Gastroenterology

GASTROENTEROLOGY

***BAD TASTE: *Less meat *dairy ok * increased fluids *Zinc sulphate *vit C chewable

***HALITOSIS: *Poor oral hygiene, *infection, *Lung abscess, *ENT cancers *Rx: Routine oral hygiene, gentle mouth washes, Sodium bicarbonate *hydrogen peroxide *antibiotics

***SORE MOUTH: *Thrush *Dentures *coated tongue • thrush *Rx Nystatin •Gingivitis: *Rx Flagyl • Ulcers: Vit C, Fresh pineapple, Mouthwash

***ANOREXIA: As the disease is progressing there is : decrease appetite, weight loss, emaciated, generalized weakness, fatigue # nausea due to Cancer meds, depression, practically any disease *not rejecting love *cancer cell may use most of the nutrients; *Rx: patient food preferences, sit up & rest before meals •Breakfast better tolerated • Alcohol & caffeine stimulates appetite • Small portion of attractive palatable meals • patients’ preference • • Decadron PO 1-2 mg q 8 hrs •prednisone 5 mg PO q 8 hrs •Megace 80-160 mg PO QID• Vit C •Reglan

*** DYSPEPSIA: # Heart burn, indigestion, burning epigastria discomfort, acid reflux, nausea *Rx: ** eliminate predisposing factors ** stop smoking ** no spicy foods ** frequent small meals ** Antacids: magnesium containing antacids causes loose BM, aluminium causes constipation ** H2 blockers ** carafate ** stop corticosteroids & NSAIDS ** Reglan to increase motility ** Prilosec

*** DYSPHAGIA: # Difficulty in swallowing, regurgitation, aspiration, retrosternal pain # cancer of esophagus / nasopharynx, ALS, Parkinson’s, CVA, MS, candida (esophagitis) • if needs w/u: Barium swallow; endoscopy *Rx: ** oral hygiene ** liquid / soft food, ** carbonated drinks with meals ** Nitroglycerine or isosorbide diniterate 10-20 mg or Procardia 10 mg ½ hour before meals ** feeding in sitting or Fowler’s position ** Candidiasis: no lesions but burning consider *Rx with Nystatin swish & swallow; Nizoral; Diflucan ** edema: neck cold compress ½ hr AC or Decadron 4 mg QD / BID ** no meat tenderizer

*** GERD: Gastro-esophageal reflux: # heart-burn, nausea # gastric contents / acid going into esophagus ® mucosal damage, heartburn, retro or substernal discomfort, increase S/S by recumbency after meals or straining, clinical Dx, 50% abnormal endoscopy # ascites, smoking, obesity, alcohol, fatty/heavy meals, heavy caffeine use *Rx: ** Eliminate the cause, ** change lifestyle, ** elevate the HOB, ** antacid, ** H2 blockers, ** Reglan, ** Prilosec

*** NAUSEA: • Sick to stomach with desire to vomit • Vomiting: throwing up # Causes: Opioids, NSAIDs, Chemotherapy, Drugs, Mechanical obstruction, CNS or G.I. Cancer, £ ICP, systemic Infection, Enteritis, Radiotherapy, Electrolyte abnormalities, Anxiety Disorders, Gastroparesis *Rx of N/V: ** frequent small palatable meals ** clear liquids ** eliminate the cause ** avoid recumbency after meals, elevate the head of bed ** Antihistamines: Benadryl, Phenergan ** Pro-kinetics: Reglan ** Corticosteriods: Pred-nisone, Decadron ** Phenothiazines: Compazine, Thorazine ** Anti-cholinergic drugs: scopolamine, atropine ** Cannabinoids: Marinol ** Butyrophenones: Haldol Inapsine ** Benzodiazepines: Ativan ** Ü Opioids ** Discontinue NSAIDS ** Scopolamine ** Chemo / rad : 5-HT3 antagonists: Zofran

***Constipation: • Anticipate in hospice patients / on pain meds • goal : normal BM; •1 hard BM > 3 days • difficult or no bowel movement or poor bowel habits, advanced age, less fiber in diet, inactivity, impaction; structural, colon ca abnormalities, hypercalcemia, anticholinergic, phenothiazines, tricyclics, iron, calcium, aluminum containing antacids, calcium channel blockers & other pain meds, Scopolamine, Oxybutanin, Bismuth*Rx** remove the cause ** Initiate bowel program ** stool softeners ** laxatives: Bulk agents, Softeners (Docusate Sodium), Colonic stimulants (senna, bisacodyl) •Osmotic agents: Sorbital, lactulose, magnesium sulfate or Miralax (Polyehtyline glycol) for severe constipation, osmotic agents increases water content in the gut ** mobilize the patient ** Diet: roughage, fluids & fiber *Glycerine supp : act in 15-30 minutes, •increase motility (Sennakot) 1 tab HS max 4 bid, or 1 tsp q hs, stimulate myenteric plexus there by intestine, evacuate with enema before using Senna (cramping), onset 6-10 hrs • Lubricants: Colace (Docusate) 100 mg q 12-24 hrs, fecal softne•rPeri-Colace, DSS, suppopsitories ** Dulcolax suppositories ** Prune Juice ** white grape juice & cranberry juice ½ oz each/day ** Reglan (not in Parkinson’s) • If no BM for > 3 days: intermittent use of mag citerate or phosphosoda, lubricants, Caster Oil, Milk of Magnesia,

** Lactulose: not absorbed, side effects: cramping / flatulence (we prefer Sorbital) ** Dulcolax supp ** Enemas ** disimpaction •enema if constipated for more than 4 days !

•Steps : check meds; increase fiber 6-25 g/d / fluid > 1500 ml /d; add osmotic agents; then add stimulants Sennakot 2-3/week, then enema (tap water -> saline -> oil retension)

•AVOID: magnesium / phosphorus contraindicated in renal failure, avoid fiber in dying patient as it causes solid impaction, osmotic agents can cause dehyderation,

*** HICCUPS: • Phrenic nerve irritation, CVA, post-operative, Irritation of nerves, psychiatric, Gastric distension, metabolic problems, Uremia • *Rx: ** keeping the tongue out for few seconds ** supraorbital pressure ** teaspoon of sugar on outstretched tongue ** avoid recumbancy immediately after meals ** hold breath for few seconds ** Mylanta ** Reglan PO / IV ** Baclofen ** Tegretol ** Haldol ** charcoal-tab ** Adalat ** IV-Lidocaine ** Chlorpromazine (Thorazine) O / IM, 80% improvement ** Peppermint water ** lastly Phrenic nerve block

*** FECAL IMPACTION: # Prolong narcotic use; chronic Constipation, debility, prolong bed rest # Overflow diarrhoea, firm mass in rectum, leakage around impaction, abdominal pain, Nausea / vomiting / anorexia, abdominal distension *Rx: ** Dulcolax or Glycerin suppository ** warm water or mineral oil retention enema ** soap suds or Fleets enema ** Reglan 60mg/day SQ continuously for 1 day followed by oral once symptoms improve ** long term care: diet, regular BM, stool softener ** Vaseline balls

*** DIARRHEA: Increase frequency > 3 stools/d, decrease consistency, Ÿ watery stool # laxative overuse, maldigestion, malabsorption, Partial bowel obstruction, GI Tumor, Magnesium, antibiotics, Clostridium difficile and pseduo membranous-colitis, chemotherapy, NSAIDS, Caffeine, Estrogens, Sulfonylureas, Reglan, Radiation, Infection (particularly in AIDS), bacterial, Viral, parasitic: giardia, AIDS, Colitis, irritable bowel syndrome, Malapsorbtion, Pancreatic insufficiency, sorbitol, Lactose, diet, tube feedings n Treatment: ** avoid offending agent ** Disimpaction ** bland low residue diet ** watch dairy products ** less carbohydrates ** Gatorade ** Stop offending meds if possible ** Kaopectate ** Pepto-Bismol ** Imodium (Loperamide) ** Lomotil (diphenoxylate / Atropine) ** Anticholinergic ** Tricyclics ** codeine ** Morphine sulphate ** Pancreatin for pancreatic insufficiency ** Questran provided no biliary obstruction ** Steroid enemas for Colitis, infiltrating tumor or Inflammatory ** Infection: Cipro + Flagyl ** Clostridium difficile: Flagyl or Vancomycin ** Desitin or A&D or Vaseline for local irritation ** discontinue Penicillin, Cephalosporin; Sulpha ** Steroids: Ulcerative colitis ** Sandostatin (octreotide) in AIDS diarrhea

*** TO INDUCE CONSTIPATION: ** Codeine phosphate ** Opiods ** Tricyclic antidepressants

*** BOWEL-OBSTRUCTION: • Abdominal pain / tenderness, abdominal distension, Overflow diarrhoea, Air-fluid levels on x-ray # colon ca, fecal impaction, ileus, meds *Rx: ** IV fluids, ** NG suction for 7-10 days ** Small meals preferably liquid/low residue ** all meals timed long before bedtime ** don’t force feed ** Vaseline ball-for-high-impaction ** Benadryl-PO-BID/QID ** Haloperidol ** Scopolamine (antispasmodic) ** Robinol po TID or SQ / IV ** Atropine (antispasmodic) SC / PO / sublingual • Droperidol (Inapsine) IM-TID ** Opiates for severe pain SL/PR ** Probanthine POQID ** Phosphate enema ** Ducolax or Senokot for small bowel obs avoid if possible ** Trial Decadron 4mg po QID or Prednisone 30mg po QID for 5-7 days ** Solumedrol 50mg IM TID x 3 days (50% response) ** Thorazine ** NG p.r.n.; ** sedation, ** control pain ** needle decompression for severe gaseous distension ** steroid retention enema ** Pepcid 20 mg POBID ** 1 wk to allow spontaneous resolution before surgery, avoid surgery, 30% perioperative mortality with surgery • Avoid Tubes

*** Abdominal insension: # Tumor, ascites, Perforation, Intestinal Obstruction, Gaseous Distension (Lactulose) *Rx: ** Treat the Cause ** No NG Tube or No flatus tube in Perforation ** Treat symptoms ** Control Pain ** Needle decompression!

*** Ascities: Fluid in the abdominal cavity # Abdominal distension, pain, discomfort, fluid thrills, Dyspnea, orthopnea, nausea, Lower Extremity edema # Any cancer primary or metastatic, cirrhosis, CHF, infection, nephrotic synd. *Rx: ** Elevate HOB 30º ** sodium restriction ** Pain Control ** Diuretics ** Para-centesis ** Peritoneovenous Shunt ** treat the cause ** symptomatic

*** RETROPERITONEAL METASTASES: • Cancer of Pancreas, breast, cervix, endomet-rium, kidney, colon, or prostate • Retroperitoneal: sarcomas, germ cell tumors, lymphomas S/S: • Backache, palpable abdominal mass, urinary frequency, venous thrombosis, pain, impotence, lymphedema *Rx: symptomatically, radiation