Journey through the GI tract

1
Journey through the GI tract

• Barb Bancroft, RN, MSN
• www.barbbancroft.com
• BBancr9271_at_aol.com

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Open wiiiiiiide

• Lets take a journey through the GI tract with a
  few stops along the way

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The Teeth

• Tooth loss and heart disease
• Periodontal disease, subclinical vasculitis and
  coronary plaque development
• State with the least teeth is the state with the
  most heart disease

4
Oral bacteria and coronary artery disease

• Specific periodontal pathogens are implicated
• Enter the bloodstream via small ulcers that
  develop in the gum tissue of patients with
  periodontal disease
• Contribute to plaque formation via inflammation
  induce platelet aggregation and clot formation
• 4 bacteria are implicatedTannerella forsythia,
  Porphyromonas gingivalis, Actinobacillus
  actinomycetemcomitans, Treponema denticola.
• Depending on the bacterial concentration, the
  increased risk of heart attack in persons with
  one or another of these bacteria ranges from
  200-300 percent, compared to people with no
  evidence of the bacteria

5
Floss

• Floss only the teeth you want to keep
• MINUTIAE On average, each person uses 54 feet of
  dental floss every month or about 1.5 feet of
  floss per day which equals 548 feet of floss in a
  year.

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Meth mouth

• 22 y.o. meth user snorted and/or injected meth x
  2 years
• Denied use of any other drugs
• Drank 2-3 liters of carbonated drinks each day
  because of a dry mouth
• How addicting is methamphetamine? Dopamine and
  addiction
• (British Journal of Medicine 2006333156)

7
Osteoporosis and tooth loss

• Osteoporosis of the mandible and maxilla on
  dental X-raysloss of trabecular bone
• Women who do NOT take estrogen have fewer teeth

8
Bites

• The bite scale. The King of the Jungle, the
  African lion, has a bite force of only 940 pounds
  (427 kg). Hyenas register a 1,000-pound (454 kg)
  bite which explains why they might get the best
  of the African lion. Dusky sharks manage only 300
  pounds (136 kg) of force.

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Bites

• Labrador retrievers nip at your ankles with 125
  pounds (57 kg) of force, only slightly surpassed
  by the infamous Mike Tyson, the heavyweight
  boxer, who chomped off Evander Holyfields ear
  with a force of 170 pounds (77 kg).
• Had we lived in the day of the dinosaur,
  Tyrannosaurus Rex, the bite would have registered
  3,011 pounds (1369 kg).
• What about Petey the pit bull? Endorphins,
  L-tyrosine and dopamine

10
Other human bites

• Self-inflicted bites
• Thumb-sucking
• Seizures (can you swallow your tongue?)
• Child abuse

11
Gingival hypertrophy

• Drugsphenytoin (Dilantin), nifedipine
  (Procardia), cyclosporine
• Leukemiasacute and chronic

12
The immunocompromised patient

• Candida albicans (inhaled steroids in asthmatics)
• Diabetics with hyperglycemia
• Fungal infections and TNF-a antagonists
  (infliximab/Remicade adalimumab/Humira
  certolizumab/Cemzia etanercept/Enbrel)
• HSV-1, HSV-2
• Kaposis sarcoma
• HPV
• HIV (TB)

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OPEN Wide

• Aphthous ulcers and celiac disease
• Mouth clues to vitamin deficiencies
• Vitamin Cgingivitis, dental erosion
• Vitamin B2 (riboflavin)stomatitis, cheilosis,
  geographic tongue
• Vitamin B3 (niacin), B6 (pyridoxine), B12
  (cobalamin), folic acid (B9)glossitis
• Calcium (hypocalcemia)numbness and tingling
  around the mouth tetany Chvosteks sign
  Trusseaus sign

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Say ah

• Soft palate and the uvula
• Relationship of the pharyngeal musculature with
  CN IX (Glossopharyngeal) and X (Vagus)
• Stroke patients
• Swallowing
• What is the hardest thing to swallow?

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Water

• Ya cant size it, ya cant shape it

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Back to CN IX and X

• The gag reflex
• CN IX and X close off the nasopharynx
• Head injured patients lose their gag reflex and
  have a high risk of aspiration pneumonia
• Open your mouth and pant like a dog
• K, K, K, K, K
• uvula midline

17
Causes of nasal speech

• Cleft palate (folic acid!!)
• Lou Gehrigs (ALS) disease
• Glossopharyngeal nerve palsy(viral)
• Guillain-Barré syndrome with bulbar onset
  (cranial nerve onset vs. ascending paralysis
  beginning with the longest nerves firstie. the
  feet)
• 1 cause of Guillain-Barré

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ACE inhibitors and angioedema

• The PRILS
• Muffled speech
• Swollen lips, pharyngeal edema
• Hives around the mouth
• Highest risk patients?
• Dont forget the cough

• Drugs discovered because of a biteBrazilian pit
  viper
• Captopril (Capoten)
• Enalapril (Vasotec)
• Lisinopril (Prinivil, Zestril)
• Perindopril (Aceon)
• Moxepril (Univasc)
• Benazepril (Lotensin)
• Quinapril (Accupril)
• Trandolapril (Mavik)
• Ramipril (Altace)
• Etc
• Diabetics, HBP, CHF, post-MI)

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Hoarseness

• Vocal cords supplied by a branch of the
  vagus--recurrent laryngeal nerve
• Causes of hoarseness? increased vocal cord
  thickness--testosterone, hypothyroidism,
  acromegaly, aneurysm of the thoracic aorta, lung
  cancer, and GERDjust to name a few
• Hypothyroidism, large tongue, teeth
  indentations--? gt ?
• Amyloidosis

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Salivary glandsparotid, sublingual, submandibular

• Parotid glandMUMPS (kids and vaccines)
• Hypertrophy of the parotid gland in women with
  eating disorders (serum amylase will be elevated)
• Acetylcholine innervates the salivary glands to
  produce saliva
• Drugs to boost acetylcholine for patients w/ dry
  mouths5 mg QID pilocarpine cevimeline (Evoxac)
• Artificial saliva?

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More on saliva

• Sjögrens syndrome (sicca)autoimmune disease
  may be primary or secondary to another autoimmune
  disease such as lupus
• Saliva as innate defense--IgA
• Taste and salivathe elderly and anticholinergic
  drugs stop the flow of saliva

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Drugs with anti-cholinergic properties

• Amitryptyline (Elavil)
• Doxepin (Sinequan)
• oxybutynin (Ditropan)
• Meclizine (Antivert)
• Theophylline
• Captopril (Capoten), nifedipine (Procardia)
• Prednisolone
• digoxin
• dipyridamole (Persantine)
• warfarin
• Furosemide (Lasix)
• isosorbide dinitrate (Isordil)

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More anticholinergic drugs

• Codeine
• Oxycodone
• Fexofenadine (Allegra)
• thioridazine (Mellaril)
• Hydroxyzine (Atarax)
• Loratadine (Claritin)
• dicyclomine (Bentyl)
• Cimetidine (Tagamet), ranitidine (Zantac)
• benztropine (Cogentin)
• trihexyphenidyl (Artane)
• Diphenhydramine (Benadryl)
• haloperidol (Haldol)

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Sublingual

• Saliva and sublingual drugsyou need saliva to
  absorb sublingual drugs
• NTG under the tongue to vasodilate the coronary
  arteries in patients with anginal chest pain
• Jaundice and soft palate/sublingual mucosa

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Speaking of saliva

• How much saliva do you make a day? about 1 liter
  of saliva per day
• How many times do you swallow in an hour?
  (70/200/10)
• Swallowing is something we take for grantedspit
  in a cup!
• Swappin salivachemistry? MHC complex

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Neurologic conditions

• Parkinson disease
• Low dopamine with a relative increase in
  acetylcholine
• Relative increase in acetylcholine results in
  excess saliva and drooling

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You take swallowing for granted--until you have
this sore throat

• Say ahhhhh
• Can you say ouch?
• Can you say I have a sore throat, and I cant
  swallow
• Group A beta hemolytic strep
• Peritonsillar abscesses

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Enlarged tonsils

• EBV infection of tonsils
• Waldeyers ring (tonsils and adenoids)
• Kids and sleep apnea kids, lack of sleep and
  growth hormon
• Adults and sleep apnea? (hypertension, CAD in
  adults)
• Behavior disorders? ADHD? In kids?
• Non-Hodgkins lymphoma

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Oral signs of an eating disorder

• The frequent vomiting and nutritional
  deficiencies often associated with eating
  disorders can severely affect health
• 89 of bulimic patients have signs of tooth
  erosion over time, loss of tooth enamel can be
  considerable
• Change in color, shape, length
• Brittle, translucent, and sensitive to
  temperature
• Swelling of salivary glands
• Dry and cracked lips
• Chronic dry mouth

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Oral cancers

• Causes? The usual suspects
• Tobacco, smoked, chewed, pipes, cigars,
  cigarettes, cigarillos
• Alcohol?

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Cut back on the booze

• Alcohol is on the list of probable cause for
  cancers of the colon, rectum and breast
  convincing cause of cancers of the mouth and
  pharynx, larynx, esophagus, liver, and possible
  cause for lung cancer.

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The big surpriseOral cancers and HPV

• HPV-16 and oral sex
• mouth/throat cancer
• Will the HPV vaccine (Gardisil) prevent this type
  of cancer if given early?

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Lets move into the esophagus

• Hollow, highly distensible muscular tube that
  extends from the pharynx to the gastroesophageal
  junction at the level of T11 or T12 vertebra.
• 10 to 11 cm in the newborn
• 23 to 25 cm in the adult
• A 2-4 cm segment just proximal to the anatomic
  esophagogastric junction, at the level of the
  diaphragm, is the LES, or lower esophageal
  sphincter

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GERD (gastroesophageal reflux disease)

• ACID is the bad guy
• The Lower Esophageal Sphincter (LES) pressure
• With GERD--decreased pressure in the lower
  esophageal sphincter due to drugs, nicotine,
  alcohol, fatty foods, peppermint, chocolate,
  citrus fruits and juices, increased pressure in
  stomach (late evening meal)
• So, how about a pizza, cold beer and a cigarette
  before bedtime?
• What drugs? Bronchodilators, NTG, tetracycline,
  quinidine, KCl, NSAIDS, Iron salts,
  bisphosphonates, Viagra and other ED drugs
• Obesity

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What are non-drug ways to reduce GERD?

• Dietary changes?
• A meta-analysis in the Archives of Internal
  Medicine revealed support for 2 measures
• Weight loss and head-of-bed elevation
• Avoiding tobacco, alcohol, high-fat foods, and
  carbonated beverages was NOT shown to alleviate
  symptoms of GERDeven tho there is substantial
  evidence that consumption of these substances has
  an adverse impact on GERD

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Pharmacology of GERD

• Classic reflux sx (heartburn, reflux) have a
  predictive value of 80
• Empiric therapy can be started without endoscopy,
  but endoscopy can only tell whether or not
  erosive esophagitis is present
• PPIs (Proton Pump Inhibitors)the prazoles are
  the mainstay of therapy in healing erosive
  esophagitis and treating symptoms of GERD
• Omeprazole (Prilosec), lansoprazole (Prevacid),
  pantoprazole (Protonix), rabeprazole (Aciphex),
  and the purple pillesomeprazole (Nexium)
• Fastest actingesomeprazole, rabeprazole,
  omeprazole, lansoprazole, pantoprazole

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Drugs to treat GERD

• MOAInhibition of the proton pump at the luminal
  surface of the stomachespecially after a
  mealwork best when taken 30-60 minutes before
  breakfast or dinner

H, Intrinsic Factor-B12
PPIs work here
Luminal surface
Parietal cell
Basilar surface
H2
H2 receptors
H2 blockers work here
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H2 blockers

• Work by blocking H2 receptors on basal surface of
  the parietal cell work best when taken at night
  to reduce nocturnal histamine secretion and acid
  production
• Cimetidine (Tagamet)
• Ranitidine (Zantac)
• Famotidine (Pepcid)
• drug interactions and side effects
• least drug interactions and side effects and
  most effective

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Has your patient been on the prazoles for
longer than 5 years?

• Check B12 levels in your patients
• The parietal cell that pumps acid also pumps out
  intrinsic factor (IF)
• Intrinsic Factor is necessary for the absorption
  of B12 from food
• If you stop pumping the acid into the stomach,
  you also stop pumping intrinsic factor for B12
  absorption
• Combine that with a decreased absorption of B12
  over the age of 50 and you may have a B12
  deficiency
• May also be caused by an autoimmune disease with
  antibodies against IF (pernicious anemia)
• No acid, no calcium (elderly and patients on PPIs
  need to take calcium citrate for absorption)
• No acid, no iron (check for iron deficiency
  anemia)

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Hematologic and neurologic symptoms of B12
deficiency

• Hematologicmegaloblastic anemia (big, immature
  RBCs)MCV is greater than 120 also known as a
  macrocytic anemia
• NeurologicCognitive dysfunction Spinal cord
  dysfunction peripheral neuropathy
• The number 1 nutritional cause of dementia is B12
  deficiencyis it reversible? Yes.
• How can you supplement with B12?

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B12 supplementation

• Pill
• Sublingual
• Nasal
• Injection
• Need 6 mcg per day take 1000 mcg by
  mouth/sublingual/nasal daily (1 via passive
  diffusion in stomach if you take B12 by mouth)
• 1000 mcg/month via injection
• Do not take over 3,000 mcg per daythe one
  dreaded side effect is

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Barretts esophagus

• Complication of acid reflux (GERD)
• Metaplasia of the lower third of the esophagus
• What is metaplasia? The substitution of one adult
  cell for another adult cell
• Usually a protective mechanism
• Gastric epithelial cells have replaced squamous
  epithelial cells of the esophagus
• Gastric epithelial cells are used to acid

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What do we know about Barretts esophagus?

• Patients with at least weekly symptoms of
  GERD3-15 are found to have Barretts
• May be a gross underestimateautopsy findings
  were 20-fold higher than clinical studies
• Caucasian males greater than 55 21 ratio big
  bellies contributeBody fat increases
  intraabdominal pressure fatty foods decrease LES
  pressure high dietary intake of nitrates
• Increased insulin resistance results in high
  serum levels of insulin-like growth factor-1
• Adenocarcinoma of the esophagus (10 in 1960 50
  in 2005)
• One of fastest rising cancers in U.S.

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What do we know about Barretts esophagus?

• Progression to dysplasia is an ominous histologic
  findingprecursor to invasive adenocarcinoma
• Annual risk is 0.5 per year
• 30x to 40 x greater risk of adenocarcinoma w/
  Barretts if greater than 2 cm of Barrett mucosa
  on endoscopy
• Does ultra-aggressive anti-secretory therapy have
  anti-proliferative effects on intestinal
  metaplasia? Recent studies say yeshigher than
  conventional PPI doses
• BID dosing if QD doesnt relieve symptoms of GERD
  (35 of patients are on BID dosing)
• Add H2 blocker at HSdouble the OTC dose (Zantac
  300 po hs)
• Nocturnal symptoms are more often associated with
  severe diseaseesophageal cancer, otolaryngologic
  and pulmonary disorders

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Esophageal candidiasis/rupture

• HIV patientsdysphagia in AIDS patientsalso
  consider Herpes simplex and CMV esophagitis
• Irritation and possible rupture in postmenopausal
  females taking bisphosphonates (Fosamax and
  friends)
• Other pills stick
• Lye, acids, and detergents

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Esophageal dysmotility syndromes

• Achalasia--LES is too tight, lack of peristalsis
  in lower third of esophagus LES needs to be
  dilated frequently
• Viagra has been used to open the LES (nitric
  oxide relaxes the sphincter)
• Esophageal spasms (women and other spastic
  disorders)

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Esophageal varices

• How do you develop esophageal varices?
• Due to increased pressure in the portal system of
  the liver
• Primarily due to cirrhosis of the liver 90 of
  patients with cirrhosis will develop varices
• Worldwide, hepatic schistosomiasis is the second
  most common cause of variceal bleeding
• Beta blockers to reduce portal pressure
• 40 die with first episode, rebleeding occurs in
  more than half within one year

48
Major causes of cirrhosis of the liver today are

• Hepatitis C (15 clear on own 85 develop
  chronic hepatitis chronic hepatitis can lead to
  cirrhosis and hepatocellular carcinoma)
• Hepatitis B (10 develop chronic hepatitis, 90
  clear on own as adults opposite percentages with
  infants and vertical transmission)
• Alcohol (fatty liver)
• Diabetes (fatty liver)
• Obesity (fatty liver)
• NASH (Non-alcoholic steato-hepatitis, also known
  as non-alcoholic fatty liver disease--NAFLD)

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Hepatitis C virus--1989

• Cirrhosis with progression to hepatocellular
  cirrhosis

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Hepatitis C virusidentified in 1989

• HIGH RISK GROUPSprimary factors
• IV drug user (even 1 time experimental drug use)
• Blood transfusions prior to July1992 or organ
  transplant recipients
• Persons who have ever received hemodialysis
• Hemophiliacs who received clotting factor
  concentrates prior to 1987
• Children born to HCV-infected moms (screen at age
  1 or older)

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Hepatitis C high risk factors

• HCW after a needle stick injury or mucosal
  exposure to HCV-positive blood
• Current sexual partners of monogamous
  HCV-infected persons (prevalence is low, but a
  negative test provides reassurance)
• How about MULTIPLE partnershow many?
• Intranasal cocaine use
• Tattoos (prison applied?)
• Body piercings
• Receipt of injection in a developing world

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• The American Association of Blood Banks requires
  a one-year wait between getting a tattoo and
  donating blood

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Treatment of Hepatitis C

• 24 weeks vs 48 weeks depending on genotype
• Pegylated interferon ribivirin

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The stomach

• Whoever said the way to a mans heart is through
  his stomach flunked geography
• --anonymous
• The stomach is a saccular organ with a volume of
  1200 to 1500 ml but a capacity of greater than
  3000 ml

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Gastric acid

• At maximal secretory rates, the stomach
  intraluminal concentration of hydrogen ion is 3
  million times greater than that of the blood and
  tissues
• The mucosal barrier protects the gastric mucosa
  from autodigestion and is created by
• mucus secretion
• bicarbonate secretion
• epithelial barrier and,
• mucosal blood flow
• Truly a physiological marvel, or gastric walls
  would suffer the same fate as a T-bone

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Peptic ulcer disease

• Usually solitary lesions less than 4 cm in
  diameter
• Duodenum, first portion
• Stomach, antrum
• GE junction, in the setting of GERD
• 4 million people have peptic ulcers 350,000 new
  cases per year, 100,000 hospitalized, 3000 die
• Male/female for duodenal 31 male/female for
  gastric 1.5 to 21
• Imbalance between the gastroduodenal mucosal
  defense mechanisms and the damaging
  forcesgastric acid and pepsin
• Hyperacidity is NOT a prerequisite
• H. pylori is present in 100 of duodenal ulcers
  and about 70 of patients with gastric ulcers

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Gastric ulcers (peptic ulcer disease)

• Helicobacter pylorithe most common infection
  worldwide
• Elaborates urease and produces ammonia which
  buffers gastric acid in the immediate vicinity
• Gastric ulcers
• Chronic inflammation (gastritis) and regeneration
  of the antrum
• The only bacteria known to be oncogenic
• Is it normal flora?
• How do you catch it?
• How do you treat it?
• Is H. pylori a good thing?

58
Gastric ulcer caused by NSAIDS

• 2.74 RR of any GI complication
• If over 50, RR is 5.57
• RR 12.7 with NSAIDS and warfarin 4.76 with
  NSAIDS and steroids
• PPIs decrease ulcer/ bleed by 4-fold

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Gastric cancer

• In 1930, gastric cancer was the most common cause
  of cancer death in the U.S.
• Annual mortality rate in the US has dropped from
  38 to 7 per 100,000 in men and from 28 to 4 per
  100,000 in women.
• Causes 2.5 of all cancer deaths in U.S. and is
  the leading cause of deaths from cancer worldwide
• H. pylori and diet play a major role
• N-nitroso compounds and nitrates, benzopyrene
• Consumption of preserved, smoked, and cured and
  salted foods
• Water contamination with nitrates

60
Bariatric surgeryBMI 30

• Swedish study2010 patients 74 followed for 10
  years 0 relapsed into obesity found that the
  most effective therapy was the gastric
  bypassremoving most of the lower part of the
  stomach and attaching to a loop of small bowel
• Stapling only half as effective
• Lap-banding
• Risk? Only about ¼ of 1 percent mortality rate
• Long-term effects? malabsorption
• Cure for type 2 diabetes? Duodenal exclusion
  surgery

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The small intestineduodenum, ileum, jejunum

• Small intestine is 6-7 meters (18 to 22 feet) in
  length large intestine is 1.5 meters in length
• First 25 cm (12 inches) is duodenum
• Normal renewal of the epithelial lining of the
  small intestine every 4 to 6 days colonic
  turnover every 3 to 8 days
• Remarkable capacity for repair, but it also
  renders the intestine particularly vulnerable to
  agents that interfere with cell replication, such
  as radiation and chemotherapy

62
The small intestine and grapefruit juice

• Metabolizing enzymes to break drugs are located
  in the small intestine
• CYP3A4 metabolized 40-60 of all drugs (11000)
• Grapefruit juice/grapefruit inhibits this enzyme
  drugs metabolized by this enzyme enter the system
  in a higher bioavailabilityhence, drug toxicity

63
Grapefruit juice interactions increase
bioavailability and increase the risk for toxicity

• Amiodarone HClincreased absorption with GFJ
  increasing risk of adverse effects and
  toxicities
• pulmonary toxicity, hypotension, and cardiac
  arrhythmias, (TSH). Avoid using Amiodarone in
  patients who may not understand the toxic
  potential of this interaction.
• Felodipine (Plendil), nisoldipine (Sular),
  nicardipine HCl (Cardene), nifedipine
  (Procardia), isradipine (Dynacirc)increased
  toxicity with headaches and peripheral edema
• Simvastatin (Zocor)300 increase in
  bioavailability with grapefruit vs. atorvastatin
  (Lipitor) 25 increase rosuvastatin (Crestor)no
  interaction

64
Grapefruit juice/grapefruit

• Avoid grapefruit juice and grapefruit with
  antibiotics
• One interaction is especially dangerous
• Interaction between grapefruit juice and
  erythromycin
• Accumulates and may cause tachycardia
• Prolongs QT interval and may cause death from
  torsades de points

65
Fluids and the small intestine

• A typical adult imbibes 2 liters of fluid per
  day, to which is added 1-1.5 liters of saliva 2
  liters of gastric juice 1 liter of bile 2
  liters of pancreatic juice, and 1 liter of
  intestinal secretions
• Of these 9 liters presented to the intestine,
  less than 200 gm of stool are excreted per day,
  of which 65 to 85 is water.
• Jejunal absorption is 3 to 5 liters/day ileal
  absorption is 2 to 4 liters per day colon
  absorbs 1 to 2 liters per day but is capable of
  absorbing almost 6 liters per day.

66
The duodenum (12 fingerbreadths), the organ of
nausea

• 5-HT3 (serotonin) receptors)
• Serotonin release causes nausea--Makes ya sick
  to your duodenum
• 5-HT3 blockers--The setronsondansetron
  (Zofran), granisetron (Kytril), doasetron
  (Anzemet), palonosetron
• Adding ondansetron to oral rehydration in kids
  reduces nausea and vomiting and decreases the
  need for IV fluids by greater than 50

67
Celiac disease and the duodenum

• 1 in 250 in U.S. greater prevalence in 1st and
  2nd degree relatives ?duration of breast
  feeding age at which a person ingests gluten
  cigarette smoking
• Autoimmune diseaseHLA-DQ2 HLA-DQ8
• Ingested gluten crosslinks with tissue
  transglutaminase released in the lamina propria
  and epithelium of the small intestine
• Ingested gluten crosslinks with tissue
  transglutaminase released in the lamina propria
  and epithelium of the intestine
• Leads to the deamidation of the gluten peptides
• CD4 cells become stimulated cytokines IF-? and
  IL-4 which damage villi flattened villi and
  malabsorption
• Anti-transglutaminase antibodies

68
Celiac disease

• Classic symptomatic presentation characterized by
  diarrhea, abdominal pain, weight loss,
  flatulence, and nutritional deficiencies
• Atypical presentation characterized by gait
  ataxia, seizures, peripheral neuropathy, aphthous
  stomatitis, arthritis, migraine headaches
• Associated with other autoimmune diseasesType 1
  diabetes, autoimmune myocarditis, primary biliary
  cirrhosis
• Gluten-free diets and the improvement of symptoms

69
Celiac disease

• Absorption problems result in anemiasiron
  deficiency (growth problems in kids) folate
  deficiency calcium absorption problems
  (osteopenia)
• Always check for osteopenia and osteoporosis in
  your long-term patients with celiac disease!
• aphthous ulcers are both strongly associated w/
  celiac disease (This Week in Medicine, MDConsult,
  1/31/07)

70
Gastroenteritis

• Umbilicus (belly button)embryologic origins with
  colon (Homer and Dr. Colón)
• Word o the day
• Omphaloskepsis (om-fuh-lo-SKEP-sis) noun
• Definition Contemplation of ones navel. (From
  Geek omphalos (navel) skepsis (act of looking,
  examination)
• Peri-umbilical pain
• Causes of gastroenteritisfood poisoning, viral
  infections, bacterial infections

71
Gastroenteritis

• Infectious gastroenteritiscauses more than
  12,000 deaths per day from dehydration among
  children in developing countries and constituting
  one half of all deaths worldwide before age 5
• Attack rates of one to two illnesses per person
  per year in U.S.results in an estimated 99
  million acute cases of either vomiting or
  diarrhea per yearapproximately 40 of the
  population

72
Viral gastroenteritis

• Rotavirus140 million cases and 1 million deaths
  worldwide per year 6 to 24 months of age shed
  1,000,000,000,000 (10¹² particles)/ml of stool
  (the minimum infective inoculum is only 10
  particles, hence the rampant outbreaks in daycare
  and pediatric populations in hospitals)
• Norwalk virus (norovirus)rare in young kids
  incubation period of 1 to 2 days followed by 12
  to 60 hours of shuking

73
Noroviruses

• Responsible for majority of nonbacterial
  food-borne epidemic gastroenteritis in older
  children and adults
• Salad bars (cold foods, raw shellfish),
  person-to-person,water on cruise ships
• Has also been found in the community and in
  nursing homes
• Vicious cycle of vomiting and diarrhea for an
  average of 23 hoursknown as shuking
• start shedding virus before symptoms occur and
  shed virus for 4 days after symptoms subside
  (hence, the rapid spread of infection) can shed
  virus up to 4 to 8 weeks after illness

74
Bacterial entercolitis

• Ingestion of preformed toxin in
  foodStaphylococcus aureus, Vibrio species,
  Clostridium perfringens
• Infection by toxigenic organisms, which
  proliferate in the gut lumen and elaborate an
  enterotoxin (Cholera toxin is the prototype
  secretagogue)
• Infection by enteroinvasive organisms, which
  proliferate, invade, and destroy mucosal
  epithelial cells (Salmonella, Yersinia
  enterocolitica)

75
Acute appendicitis

• Acute appendicitis presents initially with
  peri-umbilical pain and subsequently localizes to
  the right lower quadrant (RLQ)
• High risk occupation for acute appendicitis?
• Pig farmers

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Salmonella in raw or undercooked eggs and chicken

• Pasteurized eggs for seizure salad (Caesar
  salad), eggnog, and guacamole
• Salmonella in chicken
• No more sunny-side up, especially for high-risk
  patients (unless the eggs are pasteurized)

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Campylobacter jejuni

• Undercooked chicken
• 180º whole chicken
• 170º white meat
• 180º dark meat

78
E. Coli 0157H7the burger bug

• 3rd most deadly toxin in the world
• 10-100 pathogens to make you ill or kill you
• Very young, very old, very immunocompromised
• Acute Renal Failure in Kidshemolytic uremic
  syndrome
• Swimming pools, petting zoos
• Mickey Ds30 outbreaks per year
• Supportive Treatment
• Preventcook burgers to 160º F
• Produce is the biggest offender for E.Coli
  O157H7

79
Crohns diseaseinflammatory bowel disease

• Primarily small bowel, but can include anywhere
  from the esophagus to the rectum
• Skip lesions fistulas strictures
• Cause? Bacteria? Mycobacterium paratuberculosis?
• Autoimmune response

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Signs and symptoms

• Usually begins with intermittent attacks of
  relatively mild diarrhea, fever, and abdominal
  pain, spaced by asymptomatic periods lasting for
  weeks to many months
• 1/5th of patients with abrupt onset, with acute
  RLQ pain, fever, and diarrhea
• Diff dx suggesting acute appendicitis or acute
  bowel perforation
• Chronic disease with fibrosing strictures, marked
  loss of albumin, generalized malabsorption, B12
  malabsorption, or malabsorption of bile salts
  leading to steatorrhea

81
Treatment

• Methotrexate to reduce the immune response
• Inflammation via TNF-alpha
• Drugs that block TNF-alpha include infliximab
  (Remicade), adalimumab (Humira), etanercept
  (Enbrel)
• Certolizumab pegol (Cemzia)

82
Antibiotic-associated diarrhea

• the usual, run-of-the-mill diarrhea vs.
• Clostridium difficile diarrhea (new strain)the
  floxacins and Clindamycin are the biggest
  offenders for C. difficile

83
Clostridium difficile

• Clostridium difficile (difficult to culture,
  hence, difficile) and soap and water kill spores
  better than alcohol-based gels
• New strain (2003) produces more toxin and causes
  more severe outbreaksproduces 16x more toxin A
  and 23 times more toxin B characterized by the
  deletion of a gene that downregulates the
  production of both toxins
• Major risk factor? Use of the fluoroquinolones
  Other antibiotics? Amox/Ampicillin, 2nd/3rd
  generation cephalosporins

84
A few more notes on C. diff

• Has your patient had dental work with prescribed
  antibiotics?
• Treatmentvancomycin, metronidazole
• Stool transplants in chronic C. diff
• High risk of recurrence in patients over 65,
  patients with severe underlying disease, and
  additional antibiotic use after discontinuing
  therapy for C. diff.
• Surawicz CM. Reining in recurrent Clostridium
  difficile infectionWhos at risk?
  Gastroenterology 2009 Apr1361152.

85
Necrotizing entercolitis (NEC) of the newborn

• Acute, necrotizing inflammation of the small and
  large intestine and is the most common acquired
  gastrointestinal emergency of neonates,
  particularly those who are premature or of low
  birth weight
• Any time in the first 3 months, peak around time
  infants are started on oral foods (2 to 4 days
  old)
• Another cause Maternal cocaine use can
  compromise intestinal blood flow, too

86
The sheep

• You wanna do WHAT with my intestines?
• Clinical uses of a sheeps cecum

87
Movin right along to the large bowel

• What are the functions of the large bowel?

88
Functions of the large bowel

• Defense against bacteria--normal flora
• Production of Vitamin K
• Peristalsis and movement of feces
• Acetylcholine triggers peristalsis
  (anticholinergic drugs)
• Nicotine
• Serotonin also triggers peristalsis
• SSRIs and diarrhea

89
Functions of the large bowel

• Net absorption of water and salts/net secretion
  of K--diarrhea and potassium depletion

90
Constipation

• If you need time to think, ask older patients to
  describe their bowel habits.
• --Clifton Meador, M.D
• The scope of the problem? 15 of the population
  suffers from chronic constipation, and over 1
  billion is spent on laxatives annually
• Normal number of bowel movements?
• 3 per day to 3 per week or fewer than seven bowel
  movements over a 2-week period with no medication
  usage as a precipitating cause

91
Constipation

• Rome III criteria w/ 5 other signs other than
  stool frequency straining, lumpy or hard stools,
  incomplete evacuation, sensation of obstruction,
  need for manual maneuvers to facilitate
  evacuation
• If 2 or more of these 6 criteria are present for
  at least 12 weeks during the previous 12 months,
  a diagnosis of functional constipation can be made

92
Constipationcauses?

• Drugsanticholinergic, opiods (codeine,
  oxycodone)
• reduced fluid and fiber intake
• laxative abuse prune abuse
• dementiathe neglect of the call to stool
• cancer of the colon
• decreased activity
• The infamous other category

93
New drug for opiate-induced constipation

• Relistor (REL-i-store). Its almost impossible to
  not get constipated from opiods because of their
  effects on motility. Relistor (methlynaltrexone)
  is an opiod antagonist. Hmmmmif it antagonizes
  opiods then how do the opiods manage the pain.
  Heres the beauty of Relistor. Once the methyl
  group is added to naltrexone, it prevents the
  antagonist from entering the brain and reducing
  the opiods effects in the brain. Relistor just
  blocks the opiod effect in the bowels. Almost 50
  of the patients will find relief within just 4
  hours of taking Relistorhallelujah! Its an
  injection by the waysubQ and its primarily
  approved for palliative care patients that are
  not getting relief from any other regimen.

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Treatment for diarrhea

• Lomotil for diarrhea (atropine sulfate
  diphenoxylate HCl)
• Loperamide (Imodium)
• Undiarrhea (Taiwan)
• Stopit (Israel)
• Lomotil is so good, it will

95
Colon cancer98 adenocarcinomas (large intestine)

• The numbers
• Peak incidence for colorectal carcinoma is 60 to
  79 years fewer than 20 of cases occur before
  the age of 50
• Cecum and ascending colon, 38 transverse colon,
  18 descending colon, 8 sigmoid, 35 multiple
  sites at presentation, 1
• Risk factors?

96
Genetics

• Whos yo daddy?
• When should you start screening family members
  with a history of early-onset cancer?
• Dad with colon cancer at diagnosed at 42?

97
And yo momma?

• Patients with a family history of 2 second-degree
  relatives w/ colorectal cancer should also start
  screening at age 40

98
Risk factors--polyps

• Three types
• Tubular adenomascancer is rare in tubular
  adenomas smaller than 1 cm in diameter
• Villous adenomastend to be large and sessile
  risk of cancer is high (approaching 40) in
  sessile villous adenomas greater than 4 cm in
  diameter
• Tubulovillous adenomamixture of the two

99

• Aspirin and polyps--38 of those taking an 81.5
  mg (low-dose aspirin) had a new polyp compared to
  47 in the placebo group. This is a risk
  reduction of 9. Now, this isnt a jaw-dropping
  difference however, IF colon cancer is a high
  risk in your family or in a specific patient
  population, a low-dose aspirin might give you an
  edge against the disease. (April 2001, American
  Association of Cancer Research meeting, San
  Francisco)

100
Risk factors

• Constipation
• Gosh, I remember when happy hour was something
  other than a good bowel movement!

101
Hereditary colon cancers

• What about the use of COX-2 inhibitors for the
  prevention of colon cancer in patients with
  familial adenomatous polyposis (FAP)absolutely
• Screening should start as young as 20 in FAP
  patients

102
Ulcerative colitisinflammatory bowel disease

• Limited to the colon and affects only the mucosa
  and submucosa extends in a continuous fashion
  proximally from the rectum
• Peak onset between 20 and 25 years of age
• Risk for colon cancerrisk is highest in patients
  with pancolitis of 10 or more years duration 30
  _at_ 35 years after dx
• Dysplasia (distortion of the normal orientation
  and architecture of cells)low-grade dysplasia
  vs. high-grade dysplasia and ulcerative colitis

103
Colon Cancer

• Get it in and get it out!
• GI transit timeless than 72 hours
• How can you tell? Eat corn tonight
• Floaters vs. sinkers
• Other dietary risksobesity high content of
  refined carbohydrates intake of red meat
  decreased fiber

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Dont forget your colonoscopies! Every 10 years
after 50

• Or sigmoidoscopy every 5 years
• Dont forget to ask about a change in bowel
  habits.
• Exit time for colonoscopies should be at least 8
  minutes to increase the detection of polyps

105
Dietary prevention of colon cancer?

• Fiber decreases proliferation
• Decreases insulin release from pancreas (growth
  hormone)
• Decreases ILGF-1
• Calcium and vitamin D?
• Decreased red meat?

106
Speaking of gas

• What is the BFR (basal flatal rate)?
• How often do we pass gas per day?
• The PPFR (post-prandial flatal rate)?The PPFR
  after a meal comprised of 51 baked beans?
• Gender differences?

107
Diverticular disease

• A diverticulum is a blind pouch communicating
  with the lumen of the gut
• Rare under 30 over age 60 the incidence
  approaches 50
• Usually multiple diverticula diverticulosis
• 2 factors are important in their genesis
• a) focal weakness in the colonic wall
• b) increased intraluminal pressure
• 20 w/ diverticula exhibit symptoms lower
  abdominal discomfort, constipation, distention,
  sensation of never being able to empty the rectum
  completely

108
The rectuma portal of entry

• Comments from patients during rectal exams (Dr.
  James Ralph)
• Find Amelia Earhart yet?
• Can you hear me NOW?
• Hey, now I know how a muppet feels
• How long have you been in politics?
• Remind me never to become an altar boy.
• Could you write me a note for my wife, saying
  that my head is not, in fact, up there?

109
The rectum

• Rectal foreign objects
• HPV and rectal warts
• Herpes
• Other STIs
• Rectal cancersquamous carcinoma of the rectum
  (HPV)

110
The end.

• Barb Bancroft, RN, MSN, PNP
• CPP Associates, Inc.
• www.barbbancroft.com
• BBancr9271_at_aol.com

111
Bibliography

• Bariatric SurgeryJournal of the American Medical
  Association (2921724, 2004) Emergency Medicine
  (37731, 2005) British Medical Journal
  (331128, 2005)
• Celiac diseasePatient Care (March 2005 16-20)
  Nutrition in Clinical Care (82 55, 2005)
• Ondansetron and oral rehydrationN Engl J Med
  (3541698, 2006 April)
• Proton pump inhibitors and C. difficile colitis
  JAMA 2005 2942989-2995.
• Probiotics. Canani RB et al. Probiotics for
  treatment of acute diarrheal illness in children
  Randomised clinical trial of five different
  preparations. BJM 2007 Aug 18335-340.