. spicy foods

10. tomatoes/tomato juice

dietary factors that contribute to heartburn and GERD

1. exercise: isometric

2. obesity

3. smoking tobacco

4. stress

5. supine body positions

6. tight-fitting clothes

7. motility disorders

8. PUD

9. Zollinger-Ellison Syndrome

10. scleroderma

lifestyle/diseases that may contribute to heartburn and GERD

1 hour

Heartburn may occur alone or as a symptom of other GI disorders such as GERD and PUD. Heartburn is noted most frequently within ____ hour(s) after eating especially after a large meal or indigestion of offending foods and/or beverages.

regurgitation

a bitter acidic fluid in back of the throat and occurs more commonly at night or upon bending over

water brash

sudden filling of the mouth with clear slightly salty fluid secreted from the salivary glands

2

GERD is suggested by heartburn that occurs ____ or more times a week.

1. Postprandial fullness

2. Early satiation

3. Epigastric pain

4. Epigastric burning

Dyspepsia can present with one or more of four main symptoms:

Antacaids and H2RA

_____ and ____ should be recommended to patients with mild infrequent heartburn and dyspepsia

H2RA

_____ is preferred for mild-moderate episodic heartburn. Combing with antacids can prolong the duration and provide quicker relief.

>2 days per week

PPI can be used for frequent heartburn, >____ days per week, or when H2RA doesn't work.

3 months

Frequent heartburn for more than ____ months excludes self-treatment.

1. frequent heartburn for more than 3 months

2. Heartburn while taking the recommended dosage of nonprescription H2RA or PPI

3. Heartburn continues after 2 weeks of treatment with H2RA or PPI

4. Heartburn and dyspepsia that occur when taking a prescription H2RA or PPI

5. Severe heartburn and dyspepsia

6. Nocturnal heartburn

7. Difficulty or pain in swallowing solid foods

8. Vomiting up blood or black material or passing black tarry stools

9. Chronic hoarseness, wheezing, coughing, or choking

10. Unexplained weight loss

11. Continuous nausea, vomiting, or diarrhea

12. Chest pain accompanied by sweating, pain radiating to shoulder, arm, neck or jaw, and shortness of breath

13. Children <2 years (for antacids), 12 years(for H2RA), or 18years (for PPI)

14. Adults >45 years with new-onset dyspepsia

exclusions for self-treatment of heartburn and GERD

< 2 years old

children who present with symptoms of heartburn that are <____ years of age are excluded from self-treatment with antacids

12 years old

children who present with symptoms of heartburn that are <____ years of age are excluded from self-treatment with H2RAs

<18 years old

patients less than ____ years old who present with symptoms of heartburn should not be recommended PPI. refer them to their PCP

>45

adults >_____ years old with new-onset dyspepsia are excluded from self-treatment for heartburn

1. Identify and avoid triggers

2. weight loss for patients who are overweight

3. Elevating the head on bed by placing 6-to 8-inch blocks underneath the legs at the head of the bed or placing a foam wedge beneath the patient upper torso and head

4. eat smaller meals, reduce intake of dietary fat

5. Refrain from eating within 3 hours of going to bed or lying down

6. consult on tobacco and caffeine intake if needed

nonpharmacological therapy for GERD

<5 min

onset of relief of GERD with antacids

20-30 min

duration of action of antacids

30-45 minutes

onset of relief of GERD with H2RAs

4-10 hours

duration of action of H2RAs

<5 min

onset of relief of GERD with H2RA + Antacid

8-10 hours

duration of action of H2RA + Antacid

2-3 h

onset of relief of GERD with PPIs

12-24 hours

duration of action of PPIs

antacids

relieve heartburn and dyspepsia by neutralizing gastric acid

- short duration due to quick elimination from stomach

- must be 2 years and older

Alka-Seltzer Heartburn

Alka-Seltzer original

Sodium bicarbonate, anhydrous citric acid antacid brands

Gaviscon regular strength liquid

Aluminum hydroxide, magnesium carbonate antacid brand

Gelusil tablets

Mylanta ultimate strength liquid

Aluminum hydroxide, magnesium hydroxide antacid brands

Mylanta supreme liquid

Rolaids regular strength antacid tablets

Calcium carbonate, magnesium hydroxide antacid brand

Pepto Bismol Maximum strength liquid and original liquid

Bismuth subsalicylate antacid brand

Tums regular strength 500 tablets

Tums extra strength 750 tablets

Calcium carbonate antacid brand

aluminum hydroxide

Magnesium containing products can cause diarrhea. May be reduced if combined with _____

< 30 ml/min

Do not use magnesium containing products if CrCl is <____ ml/min

hypophosphatemia

Aluminum content in antacids is associated with constipation. Prolonged use can cause _____ because it binds dietary phosphate in the GI tract

2500 mg/d

what is the daily recommended intake of calcium for people 19-50 with normal renal function?

2000 mg/d

what is the daily recommended intake of calcium for people 51+ with normal renal function?

H2RA

Decreases fasting and food-stimulated gastric acid secretion and gastric volume by inhibiting histamine on the histamine-2 receptor of the parietal cells.

- indicated for treatment of mild-moderate, infrequent, or episodic heartburn and for the prevention of heartburn-associated with acid indigestion and sour stomach

- indicated for patients 12+

Tagamet

brand for Cimetidine

Pepcid AC

brand for Famotidine

Famotidine

Calcium carbonate

Magnesium hydroxide

what is in the combination product Pepcid complete?

< 50 ml/min

reduce the dose of H2RAs in patients with a CrCl < ____ ml/min and in patients of advanced age

PPIs

block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane. This process blocks the final step in gastric acid secretion providing a more potent and prolonging antisecretory effect than that of H2RA

- indicated for frequent heartburn in patients who have symptoms 2 or more days a week; not intended for immediate relief or acute episodes of heartburn and dyspepsia

- most effective taken 30-60 min before a meal

- self treatment is limited to 14 days and no more frequent than every 4 months

2 or more days a week

PPIs are indicated for frequent heartburn in patients who have symptoms ____ or more days a week; not intended for immediate relief or acute episodes of heartburn and dyspepsia

14 days

self-treatment with PPIs is limited to _____ days and no more frequent than every 4 months

Prilosec OTC

brand for Omeprazole magnesium

Zegerid OTC

brand for Omeprazole/Sodium Bicarbonate

Prevacid

brand for Lansoprazole

Nexium 24 h

brand for Esomeprazole

constipation

- Patients' perception of and definitions of normal bowel frequency and constipation vary widely.

defined in adults as occurrence of fewer than 3 bowels movements per week, associated with straining and difficult passage of hard, dry stools

<7 days

FDA labeling limit use to short term treatment without medical referral for constipation is ____ days

1. marked abdominal pain or significant distention or cramping

2. fever

3. presence of chronic medication that may preclude self-care laxative treatment (IBS, colostomy, paraplegia)

4. unexplained changes in bowel habits

5. anorexia

6. marked change in character of stool

7. any bowel symptoms that recur after dietary or lifestyle changes or laxative use

8. marked or unexplained flatulence

9. n/v

10. daily laxative sue (except fiber-based therapy)

11. blood in stool or dark, tarry stool

12. any bowel symptoms that persist > 2 weeks or recur over a period of at least 3 months

13. IBS

14. age < 2 years

1-2 weeks

Gradually increase fiber intake over a period of _____weeks to avoid GI side effects

2 L/day

for nonpharmacological therapy for constipation, increase fluid intake to approximately ___ L/day

- Methylcellulose (Citrucel powder)

- Calcium polycarbophil (FiberCon Caplets)

- Psyllium fiber (Metamucil smooth texture)

list the bulk forming laxatives that vwork by pulling fluid into the intestines to make the stool softer and bulkier. This can help to produce muscle contractions in the intestines, which means the muscles tighten or squeeze. The contractions push the stool through your system.

- onset of action: 12-24 hours; onset may be delayed up to 72 hours

- may be used in patients on low fiber diet, postpartum women, older adults, IBS, or diverticular disease

- avoid in patients should be avoided in patients who have swallowing difficulties or esophageal strictures

avoid in patients should be avoided in patients who have swallowing difficulties or esophageal strictures

avoid bulk forming agents in which patients?

- Methylcellulose (Citrucel powder)

- Calcium polycarbophil (FiberCon Caplets)

- Psyllium fiber (Metamucil smooth texture)

- Glycerin (Fleet Glycerin Suppository)

- Polyethylene glycol 3350 (MiraLAX)

hyperosmotic agents that are poorly absorbable and draws water into the colon or rectum through osmosis to stimulate a bowel movement.

- site of action: colon

- onset of action: 12-72 hours for oral; 0.25-1 hour for rectal

- use with caution in renal or cardiac dysfunction

- SEs: bloating, abdominal discomfort, cramping, flatuence

use with caution in renal or cardiac dysfunction

use hyperosmotic agents with caution in patients with

- Glycerin (Fleet Glycerin Suppository)

- Polyethylene glycol 3350 (MiraLAX)

Docusate sodium (Colace)

Emollient laxatives, also known as stool softeners, are anionic surfactants that enable additional water and fats to be incorporated in the stool, making it easier for them to move through the gastrointestinal tract.

- site of action: small and large intestine

- onset: 12-72 hours

- used to prevent straining and painful defecation in patients with anorectal disorders or in those who should avoid straining

Docusate sodium (Colace)

- Emollient (stool softener)

which agents are used in combination with stimulant laxatives to relieve opioid induced constipation?

- Mineral oil 100% (Fleet mineral oil enema)

- Mineral oil 55% (Kondremul emulsion)

Lubricant laxatives are substances that coat the stool with slippery lipids and decrease colonic absorption of water so that the stool slides through the colon more easily. Lubricant laxatives also increase the weight of stool and decrease intestinal transit time

- site of action: colon

- onset of action: 6-8 hours for oral; 5-15 min for rectal

- can cause lipid pneumonia, resulting from aspiration into the lungs after an oral dose

- do not take before lying down and should avoid in patients with aspiration risk

- do NOT use in patients ≤ 6, pregnant women, bedridden or older adults, and individuals with difficulty swallowing

lipid pneumonia, resulting from aspiration into the lungs after an oral dose

risk with use of Mineral oil for constipation

- patients ≤ 6 years old

- pregnant women

- bedridden or older adults

- individuals with difficulty swallowing

which patient populations should not use Mineral oil for self-treatment of constipation?

- Magnesium citrate

- Monobasic sodium phosphate/dibasic sodium phosphate (Fleet enema, Pedia-Lax enema)

- Magnesium hydroxide (Philips' Milk of Magnesia Suspension)

Saline laxatives are non-absorbable osmotically active substances that attract and retain water in the intestinal lumen, increasing intraluminal pressure that mechanically stimulates evacuation of the bowel.

- Site of action: small and large intestines

- Onset of action: 0.5-3 hours (oral), 2-15 minutes (rectal)

- Saline laxatives are used to treat constipation or for acute bowel evacuation required before a procedure

- Bisacodyl (Dulcolax)

- Sennosides (Senokot)

- Senna concentrate (Fletchers Laxative for kids)

- Sennosides/docusate sodium (Senokot-S)

Stimulant laxatives are substances that act on the intestinal mucosa or nerve plexus, altering water and electrolyte secretion. They also stimulate peristaltic action and can be dangerous under certain circumstances.

- Site of action: colon

- Onset of action: 6-10 hours

- Onset of effect: up to 24 hours

- Stimulant laxatives are known to cause abdominal pain.

diarrhea

Abnormal increase in stool frequency, liquidity, or weight.

- Having more than 3 bowel movements per day is considered abnormal

< 14 days

acute diarrhea is < ____ days

persistent

diarrhea that lasts 14 days - 4 weeks

**not treated OTC

4 weeks

chronic diarrhea lasts more than ____ weeks

**not treated OTC

gastroenteritis

- The remaining 10% of acute diarrhea cases are caused by medications, toxic ingestions, ischemia, food intake, and other conditions.

Acute diarrhea generally involves the sudden onset of three or more loose or liquid stools above baseline in a 24-hour period. More than 90% of cases of acute diarrhea are caused by infectious agents. Acute diarrheal infection is also referred to as ______

Acute diarrhea

_____ is a leading cause of outpatient visits and hospitalizations and has a direct negative impact on quality of life.

Rotavirus

Norovirus (Norwalk)

Adenovirus

which viral pathogens are known to cause acute diarrhea?

Escherichia coli

Salmonella species

Shigella species

Vibrio cholerae

Clostridioides difficile (especially if antibiotics have recently been administered)

bacterial causes of acute diarrhea

dysentery

The term _____ describes some of these bacterial infections when associated with serious occurrences of bloody diarrhea

Entamoeba histolytica

Microsporidium

Giardia lamblia

Cryptosporidium parvum

parasitic/protozoal causes of acute diarrhea

focus on fluid and electrolyte replacement

general treatment approach to diarrhea

48 hours

If condition worsen after _____ hours, medical referral is necessary to prevent complication

1. young age: < 6 months or weight < 17.5 pounds

2. persistent fever: > 102.2 F for patients >6 months

3. visible blood, pus, or mucus in stool

4. high output, including frequent and substantial volumes of diarrhea

5. persistent vomiting

6. signs of severe dehydration: mental changes, no urination in 8 hours, children who have no tears when crying, orthostatic hypotension

7. severe abdominal pain/distress

8. chronic conditions: diabetes, CVD, renal disease, immunocompromised patients

9. pregnancy

10. chronic or persistent diarrhea

exclusions for self treatment of diarrhea

Loperamide (Imodium)

FDA-approved to help control symptoms of diarrhea, including Travelers' Diarrhea; acts on opioid receptors in the gut to slow the movement in the intestines and decrease the number of bowel movements.

48 hours

Loperamide (Imodium) should only be used for up to ____ hours

8 mg per day for OTC use and 16 mg per day for prescription use

max daily dose of Loperamide (Imodium) for adults

Bismuth Subsalicylate

- Pepto Bismol

- Kaopectate

has antisecretory and antimicrobial effects and used to treat acute diarrhea. Although it passes largely unchanged through the GI tract, the salicylate portion is absorbed in the stomach and small intestine.

- Caution should be exercised with regard to the total dose given to patients taking salicylates for other reasons to avoid salicylism.

- Patients should be informed that their stool will turn black.