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What arc 3 causes of peptic ulcer disease?
- → (1) The release of HCl (hydrochloric acid) is influenced by histamin, gastrin and acetylcholine. Peptic ulcers occur when there is a hypersecretion of HCl (and pepsin) from the parietal cells of the stomach.
- → Gastrin is a hormone released bt the stomach and duodenum for digestion.
- → These influencers act as proton pumps to move the HCl.
- → Aprox 2L of gastic juice a day
- → (2) Pepsin, a digestive enzyme, is activated at pH=2 and the pepsin-acid complex of gastric secretions can cause mucosal damage leading to ulcerration within hours.
- → (3) H. Pylori, a gram-negative bacteria, infect gastric mucosa leading to ulcers. Serology and breath tests can detect.
Serology usually refers to the diagnostic identification of antibodies in the serum. Such antibodies are typically formed in response to an infection (against a given microorganism).
Discuss antacid considerations.
- → Neutralize gastric acid/decrease pepsin production / raise pH to 3.5
- → Aluminum compounds: large doses needed, cause constipation
- → Al combines with phosphates - decreased phosphorus over time, but not an issue for renal Pt
- → Magnesium based: diarrhea, hyperMg/NA (edema)→ Combo: Gelusil, Mylonta, Maalox
- → Do not give "Antacids" with H2 blockers ("Antiulcers", e.g. tagamet) at the same time (space 1-2 hours apart)
→ Low Mag → VTAC & High not good for renal Pt.
→ Alka Seltzer is Na-base → edema
- → Antiulcer/Antacid
- → Aluminum Hydroxide
- → Aluminum compounds: large doses needed, cause constipation
- → Decreased phosphorus over time, but not an issue for renal Pt
calcium carbonate (Tums)
- → Heartburn, acid indigestion, esophagitis
- → Can cause constipation
- → Also for hyperphophatemia in renal Pts.
magnesium hydroxide, aluminum hydroxide w/Selenium
(Mylanta, Maalox, Gelusil)
- → Aluminum compounds: constipation
- → Magnesium based: diarrhea
- → Low Mag → VTAC & High not good for renal Pt.
sodium bicarbonate (Alka Seltzer)
- → "Previously" used for gastric hyperacity
- → Acid-base imbalance could occur
What are H. pylori agents?
→ Amoxicillin, clarithromycin, metronidazole, tetracycline, and flagyl, which cannot be taken with alcohol
What are H. pylori drugs also administered with? Why?
- → Combinations of antiinfective agents such as amoxicillin, along with a PPI (proton pump inhibitor) and an antacid such as bismuth subsalicylate.
- → Usually a triple combo works but sometime a quad is necessary.
- → Combos are necessary becaue H. Pylori easily becomes resistant to a single antiinfective.
- → May also be given with Carafate, which coats an ulcer and provides a barrier. It should be given on an empty stomach (1b or2a meal). May cause constipation.
- → A 4-way combo could include 2 antiinfectives, a PPI, and either Busmuth or a histamine2 (H2) blocker
- → Wx diarrhea, abd pain, N/V
What arc proton pump inhibitors?
- → Prilosec is an example and it inhibits acid production.
- → They block the final steps of acid production by inhibiting the enzyme hydrogen or patassium APTase, which makes gastric acid
Give 3 examples of proton pump inhibitors
- → omeprazol (Prilosec)
- → lansoprazole (Prevacid)
- → Nexium
- → Protonix
→ Helidac (convenient dosing pkg to ensure Pt comnpliance)
→ Triple combo: Bismuth, Flagl, Tetracycline
What may the patient on proton pump inhibitors experience?
→ Wx diarrhea, abd pain, N/V
How does Carafate work?
→ Coats an ulcer by combining with gastric acid to provide a barrier. It should be given on an empty stomach (1b or2a meal). May cause constipation.
What arc 2 considerations regarding Carafate?
- → Does not neutralize or decrease gastric acid.
- → It should be given on an empty stomach (1b or2a meal).
- → May cause constipation.
What is Helidac?
- → Helidac (convenient dosing pkg to ensure Pt comnpliance for Tx of H. Pylori)
- → Triple combo: Bismuth, Flagl, Tetracycline
Complete the table below for H2 blocking agents.
- → Inhibit gastric acid secretion stimulated by histamine, acetylcholine and gastrin.
- → Tagament, Pepcid, Axid. Zantac
- → TAGAMENT INTERFERES WITH MANY DRUGS!
- → May cause gastric irritation with caffeine, alcohol and spices.
What are bulk-forming laxatives?
- → Add bulk to stool; unabsorbed by the intestine (similar to dietary fiber)
- → Good for those unable/unwilling to eat: elderly, debiliated
- → CHECK FOR IMPACTION FIRST
- → Give with 8 ounces H2O/f luid
- → Citrucel, Metomuctl, FiberCon
- → Monitor for impact ion/obstruction
- → Pulls H2O into the stool/creates expansion
What are stool softeners?
- → Decreasc surface tension of stool to allow water to enter/detergent properties as well
- → For those when straining is harmful/painful
- → Colace, Surfak
What are saline cathartics?
- → Cause water to be retained by raising intestinal osmotic pressure
- → Distention of bowel/increased peristalsis/semisolid stool
- → Milk of Magnesia, Golytely, Mg Citrate (Produces liquid cleansing)
- → Those with Mg, PO4, K salts are not for renal Pts.
- → Those with Na salts are not for CHF/edema Pts because Na absorption will cause further retention
What are irritant/stimulant cathartics?
- → Strongest/most abused
- → Irritate GI mucosa/stool eliminated rapidly → watery stool
- → Castor oil, senna products, caseara
- → Glycerine = irritant effects on rectal mucosa
What arc lubricant laxatives?
- → Lubricates intestine/decreased H2O absorption
- → Mineral Oil/ Fleets Mineral Oil Be careful
- → Decreased absorption of fat-soluble vitamins
- → Lipid pneumonia if aspirated - Make sure Pt can swallow
- → NOT AN ORAL LAXATIVE OF CHOICE!
What is lactoluse and when is it used?
- → Osmotic (saline) Laxative
- → Pulls water into the intestines.
- → Used in liver disease for amonia elimination and the goals for these Pts is 2-3 stools. When used as a laxitive, 1 stool will do.
What is Kayexalate and when is it used?
→ "K ex" is used to lower K+ levels.
Review causes of diarrhea and indications for antidiarrheal medication.
- → Too many Laxitives
- → Infection
- → Spicy food
- → Lack of lactose
- → Imflammatory Bowel Disease
- → Drugs
- → Intestinal tumors
- → Stress or anxiety
- → Intestonal surgery
- → HIV infection
- → Longer than 2-3 days
- → Very young or old Pt
- → Ulcerative colitis / Crohn's disease
- → Ileostomy Pt
- → HIV/AIDS diarrhea
Discuss contraindications for antidiarrheal medication.
- → Known microorganisms, e.g. E. Coli, Salmonellla, Shinella
- → Antibiotic associated colitis
- → Opiate D"something"
- → With Pseudomembranous Colitis C-diff organisms proliferate with antibiotic therapy leading to symptoms days or weeks after.
- → Clostridium difficile causes severe diarrhea and other intestinal disease when competing bacteria in the gut flora have been wiped out by antibiotics.
Ipecac syrup considerations
"Bad for the Heart"
Considerations for Opiate antidiarrheal medicines
- → Most effective
- → Drug of choice
- → Paragoric, Iomotil, Immodium
- → Lomotil contains atopine → Caution
- → Dry mouth, drowsiness, blurred vision
- → Assess Bowel Sounds Q shift
Considerations for Bismuth Salts antidiarrheal medicines
Considerations for Sandostatin antidiarrheal medicines
→ Hormone and decreses GI secretions and motility
Considerations for Anticholinergic antidiarrheal medicines
→ Atropine (in Lomotal) → not used r/t side effects
Considerations for Metamucil antidiarrheal medicines
→ Decreases fluidity of stools (absorbs water)
Considerations for Enzymes antidiarrheal medicines
→ Diarrhea cause by pancreatic enzyme deficiency is treated by Viokase or pancrelipase
Review causes of nausea and vomiting.
- → GI Problems
- → Drug therapy
- → Heart, neuro, metabolic, infectious diseases
- → Pain
- → Unpleasant sights/odors
- → Stress
- → Radiation or Chemo
- → Motion sickness
- → Post-op pain
Where is the vomiting center located?
How do the following antiemetics work: Phenothiazines (Compazine)
- → Thorazine blocks dopamine from receptors.
- → Infrequently used r/t side effects.
How do the following antiemetics work: Antihistamines?
- → H1 and Acetocholin blocking
- → Benadryl, Dramamine & Vistaril
How do the following antiemetics work: Steroid?
→ Unknown action for antiemetic effect
How do the following antiemetics work: Benzodiazepines?
- → Xanax, Valium & Ativan control emesis r/t/ cancer chemotherapy
- → Used post-op & 20-60 minutes before chemo
How do the following antiemetics work: Seratonin antagonist?
- → Block the serotonin receptors in the CTZ (Chemoreceptor trigger zone in neuroscience) and the afferent vagal nerve terminals of the upper GI track
- → Work Fast
- → e.g. Zofran
How do the following antiemetics work: Prokinetic agents?
- → e.g. Reglan, a cholinergic drug
- → Contraindicated w/ bowel obst
- → Wx for diarrhea
"Demerol causes seizures, so it is not used."
Review indications/contraindications for antiemetics.
- → Prevent Tx N/V
- → Surgery, Pain, Motion sickness, Chemo, Radiation
- → When Dx may be prevented/delayed r/t masking of symptoms
- → When drug toxicity may be masked
- → Routine prevention of post-op
- → Contr for Parkinson's Pt becsuse it depletes dopamine reducing effectiveness if Tx
When are emetics used? give an example.
- → When a person has consumed a poison that is not caustic (e.g. ammonia, chlorine bleach, lye, toilet cleaners, battery acid)
- → Also evoid emetics becuase of aspirtation risks for swallowed gasoline, kerosene, paint thinner, and lighter fluid.
- → When emetcis are conttraindication for poison, activated charcoal is given.
- → Non-Rx antiemetic: antihistamine
- → Primarilly motion sickness
- → Wx drowsy, dizzy, hypotension
- → Non-Rx antiemetic: Antihistamine
- → Px (prevents) N/V & dizziness
- → Drowsiness may occ
- → Rx antiemetic: Antihistamine
- → Tx post-op N/V & vertigo
- → Give deep IM
- → Rx antiemetic: Dopamine Antagonist
- → Tx severe N/V
- → EPS (Extrapyramidal symptoms such as akinesia inability to initiate movement) may occur
- → Rx antiemetic: Benzodiazepine
- → Tx N/V r/t cancer chemo
- → Rx antiemetic: Serotonin Receptor Antagonist
- → Tx N/V r/t cancer chemo esp. cisplatin