Gastrointestinal Motility Disorders

Jassin M. Jouria, MD

Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.

Abstract

The muscles of the gastrointestinal (GI) tract perform an important job. The GI tract peristalsis, or contractions, mix the contents of the stomach and propel contents throughout the entire GI tract until they exit as waste. When these muscles underperform or fail to perform, it can create serious and painful consequences, diagnosed as GI motility disorders. Although these disorders are rarely fatal, they can cause physical and emotional effects that negatively impact a patient's quality of life. However, there are many options for treatment of GI motility disorders available to healthcare professionals. Treatment is discussed in context of the current research and trends to develop new criteria to diagnose and clinically manage care. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1 Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 7 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Pharmacology content is 1 hour.

Statement of Learning Need

Clinical criteria to treat patients diagnosed with a gastrointestinal motility disorder have developed options for primary and acute care clinicians involved in managing treatment. Research in the area of neurogastroenterolgy is focused on primary care to access new criteria to diagnose and guidelines to treat.

Course Purpose

To provide health clinicians with knowledge of gastrointestinal motility disorders diagnosis, treatment and interventions to support improved quality of life.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2 Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 3 1. Ninety percent of absorption of nutrients occurs in the

a. stomach. b. . c. . d. .

2. True or False: The small intestine is referred to as “small” because it is the shortest segment of the GI tract.

a. True b. False

3. The junction between the small intestines and the colon is the

a. ileocecal valve. b. cecum. c. pyloric sphincter. d. duodenum.

4. When disorders of motility occur in the small intestine, the affected patient may suffer from

a. malnutrition. b. fluid and electrolyte imbalances. c. overgrowth of intestinal bacteria. d. All of the above

5. True or False: An opioid , a drug used to manage moderate-to-severe pain, may cause side effects, such as , , and .

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 4 Introduction

The gastrointestinal (GI) tract serves a multitude of important functions to keep the body healthy and active. Much of the work of the GI tract goes on behind the scenes within the body and is beyond physical or voluntary control. Gastrointestinal motility describes the process of food, fluids, and other secretions moving through the GI tract. The intestinal tract normally carries out a certain number of contractions that advance food and liquids through the gastrointestinal system as part of digestion and absorption of nutrients. When disorders of motility occur, the GI tract is said to have some sort of abnormal amount of motility; it may be working too fast, pushing food and fluids through at an abnormal rate, resulting in dumping syndrome or . Alternatively, GI motility may be sluggish and working at a rate much slower than normal or, in the case of aperistalsis, not at all.

The muscles that move and transition food and waste through the GI tract are involuntary and cannot be physically controlled. The work of the GI musculature continues at a set pace that makes up part of a complex system of digestion, absorption of nutrients, and excretion of waste. If the pace of GI motility is abnormally fast or slow, the affected person will experience symptoms that can cause discomfort and that could lead to illness. Whether GI motility problems occur as a result of chronic disease, damage to the intestinal tract, or short-term illness, the affected patient typically suffers the effects when normally routine motility and transfer of food goes awry.

The

A pathway that extends throughout the body from the upper portion in the face and head to its terminal location below the pelvis, the gastrointestinal tract, is between 23 and 26 feet long, beginning with the mouth and ending with the anus. Instead of being one complete organ, the GI tract consists of nursece4less.com nursece4less.com nursece4less.com nursece4less.com 5 a number of different organs throughout the length of the system. Together these organs are designed to carry out the processes of digestion but each organ has its specific purpose and function.

The various organs include those of the upper GI tract, which consists of the structures of the mouth and throat, the , the stomach, and the duodenum of the small intestine. The lower GI tract is comprised of most of the small intestine and the colon, including the distal portions of the large intestine containing the sigmoid colon, the , and the anus. Accessory organs of the gastrointestinal tract are those that are not technically considered gastrointestinal organs; however, they do play important roles in the process of digestion and in supporting the work of the GI tract. Accessory organs include the tongue, salivary glands, the liver, gall bladder, and . This course will focus primarily on the main organs of the GI tract, their functions and disorders of motility.

Esophagus

The esophagus, also referred to as the alimentary canal, is a hollow tube found in the upper GI tract that is vertically located at approximately the level of the chest. It is about 10 inches long and connected to the pharynx at the back of the throat on one end and the stomach at the other end. The esophagus runs through an opening in the diaphragm known as the diaphragmatic hiatus before connecting with the stomach.

The process of digestion actually begins before food reaches the esophagus. It starts in the mouth as a person chews his or her food. The enzymes in saliva interact with food and start to break food down before it is even swallowed. As an individual chews and prepares to swallow, ptyalin, the main enzyme within saliva, works to break down starches and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 6 in foods. Chewing involves using the teeth to break down food until it is in small enough pieces that it can enter the esophagus; the tongue then pushes the food toward the back of the mouth so that it can be swallowed.

When swallowing, the food passes through the pharynx and enters the esophagus as it travels toward the stomach. Despite being a hollow tube that stretches from the neck to the abdomen, the esophagus does not simply act as a chute for food to slide from the mouth to the stomach. Instead, the esophagus contains three layers of tissue where each has a different function: the interior layer lining or the inner lumen of the esophagus, a mucosal layer that secretes mucus to provide lubrication for food as it moves through the esophagus, and, the layer underneath the mucosal layer, which contains smooth muscles that contract in sequence to propel food along the tract. The esophageal muscles work in sequence to control the food’s movement instead of letting it slide toward the stomach by gravity. The muscles are arranged circumferentially around the esophagus and also longitudinally along the length of the esophageal lumen.

Toward the top of the esophagus, near the pharynx, the muscles work voluntarily. When swallowing, a person has more control over muscular processes used in this area and can better manage the passage of food. As food gets closer to the stomach at the lower end of the esophagus, the muscles are smooth and the work of the esophageal musculature is involuntary; the person eating food does not control the muscular movements in this area.3 The process of the muscles moving the food throughout the esophageal tube is known as peristalsis and it occurs whether or not the person is eating while standing up, sitting, or lying down.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 7 At the base of the esophagus is the lower esophageal sphincter (LES), a muscle that forms the connection between the esophagus and the stomach. As food is propelled through the esophagus, the LES relaxes and opens slightly, which allows the food to pass into the stomach. As soon as the food enters the stomach, the LES then closes tightly again. It remains closed when the individual is not eating or swallowing, which prevents stomach acid and food from being regurgitated and backing up into the esophagus again.

The main function of the esophagus is to transport the food between the mouth and the stomach. There is very little digestion that occurs within the esophageal lumen; whatever was first broken down in the mouth and partially digested is transferred to the stomach to further the digestive process. Alternatively, some foods are not broken down for digestion until they reach the stomach. The esophagus therefore plays a very important role in transferring food from one area to the next so that the body can digest food, absorb nutrients, and gain energy.

Stomach

The stomach is a curved, hollow organ at the base of the esophagus, and it consists of four different sections: the cardia, fundus, body, and . Food enters the stomach after passing through the esophagus and the lower esophageal sphincter where it is then partially digested as well as broken down into smaller pieces so that it can continue to move along the gastrointestinal tract. The stomach is able to expand and contract, depending on the volume of food eaten.

The stomach is lined with millions of gastric glands that are made up of various types of cells that secrete different substances, such as hydrochloric acid, digestive enzymes, intrinsic factor, and certain hormones. After food

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 8 passes through the esophagus, it enters the gastric cardia, which is the first portion of the stomach. Gastric juices are created in the cardia of the stomach; these juices contain mucus, hydrochloric acid, and enzymes that work to break down the food as it enters the stomach. Hydrochloric acid, while often well known as a component of gastric juice, is only one product excreted in the stomach that contributes to the breakdown of food during digestion. Hydrochloric acid has a pH between 1 and 2, which facilitates food breakdown and kills most types of bacteria that may be present in food.

The fundus is the next portion of the stomach after the cardia. Food is temporarily stored in the fundus, and this is the point where food is churned and broken down when it is mixed with enzymes. The chief cells of the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 9 stomach secrete pepsinogen, which converts to form pepsin, an enzyme needed for protein digestion. The parietal cells lining the stomach secrete gastrin, a hormone that stimulates production of gastric juice and all of its components. Intrinsic factor is a type of protein that allows the body to take in vitamin B12 by combining with the nutrient so that it can be absorbed in the small intestine.

Food digestion continues in the body of the stomach, which is the largest portion. Digestion occurs as the stomach secretes gastric juices to break down food particles. In addition to secretion of gastrin, which stimulates production of gastric juices, there are other factors that may increase or decrease the rate of digestion because of how much gastric juice is released. For example, as food enters the stomach, the walls of the stomach stretch, stimulating certain receptors that promote the release of gastric juice. Release of gastric juice may also occur when a person smells or sees food; this process is known as the cephalic phase of digestion.

The body of the stomach is where most of the enzymatic breakdown of food occurs and it is considered the primary area of digestion. Like the esophagus, the stomach is lined with several layers, one of which contains muscles that contract in different directions to move the food around and to churn it within the stomach cavity. After spending time in the body of the stomach, food reaches the antrum, which is the last portion of the stomach before the small intestine. Similar to the esophagus, the stomach also has peristaltic waves that propel food toward the small intestine. The word antrum actually means ‘cave’ and it is in this location that food is slowly released into the duodenum in small amounts to avoid dumping it into the next section all at once.4

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 10 The length of time that food remains within the stomach varies between 30 minutes to several hours, depending on how much food was eaten and the composition of the meal, but the average amount of time food spends in the stomach is four hours.4 As food is broken down and partially digested, it turns into a semifluid mass known as chyme as it travels through the rest of the GI tract. The sphincter separating the stomach from the small intestine is known as the pyloric sphincter. Large food particles cannot pass through the pyloric sphincter, so if food is not broken down well enough as it approaches the small intestine, it is churned back within the body of the stomach to break it down further. As with the LES, the pyloric sphincter is also a muscle that opens to allow small amounts of chyme to enter the small intestine at a time and then closes tightly again to keep stomach contents within the pouch.

As part of the GI tract, the stomach plays an important role in digestion and motility of food. The stomach can develop its own issues of motility that are separate from other sections of the GI tract; when this organ develops motility problems, the affected patient may suffer from a number of symptoms, depending on whether food is being moved too quickly, too slowly, or is being regurgitated in the wrong direction. Any of these symptoms can wreak havoc on other parts of the body, so regulation of stomach motility is essential for normal GI function.

Small Intestine

Although it is referred to as “small,” the small intestine is actually the longest segment of the GI tract. Its description as being small refers to its diameter, which is less than that of the nearby colon. The small intestine is connected to the base of the stomach; and, the muscular sphincter between the two structures is known as the pyloric sphincter, which is responsible for

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 11 controlling the rate of chyme, or partially digested food, entering the small intestine from the stomach. The small intestine makes up approximately two-thirds of the total length of the GI tract, but it remains within a compact cavity by winding around in loops and coils within the area.

The small intestine consists of three main segments, each of which has its own purposes and activities as part of digestion. The first section is the duodenum, which is proximal to the stomach and first receives chyme as it enters the small intestine. The duodenum is where much of digestion occurs that finishes what was started in the stomach. Accessory digestive organs, including the pancreas and gall bladder secrete substances into the duodenum to aid in digestion. Following this segment is the middle portion of the small intestine, called the , which has various folds within its interior layer. These folds increase the overall surface area of this portion of the small intestine; consequently, the jejunum is the section of the small intestine where much of the absorption of nutrients takes place. The distal section of the small intestine is the , the end of which connects to the large intestine at the ileocecal valve. This valve is actually another sphincter found along the GI tract that controls the amount of partially digested food as it enters the colon.

The small intestine moves chyme throughout its tract by two different actions: intestinal peristalsis and segmentation. The presence of chyme within the small intestine stimulates peristalsis, which is the movement of the smooth muscles to propel the food forward as it moves along the tract. Segmentation refers to intestinal contractions that create small waves that churn the chyme as it moves through peristalsis.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 12 Digestion occurs within the stomach of the GI tract. The stomach begins absorption of nutrients, and, the small intestine completes the process of food digestion and absorbs many nutrients as the chyme passes through it. The pancreas and gall bladder, both located next to the small intestine, secrete digestive enzymes, including amylase and lipase into the duodenum to stimulate further digestion of food. Once food enters the duodenum, this action stimulates other areas to secrete other substances as well, such as bile from the liver, which work together to facilitate food digestion and the breakdown of fats, starches, and other substances in the chyme. The rate of motility of the small intestine is regulated by secretion of hormones and neuroregulators found within intestinal secretions.

Chyme travels through the small intestine during an average time of 3 to 6 hours. Absorption occurs because of the microscopic projections on the surface of the small intestine; these projections, known as villi, are located on the mucosal surface and are where absorption takes place. Ninety percent of absorption occurs in the small intestine along its full length. Water enters and is reabsorbed in the small intestine as well. Each villous is connected to a tiny capillary network that allows for absorption of nutrients such as carbohydrates, vitamins, and fatty acids directly into the bloodstream.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 13 Absorption begins in the jejunum of the small intestine as nutrients pass from the villi and are diffused through the intestinal wall into the capillary network. Absorption continues in the ileum of the small intestine, with specific nutrients being absorbed in certain locations throughout; for instance, sodium and chloride are absorbed in the jejunum, while vitamin B12 and bile salts are absorbed in the ileum.1 Most of the nutrients are absorbed in the small intestine. The remaining substances move into the colon. The substances first move into an area known as the terminal ileum, which is the very end of the small intestine, and then pass through the ileocecal valve. What is left is indigestible and will travel through the colon where a certain amount of fluid is absorbed before the matter finally exits the body.

The extraordinary length of the small intestine means that food and chyme spends a significant amount of time moving through this organ of the digestive tract. When the small intestine develops a motility disorder, food can move through this organ much more quickly and may spend very little time in the small intestine. Because the small intestine is responsible for much of the absorption that takes place in the GI tract, when motility disorders occur, the affected patient may then suffer consequences associated with , including malnutrition, fluid and electrolyte imbalances, and overgrowth of intestinal bacteria.

Colon

Also referred to as the large intestine, the colon is shorter than the small intestine but its diameter is much larger in size. The colon is divided into three areas, based on its position in the abdominal cavity. The ascending colon is connected to the small intestine at the ileocecal valve and is located on the right side of the body; undigested material travels through this

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 14 portion of the colon first. The large intestine turns and then becomes the transverse colon, which extends from the right to the left side of the abdomen. At this point, the intestine turns again to become the descending colon that travels down the left side of the body. The terminal portion of the descending colon is the sigmoid colon, the S-shaped final portion that connects to the rectum, and finally, the anus.

The end of the small intestine and the junction between the small and large intestines contains the ileocecal valve, which connects the small intestine to the colon. Each wave of peristalsis of the small intestine opens the ileocecal valve briefly to allow a small amount of material to pass into the colon. Near the ileocecal valve is the cecum, which is a pouch that absorbs some fluid and salts from undigested food. Next to the cecum is the , a finger-like projection that may serve as a reservoir for beneficial bacteria in the gut. Undigested materials enter the colon from the small intestine and travel through its segments over the course of several hours; the average amount of time that these materials stay in the colon is approximately 24 hours.4

The colon has a segmented appearance and contains layers of tissue that are similar to the small intestine; however, the interior layer of tissue in the large intestine does not contain villi needed for nutrient absorption. The mass of material is moved through the colon in peristaltic waves that occur on an intermittent basis, typically from stimulation by secreted hormones

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 15 that are released after another meal is eaten. In other words, food from the last meal may move through the digestive tract and, once it reaches the large intestine, it is further stimulated to move through this organ when the person eats the next meal.

The remainder of material that enters the colon is further broken down, as it becomes waste products that will eventually be evacuated from the body as stool. This process occurs in the colon through intestinal secretions and the work of bacteria, which are always present within the large intestine. The intestinal secretions lubricate the fecal mass as it moves through the colon; and, the bacteria break down any other nutrients that are present at this point. The mass moves through the colon much more slowly when compared to the small intestine. During transit, extra water and electrolytes are absorbed so that the material eventually forms the fecal mass that becomes stool.

When the fecal mass reaches the rectum, it distends to contain the stool. This fecal matter is mostly fluid with some solid material. It contains indigestible particles of food and bacteria. As the stool stretches the rectum, it stimulates the autonomic nervous system that controls the internal sphincter near the anus. The anal opening contains both an internal and an external sphincter to control passage of stool out of the body. Normally, the external sphincter stays contracted and closed until the point when defecation occurs, and it then relaxes to allow stool to pass. The work of the colon is largely involuntary until stool reaches the rectum and the anus; at this point, some control of the external anal sphincter is voluntary, allowing the individual to control defecation.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 16 A significant portion of the colon’s purpose is to absorb fluid and prepare waste for evacuation, which is healthy and necessary to rid the body of waste products and those materials that cannot be used by the body. This last portion of the GI tract is necessary to complete the digestive process, to eliminate stool and materials that the body does not need, to regulate fluid and electrolyte levels, and to maintain overall health of the body.

Etiology Of Gastrointestinal Motility Disorders

There are multiple factors that contribute to motility disorders. Because dysmotility may be manifested in different ways, for instance, as delayed motility that results in too slow of transit or increased motility that prevents proper nutrient absorption, there are also various causes of dysmotility. Some factors may be related to patient health, such as, a decline in overall health as a result of aging or chronic disease, which can affect the gastrointestinal system and its rate of motility. Alternatively, there are some elements in the environment that also affect gastrointestinal function, such as with drug use. Understanding the potential etiologies of motility problems may better assist healthcare providers with diagnosing these conditions when patients present for care.

Degenerative Disorders

The motility of food and materials through the digestive tract is a complex process that involves stimulation of the muscles and tissues of the esophagus, stomach, and intestines to propel food through the tract using peristalsis. Factors such as hormones, enzymes, blood flow, nerve activity, and intestinal secretions all impact the rate of food transit and digested materials. Because degenerative disorders can affect many of these factors, people who suffer from these illnesses may be more likely to develop disorders of motility within the gastrointestinal tract. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 17 Chronic Intestinal Pseudo-Obstruction

Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that results in poor intestinal motility. The patient may suffer from signs or symptoms that would occur with an intestinal obstruction but there is actually no evidence of any sort of blockage or barrier upon exam. The condition may develop because of various factors, including surgical trauma or chronic disease, as well as various nerve and muscle disorders, including scleroderma, Parkinson’s disease, and lupus.

A person who develops CIP will often suffer from symptoms characteristic of intestinal obstruction, including abdominal distention and pain, nausea and vomiting, and either constipation or diarrhea. The patient actually presents with symptoms that lead the healthcare provider to believe, upon initial assessment, that some sort of intestinal obstruction is present. However, after diagnostic testing, the patient is then found to have no lesions or occlusions in the intestinal tract that would cause the symptoms.57,85

Diagnosis of CIP requires a physical exam and diagnostic testing, which typically involves imaging studies. The patient most often needs an abdominal X-ray, a CT scan of the abdomen, or even endoscopy to verify what is causing the symptoms or to rule out any other cause, such as an actual intestinal obstruction. Chronic intestinal pseudo-obstruction affects GI motility because the condition affects intestinal peristalsis, including causing delayed

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 18 gastric emptying or rapid transit of digestive substances.

Management of CIP is usually not curative and the best approach is to treat the patient’s symptoms and to prevent complications, such as malnutrition or dehydration that may develop from the condition. The patient often needs nutritional guidance and to be counseled about food intake, as weight loss is common. In some cases, the symptoms are so severe that the patient requires a feeding tube to ensure that he or she is getting enough nutrients. A feeding tube can ensure that the patient continues to gain nutrition because CIP tends to affect how the food moves through the intestinal tract but does not necessarily cause changes in the intestinal lining that would otherwise affect nutrient absorption.

The medications required as part of management of CIP are also prescribed to control symptoms and to reduce complications. If the patient primarily suffers from delayed gastric emptying and constipation, then drugs such as stool softeners, laxatives, and antiemetics may be necessary. Alternatively, if the condition leads to frequent diarrhea, then antidiarrheal medications would be required. If the CIP is caused by an infection, the provider can prescribe antimicrobial drugs to contain the infection and to control symptoms.

Ideally, CIP is managed by controlling the condition that is causing it; however, when it develops because of chronic disease that has no cure, such as lupus or scleroderma, CIP management becomes symptomatic only. The patient may then continue to take medications and undergo treatments to control his or her chronic illness while simultaneously managing GI dysmotility. If symptoms are severe or are unresponsive to medication, the patient may need surgical treatment. Treatments involved also prevent

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 19 complications and may include decompression of the gas that has accumulated in the intestinal tract, removal of excess stool and waste in the large intestine, or surgically manipulating intestinal sphincters to improve muscular control.

Swallowing and Esophageal Disorders

Gastrointestinal motility problems may develop within various segments of the GI tract. When motility issues occur in the upper gastrointestinal tract and affect a person’s ability to swallow or transport food to the stomach, the person is at risk of complications such as dehydration, malnutrition, and electrolyte imbalance because he or she may have greater difficulties with getting enough to eat and drink. Motility problems in this portion of the GI tract are typically classified as swallowing problems or esophageal motility disorders.

Dysphagia describes difficulty with swallowing; when a person develops dysphagia, he or she has trouble transitioning food from the back of the mouth and into the esophagus. Dysphagia can develop as a consequence of a number of conditions, including physical disabilities, stroke, and carcinoma, and, it may also develop because of difficulties related to certain types of degenerative disorders. The problem not only causes issues with GI motility and food transport, it can lead to other complications, such as malnutrition, dehydration, and aspiration if food or liquid accidentally enters the lungs instead of the esophagus.

Degenerative disorders can cause swallowing problems when the nerves that impact a person’s ability to coordinate swallowing become damaged or injured as a result of the disease process. Many degenerative conditions cause loss of neurons in the brain and spinal cord, which further affect nursece4less.com nursece4less.com nursece4less.com nursece4less.com 20 movement and coordination in the GI tract. Degenerative diseases are typically progressive and are often incurable, with treatment focusing on management of symptoms and maintaining quality of life. Examples of degenerative diseases that affect neurological function and swallowing include such conditions as Huntington’s disease, dementia, or Creutzfeldt- Jakob disease.

Dysphagia causes motility problems in that an affected person is unable to adequately coordinate how to transition food from the mouth into the esophagus so that it can travel to the stomach. The process of swallowing requires sequencing of various muscles, including those of the face, neck, mouth, and esophagus; it also requires recognition of the sensations needed to move the muscles to pass the food along, enough muscle strength to coordinate movement of the food, and intact reflexes in the pharynx and the larynx.7 When considering that swallowing is something that most people do multiple times per day, and that it is a mostly voluntary action, the act of swallowing is surprisingly complex.

Degenerative changes can also further complicate dysphagia with advancing age and with other factors that affect cognitive ability, including reduced cognition because of a decline in the number of neurons in the brain, poor dentition, decreased salivary production, poor oral hygiene, and decreased mobility. Strategies to increase quality of life can help to maintain an affected person’s ability to swallow, despite progression of the disease. This may involve thickening liquids to make them easier to swallow or choosing soft and moist foods that are not sticky or hard, making them easier to pass and less likely to be aspirated.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 21 According to Walse in the Journal of and , the mode of dysphagia can vary depending on the type of degenerative condition present. For instance, a person with Alzheimer’s disease may have difficulty with sensing that food is in the back of the mouth to be swallowed, while a person with vascular dementia may have difficulty with chewing.7 Because dysphagia is so complex of a process, each patient who suffers from a medical condition that affects swallowing may have differences in abilities to contend with when compared to another patient who is also classified as having dysphagia.

Interventions for people who struggle with dysphagia are centered on preventing complications associated with the condition and improving overall wellbeing. Eating is such a social activity that a person’s inability to swallow normally may further impair the person’s ability to enjoy a meal and to eat with others. This potentially leads to social isolation and feelings of loneliness. It is therefore important to consider that dysphagia can deeply impact quality of life for the affected patient, and improving the ability to swallow may then increase quality of life for those involved.

The healthcare provider who works with a patient with dysphagia may provide some interventions that would facilitate easier swallowing. As mentioned, this may involve thickening liquids and otherwise modifying food textures and consistencies. The provider may also help the patient to straighten or move the neck or posture to make swallowing easier and to reduce the risk of obstruction. Some forms of rehabilitation utilize adaptive utensils and other methods that make eating easier for the patient.

Further interventions are aimed at preventing aspiration pneumonia, a potentially serious complication that can develop when the patient aspirates

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 22 food into the lung tissue because he does not have control over food and liquids while swallowing. Silent aspiration occurs when the person swallows incorrectly and the food or liquid enters the lungs but there is no physical response from the individual, such as with coughing or choking. Silent aspiration can be one of the more dangerous complications of dysphagia because it can be difficult to detect and control, and yet can lead to pneumonia and breathing difficulties.

Pharmacological and surgical interventions can be helpful for some people who have difficulties with swallowing, but in most cases, they are not terribly effective and only help with some of the symptoms.7 For instance, if drooling is a problem, drug administration may help to control the amount of saliva production. In many cases, palliative care is often the only management strategy after attempts at helping the patient to achieve normal swallowing have been exhausted. Administration of enteral feedings through a feeding tube may be necessary for some patients who are no longer able to swallow and who are at risk of malnutrition and dehydration from an inability to pass food and liquids from the mouth to the esophagus. Caregivers who determine when and what type of enteral feedings are needed must consider numerous factors related to the patient’s health, age, living situation, and prognosis, as changing to this form of feeding may involve a certain amount of ethical decision making on the part of the healthcare provider. However, it can continue to provide nutrients and fluid to a patient who is otherwise unable to adequately swallow.

Achalasia describes a condition that affects how food is transitioned between the mouth and the stomach. Achalasia develops after damage to the nerves of the esophagus, causing aperistalsis, in which the esophagus is unable to propel food and liquids because it lacks the muscular action. The condition

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 23 also causes weakening and incomplete closing of the lower esophageal sphincter, leading to acid reflux and difficulty swallowing. Over time, the patient with achalasia develops greater difficulties with eating and drinking, and may suffer from severe gastroesophageal reflux, all of which could potentially lead to weight loss and malnutrition.

The exact reason why achalasia develops in some people is not entirely clear, but there are some theories. One common opinion is that the nerves that control the esophagus become damaged because of an autoimmune disorder, in which the body attacks its own nerve cells, rendering them useless for maintaining normal motility in the esophagus.6 The nerve cells within the muscles of the esophagus slowly degenerate until they are almost non-functional. Achalasia typically does not develop all at once; instead, symptoms progressively worsen over time as the patient loses more ability to drink liquids and to eat solid food. The condition may initially cause symptoms of mild reflux that can eventually develop into severe pain any time that the individual tries to eat.

Unfortunately, achalasia is a progressive condition in that the nerve cells continue to degenerate and the condition continues to worsen. Achalasia can be managed, though, and depending on the type of treatment, the affected patient may go for months to years without further symptoms. Treatment with medication includes administration of botulinum toxin injection into the LES, which paralyzes the sphincter and allows for food to pass into the stomach. Surgical myomectomy is another option for treatment that involves cutting the muscles around the LES, which allows for food to pass into the stomach.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 24 Stomach and Small Intestine Disorders

Some disorders affect the body’s ability to transition food through areas of the GI tract; food may have reached a certain point within the gastrointestinal system but because of some degenerative conditions, the patient’s body may have enough motility difficulties that it has problems with further movement. Disorders that affect the nerves of the stomach and small intestine can cause delayed gastric emptying, dumping syndrome, or difficulties with absorbing food properly.

Polymyositis degenerative disorder is a relatively rare condition that causes inflammation of connective tissues. It is characterized by muscle inflammation, weakness, and elevated serum muscle enzymes, as well as patient fatigue, shortness of breath, and dysphagia or speaking difficulties.8,9 The exact cause of the condition remains unknown, but it is thought that the muscle inflammation develops as an autoimmune condition. Most people with the condition develop pain and inflammation in the muscles of the upper body, including the neck, shoulders, upper back, and upper extremities, however, GI symptoms and motility problems are also common with this condition.

Polymyositis has been known to be responsible for a number of GI conditions that affect anything from swallowing to lower esophageal sphincter tone. One condition that may be more likely to develop with polymyositis is delayed gastric emptying, also called , which occurs when food moves too slowly from the stomach and into the small intestine. The condition can often cause gastroesophageal reflux, abdominal pain and , and anorexia in affected individuals and can lead to an increase of bacterial proliferation within the stomach and painful lumps of undigested

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 25 food in the stomach that are difficult to break down and pass into the small intestine.

Patients with polymyositis have also developed GI symptoms of diarrhea or constipation, colonic dilatation, GI bleeding, and pseudodiverticula, which occur as small projections of the mucosal layer of the intestine into the muscular wall. All of these symptoms can cause significant discomfort for the affected patient, potentially resulting in malnutrition and anorexia if the patient is unable to eat or digest food properly and if the patient struggles with painful symptoms when eating. Treatment involves administration of corticosteroids to reduce inflammation and symptom management to control gastrointestinal motility problems, such as through modifying food textures to facilitate easier chewing and swallowing, increasing fluid intake, and eating smaller but more frequent meals.

Another type of disorder that causes too rapid intestinal motility from the stomach to the small intestine is known as dumping syndrome. The condition often develops following certain surgical procedures when the muscles and nerves have been damaged or changed and no longer work correctly to control gastric motility. Dumping syndrome is said to affect up to 50 percent of patients who have undergone gastric surgery.66 It occurs when food moves too quickly out of the stomach and into the duodenum of the small intestine. The condition is actually a collection of symptoms that develop with the increased movement of food through the intestine; it is classified as being early phase or late-phase dumping syndrome according to the timing of symptoms.

Early phase dumping syndrome occurs within 30 to 60 minutes after a meal. The affected patient may develop abdominal pain and cramping and may

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 26 start to sweat or feel flushed and lightheaded. Other symptoms include a distinct feeling of fullness in the abdomen, nausea, vomiting, diarrhea, and a rapid heart rate. Up to three hours after a meal, late dumping syndrome may develop, which causes symptoms of flushing, sweating, fatigue, tremor, dizziness, tachycardia, and mental confusion.67

Dumping syndrome is said to develop because of changes in the size of the intestinal tract during digestion, the release of certain hormones after eating that can affect blood pressure, rapid swings in blood glucose levels after eating, and increased fluid absorption from the bloodstream and into the small intestine.66 When a patient has bariatric surgery, such as with gastric bypass, the patient may also develop dumping syndrome because the procedure may affect innervation of the stomach muscles. If the nerves controlling the muscles are cut during surgery or are otherwise damaged, the patient may then lose control over stomach contractions, leading to dumping syndrome.

Dumping syndrome is best managed with changes in dietary practices, including avoiding anything that would overstimulate the muscles of the stomach and cause it to contract too quickly. For instance, the patient should be advised to slow down while eating and to eat small meals, chewing every bit thoroughly before swallowing. A patient may also be instructed to avoid drinking large volumes of liquid before, during, or after meals, and may need to increase fiber intake while decreasing intake of sugar, alcohol, and caffeine.

For some patients, dumping syndrome is only managed through medications or surgery if it does not respond to lifestyle changes. Antidiarrheal medications can help to control some of the abdominal pain, flatulence, and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 27 diarrhea that often develop because of dumping syndrome. In severe cases, surgery to alter the muscles of the pyloric sphincter can best manage dumping syndrome in order to control the rate at which food passes between the stomach and the small intestine.

Muscular dystrophy is another type of degenerative disease that may cause GI motility problems throughout the entire GI tract; however, many symptoms of motility disorders can be concentrated within the stomach or small intestine regions with this disorder. Muscular dystrophy is actually a group of more than 30 degenerative diseases that involve breakdown of muscle tissue, affecting movement and coordination. Muscular dystrophy has no treatment, and management is focused on physical therapy and use of assistive devices to maintain quality of life and to offset some of the muscle weakness experienced by the patient.

In addition to the symptoms affecting various skeletal muscles of affected patients, muscular dystrophy can also cause gastrointestinal changes that affect motility; the most frequently cited symptoms include dysphagia, dyspepsia, gastroesophageal reflux, and vomiting.10 Other symptoms may also include constipation or diarrhea, early satiety, delayed gastric emptying, abdominal pain, and bloating. The extent of symptoms experienced by the patient is typically not correlated with the extent of the disease, as muscular dystrophy affects skeletal muscles and not necessarily the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 28 smooth muscles of the GI tract. Still, those who have more advanced forms of muscular dystrophy have been shown to also struggle with more severe gastrointestinal symptoms, suggesting that motility problems seem to worsen over time.

The progressive muscle weakness that develops from muscular dystrophy is related to skeletal muscles; those that are used for physical movement and functioning and are voluntarily controlled. While some of the gastrointestinal tract utilizes the work of voluntary muscles, much of the peristalsis and transit of food and chyme is done through involuntary control of the smooth muscles lining the GI tract. Experts are not sure why patients with muscular dystrophy then develop gastrointestinal disturbances, but many believe that it is due to an alteration in gastrointestinal secretions and changes in nerve function associated with the disease.10

Because of the potential for altered nutrition due to gastrointestinal motility problems in patients with muscular dystrophy, healthcare providers often include interventions designed to improve motility, increase appetite, and assist the patient with eating and digesting food properly, despite the condition. This may mean administering medications that increase bowel motility and to treat diarrhea, and dietary modifications to facilitate easier chewing and swallowing. As with some other progressive degenerative diseases that affect gastrointestinal motility, tube feedings may be necessary to maintain adequate nutrition once the patient’s condition has advanced.

Disorders of the Large Intestine

Although degenerative disorders can affect motility at any point along the digestive tract, the areas of concern are most often within the colon and the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 29 rectum. In the large intestine, extra water is absorbed and stool is stored until the individual can evacuate stool voluntarily. When a degenerative disease develops, it can impact a person’s ability to control stool evacuation or to sense the need to defecate. Consequently, patients diagnosed with degenerative disorders often suffer from motility problems, including constipation, fecal incontinence, or .

Degenerative neurological disease can affect nervous pathways leading to the large intestine, causing potential complications for a patient diagnosed with this type of disease. Degenerative conditions such as multiple sclerosis, Parkinson’s disease, and spinal cord lesions have all been shown to impact nervous system pathways to the large intestine, leading to dysregulation of intestinal smooth muscle and difficulties with peristalsis and transit.5

The greater risk of complications tends to occur with further progression of the degenerative disease. In other words, the more advanced the stage of the neurodegenerative disorder, the more likely the patient will be affected with gastrointestinal motility problems. A report by Wald of the International Foundation for Functional Gastrointestinal Disorders stated that among patients with multiple sclerosis (MS) analyzed in a large research study, about two-thirds struggled with constipation or fecal incontinence, and, most were considered to have moderate or severe disability associated with MS.5 It should be noted that patients who are considered to have even mild forms of some degenerative disease may still suffer from intestinal motility problems.

Degenerative diseases may also contribute to muscle weakness that impact the body’s abilities to control sphincter muscle tone. Patients who have mellitus may experience muscle weakness and may have an

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 30 inability to control the external anal sphincter muscle that normally tightens and relaxes to control defecation. When the patient is unable to control the external anal sphincter because of muscle weakness, he or she is at higher risk of fecal incontinence because of an inability to control stool and defecation. Patients who suffer from some neurodegenerative disorders may be more likely to struggle with constipation from decreased motility rather than diarrhea. If there is a risk of fecal incontinence because of muscle weakness and poor anal sphincter control, the healthcare provider should carefully consider management of constipation as aggressive treatment could not only reverse the condition, but could also cause diarrhea that would be difficult to control with muscle weakness.5

Hirschsprung’s disease, also called congenital intestinal aganglionosis, occurs as a type of birth defect in which a person is missing some of the nerve cells that control the GI tract. It typically affects the large intestine. Normally, the nerve ganglia develop between muscle layers that line the colon; and, these nerve bundles are usually present throughout the length of the large intestine. With Hirschsprung’s disease, nerve growth is incomplete and, in some areas, nerve bundles fail to form at all, which results in aganglionosis. The length of aganglionosis may vary between individuals; some people are born with aganglia only in the sigmoid colon and the rectum, while others may have absent nerve bundles extending to proximal portions of the large intestine. Approximately 80 percent of patients have aganglionosis within the recto-sigmoid portion of the colon.11 This affected area is also classified as short-segment disease.

Because Hirschsprung’s disease is a congenital condition, symptoms start to appear during infancy. Symptoms are typically manifested as an inability to pass stool in a normal manner, including difficulties with passing first

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 31 meconium after birth among some infants. Other symptoms include frequent emesis, chronic constipation, and abdominal pain and distention. As the person grows, he or she may suffer from long-term problems with constipation, flatulence, and fatigue.

Unfortunately, patients with Hirschsprung’s disease are at risk of intestinal infection because of poor motility. Stool tends to back up within the colon, causing intestinal distention and the potential for bacterial growth, which can lead to . The backup of stool in the colon also causes intestinal obstruction so that the patient has difficulties with passing stool at all. The intestinal walls could become overly distended thereby increasing the risk of intestinal perforation.

The most common type of treatment for Hirschsprung’s disease is surgical resection of the affected areas of the colon where aganglionosis is present. For patients who have short-segment disease, this may mean removal of the diseased portion and placement of a colostomy. If longer sections of the bowel are affected, the patient may need an ileostomy to pass stool after a significant section of the bowel has been removed. Other interventions that are often necessary involve monitoring food intake, including high-fiber foods, to reduce the risk of constipation, increasing fluid intake and physical activity, and possible administration of laxative medications to stimulate gut peristalsis.

Endocrine Disorders

Endocrine disorders develop from dysfunction of the endocrine glands that result in either over- or underproduction of hormones. Endocrine dysfunction can lead to long-term problems and symptoms that affect the entire body, including the gastrointestinal tract. Gastrointestinal motility disorders may

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 32 develop in some patients with endocrine dysfunction, even if the endocrine disorder seems otherwise unrelated to the GI condition.

Diabetic Gastroparesis

Defined as delayed gastric emptying, gastroparesis occurs when a person’s ability to transport food from the stomach to the small intestine slows down, despite a lack of obstruction. The condition is more often associated with diabetic patients, although it can develop among those who do not have diabetes. Gastroparesis more commonly occurs among diabetic patients because uncontrolled blood glucose levels can damage the vagus nerve, which controls the rate of stomach emptying. As a result, food tends to stay in the stomach longer and is slower to transition to the small intestine for further digestion and absorption.

Gastroparesis can lead to multiple uncomfortable symptoms related to delayed gastric emptying. The most common symptom typically includes nausea, vomiting, abdominal bloating, early satiety, and epigastric fullness. The patient is more likely to suffer from poor quality of life because of symptoms and may eventually develop malnutrition and weight loss when food cannot be transitioned normally in the GI tract. Furthermore, some patients with gastroparesis are unable to absorb oral medications in a normal manner, making this route of medication administration ineffective; these groups of people may then need to utilize other methods of drug administration to control symptoms. The vomiting and anorexia associated with gastroparesis can also significantly impact the diabetic patient’s blood glucose levels.

Diabetes mellitus is an endocrine disorder that impacts how the body uses glucose for energy. It is a complex disease that is divided into types 1 and 2.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 33 Type 1 diabetes develops when the pancreas, the main organ responsible for secreting to get glucose into the cells for energy, is damaged or otherwise unable to secrete enough of the insulin hormone to control how much glucose enters the bloodstream. Type 2 diabetes tends to develop because of insulin resistance, in which the cells are unaffected by insulin and thereby become unable to take on enough glucose for energy. Without treatment, both types of diabetes result in elevated levels of glucose in the bloodstream, which can be damaging to blood vessels and to the nerves that serve various organs throughout the body. For this reason, diabetes has been known to cause many different types of health conditions, such as circulatory and peripheral , as well as blindness.

Diabetes is also closely linked to gastrointestinal motility problems. As food is absorbed in the digestive tract, it is transformed into glucose so that the body can use it for energy; however, when there are GI motility problems that affect absorption, the body may be unable to take up enough nutrients to provide glucose for energy. Alternatively, too much glucose in the bloodstream that circulates without being used for energy damages parts of the GI system, including the nerves that serve the intestinal tract, which may lead to severe GI motility disturbances.

Between 5 and 12 percent of patients with diabetes report symptoms of gastroparesis.12 Gastroparesis is not necessarily a condition that develops early on after a diabetes diagnosis, instead, it is more likely to occur later in the course of the disease, after the patient has had diabetes for several years and may more likely suffer from concurrent conditions that have also developed as a result of diabetes, including nephropathy, neuropathy, or retinopathy.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 34 Normally, the stomach uses muscular contractions to churn and propel food within it, and the stomach’s peristaltic waves then move the food, coordinated with the opening and closing of the pyloric sphincter (between the stomach and duodenal (small intestine) bulb, to push it into the first portion of the small intestine. Once damage has occurred to the vagus nerve that controls this process, there is no cure for the condition. The patient is at risk of several complications, including malnutrition and dehydration when food and liquids cannot be processed normally. A bezoar may develop, which is a hard mass of undigested food that sits in the stomach and cannot be passed into the small intestine. The patient typically develops nausea and may vomit when a bezoar is present; and, it can eventually be dangerous for the patient if it blocks the pyloric sphincter and prevents other food from passing into the small intestine.

Management of gastroparesis involves controlling the underlying condition and taking steps to improve the rate of gastric emptying. For the patient with diabetes, the damage to the vagus nerve that causes gastroparesis is typically irreversible, even with later blood glucose management. However, it is still important to help the patient to control blood glucose levels to better prevent other complications of the condition and to inhibit the potential for gastroparesis symptoms to affect blood glucose levels.

Gastroparesis is also managed through dietary changes that help the patient to eat foods that are easier to digest. The patient may need to chew food very thoroughly so that bites are very small and easier to pass through the stomach. Other dietary interventions often include increasing fluid intake and avoiding certain foods; those foods that are very fibrous or that contain hard particles, such as nuts and seeds, may be more difficult to digest and can complicate symptoms of gastroparesis. Some medications may stimulate

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 35 stomach contractions to help with the passage of food. Metoclopramide (Reglan®) may be given to improve the rate of gastric emptying; and, erythromycin is another drug that has been shown to be successful. Erythromycin stimulates the smooth muscles in the stomach and the duodenum of the small intestine to increase gastric motility.12

Electrical stimulation may also be used as part of treatment for gastroparesis. The process uses a permanent implanted device, inserted surgically, that stimulates the lower gastric nerves of the stomach, which helps the stomach to contract. The most common device is called Enterra™ and it is used when the clinician laparoscopically inserts the electrodes into the patient’s stomach to deliver the electrical current. A study published in the Journal of Minimal Access Surgery demonstrated that a permanently implanted device such as Enterra to deliver electrical stimulation improved symptoms in 70 percent of patients with severe gastroparesis who had participated in the study.13 Once implanted, the Enterra device stays in place for the long-term and provides permanent stimulation to control gastroparesis and prevent it from worsening; and, it is typically reserved for patients with delayed gastric emptying who have not otherwise responded to other therapies.

Because there is no cure for diabetes, the patient who is diagnosed must be educated about the damaging effects of the disease and the need for control of blood glucose levels to prevent complications. Gastroparesis that develops as a result of diabetes is also a permanent condition that will require lifelong management once it occurs. If possible, it is better to prevent the condition from developing instead of trying to manage it after it has already occurred.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 36 Thyroid Disorders

Over-activity or underactivity of certain glands causes endocrine problems and potentially debilitating symptoms that can lead to gastrointestinal issues. The thyroid gland, which releases hormones that regulate body metabolism, temperature, and heart rate, may not function properly if there are complications associated with the gland itself or with the portion of the brain that stimulates its release of hormones. Hyperthyroidism develops when the thyroid is overactive and produces too many hormones; it normally results in a rapid heart rate, increased appetite, shakiness, and anxiety, but it can also lead to motility problems.

A commonly seen gastrointestinal motility disorder associated with hyperthyroidism is diarrhea, as the transit times in the intestine are increased due to the effects of the hormones. Diarrhea may also be more likely to develop in hyperthyroid patients when there are abnormal rates of intestinal secretions, whether because they are secreted in too high of quantities or if there are not enough.9 Patients with hyperthyroidism may suffer from other gastrointestinal symptoms as well, including , which describes increased amounts of fat within the stool, epigastric pain, abdominal fullness, and dyspepsia.

In contrast to hyperthyroidism, low levels of thyroid hormone result in hypothyroidism, which has also been shown to cause gastrointestinal motility disorders. Hypothyroidism is associated with slowing of many metabolic processes, and affected patients often struggle with symptoms of weight gain, fatigue, muscle and joint pain, depression, and increased sensitivity to cold. One of the most common GI complaints among patients with hypothyroidism is constipation, as colonic motility slows with a decrease in thyroid hormone production. Hypothyroidism is also responsible for a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 37 number of other GI symptoms, which may include delayed gastric emptying and bezoar formation, reflux , and abdominal distention.

The gastrointestinal changes that develop as a result of hypothyroidism often occur because the bowel wall becomes thickened and sometimes dilated. There may also be cellular changes that occur in the bowel mucosa, including an increase in mucopolysaccharides, which can affect metabolism. This may relate to an explanation of why the patient with hypothyroidism is more likely to have slower gut motility and constipation.

Treatment of gastrointestinal motility problems in relation to hyper- or hypothyroidism involves controlling these underlying conditions. The initial goal is to achieve normal levels of thyroid hormone, typically through medications or procedures, in order to regulate metabolic processes within the body and to diminish symptoms. Hyperthyroidism is often controlled through radioactive iodine, which damages some of the thyroid cells so that they stop overproducing thyroid hormones, or surgery to remove part of the thyroid gland. Alternatively, hypothyroidism is most often controlled through prescription synthetic thyroid hormone replacement to bring hormone levels back to within normal limits. Often, prescription medication is administered lifelong, as discontinuing the drugs will usually cause the body to revert back to a state of hypothyroidism and continued problems with low hormone levels.

Patients who suffer from thyroid abnormalities may not initially develop gastrointestinal motility problems. These difficulties may occur later in the course of thyroid disease, particularly when there is poor control over thyroid hormone secretion and poor management of thyroid disease. It is therefore important to be aware of the gastrointestinal effects that can

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 38 develop as a result of abnormal thyroid production so that when symptoms of motility problems do develop, the healthcare provider and the patient can be prepared for a possible diagnosis and for treatment of the condition.

Adrenal Gland Disorders

The adrenal glands are another set of endocrine glands that can cause various health problems when they are not functioning appropriately. The adrenal glands sit on top of the kidneys in the lower back and are responsible for secreting hormones that help the body respond to stress. There are various types of adrenal gland disorders, most of which produce varying symptoms, and gastrointestinal motility problems may be included in some of these symptoms. Some of the more common types of adrenal disorders include Cushing’s syndrome, pituitary tumors, pheochromocytoma, and Addison’s disease.

Patients with Addison’s disease tend to develop gastrointestinal symptoms related to nausea, vomiting, and anorexia; the symptoms seem to worsen as the condition progresses. Addison’s disease is most often caused by an autoimmune disorder in which the body attacks its own tissues and causes the adrenal glands to work inappropriately. Eventually, the damage from the autoimmune system destroys the adrenal cortex, which is the outer protective covering to the adrenal glands. The patient is no longer able to secrete sufficient amounts of cortisol and aldosterone needed to regulate nursece4less.com nursece4less.com nursece4less.com nursece4less.com 39 various body functions, including weight control, the ability to fight infection, and control of heart rate and blood pressure. For this reason, Addison’s disease is also known as hypocortisolism.

Addison’s disease is difficult to diagnose because many of the symptoms, whether they are gastrointestinal in nature or not, are non-specific and could be attributed to any number of medical conditions. General symptoms of Addison’s disease include hyperpigmentation of the skin and mucous membranes, weakness, fatigue, poor appetite, and weight loss, as well as joint pain, a heightened sense of smell, hypoglycemia, myalgia, and muscle paralysis. Addison’s disease typically develops as a result of autoimmune adrenocortical insufficiency; and, because over 80 percent of cases are related to autoimmune adrenal damage, Addison’s may be seen in association with some other types of autoimmune diseases that affect the GI tract, including celiac disease, type 1 diabetes, Hashimoto thyroiditis, pernicious anemia, and biliary .14

Management of Addison’s disease improves the likelihood of controlling GI motility problems that develop as a result of the condition. Treatment involves correcting the levels of hormones through hormone replacement therapy; this includes administration of corticosteroids and androgen replacement therapy, if necessary. Treatment with corticosteroids may resolve some of the GI symptoms as well as many of the other symptoms of the condition. Symptoms develop due to hormonal imbalance; the hormones secreted by the adrenal glands are involved with regulation of the body’s inflammatory responses, proper balance of electrolytes, and sexual development. With hormone replacement and medications, the affected patient may find relief from many symptoms where hormone imbalance is the root cause. For example, a patient with an imbalance in sodium levels in

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 40 the body may struggle with symptoms of diarrhea and dyspepsia. By replacing mineralocorticoid levels that would otherwise be out of balance with Addison’s disease, the body would be more likely to regulate sodium and potassium levels, potentially diminishing the risk of diarrhea from the condition.

Another endocrine condition that affects the adrenal glands and that is sometimes confused with Addison’s disease is Cushing syndrome. Cushing syndrome, also called hypercortisolism, develops when the adrenal glands create too much cortisol; one of the most common causes of this condition is when an individual takes in too many steroid medications, however, it can also develop from such conditions as adrenal tumors or excess production of adrenocorticotropin hormone (ACTH), which normally stimulates the adrenal glands to produce cortisol.15

Excess cortisol production can have a number of effects on the gastrointestinal system. Cortisol is sometimes referred to as the “stress hormone” in that the body may produce greater amounts in response to stress. Cortisol can also impact an individual’s nutritional status, as it normally regulates energy by selecting the correct amount of carbohydrates, fats, or proteins to meet the physiological needs of the body.16 Elevated levels of cortisol, as seen with Cushing syndrome, can lead to elevated blood glucose levels, weight gain, increased appetite, and cravings for high-calorie foods. Elevated cortisol levels also affect the sympathetic nervous system, which can affect GI function and can cause uncomfortable symptoms in the patient with Cushing syndrome. When the person eats a meal, his or her GI system responds poorly due to elevated cortisol levels and is more likely to lead to suffering from problems with digestion, nausea, vomiting, , and mucosal inflammation.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 41 Control of gastrointestinal motility symptoms associated with Cushing syndrome is achieved by managing the symptoms when they occur and by treating the syndrome to regulate cortisol levels. The type of treatment needed depends on the cause of Cushing syndrome; for instance, if it develops from excess corticosteroid use, the patient should be assisted to decrease or eliminate use of this drug to avoid further deleterious effects. Nursing interventions are focused on helping the patient to perform self-care measures, keeping the patient safe when symptoms develop, and helping the patient to control stress levels.

Irritable Bowel Syndrome

One of the more common functional gastrointestinal motility disorders, (IBS) is thought to affect up to 10 percent of the population of the United States.17 Irritable bowel syndrome is considered a functional gastrointestinal disorder because its symptoms develop from abnormal functioning of the GI tract. Diagnosis of IBS can be difficult and clinicians are sometimes perplexed by its expression and manifestations, as imaging studies and laboratory results tend to be completely normal in affected patients.

A patient with IBS may suffer from severe symptoms but upon examination, there is no sign of disease or any change in the colon. Experts have determined that there are several factors that play a role in the development of IBS, and control of some of these factors may help to control the negative symptoms associated with this complex condition. Irritable bowel syndrome has also been referred to as , spastic colon, and functional bowel disease,18 although these terms are often designated by the general public and are not entirely accurate to the disease process that occurs with IBS.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 42 The exact cause of IBS is unclear, but those who develop the disorder often have several risk factors in common, including increased levels of stress, a low-fiber diet, recent history of infectious diarrhea, and a history of physical or sexual abuse. The condition is seen much more often in women when compared to men, with a 50 percent greater incidence; it is also much more common among young- and middle-age adults, with most diagnosed cases occurring before the age of 50 years.19

Irritable bowel syndrome can cause symptoms that predominantly involve diarrhea or constipation, although some patients suffer from both. It is classified according to the predominant forms of stool that occur with symptoms, and may be considered IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), IBS mixed (IBS-M), or IBS unsubtyped (IBS-U) in which the stool consistency does not meet the criteria for the other forms of the condition. The affected patient may also have abdominal bloating, cramping pain, flatulence, mucus in the stool, and the feeling of incomplete emptying after having a bowel movement.

In addition to GI symptoms, IBS often causes other symptoms that seem unrelated to gastrointestinal functioning, including anxiety, depression, headache, and fatigue. The severity of symptoms may range between mild gastrointestinal disturbances to severe enough symptoms that impact the patient’s ability to participate in normal activities and thereby affects his or her overall quality of life.

There are various theories as to the potential cause of IBS; experts have proposed that IBS symptoms develop due to altered levels of serotonin in the GI tract, increased release of inflammatory mediators, abnormal muscle contractions in the GI tract, visceral hypersensitivity, and brain-gut

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 43 dysfunction.18,19 Some patients with IBS may have sensitivities to stimulation in which the muscles of the large intestine react abnormally and either increase peristalsis to propel stool through the colon more quickly, or to slow it down to cause constipation. Visceral hypersensitivity refers to a situation in which the nerves of the intestinal tract are very easily stimulated and can send pain messages to the brain in response to potentially mild environmental triggers. When this occurs, the body may further stimulate the involuntary muscles of the GI tract to increase peristalsis; the patient may also be more likely to experience abdominal pain and discomfort in response to triggers.

Brain-gut dysfunction describes a condition in which a patient may experience gastrointestinal symptoms in response to emotions and psychological distress. Feelings of distress may trigger further symptoms of IBS, causing greater intensity of GI symptoms if the patient is suffering from psychological symptoms. Unfortunately for some, there are certain environmental triggers that are more likely to cause symptom exacerbation in IBS. Persons with IBS have stated that they have been more likely to experience symptoms after eating a meal containing certain foods, such as greasy, fried, or spicy foods; and, after drinking alcohol or beverages containing caffeine, or when experiencing distressing situations or feeling stress because of traumatic events. Many women with IBS say that they are more likely to experience symptoms during the days surrounding their menstrual periods.

Irritable bowel syndrome may be diagnosed after consideration of the Rome III Diagnostic Criteria, a set of measurements developed by research teams of neurogastroenterolgy specialists affiliated with the Rome Foundation for the diagnosis of functional gastrointestinal disorders. According to the Rome

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 44 III Criteria, IBS is diagnosed when a patient has had symptoms for at least three months with symptoms involving recurrent abdominal pain and either improvement in pain after defecation, change in stool frequency at onset, or change in stool appearance at onset. These symptoms must have occurred for at least three days per month.19

Other tests are important when diagnosing IBS, as the condition could be related to another gastrointestinal illness. Irritable bowel syndrome is not associated with a greater risk of colon cancer, nor does it cause intestinal bleeding. If a patient has symptoms of intestinal obstruction, bleeding, or has a fever or significant weight loss, the patient most likely has another GI illness that is not irritable bowel syndrome. In addition to utilizing the Rome Criteria, the clinician may check a stool sample, perform a rectal exam, and check a blood count. There are no specific biomarkers for IBS that would appear in a stool or serum sample and that would specifically identify IBS based on physical data alone. Instead, these tests are performed to rule out other conditions that may be the cause of the patient’s symptoms. A thorough medical history is also important to determine how long the patient has been experiencing symptoms and whether the symptoms are triggered by outside events.

Because it is not entirely clear what causes IBS, treatments may vary; they are usually based on controlling symptoms and preventing patient complications that can develop as a result of chronic IBS, including malnutrition, chronic pain, social isolation, dehydration, and electrolyte imbalance. Drug therapy is a common method of treatment and may include administration of medications to relieve cramping pain and increased peristalsis that causes diarrhea, including antidiarrheal medications, anti-gas formulations, fiber supplements, and anticholinergic drugs that relax the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 45 smooth muscles of the intestines. Alternatively, a patient who struggles with IBS-C type may need medications and diet therapy that manages and prevents hard stools from forming, such as osmotic laxatives, stool softeners, and bulking agents. The type of drug administered is based on the patient’s predominant form of IBS.

There are also two different drugs that have been approved specifically for the management of IBS. Lubiprostone (Amitiza®) is used for IBS that involves predominant symptoms of constipation; it improves symptoms by increasing fluid to the colon where it would otherwise be absorbed. Increased fluid in the large intestine prevents the formation of hard stools that are difficult to pass, as associated with constipation. Lubiprostone is only approved for use in women. Alosetron (Lotronex®) is a second drug that has been approved specifically for IBS treatment. This drug is more commonly prescribed for patients who suffer from IBS with predominant diarrhea symptoms; it works by slowing peristalsis in the large intestine by relaxing the intestinal tract. This ultimately slows the passage of stool to prevent diarrhea and to enhance normal stool formation and excretion.17

For some patients, it has been thought that IBS is caused by food allergies in which the patient develops severe gastrointestinal symptoms as a type of allergic response. When food allergies are suspected, the patient may need to follow an elimination diet in which the potential allergen is avoided for a certain period of time to see if symptoms abate. An elimination diet may take quite a while for results, as the patient may need to eliminate more than one kind of food, avoid it for several weeks to see if symptoms change, and then reintroduce the food slowly. If there is no change, the patient then eliminates another potential source of allergy and starts the process again.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 46 For many, following a healthy diet and eating small meals is enough to control symptoms. Other lifestyle interventions that the nurse could promote include recognizing potential triggers and avoiding them, controlling stress and overly taxing activities, increasing activity levels, and participating in exercise.

Antidepressants have been shown to be beneficial for patients with IBS when they are used off label to manage symptoms. Antidepressants are helpful among patients with IBS that is otherwise unresponsive to other medications and lifestyle interventions. Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are the most common types of antidepressants prescribed in these situations. Because IBS has been associated with greater levels of anxiety and depression among some patients who develop the condition, prescription antidepressants can help to control many psychological symptoms that develop as a result. When further considering the brain-gut dysfunction theory, management of emotional stressors and depression could also physically alter the body’s gastrointestinal response to psychological factors.

Tricyclic antidepressants have also been shown to decrease transit times in the gastrointestinal tract, which could potentially control symptoms of diarrhea. They are also somewhat effective in relieving abdominal pain associated with IBS. Some types of TCAs that may be prescribed include desipramine (Norpramin®) and nortriptyline (Pamelor®). Selective serotonin reuptake inhibitors are more likely to increase GI motility and may be more appropriate for patients who suffer from predominant constipation. Some types of SSRIs that are prescribed in these cases include fluoxetine (Prozac®) and citalopram (Celexa®).19

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 47 Patients with IBS have also been helped with controlling stress through nonpharmacological interventions, including cognitive-behavioral therapy (CBT) and gut-directed hypnotherapy. These interventions and others, including stress management techniques of relaxation therapy, aromatherapy, massage, and yoga may be included as part of treatment for IBS. Because the symptoms of IBS have been associated with some psychological manifestations as well, it is important to not only manage the physical GI symptoms that develop with this condition, but to also consider the mental health of the patient.

Fecal Incontinence

Although less common than urinary incontinence, fecal incontinence is thought to affect up to 20 percent of older adults living in the community and up to 50 percent of long-term care residents.26 Fecal incontinence is described as the unintentional loss of solid or liquid stool. Involuntary loss of gas or liquid stool is known as minor incontinence whereas loss of solid stool is referred to as major incontinence. The condition most often occurs due to loss of control of the anal sphincter, which is normally responsible for tightening the sphincter and maintaining stool within the rectum until the person is ready to defecate. Without adequate sphincter control, the individual may have little to no control over stool evacuation. Loss of anal sphincter control may occur due to trauma or injury to the pelvis, from medical conditions that affect nerve function in the area, or due to chronic GI conditions that affect stool characteristics and bowel frequency, such as Crohn’s disease.

Furthermore, fecal incontinence could develop through other conditions that are unrelated to damage to the anal sphincter. Instead, the affected patient could develop difficulties with controlling sphincter tone to keep it closed in nursece4less.com nursece4less.com nursece4less.com nursece4less.com 48 enough time to retain stool. Neurologic damage from some chronic conditions causes the patient to lose the normal awareness of needing to defecate and may lead to incontinence of stool because of decreased sensation. Examples of conditions that may lead to this damage include uncontrolled diabetes or multiple sclerosis.28 Alternatively, fecal impaction that develops from constipation could also contribute to fecal incontinence in a condition known as overflow incontinence. If the patient develops a stool impaction in the lower GI tract, he or she may actually leak stool around the impaction when the anal sphincter relaxes to the point that stool can escape.

Fecal incontinence may be considered either an acute or chronic condition. A person may lose control of defecation during times of acute illness, leading to incontinence of stool that is often diarrhea. This may or may not occur more than once and may be settled when the illness or current condition is resolved. For example, a patient who suffers from a viral infection affecting the gastrointestinal tract may develop severe and explosive diarrhea and may suddenly experience cramping that indicates that a bowel movement is going to occur. The patient may experience fecal incontinence if he or she is unable to get to the bathroom in time to defecate, but once the viral illness has resolved and the patient’s stools have returned to normal, he or she may resume a normal pattern of bowel movements without incontinence.

Alternatively, when a chronic condition develops, the patient may struggle with fecal incontinence and involuntary loss of stool on an ongoing basis. The patient may or may not be incontinent of feces with each bowel movement, but may have a condition that causes incontinence of stool over a longer period of time that is not resolved despite ongoing medical management. The patient with chronic incontinence is also at higher risk of complications associated with involuntary loss of stool, including skin

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 49 irritation and breakdown from repeated contact between the feces and the skin.

Fecal incontinence is also embarrassing for the affected patient. Uncontrolled fecal incontinence can lead to feelings of depression and anxiety and the patient may be more likely to suffer from social isolation if he or she is afraid to leave the house or attend social functions because of an inability to control defecation. Although there are statistics about how many people suffer from fecal incontinence, the actual numbers may be higher since many who struggle with this condition avoid talking about it and bringing it to the attention of their healthcare provider because they are too embarrassed. Management of fecal incontinence depends on whether the condition is acute or chronic and on the underlying situation that leads to loss of control. Treatment of the condition typically is through medication and non-pharmacological measures, surgery, or biofeedback.

When diarrhea is a major cause of incontinence, medications that increase stool bulk can reduce the risk of leaking liquid stool. Bulking agents, including fiber supplements, such as methylcellulose or psyllium, are often used for management of constipation but can be helpful for fecal incontinence as well. Bulking agents prevent diarrhea and, by adding more bulk to the stool, they may help the patient to retain formed stool within the rectum until there is a chance to voluntarily pass it. Increasing dietary fiber will have a similar affect. The nurse may ask patients about their diet history and calculate daily fiber intake, counseling patients to increase fiber slowly, day-by-day to reach a high-fiber diet. The soluble and insoluble fiber in some foods also provides bulk for stools, potentially reducing instances of diarrhea and fecal incontinence.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 50 Some medications that are given to control diarrhea may also be helpful in cases of fecal incontinence. These are available without a prescription, but the affected patient should consult with a healthcare provider before using them to determine the best course of action for control of incontinence. Antidiarrheal medications available without a prescription are either loperamide (Lomotil®), which works by slowing down the rate of intestinal motility, or bismuth subsalicylate (Pepto Bismol®), which alters fluid levels in the intestine to prevent liquid stool.29 These medications are recommended for short-term use and should not be used for someone with chronic incontinence as the main form of treatment. They can, however, be taken when someone experiences occasional stool incontinence on a short- term basis, such as when suffering from a viral illness that causes diarrhea.

When overflow incontinence develops, as when the patient has fecal impaction and leaks stool, he or she may benefit from laxatives or stool softeners. These drugs should be used with caution, however, as they could worsen diarrhea, and the patient may be even less likely to control stool. There are various types of laxatives and stool softeners available, which are designed to change fluid content in the large intestine or the consistency of stool to make it easier to pass. Normally reserved for cases of constipation, these drugs can be helpful for some patients with incontinence but a healthcare provider should direct drug use.

Other non-pharmacological interventions may also be employed that either prevent diarrhea and stool incontinence or that manage stool incontinence when it occurs. Examples of changes that could be made to manage stool incontinence include the use of fecal collection devices, such as pouches, and bowel retraining programs. A pouch may be placed around the anal opening, and secured to the skin by an adhesive, to collect stool that leaks

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 51 involuntarily. The pouch is a good idea for patients who are frequently incontinent of stool, as it saves them from repeated accidents and stool loss. Alternatively, if a patient is very active and involved in many activities, may the pouch may not be preferred since it can be bulky and difficult to contain within clothing. The end of the pouch often has an opening that allows the stool to be drained out without changing the bag. A person who is immobile and cannot use a collection device may utilize disposable underpads and undergarments designed for adults to collect stool, which can be changed quickly and replaced with a clean, dry garment to promote skin integrity.

Bowel retraining programs are behavioral programs that are designed for those who have difficulties with fecal incontinence. These types of programs are developed to help affected persons re-establish control over their bowel habits. A bowel-training program may not work for everyone but it can help to develop a routine that some people may benefit from related to building on necessary skills to recognize the need to defecate and to control their bowel movements to avoid being incontinent of stool.

A bowel-retraining program first addresses stool consistency. If the patient is suffering from diarrhea or overflow incontinence because of constipation and bowel impaction, he or she may need medication to change stool consistency and to provide bulk.29 After this has been addressed, the program then focuses on establishing a schedule for elimination in which the patient attempts to defecate at certain times on a schedule. Finally, part of bowel retraining includes understanding how to stimulate the rectum to empty of stool. This may be done through interventions such as laxatives or enemas; however, the method typically varies between patients depending on their conditions and success to eliminate stool.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 52 Biofeedback is a second method of controlling fecal incontinence. With biofeedback, the patient learns to consciously contract the muscles of the rectum that control defecation. The healthcare provider may perform biofeedback during a procedure known as anorectal manometry, which involves insertion of a balloon past the anal sphincter and inflating the balloon inside the rectal vault while a manometer records the sphincter’s response. The patient then learns through this method of biofeedback how much pressure is needed to apply to the sphincter muscles to retain stool within the rectum and to avoid incontinence. Biofeedback is a non-invasive method of re-training some of the muscles in the lower pelvis to control stool elimination; however, it has not been shown to be successful for everyone who has difficulties with stool incontinence.

Whether or not to choose biofeedback, as a method of controlling incontinence, is decided on a case-by-case basis, depending on the patient’s condition. Studies have shown, though, that when used in combination with other methods of managing fecal incontinence, biofeedback can be very helpful for some patients. A study in the Scandinavian Journal of Gastroenterology showed that women who combined biofeedback therapy with use of loperamide and stool-bulking agents showed symptom improvement in terms of fecal consistency, reduced urgency, and increased rectal sensory thresholds.31 If possible, the provider working with the patient in this condition may need to explore more than one idea about the best method of controlling incontinence, even combining more than one method to provide adequate treatment.

Surgery may be particularly helpful for people who suffer from fecal incontinence when the cause is from damage to the anal sphincter. Surgical procedures have been shown to be successful in up to 80 percent of cases of

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 53 fecal incontinence among women who have suffered damage to the anal sphincter from torn tissue during childbirth.30 Surgery in these cases involves using a piece of a muscle from another part of the body and connecting it to the rectum to replace the muscle of the anal sphincter. Alternatively, a synthetic option is to replace the anal sphincter with a cuff that can be inflated and deflated as needed to have a bowel movement.

When a patient continues to suffer from fecal incontinence and is unable to control bowel movements, and the condition is unable to be corrected by surgical muscle replacement, a colostomy may be yet another option for management of the condition. A colostomy involves surgically attaching the end of the colon to the abdominal wall so that feces are collected in a bag outside of the body instead of being routed through the rectum and eliminated through the anus. Surgery for colostomy placement is a complicated procedure and this type of surgery is typically only reserved for those that have not responded to any other therapy or treatment.

Constipation

Constipation is a common problem that may develop after use of various drugs, it may occur with fluid loss or after eating certain foods, or it can be a chronic condition that develops as a result of increasing age or chronic disease. Constipation describes a situation in which a person has difficulty with defecation because stool in the large intestine has become dry or colonic motility has slowed to the point that it takes much longer for feces to reach the rectum. As stool passes through the colon, it is eventually held in the rectum before being eliminated. When stool remains in the rectum for a longer period, the person can develop constipation, which makes feces difficult to pass due to it being hard and dry.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 54 Constipation is classified as being either a primary or secondary condition. Primary constipation is also referred to as functional constipation in that symptoms are typically ongoing and are frequently a routine part of the person’s life. Alternatively, secondary constipation develops as a result of a condition or illness that affects the person’s ability to form stool and pass it in a normal manner. Primary constipation is further divided into three sub- groups: 24 1. Normal transit constipation, in which the person is able to pass stool at a normal rate, but stools are very hard and difficult to pass. 2. Slow transit constipation, in which the rate at which a person passes stool is abnormally long, as it takes much longer for the stool to pass through the large intestine and into the rectum for defecation. 3. Pelvic floor dysfunction, which affects the person’s ability to pass stool at all, regardless of transit time or stool consistency. Stool is more likely to be retained in the rectum, causing feelings of fullness and incomplete evacuation.

Assessment of the patient involves taking the medical history information about current or previous illnesses, changes in dietary and lifestyle habits, and changes noted with the toileting routine. The nurse should consider whether the patient has noted changes in bowel habits and how long such changes have been happening, and, if the patient has had to utilize manual maneuvers to eliminate stool, pain with defecation, and fecal incontinence. There may be psychosocial factors present that could also contribute to the patient’s constipation through changes in diet and lifestyle; and, psychosocial symptoms to consider include the existence of depression, anxiety, or cognitive changes.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 55 According to the Rome III Criteria for Functional Gastrointestinal Disorders, a diagnosis of functional constipation is made when a patient experiences two or more of the following: • Straining with at least 25 percent of defecations • Passing lumpy or hard stools with each defecation at least 25 percent of the time • Experiencing the feeling of incomplete evacuation for at least 25 percent of the time • Sensing an obstruction or blockage that prevents the passage of stool for at least 25 percent of evacuations • Using manual maneuvers, such as pelvic floor support, in at least 25 percent of defecations • Having fewer than three defecations per week

Although the diagnostic criteria include defecations fewer than three times per week, there is great variation with what is considered to be a normal number of defecations for the average person.23 Some healthcare providers consider whether the patient has experienced fewer defecations than is normal for the patient when considering constipation, instead of attaching a specific number to what is considered normal for the general population.

Secondary constipation can develop from a number of situations; the rate of stool passage, the length of time stool remains in the rectum, and the amount of water absorbed can all be affected by situations related to a medical illness, use of certain medications, or psychological distress that further contribute to constipation. Common conditions that typically lead to constipation include:22

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 56 • Pain in the rectum or the anus: and anal fissures can cause pain while having a bowel movement. The patient may avoid passing stool for as long as possible to avoid the pain. This actually further aggravates the situation, as the stool becomes hard and dry from holding it in, which makes it even more difficult and painful to pass.

• Medications: Certain drugs, particularly opioid medications, contribute to constipation by decreasing motility of the colon.

• Dietary influence: A diet low in fiber and fluids may contribute to constipation when there is less bulk and stools become dry.

• Medical conditions: Injuries or illnesses that affect the patient’s ability to sense the need for a bowel movement, such as diabetes or spinal injury, can delay defecation and the stool remains in the rectum longer than needed.

• Advancing age: As a person ages, there is more likelihood to develop constipation because of impaired mobility, muscle weakness, an increase in the average number of medications that can affect bowel motility, and dietary changes that affect stool bulk. Despite the increase in cases of constipation among older adults, constipation is not considered a normal part of aging.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 57 • Obstruction: At times, partial obstruction of the large intestine, such as through polyps or colon cancer, can make passage of feces difficult and the stool becomes hard and dry.

Upon assessment of the patient with constipation, the healthcare provider should note any abdominal distention or the appearance of abdominal masses, rectal hemorrhoids, signs of dehydration or anemia, and characteristics of bowel sounds. The nurse should also assess for any other factors in the patient’s life that may contribute to bowel changes and the development of constipation, including checking a list of the patient’s current medications, noting whether the patient has a history of a medical illness that could contribute to slowed GI motility, determining if the patient has a history of any other GI disorders, and assessing for any other clinical manifestations that could cause and prevent the patient from passing normal stools.

Because constipation can develop from so many different situations, the condition is not simply isolated to those with certain medical illnesses or with predisposing conditions. Instead, constipation can be a widespread problem that affects people with illness and healthy people alike; it can occur in older adults, young- or middle-age adults, and children. In addition to difficulty with passing stools, the patient with constipation may also suffer from abdominal pain, bloating and distention, a feeling of fullness in the abdomen, a feeling of pressure in the rectum, and the sensation of incomplete emptying after defecation. Some people with constipation also develop other symptoms such as headache, nausea, fever, pain in the urinary tract, and decreased appetite.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 58 While pain is often associated with constipation and may be a factor determined through the patient’s assessment, pain is not always a characteristic of constipation and should not be held as a deciding factor during the diagnostic process. A technical review by the American Gastroenterological Association in the journal Gastroenterology stated that abdominal pain with constipation is more often associated with a more significant disorder, such as in the case of irritable bowel syndrome, predominant type. In contrast to IBS, a patient with constipation related to other factors will have symptoms of hard, dry stools that are difficult to pass, but will not necessarily have abdominal pain.88 This is an important distinction to make when taking a health history with the patient and performing a physical exam because the information may assist the healthcare provider with making a more accurate diagnosis of IBS that involves predominant constipation versus constipation caused by another situation or condition that could be remedied.

A patient who suffers from constipation is at risk of certain complications associated with an inability to pass stool in a timely manner. A patient who already has a condition that affects the cardiac or respiratory systems could develop complications from constipation if he or she has to strain to have a bowel movement. Straining to defecate typically involves the Valsalva maneuver, which entails exhaling against a closed airway, increasing pressure and force. The maneuver temporarily decreases venous return to the heart and increases peripheral venous pressure. If a patient has a history of certain cardiac illnesses such as heart failure, or has previously suffered a myocardial infarction, repeated episodes of performing the Valsalva maneuver could put the patient at risk of cardiac rupture or death.22

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 59 Constipation has the potential to cause various other complications in affected patients. A patient who suffers from this condition may also be at risk of fecal impaction when the mass of stool becomes so dry that it cannot be passed. If stool obstructs the colon, but the person continues to digest and absorb food, he or she may be unable to pass more stool around the obstruction. At times, the patient may be incontinent of liquid stool that leaks around the site of obstruction. This diarrhea that flows past the obstruction is known as overflow incontinence.

The treatment for constipation is typically related to the cause of the condition. Management of constipation may be utilized through non- pharmacological interventions or through medications. Non-pharmacological interventions involve making dietary changes, encouraging activity, and helping the patient to develop a normal toileting routine. Constipation that develops from poor diet could be remedied by lifestyle changes alone, in which the patient increases fiber intake through foods or supplements to improve stool bulk. The individual in this case would benefit from increasing fluid intake as well, which will make stool easier to pass and prevent feces from becoming hard and dry. As a patient increases dietary fiber intake, he or she should be counseled to increase fluid intake accordingly.

Significantly increasing fiber intake without adjusting fluid intake can cause symptoms to worsen and the patient may suffer from abdominal pain, bloating, and flatulence. The patient should also be counseled to slowly increase fiber intake each day, rather than suddenly jumping up in total daily fiber. For example, a person who normally consumes 15 g of fiber daily and who suffers from constipation should not start eating fiber-rich foods to increase daily fiber to 60 g per day all at once. Instead, the patient should

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 60 be counseled to increase fiber intake by 5 g to 10 g each day to achieve appropriate amounts and to avoid uncomfortable side effects.

The patient should include a mixture of foods in the diet that contain soluble and insoluble fiber, both of which can increase stool bulk; additionally, insoluble fiber helps to prevent excess water absorption in the colon that can result in stool becoming too dry. Foods that are good sources of soluble fibers include cereal, nuts, seeds, and fruits. Items that can be included to increase insoluble fiber include wheat bran, vegetables, and legumes.24

If possible, the patient should increase physical activity to best prevent constipation. Exercise helps food to move more quickly through the intestine, preventing slow motility and its associated problems. It is important to remind patients that if they are increasing activity levels, particularly when taking on an exercise routine, they should continue to drink fluids and increase fluid intake around the time of activity, as increased exercise could lead to fluid loss through sweat and could further perpetuate constipation.

It may be helpful for some patients with constipation to develop a toileting routine and to maintain good habits when using the bathroom. The person should be taught to try to defecate as soon as the urge is felt, rather than trying to hold stool in the rectum, which can further contribute to uptake of water in the colon and dry stools. The patient may also be taught pelvic floor exercises to strengthen the muscles used for defecation and to sit in a position that facilitates easier defecation. If the patient has an issue with using a toilet or does not want to try to eliminate stool because of pain or discomfort, the nurse may need to help the patient find strategies to increase efforts at elimination. For example, a patient may avoid trying to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 61 defecate because of hemorrhoids; and, the nurse may help the patient by treating the hemorrhoids to alleviate discomfort so that the patient will not feel the need to avoid defecation because of pain.

Pharmacological interventions for the treatment of constipation include medications designed to stimulate bowel motility and to relieve the patient’s constipation through the passage of stool. Medications administered for constipation are often given if the non-pharmacological interventions have been unsuccessful or if the patient has a condition that prevents an ability to pass stool, leading to further risk of constipation. Pharmacological interventions include medications such as laxatives, stool softeners, enemas, and oral medications that alter fluid absorption in the large intestine to manage constipation.

Whether it is an acute case of constipation that is easily resolved with medications or whether a patient suffers from chronic constipation as a result of illness or disease, constipation can be difficult to manage and to accept for some people. The potential for complications associated with this condition make it even more important of a situation to be remedied to help the affected patient achieve normal defecation once again. Fortunately, because constipation is so prevalent, there are many options for treatment and healthcare providers have discovered numerous ways to prevent constipation and to manage it if it does occur.

Genetic Factors

The role of genetics may be overlooked when considering some gastrointestinal motility problems. When dysmotility can be explained by a chronic illness or its development occurs as a result of medication use or lifestyle factors, healthcare providers may be less likely to consider whether

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 62 the condition is supported by any genetic factors. There are some cases, however, when it is not entirely clear how or why a patient develops a GI motility problem, which may cause clinicians and researchers to dig deeper into genetic factors that contribute to development of the disease.

There is evidence that suggests there are some genetic factors that contribute to functional gastrointestinal disorders. These disorders are classified as conditions in which symptoms are recurring and persistent, and they typically develop because of abnormal functioning in the GI tract. However, functional GI disorders can vary extensively in terms of their causes and manifestations. For instance, irritable bowel syndrome, functional dyspepsia, and globus (the sensation of something being stuck in the back of the throat) are all functional GI disorders, yet they have various characteristics and symptoms. Because of the differences in the types of GI motility disorders, and of functional motility disorders in particular, they may be categorized according to the section of the GI tract most commonly affected.

Esophageal Disorders

Functional gastrointestinal disorders of motility that affect the pharynx and esophagus include globus, functional chest pain (which is pain that is most likely caused by esophageal damage and not cardiac problems), functional heartburn (which is similar to that experienced with gastroesophageal reflux but without evidence of esophageal sphincter problems), and functional dysphagia.89

Achalasia, as described earlier, is a motility disorder of the esophagus. It is characterized by weak or absent esophageal peristalsis, which leads to difficulties during swallowing with transferring food from the back of the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 63 throat to the stomach for digestion. Idiopathic achalasia has an unknown etiology and is also characterized by weakening of the lower esophageal sphincter (LES), regurgitation of gastric secretions, and non-cardiac chest pain from heartburn. Achalasia is an example of an upper gastroesophageal motility disorder that may stem from genetic factors.

It is known that achalasia develops when the affected patient loses neurons that provide sensation and motor function to the esophagus; the loss of nerves typically begins in the lower portion of the esophagus and is thought to be related to nerve cell neurodegeneration.90 Although there is some understanding about the damage or loss of neurons in the esophagus that occurs with achalasia, researchers still do not entirely understand why this occurs and other causes, including genetic factors, continue to be investigated.

Achalasia has been shown to have familial tendencies in that people who develop the condition are more likely to have a family member who also suffers from achalasia. There have been some twin studies that have examined the incidences of achalasia development between twin siblings, but these results are still inconclusive. Still, research has confirmed that there is some amount of familial connection in the development of achalasia and that affected patients should be aware of the possibility that the condition may also develop among family members. Furthermore, there are some genetic syndromes in which achalasia is more likely to develop among affected patients, for example, persons with Down syndrome are more likely to have achalasia than the general public; and, the swallowing disorder is typically manifested just after birth in these situations.90

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 64 Sarnelli, et al., in their work published in the World Journal of Gastrointestinal Pathophysiology, investigated specific genes that may contribute to the development of achalasia among certain patients. Inflammatory-based neurodegeneration of nerve cells affecting the esophagus is more prevalent among neurons that contain nitric oxide (NO). Nitric oxide is produced in the body, and, it is a molecule that allows for greater communication through the nervous system and between tissues. The production of nitric oxide is genetically regulated. The researchers in the study determined that achalasia may be more likely to occur in some patients who express the longer form of a certain gene, as this gene may be involved in greater amounts of nitric oxide production.90 This concept could more likely explain some of the breakdown of certain nerves in the lower esophageal tract associated with the condition.

Clearly, it is important that research continue to find genetic influences and those other factors that contribute to development of certain conditions such as achalasia. While it is important to understand familial influences in the development of the condition in order to better prepare affected patients, more research is needed to find the connection as to why certain neurons are destroyed in this condition.

Stomach and Small Intestine Disorders

Disorders of motility affecting the stomach and small intestine can include any number of conditions, including gastroparesis, functional dyspepsia, functional vomiting, and aerophagia. As with disorders affecting the pharynx and esophagus, it is difficult to define the exact etiology of why some of these conditions occur. Although damage to the nerves or muscles of the GI tract is typically involved, there may also be familial or genetic factors that predispose some people to increased risks of developing these conditions. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 65 Functional dyspepsia is an example of a gastrointestinal motility disorder that causes recurrent pain and epigastric discomfort, as well as abdominal distention and a feeling of fullness in the abdomen. It may develop from a number of acute or chronic conditions, including Helicobacter pylori infection in the gut, increased pain sensitivity; or psychological factors, such as increased anxiety or depression.91 Unlike simple indigestion that follows a meal, symptoms of functional dyspepsia are recurrent and often require lifestyle changes and medication to control the symptoms.

Another potential cause of functional dyspepsia is damage or other problems with the nerves and muscles that control the GI tract. When damage occurs to these structures, the affected person is more likely to experience nausea, vomiting, and abdominal fullness if the stomach empties more slowly than normal. The damage done to muscles and nerves of the stomach and small intestine that causes functional dyspepsia could be related to chronic illness, such as in cases of diabetes; however, there are some conditions where the patient may suffer from symptoms of dyspepsia but the cause is unknown. Researchers continue to look for genetic factors that may explain why damage sometimes occurs in this area.

There is some evidence that indicates that functional dyspepsia may be an inherited trait and is more likely to occur within families. Studies have shown that patients with functional dyspepsia are more likely to have family members also affected by the condition. A review by Yarandi and Christie in Gastroenterology Research and Practice discussed the impact of genetic factors on the development of functional dyspepsia, stating that certain genes that are more likely to activate G-proteins in the GI system may lead to dysfunction of the motor neurons in the intestinal tract. G-proteins are cellular membrane receptors; if they do not work properly, there is potential

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 66 for some communication breakdown between nerve signals. Some people have certain genes that activate these G-proteins, which can ultimately cause dysfunction of receptors that control the muscles and nerves of the GI tract.92

While research continues to investigate the probability of specific genes that contribute to damage in the GI tract and cause functional motility disorders, there are well-known factors that also can cause symptoms of dyspepsia. While most people are unaware if they have a specific gene that contributes to dyspepsia symptoms, they can still learn more about the symptoms of GI dysfunction and understand whether family members are affected by similar symptoms, which may be a better predictor of health.

Large Intestine Disorders

Functional disorders affecting the large intestine can vary from irritable bowel syndrome, functional constipation, functional diarrhea, and fecal incontinence to those that are more often associated with disorders of the rectum and anus, including functional anorectal pain and dyssynergic defecation.89 There are some genetic factors that play a role in the development of fecal incontinence. A person with a parent who suffers from fecal incontinence is at higher risk of developing the condition. Twin studies have shown similar results in that someone who has a twin who suffers from fecal incontinence is at greater risk of developing fecal incontinence as well. Rates are higher between monozygotic twins when compared to dizygotic twins.93

Similar to other types of functional motility disorders, conditions affecting the colon and rectum that cause changes in how the GI tract functions can have obvious causes or their sources may be more obscure. Fecal

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 67 incontinence may often be associated with chronic constipation, resulting in overflow incontinence when stool leaks out of the rectum around a fecal impaction in the lower bowel.

There are a number of risk factors that increase the probability that a person will develop difficulties with retaining stool. Known risk factors for fecal incontinence include advancing age, female gender, physical disabilities, and injury to the nerves affecting the anal sphincter, such as through childbirth. Some risk factors are environmental and could be prevented while others, including age and gender, are uncontrollable.

There are some genetic conditions that can also contribute to fecal incontinence. These conditions may be listed as the cause of stool incontinence itself and they develop because of genetic factors, thereby indirectly affecting the risk of fecal incontinence. For example, structural abnormalities may be present in the rectum because of a congenital condition present at birth. As a result, the patient may suffer from fecal incontinence because of an inability to properly retain stool within the rectum. Additionally, a GI condition such as inflammatory bowel disease, can also contribute to fecal incontinence because of abnormalities in the anal sphincter. A person who has a close relative with inflammatory bowel disease is at higher risk of developing the condition as well because of familial tendencies.

At times, the cause of colonic motility disorders may be obvious, while in other cases further research and education is needed to fully understand the risks and causes of these complex conditions. In some cases, genetic factors do not play a role in whether a patient will develop symptoms of a disorder;

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 68 alternatively, genes and familial tendencies are a large part of whether certain patients are at high risk of GI motility problems.

Classification Of Gastrointestinal Motility Disorders

It is well known that there are numerous conditions that can be classified as being gastrointestinal motility disorders. They may affect various portions of the GI tract and can cause multiple symptoms that range in severity from mild discomfort to potentially life-threatening complications. In addition to the different areas affected and their manifestations, GI motility disorders may also be classified according to the entities that individually demonstrate abnormalities within one or more areas of the GI tract and that may be associated with systemic conditions as contributors to the clinical condition.

Charles Knowles and Professor Joanne Martin, in their work studying slow transit constipation, defined a classification system of gastrointestinal motility disorders that categorizes the various causative conditions into different entities.57,58 A classification system to categorize GI motility disorders based on demonstrated abnormalities and associated clinical conditions is a sensible approach to performing diagnostic measures when managing a patient who suffers from dysmotility symptoms. To classify motility conditions based on certain entities can further assist the clinician with identifying a diagnosis and providing appropriate treatment for the patient’s condition.

Motility of the GI tract is more than muscle movements that propel digestive tissue through the expanse of the system. Instead, motility is described as a combination of muscular movements that are controlled by specific nerves; furthermore, innervation of the GI tract can actually be classified as being motor innervation and sensory innervation.56 If one type of nerve system is

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 69 damaged, it can impact the other; for example, if a person suffers from illness that damages sensory innervation of the GI tract, he or she may also suffer from problems with motor movements because the two types of nerves that control the gut are closely intertwined.

Knowles-Martin Classification System

Motor disorders that affect motility, whether by producing increased motility that leads to uncontrollable stool output and abdominal pain, or delayed motility that slows colonic movement and results in constipation and bloating, can be classified according to the regions affected, such as the esophagus, small intestine, or large intestine; and, the clinical condition that causes each entity and any associated disorder involved that would be causing symptoms. According to the Knowles-Martin classification system, entities are grouped into different categories, including well-defined entities (those that are understood and straightforward), variable dysfunction- symptom relationship entities, questionable entities, and entities related to behavioral disorders (those impacted by the individual’s habits and actions).

Well-Defined Entities

Well-defined entities may be further broken down into sub-classifications that affect the different regions of the GI tract, including the esophagus, the stomach, the small intestine, and the bowel. Within the esophagus, well- defined entities include excessive acid exposure, esophageal spasms, and achalasia. Excessive acid exposure is often associated with gastroesophageal reflux disease (GERD), which is most often diagnosed according to the pattern of damage it causes to the lining of the esophagus. However, GERD can also be identified because of its causative conditions, such as poor control in the lower esophageal sphincter, which leads to subsequent acid reflux and tissue damage. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 70 Achalasia, which results in poor motility within the esophagus or even lack of peristalsis entirely, is another example of a well-defined esophageal entity. The associated motility problems with achalasia also can lead to regurgitation of food and liquids from the stomach and damage to the tissue lining of the esophagus. Both achalasia and GERD can occur from damage to the nerves that affect the esophagus, leading to poor motor control and dysmotility. Systemic diseases often contribute to nerve damage that ultimately affects motility; for example, damage from scleroderma may contribute to loss of muscle tone in the intestinal tract. Scleroderma is a connective tissue disorder that results in deposits of collagen building up between smooth muscle fibers.68 According to the Scleroderma Foundation, the esophagus is the area where most patients with scleroderma suffer from intestinal motility problems, including symptoms of GERD, and weakening of esophageal muscles that result in poor peristalsis and increased damage from regurgitation.59 Other systemic diseases that may contribute to conditions classified as well-defined entities of the esophagus include diabetes, enteric neuropathy, and Chagas disease, which is caused by parasitic infection.

Well-defined abnormalities that specifically impact the stomach and small intestine involve accelerated gastric emptying and abnormal contractile activity.56 These occurrences are most often demonstrated as clinical entities of dumping syndrome and intestinal pseudo-obstruction. As previously stated, dumping syndrome is defined as rapid gastric emptying, in which food leaves the stomach at a faster rate than normal and is quickly deposited into the small intestine. The patient often suffers from symptoms such as diarrhea, flushing, sweating, heart palpitations, and abdominal cramping within a few minutes after a meal. Dumping syndrome is not the same as dyspepsia or indigestion; it is classified as an actual disorder of the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 71 stomach related to changes in hormone secretion and gastric mucosal secretions.

Pseudo-obstruction often causes symptoms of intestinal obstruction without identification of any specific blockage. Both pseudo-obstruction and dumping syndrome can develop from defects in innervation to the stomach and small intestine, which ultimately affect the rate of food transition between these areas during the digestive process. Systemic conditions that often lead to these clinical entities affecting the stomach include surgical procedures to treat obesity; these include , as well as surgery (which reduces gastric secretions) when part of the vagus nerve is cut. Other systemic conditions include enteric neuropathy, and in some cases, scleroderma.

Within the large intestine, well-defined entities include dilated colon with or without small bowel involvement, absent rectoanal inhibitory reflex, and delayed colonic transit.56,57 Dilated portions of the colon may be caused by such conditions as or where the affected areas of bowel may be localized to one region or may be found throughout the entire large intestine. Ogilvie syndrome is the same condition as pseudo- obstruction of the intestine; it develops when the patient suffers from symptoms of bowel obstruction but there are no lesions present.

Megacolon

There are various types of megacolon that could be the cause of significantly dilated portions of the bowel, including acute or , as well as the chronic form of the condition. Chronic megacolon may be used as a term to describe the condition when it is congenital, although it can be later acquired because of illness or toxicity. Megacolon occurs with dilated nursece4less.com nursece4less.com nursece4less.com nursece4less.com 72 sections of bowel that are not caused by obstruction. Because the lumen of the colon is enlarged, the body is unable to carry out normal colonic transit and to pass stool in the usual manner. Megacolon can develop due to different reasons, which depend on the type present; however, it may be associated with damage to the nerves that serve the large intestine and the rectum in that they are inhibited or do not activate the colon to work in a normal fashion. Systemic conditions associated with both Ogilvie syndrome and megacolon include enteric neuropathy and enteric myopathy.

Hirschsprung disease is another clinical entity that affects the large intestine. It too often occurs due to damage of the nerves that serve the colon, which causes difficulties for the patient to have normal defecation. Hirschsprung disease is related to a poor or even absent rectoanal inhibitory reflex, which is the reflex that controls the anal sphincter to retain stool within the rectum or to pass stool when defecating. The reasons why some people are born with this type of nerve damage in the large intestine are not clearly known.

Constipation is a well-defined entity affecting the large intestine; slow-transit constipation (STC) leads to a long period of time for stool to pass through the colon. The affected patient often has stools that are hard to pass and are dry, as well as abdominal pain and, at times, fecal incontinence. As with other entities defined in this section, slow transit constipation is thought to occur due to damage to the nerves that serve the large intestine. People with STC may have abnormal amounts of neurotransmitters in the muscular layer of the colon, which affects the movements and transit of stool through the large intestine. Other nerve cells affecting the colon may also be abnormal in their appearance or there may be too few cells, ultimately affecting the rate of colonic transit.69

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 73 Variable Dysfunction-Symptom Relationship

Entities classified as having variability in the relationship between dysfunction and symptoms are those in which the connection between the abnormalities of the clinical entity present and its associated symptoms may be inconsistent. The basis for whether certain entities are classified in this category is not entirely clear, but associated entities within the classification are often related to increased or decreased muscle pressure within the intestinal tract as well as delays in intestinal transit rates.

Variable dysfunction-symptom entities found in the esophagus include high and low amplitude peristalsis, low LES pressure, and incomplete relaxation of the LES.56 All of these conditions result in abnormalities in how the esophagus or LES function when compared to normal motility. Whether esophageal peristalsis is of high amplitude or low amplitude often depends on the type of innervation affected, whether it is inhibitory or excitatory. Inhibitory innervation of the nerves affecting the esophagus causes problems with low amplitude peristalsis and low LES pressure.68 These conditions can further lead to gastroesophageal reflux when the esophagus is unable to adequately propel food toward the stomach and when the muscle tone of the LES is sporadic. Stomach acid and undigested food is then more likely to reflux back into the esophagus, causing damage to the esophageal mucosa or interior lining.

Within the stomach, delayed gastric emptying occurs as a type of entity described as having variable dysfunction-symptom relationship. This most often occurs as a result of gastroparesis associated with diabetes, however, there are many other systemic conditions that also contribute to the situation, including scleroderma, enteric neuropathy, a post-vagotomy state, and enteric myopathy. Abnormalities within the stomach may also lead to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 74 impaired gastric relaxation, which often develops in conjunction with and results in the dumping of food into the antrum of the stomach instead of the fundus where it accumulates. Affected patients typically suffer from symptoms of dyspepsia and indigestion.

The term enteric dysmotility is used to describe motility disorders of the small intestine. Enteric dysmotility is also a clinical entity included as an example of the variable dysfunction-symptom relationship in the small intestine. It is demonstrated as abnormal contractions in the intestinal tract that typically lead to delays in the transport of food through the small intestine. There are a number of systemic conditions that can cause enteric dysmotility within this section of the GI tract. Some examples include intestinal neuropathy, as with what occurs through poorly controlled diabetes, as well as Parkinson’s disease, scleroderma, and spinal injury.56

Within the large intestine, low levels of pressure within the can lead to fecal incontinence. When pressure is low in this area, the affected person is unable to control stool output, often because of muscular weakness. Fecal incontinence results when low pressures in the anal canal prevent the individual from retaining stool within the rectum and it passes through the anus with little to no control. The condition may be caused by spinal injury when the patient suffers a lack of motor control or sensation in the lower body, or because of nerve damage due to diabetes and uncontrolled blood glucose levels. Some women who have endured traumatic childbirth and had nerve injuries due to tearing of perianal tissue may also suffer from fecal incontinence and low pressure in the anal canal, causing difficulties with normal defecation and poor control of stool output.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 75 Questionable Entities

Conditions classified as questionable entities within the gastrointestinal tract can vary but often seem to be related to accelerated transit of food and fecal material through the GI system. This may be due to high pressures found in the GI tract as well as overstimulation of the nerves that affect the GI system.

An example of a questionable entity associated with the esophagus is increased pressure found within the lower esophageal sphincter. The condition may be referred to as hypertensive LES, in which it maintains high contraction pressures when it opens and closes. Similar to other disorders of the LES, hypertensive LES occurs when there are changes to the nerves affecting the esophagus. In this case, there is increased function of the excitatory nerves feeding the esophagus, such that the neurons are working at a faster pace and are causing increased muscle contractions within the LES.68 Hypertensive LES can cause dysphagia, heartburn, non-cardiac chest pain, and symptoms of GERD.

Tachygastria is a condition that causes high-frequency electrical activity within the stomach during digestion. The condition most often occurs because of motion sickness or as nausea during the first trimester of pregnancy. The motility of the stomach is somewhat controlled through myoelectrical activity, typically generated by the antrum portion of the stomach cavity.56 High frequencies of electrical activity in the stomach lead to tachygastria, which generally causes feelings of nausea, dyspepsia, and indigestion.

Within the small intestine, food and undigested materials may be transitioned too quickly through the GI tract because of intestinal hurry,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 76 which describes the intestine pushing food through at an accelerated rate. Intestinal hurry may be a type of malabsorption disorder, in which the affected person is unable to adequately absorb food because it moves too quickly through the small intestine. The condition most often occurs following vagotomy surgery that is done to control gastric secretions.

Finally, questionable entities found within the large intestine involve colonic hurry and accelerated transit of food and fecal matter through this portion of the GI tract. Colonic hurry is similar to intestinal hurry in that materials move through the colon too quickly and there is potential for malabsorption of electrolytes and fluid. The patient may suffer from diarrhea and watery stools if too little fluid is absorbed during this section of the GI tract. Colonic hurry can develop because of electrolyte imbalances, certain metabolic disorders, and following colon surgery that results in .56

Entities Related to Behavioral Disorders

Psychological symptoms and manifestations of mental illness may impact gastrointestinal motility and function. Although there are often fewer cases of behavioral disorders that lead to symptoms when compared to some other well-known clinical entities, it is still important to consider how behavioral disorders can impact GI function. The behaviors performed that lead to problems with motility may appear purposeful in that it would seem the affected patient is choosing to continue in the behaviors; however, when the disordered behavior occurs as a result of mental illness, the patient may be unable to control his or her actions.

Behavioral disorders related to the esophagus include rumination and aerophagia.56 Rumination refers to swallowing food and then regurgitating it;

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 77 the patient may then repeatedly swallow the food or may vomit it. The condition is most often seen among people who suffer from eating disorders such as bulimia as a method of purging food to avoid weight gain after eating or bingeing. Aerophagia is a rare type of disorder in which a person swallows large amounts of air. The air passes through the esophagus and enters the stomach but is then regurgitated, causing frequent belching. The air may also pass into the intestinal tract, where it causes abdominal bloating and increased flatulence. Some of the symptoms of aerophagia may be related to GERD; however, the two conditions are distinct due to their causes.

Wingate, et al. produced a working party report in the Journal of Gastroenterology and Hepatology that effectively describes the various entities found within the Knowles-Martin classification system. As part of this classification, the authors do not identify any entities associated with behavioral disorders that directly affect the stomach or small intestine.56 Alternatively, there are two conditions that exist as behavioral entities that affect the large intestine, including impaired pelvic floor relaxation and avoidance of defecation.

Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate. Normal defecation requires the patient to relax the muscles of the pelvic floor to expel fecal contents from the rectum. However, when the patient does not relax these muscles, or even contracts them instead while trying to defecate, he or she will be unsuccessful and will end up retaining stool within the rectum.

Additionally, purposely retaining stool within the rectum is a behavioral activity done to avoid defecation. The reasons behind why a person would

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 78 deliberately keep stool in the body instead of excreting it are varied. Some people may avoid defecation because of pain while passing stool, such as when hemorrhoids are present; alternatively, some people choose to avoid defecation because of muscle weakness with straining, discomfort with the act of having a bowel movement, or the feeling of an obstruction in the rectum or the anus. Regardless of the reason, the purposeful holding of stool within the body leads to constipation when excess fluid is absorbed from feces held in the rectum. This paradoxically can lead to an even more difficult time with having a bowel movement if the original reason for avoiding defecation is because of the effort it takes to pass stool. The clinical entity in these situations is known as functional fecal retention; it is the most common behavioral disorder that causes motility problems in the large intestine, rectum, and anus.56

Diagnosis Of A Gastrointestinal Motility Disorder

Correct diagnosis of a gastrointestinal motility disorder is essential to avoid unintentionally missing a potentially life-threatening condition or complication affecting the GI tract. The healthcare provider has several tools that can be used to identify and analyze problems of dysmotility. Using imaging studies, laboratory measures, and other forms of diagnostic testing along with an accurate medical history from the patient, the healthcare provider is more likely to formulate a diagnosis of a GI motility disorder and its contributing factors.

Medical History

With the increase in diagnostic capabilities in the form of surgical practices, imaging techniques, and laboratory measurements, the patient’s account of his or her health may seem unnecessary as part of diagnosis. However, taking a patient’s medical history, particularly as it relates to the patient’s nursece4less.com nursece4less.com nursece4less.com nursece4less.com 79 current symptoms of gastrointestinal motility problems is still important, as the patient is aware of his or her signs and symptoms and medical condition. Furthermore, many causes of GI motility disorders have microscopic sources; for example, when nerve damage causes delays in motility and problems with intestinal motor function, the exact cause of the condition cannot be observed without specialized equipment that is able to visualize affected tissues at the microscopic level. This then requires in-depth examination and testing to fully diagnose the cause of the patient’s symptoms.

The patient’s history is therefore important to begin to narrow down the mechanisms that may be causing GI motility problems, what the individual has done or not done to manage the condition, and if there are any other factors affecting the particular situation that can be changed to best control uncomfortable symptoms. GI motility disorders can produce a number of symptoms that can range from mild and intermittent to those severe symptoms significantly affecting bowel function and decreasing the patient’s quality of life. It cannot be overemphasized that a thorough patient history at the beginning of the provider-patient relationship, and again periodically over the course of care as the patient’s condition changes, is very important.

The healthcare provider should obtain information about the patient’s current condition, including how long the patient has been suffering from GI motility problems, since the length of time a person has been experiencing symptoms will help the provider to make a diagnosis. Other information to gather from the patient may include the symptoms being experienced, and whether the patient has had any other complications associated with a condition.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 80 Upon the initial meeting, the patient may present with symptoms that vary according to the disorder present. Because the patient most likely will not know the cause of his or her symptoms upon arrival, it is up to the healthcare provider to make a diagnosis based on the information presented. The nurse should ask questions that focus not only on symptoms affecting the GI system, but also other symptoms that may be impacting different areas of the body. Starting with the GI system, the nurse should question the patient about symptoms, including history of pain, changes in stool output, feelings of pressure or bloating in the abdomen and lower pelvis, and any changes in toileting practices.

The nurse may also need to assess the patient's abdomen by performing a focused physical examination. This involves inspection of the abdomen, auscultation of bowel sounds to determine GI motility, and palpation to assess for areas of tenderness or abnormalities, such as any abdominal swelling or solid areas. The nurse should include an assessment of the patient's dietary intake, including food and fluid consumption, to check for possible electrolyte imbalance, dehydration, or malnutrition, all of which can impact GI motility.

In addition to reviewing the patient’s current symptoms, the nurse should also question the patient about any known GI disorders, such as gastroesophageal reflux, dyspepsia, constipation, or diarrhea. The nurse should include questions about any recent illness or injury that may have affected the GI system. For example, the patient may have recently recovered from a bout of food borne illness that caused vomiting and diarrhea, from which he or she has since recovered. Although the patient may no longer be suffering from acute symptoms of the illness, it could still have an impact on the patient’s GI motility that leads to long-term

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 81 symptoms that are slower to resolve. Further questions regarding patient history should include a history of chronic disease, food allergies, and surgical procedures that would affect the intestine.

Following the gastrointestinal portion of the patient's history, the nurse should question the patient about other previous illnesses or injuries that could indirectly lead to GI motility problems. For instance, a patient with diabetes who has uncontrolled blood glucose levels could develop neuropathy and gastroparesis to the point that he or she is unable to detect the need to have a bowel movement. Although it may seem that diabetes would not directly affect GI motility, it is important to be aware of this chronic disease as the change in blood glucose levels can cause nerve damage.

Other conditions that should be included as part of the assessment and patient history consist of metabolic disorders, a history of injury or infection to the spinal cord or the central nervous system, history of drug or alcohol abuse, autoimmune diseases or those affecting the muscles and nerves, such as lupus or scleroderma; additionally, previous injuries or accidents that have caused periods of immobility, previous head injuries that have resulted in changes in level of consciousness, and any neurological or neurodegenerative disorders, such as Alzheimer's disease, Parkinson's disease, or multiple sclerosis should be considered.

Imaging Studies

Imaging studies create visual depictions of the internal organs and are very useful as diagnostic procedures when assessing gastrointestinal motility dysfunction. Most imaging studies are non-invasive for the patient and the results can be obtained relatively quickly. Imaging studies may consist of

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 82 general examination of the abdomen to assess for global issues that affect GI motility, or they could specifically analyze certain structures within the GI tract. Most imaging studies involve various forms of radiology, such as X- rays, ultrasound, computed tomography, or magnetic resonance imaging. Endoscopic procedures have been included in this section as well, as they often involve a combination of radiological imaging with technology to visualize the interior structures of the GI tract through instruments placed within the cavity.

Scintigraphy

Scintigraphy utilizes radiographic isotopes that are transferred into the gastrointestinal tract to assess a patient’s motility and gastric emptying time. The patient eats a meal, typically scrambled eggs, which contain the isotopes needed for the study; the most common isotopes used are technetium and iodine. After consuming the meal, the images are taken to detect the food as it passes through the patient’s GI tract. The measuring device that monitors food passage is a scintiscanner, which scans the isotopes and can follow them through the body. This type of study is often used when the provider suspects a disorder of GI motility affecting the stomach and small intestine, including cases of gastroparesis and dumping syndrome.

A similar form of scintigraphy is a colonic transit test, which checks the motility of the large intestine. This test also uses radionuclide markers, which are placed in a capsule that the patient swallows. The person then goes through normal, everyday activities, including eating normal meals. The capsule contains 20 radionuclide markers and the patient will have an abdominal X-ray approximately every 24 hours until each of the markers has been excreted. The process typically takes about five days.1 Each X-ray can nursece4less.com nursece4less.com nursece4less.com nursece4less.com 83 visualize the markers and determine at which points they are at in the intestinal tract. The test analyzes how the markers move through the GI tract and can determine their rate of motility and whether it is too fast or too slow. According to the test, if after five days more than 20 percent of the markers are still present in the patient’s body, the patient is said to have delayed colonic transit times.47

X-Ray

Radiographic testing through an X-ray takes an image of the gastrointestinal tract at one specific point in time. The X-ray machine sends energy beams into the body, which form a picture of the structures inside. It allows the medical provider to view what is happening in the GI tract through one snapshot, such as with a single-view X-ray, or it could be more complex and could involve taking images of the GI tract from various angles or while food or liquid is passing through the intestines.

A radiographic procedure that looks at the upper portion of the GI tract, including the esophagus, stomach, and small intestine, is the upper GI series that can help to diagnose conditions possibly causing GI motility problems in these segments of the GI tract. The procedure is often referred to as an upper GI test. The upper GI test requires that the patient drink barium contrast in order to visualize sections of the GI tract. As the patient drinks the barium contrast, the medical provider monitors the passage of the fluid through the esophagus, stomach, and small intestine, since the contrast will show up on X-ray examination. The process involves taking several X-rays over time to check where the barium is in the GI tract and how quickly it is moving through.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 84 An upper GI test is appropriate for diagnosing dysmotility conditions that affect the upper gastrointestinal tract, including achalasia, gastroparesis, or dumping syndrome. The test may also note whether there are obstructions in the GI tract that can affect food passage; strictures or narrowing, such as with , or whether inflammation is present, which can affect the body’s ability to digest and absorb food.48 However, this test is not able to detect certain other conditions that could cause GI motility problems, such as small ulcers or infection with H. pylori, which could also cause symptoms. Often, confirmation testing, such as through endoscopy, is necessary to authenticate the results seen on the X-ray.

Enterography

A type of imaging test that uses a CT scan or MRI, enterography allows the provider to visualize the small intestine and other areas of the abdomen. To perform the exam, the patient drinks a liquid contrast medium or is administered the contrast intravenously. The contrast then shows up in the patient’s GI tract where the MRI can pick up images in the intestine and check for abnormalities that may be causing GI motility problems, such as obstructions, inflammation, or bleeding.

Enterography is beneficial because it is less invasive than endoscopic procedures. The images produced through enterography are more complex and can reach certain areas that an endoscopic tube would miss and the type of study is sensitive to pick up small changes that can occur in the GI tract that affect motility. A study by Menys, et al., in the journal Radiology demonstrated that MRI enterography can detect changes with administration of drugs to patients that will stimulate small bowel motility. The study showed that the test was able to pick up the differences in GI motility whether the participants were administered drugs that affected motility or nursece4less.com nursece4less.com nursece4less.com nursece4less.com 85 placebo.50 Because of the non-invasive process involved with this type of study, and that it is sensitive enough to pick up changes in GI motility, enterography is a viable option for diagnostic treatment among patients who are suffering GI motility disturbances.

Endoscopy

Endoscopy is an umbrella term used to describe any test that involves insertion of a tube into the gastrointestinal tract to visualize and take pictures of the internal structures. Upper GI endoscopy involves testing of the throat, esophagus, stomach, and small intestine, while lower GI endoscopy involves testing of the large intestine, sigmoid colon, rectum, and anus. Endoscopy differs slightly from other imaging studies in that contrast medium is not always used and the GI endoscopist does not always utilize radiographic images to make a diagnosis. However, endoscopy is a valuable process that helps the endoscopist to visualize the internal segments of the GI tract, which can better pinpoint a diagnosis when GI motility problems are present.

Upper endoscopy, also called esophagogastroduodenoscopy or EGD, involves insertion of a tube into the patient’s mouth and then advancing it down the esophagus. Depending on the area of concern, the endoscopic tube insertion may also need to be advanced into the stomach or the duodenum of the small intestine. The patient’s mouth is sprayed with anesthetic to maintain comfort during the procedure; in many cases, the patient is mildly sedated for the procedure as well so that he or she will be relaxed.

The EGD is performed in an endoscopy suite where the patient can be monitored closely before, during, and after the procedure. The process does not require contrast media because it does not involve radiographic imaging,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 86 but it does allow the endoscopist to look at images of the esophagus, stomach, and a portion of the small intestine. The test is beneficial to look for conditions that may be causing the patient’s symptoms of pain, nausea, or vomiting, which may or may not be related to GI motility problems. It may also be done to rule out another condition and narrow down the cause of the motility issues.

The upper endoscopy is more accurate than traditional X-rays when looking for certain issues within the gastrointestinal tract, such as inflammation.49 The endoscope can also be used to insert biopsy forceps through the channel to remove small tissue samples from the GI tract if the endoscopist determines its necessary to perform a tissue pathology test.

To examine the entire large intestine, a colonoscopy is typically performed, which allows the endoscopist to visualize the colon. The colonoscopy is often used as a cancer screening tool to initially assess and perform surveillance exams for colon cancer, but it may also be utilized to assess for potential obstructions in the large intestine, the presence of inflammation or polyps, bleeding, , or whenever the patient is suffering symptoms and is experiencing a change in bowel habits. A colonoscope, a flexible tube is inserted into the anus and advanced through the large intestine all the way from the left colon to the right colon and cecum. Prior to the procedure, the patient must undergo a bowel cleanse as preparation in order to remove any fecal matter in the intestine. This often requires a clear liquid diet for one day before the procedure and administration of a laxative that will empty the colon. During the procedure, the patient lies on a table, usually on the left side, and is given a mild sedative to be comfortable. The procedure is expected to last 30 to 60 minutes.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 87 Because the colonoscopy is relatively invasive, there is another option to visualize the bowel for some patients who would not tolerate a colonoscopy. A procedure known as CT colonography, also referred to as virtual colonoscopy, can be performed to assess for similar changes in the colon that would be detected during a colonoscopy. The patient typically has to undergo the same amount of bowel preparation, using a laxative and changing the diet temporarily before the procedure. The patient will need to drink a contrast medium and then lie on a table while the radiologist inserts a tube into the anus and injects air into the rectum and the colon. This air allows for better viewing during the procedure.

The colonography uses CT imaging to take pictures of the patient’s colon and then demonstrate the results on a monitor to better visualize the interior of the large intestine. Like the colonoscopy, the colonography test can detect changes that can cause GI motility disorders and that lead to patient symptoms; and, because it uses CT, it can identify areas of concern. Alternatively, the colonography does not allow for biopsy sampling or direct tissue examination as would be available through the colonoscopy, as there is no endoscope being inserted into the large intestine to provide access to tissue to biopsy.49

Endoscopic procedures of the anus, the rectum, and the sigmoid colon are known as anoscopy, proctoscopy, and sigmoidoscopy, respectively. These tests can be performed to assess GI motility and to determine if there are obstructions within the descending colon and areas of the lower GI tract that are preventing normal motility and slowing colonic transit, preventing normal defecation. Some conditions that these tests may be used to diagnose include fecal incontinence and chronic diarrhea.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 88 Anoscopy is performed to look at the structures of the anus, the anal sphincter, and the lower portion of the rectum. The medical provider may perform a digital rectal exam before the procedure to ensure that there are no blockages that would prevent passing the scope. The patient may also need to take a laxative or have an enema prior to the procedure to clear the bowel, particularly the sigmoid colon and the rectum, if stool is present in these areas. Anoscopy is done by insertion of an anoscope, also called an anal speculum, into the anal opening. The patient lies on a table but is generally not sedated for the procedure. Instead, the insertion tube is coated with an anesthetic cream that desensitizes the area to prevent much discomfort.

The insertion tube has a light source and a camera, similar to other equipment used for endoscopic procedures. The anoscope allows the provider to view approximately 2 inches of the distal portion of the anal canal. Anoscopy is most often performed to check for patient hemorrhoids or polyps, which could be obstructing the anal opening, making stool passage difficult. The test may also diagnose other conditions, such as inflammation or anal fissures; although these conditions do not directly affect GI motility, they can make it painful for the patient to defecate, potentially leading to problems with constipation.

Proctoscopy involves examination of the rectum. The process is similar to that of a colonoscopy or anoscopy in that the physician inserts a scope into the patient’s anus and advances it to the rectum to visualize the internal structures of this portion of the colon. The proctoscopy allows the physician to visualize whether there are obstructions in the rectum that prevent the passage of stool or whether any other abnormalities are present that would affect gastrointestinal motility.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 89 As with other endoscopic procedures, the patient may need to be in a fasting state for several hours before the test and may need to use an enema or a laxative to clear the rectum of stool. The medical provider may also perform a digital rectal exam just before the procedure. The entire procedure takes about 15 to 20 minutes, plus time before and after the procedure for preparation and recovery. Because proctoscopy allows visualization of the rectum, the main area where stool is stored before defecation, it is useful to ability the patient’s ability to defecate normally and to diagnose conditions that affect GI motility, such as fecal impaction or chronic constipation. Furthermore, if there is inflammation or bleeding present in the rectum that affects the patient’s ability to defecate, the proctoscopy can pick up on these conditions as well. The patient may have polyps present in the rectum; by utilizing a specialized snaring or biopsy tool, the physician can remove some of the tissue and send it for a pathology study.

Sigmoidoscopy examines the sigmoid colon, which is the lower portion of the large intestine that connects the descending colon with the rectum. Because the procedure involves further advancement of the sigmoidoscope as compared to an anal or rectal exam, the patient may need to be lightly sedated for the procedure. Sigmoidoscopy requires that the patient lie on a table with the knees drawn toward the chest, and the physician generally will perform a digital rectal exam to ensure there are no obstructions or tenderness in the area. The physician will advance the sigmoidoscope past the rectum and into the sigmoid colon; and, the scope is flexible so that it can be navigated according to the shape of the intestinal tract.

During the sigmoidoscopy, air may be instilled into the bowel to help with viewing the internal structures. The patient will pass this air back out of the rectum following the test. The procedure typically only lasts a few minutes

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 90 and most patients tolerate it well without any pain. The sigmoidoscopy can be used to assess for obstructions, such as polyps, found in the sigmoid colon, the presence of stool or inflammation of the intestinal lining, or whether any bleeding is present in this portion of the large intestine. If polyps or other suspicious tissue is present, the physician can use instruments that are inserted through the endoscope channel to extract tissue for biopsy.

Barium Studies

Barium is a commonly used contrast medium for imaging studies. It is radiopaque contrast used to coat the internal structures of the gastrointestinal tract that can be seen during X-ray or CT scan. Barium studies can be performed to assess the GI tract. By using barium, the healthcare provider can assess for changes in the intestinal tract that could contribute to GI motility problems. Barium studies can be performed to test for upper GI tract disorders, often called barium swallows, or for lower GI tract disorders in which the contrast is typically administered as a barium enema.

The barium swallow is actually called an esophagography. It is referred to in simpler terms as a barium swallow because the patient actually drinks barium contrast that has been prepared as a mixture. When the patient drinks the mixture, the clinician can take X-rays to follow the barium contrast as it moves through the digestive tract. The barium can be seen flowing down from the posterior pharynx where it was swallowed and the physician may note how the esophagus propels the contrast toward the lower esophageal sphincter and stomach, using peristaltic waves. The test also examines patency of the lower esophageal sphincter as it opens to allow the contrast to pass into the stomach.51

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 91 Although the barium swallow may demonstrate some factors that contribute to the patient’s GI motility problems, they must typically be confirmed with manometry or biopsy after the barium swallow. For example, if the physician were to determine that the patient’s motility problems were the result of lesions found in the intestinal lining, the condition could not actually be diagnosed using the barium swallow results alone and would require biopsy to do so.51 The barium swallow may be combined with an upper GI test to identify a GI motility problem before other studies, such as biopsy, are completed to confirm a diagnosis.

A barium enema is an examination of the lower gastrointestinal tract that uses contrast medium, and it is administered rectally as an enema to allow the medical provider to visualize the internal structures of the large intestine when using imaging studies. The single-contrast technique describes application of contrast through administration of barium enema alone, while the double-contrast technique involves administration of a barium enema and air into the large intestine. The colon expands slightly with the barium in place and the contrast coats the inside of the intestinal tract. In this way, the healthcare provider can see many details of the surface of the colon, including whether obstructions are present or any other reason why the patient may be experiencing changes in bowel habits. After enema administration, the patient may lie on a table but be asked to change positions occasionally while the healthcare provider visualizes the results within the large intestine.

A further test that may use imaging of the large intestine is known as defecography, which utilizes barium contrast and X-ray to take images while the patient defecates. The test is done to determine how the stool moves through the rectum and out of the body in situations where the patient

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 92 reports difficulties with colonic motility and stool evacuation. Barium paste is inserted into the anal and rectal canals using a tube similar to an enema.

During the test, the patient sits on a specialized chair that can record the movement of the contrast through defecation. The test then analyzes the process of how the rectum empties itself of the barium paste. It can determine whether there are problems associated with the rectal muscles and the rectum’s ability to retain the contrast, motility problems with passage of stool between the rectum and the anus, or whether there are structural problems with the anus, such as poor sphincter control, that affect the patient’s ability to evacuate stool.

Defecography is a useful test for identifying a number of GI motility problems. Among others, it has been successfully used to identify and diagnose patients who suffer from chronic functional constipation and dyssynergic defecation. A study in the British Journal of Radiology showed that magnetic resonance (MR) defecography can detect abnormal findings in adults who suffer from dyssynergic defecation, which is defined as a functional defecation disorder characterized by impaired pushing forces, paradoxical contractions, or an inability to relax the anal sphincter muscle.52 The test has also been shown to be useful in identifying other disorders of GI motility, including fecal incontinence and , which occurs as inappropriate spasms of the anal sphincter.

Capsule Endoscopy

Capsule endoscopy is a newer technique that allows the healthcare provider to visualize the inside of the gastrointestinal tract when the patient swallows a capsule that contains a tiny camera. The patient wears a recording device during the test and the camera has its own light so that when it enters the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 93 gastrointestinal tract, it can record data and send it wirelessly to the storage device. The camera transmits the images over the course of approximately eight hours. The test is beneficial because the capsule can reach certain areas of the GI tract that could otherwise not be visualized through upper endoscopy or colonoscopy.

Prior to the exam, the patient must have an empty stomach before swallowing the capsule. If the patient takes medications that can cause stomach irritation, such as NSAIDs, he or she may need to stop taking them temporarily before swallowing the capsule. The recording device that receives the information from the capsule is typically worn on the upper body, where it keeps note of the images from the capsule throughout the time of testing. At the end of the testing period, the patient will excrete the capsule normally and it does not need to be retrieved from the intestine.

A drawback to capsule endoscopy is that if it detects a problem within the gastrointestinal tract, it only takes pictures of it with the camera; the healthcare provider must still follow up with further testing to diagnose a condition or to obtain tissue samples. Because of the length of time the capsule is able to function, it often does not examine areas past the small intestine. There is also the small chance that the capsule could become stuck in one of the loops of the intestine or at the junction between sections of the GI tract, such as near one of the muscular sphincters. Despite these risks, capsule endoscopy is generally safe to use for most patients and is a very convenient method of visualizing the internal structures of the intestinal tract for patients with GI disorders that may be co-occurring and/or contributing to a problem of motility.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 94 Electromyography

Electromyography (EMG) describes testing conducted to examine the function of motor neurons, the nerves that control muscles. Normally, motor neurons work by sending electrical signals to stimulate the muscle tissue. An EMG is performed to monitor these signals to determine whether the motor neurons are working at an appropriate amount. While EMG is often used as part of diagnostic testing to analyze skeletal muscle tissue, it may also be used to assess gastrointestinal function. The process tests the motor neurons that stimulate the muscles that control intestinal tissue and checks whether they are sending signals too quickly, or whether they are working at a pace that is too slow.

The process of electromyography is one of the only diagnostic tests available that can directly analyze specific muscle activity. Muscles are made up of motor neurons as their basic units of function. When a nerve impulse arrives at the junction of the muscle and the nerve, the body secretes acetylcholine in response and the muscle contracts. The electrodes from the EMG gather information from the surrounding muscle fibers and send a signal to an amplifier where the information is displayed on a digital screen. The information is also recorded so that it can be referred to later, if necessary.

Electromyography picks up the signals sent by motor neurons when electrodes are positioned in specific locations in the muscles of the GI tract. Contrary to the surface electrodes used as part of cardiac testing, electrodes used with EMG are often special types of needles that are placed within the muscle tissue. Electromyography is performed whenever there are potential problems with different muscles and the organs and body systems that they affect. For example, EMG may be utilized if there has been damage to the spinal cord, which can impact muscle movement and nerve function, and to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 95 determine the amount of damage to the muscles that has occurred from the injury. If a patient suffers from a degenerative condition, EMG can be used to analyze the extent of nerve damage and its effects on the muscles.

Electromyography recordings can be difficult to undertake when studying GI function. For instance, when needle electrodes are used for measurement, there are few people who wish to undergo intramuscular needle placement into the jaw, pharynx, or esophagus. Likewise, it may be difficult to place needle electrodes into locations such as sphincter muscles to obtain measurements. However, it is possible that some patients could undergo needle placement of electrodes for EMG monitoring as part of a surgical process; the testing could be performed during a surgical procedure, even if the procedure is not intended for surgical diagnosis or correction of a GI disorder.114

A study published in the Journal of Investigative Surgery utilized EMG to test for LES function in persons with reflux. The study examined patients who were undergoing surgical procedures and who underwent simultaneous EMG recordings of the lower esophageal sphincter during the process. At the end of the surgical procedure, the patients were stimulated to cough by manipulation of the endotracheal tube and researchers examined the differences between the amount of pressure and muscle activity of the esophageal sphincter on the EMG with coughing as compared to time at rest. The results showed higher-level pressures during induced coughing, which suggests that the LES is less likely to function normally during periods of straining or coughing, which may contribute to weakened musculature found among those with GERD.115

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 96 Alternatively, EMG may be used to diagnose conditions associated with the lower GI tract, such as within the colon, rectum, and anus. A patient who suffers from fecal incontinence or abnormalities associated with the rectum and anus may undergo anal sphincter EMG. The test is indicated for any patient who has had changes in bowel habits related to loss of sensation in the anal tract, damage to the pudendal nerve in the lower pelvis, or spinal cord lesions that can affect motor and sensory function in the lower GI tract.116 To utilize this method of EMG recordings, the clinician may take measurements using a combination of needle and skin electrodes for the test. The patient is placed in a position that allows for easy access to the anal sphincter and the clinician inserts the electrode needle directly into the muscle of the sphincter. The patient may be asked to contract the sphincter muscle during the test, using muscles normally involved for holding stool within the rectum. The process takes approximately 60 minutes.

An EMG is typically performed at a hospital or through a specialty clinic. The patient rests on a table or bed and the technician performing the test places electrodes in the appropriate locations. During the test, the patient will most likely need to lie still in order to get the most accurate results, although he or she may be directed to change positions or use certain muscles during the test to determine how these movements will affect the test outcome. Because the electrodes typically puncture the skin or muscle tissue during the test, the patient should be monitored for a period of time after the test for safety.

The EMG is not necessarily the first choice of diagnostic procedures to consider with a patient who suffers from a GI motility disorder. The process is relatively invasive and may involve patient discomfort, particularly related to electrode placement. However, because the EMG has the potential to

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 97 measure such miniscule muscle contractions and can record very slight changes in muscle tone and movement, this test can be capable of detecting abnormalities that cause GI motility problems that other types of testing may miss.

Manometry Testing

Manometry testing measures the amount of pressure within the gastrointestinal tract. The muscular layer within the lining of the intestine exerts a certain amount of pressure to stimulate peristalsis and movement of chyme and stool through the intestine. Manometry is a specialized form of diagnostic testing that can measure and analyze the pressure exerted by the muscles in the intestinal tract. Colonic manometry measures the strength of muscle contractions in the large intestine, while esophageal manometry is performed to assess motility of the esophagus.

Esophageal Manometry

Esophageal manometry gauges the patterns of peristalsis that move food from the pharynx after swallowing to the stomach where it can be further digested. Patients who suffer from esophageal motility disorders may experience epigastric pain, heartburn, of difficulty swallowing; in cases of achalasia, the patient may also experience chronic cough or regurgitation of food, fluid, or stomach acid into the back of the throat. Esophageal manometry can measure the motility of the esophagus by checking the lower esophageal sphincter and the muscle tone of the esophagus, as nerve damage in these areas can result in many of the patient’s symptoms.

According to Katz, author of an article called Esophageal Manometry, this test is indicated for specific conditions, including evaluation of symptoms

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 98 that have not been diagnosed through endoscopy, evaluation of non-cardiac related chest pain, assessment of dysphagia not caused by an obstruction, analysis for diagnosis of achalasia, pre- or post-operative measurements for patients undergoing procedures for treatment of gastroesophageal reflux disease, and monitoring for placement prior to pH probe and electrode positioning in the lower esophageal sphincter.39 The patient should remain in a fasting state for at least four hours prior to the start of the esophageal manometry study.

Many patients are apprehensive about the procedure, as it involves inserting a tube into the nose and advancing it into the stomach. The nurse who is working with the patient undergoing this procedure should carefully explain the process and provide appropriate education and guidance to best alleviate the patient’s fears. In most cases, the patient does not have to stop taking medications that are taken on a daily basis, even if they are drugs used to control gastrointestinal motility, as the test will measure the effects of these drugs in the system anyway. The patient remains awake during the procedure, but the nose and the back of the throat may be anesthetized with lidocaine spray prior to starting the process.

To perform the test, a catheter is passed into the esophagus and all the way through the lower esophageal sphincter into the stomach. The manometry tube is slowly pulled back up from the stomach through the esophagus, and it is during this time that pressure measurements are taken. Some of the newer manometry equipment have increased catheter sensors and potential to measure pressures within the esophagus thereby requiring less manipulation or movement of the tube to complete testing, and producing less discomfort to the patient undergoing the manometry procedure.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 99 The results of the manometry vary depending on the patient’s condition. For example, if the patient has achalasia, the manometry will measure abnormal muscular contraction in the esophagus and pressures of the lower esophageal sphincter characteristic of the condition. Abnormal esophageal contractions measured through the test may indicate esophageal spasm or some form of hypermotility disorder. When the lower esophageal sphincter lacks tone and is prone to loosening and allowing gastric fluids to escape, the patient may have a history of gastroesophageal reflux. Manometry is often useful with other studies performed to diagnose and treat reflux, such as with fundoplication or surgery to strengthen the lower esophageal sphincter.

Antroduodenal Manometry

Another test, known as antroduodenal manometry, measures the motility of the stomach and the small intestine. It is a valuable test that can be performed on some patients who have motility problems that are otherwise difficult to detect through X-ray or clinical manifestations. A patient with GI motility problems may have generalized symptoms of nausea, vomiting, or constipation but, in some cases, it can be difficult to determine the location of the motility problems through clinical symptoms alone. According to a study in the Journal of Neurogastroenterology & Motility, antroduodenal manometry is most likely indicated for patients with certain clinical manifestations, including patients with suspected pseudo-obstruction in the small intestine, persons with unexplained abdominal pain and nausea and vomiting, and for those who require GI motility tests to exclude disseminated GI motility disorders.37

Although the antroduodenal test can measure gastrointestinal motility after eating, the patient must remain in a fasting state for several hours before nursece4less.com nursece4less.com nursece4less.com nursece4less.com 100 starting the test. If the patient has prescription medications for drugs that affect stomach activity or motility, such as metoclopramide or antispasmodic medication, they will usually be stopped for at least 3 to 7 days before the test as well, as these types of drugs can affect the test outcome.

The antroduodenal manometry test is performed through the insertion of a flexible catheter into the patient’s nose and threading the catheter down into the esophagus, stomach, and then the small intestine. Confirmation of tube placement is done via X-ray before starting the test. The tube contains sensors spaced at various intervals along its length that measure pressure levels during the test; and, a transducer picks up the readings from the sensors and displays the output as pressure tracings. There are two types of tubes that may be used for the procedure. One tube requires that the patient remain on bed rest during the test, while the other tube allows the patient to be ambulatory and will record pressure readings for up to 24 hours.

The study measures small intestine motility during the fasting period, during the time that the patient ingests a meal, and then for several hours after the meal. Studies have shown that when patients undergo the ambulatory test, the results are often clearer for clinicians who review them since the ambulatory system test is performed over 24 hours and through several meals. This permits the clinician reading the results to see the effects of more than one meal and the fasting period on the patient’s motility, rather than checking motility during a stationary period and one meal.

The test records the patterns of muscle contractions made within the GI tract, and consider three phases of muscle contractions, which appear at various times throughout the digestive process. Phases I and II involve

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 101 periods of rest and mild or intermittent contractions, respectively. Often, the test checks the frequency and duration of Phase III contractions, which are rhythmic movements that transfer undigested material from the stomach into the small intestine.38 It is understood that eating a meal produces more frequent Phase III contractions, which is why the patient will eat a meal during the manometry test to determine how the stomach and small intestine respond. The test can further measure whether GI motility problems are caused by muscle weakness that do not allow for normal Phase III contractions, or whether the motility disorder is caused by interruption in nerve conduction, which can affect the rate and force of stomach contractions.

Colonic Manometry

Colonic manometry determines the amount of pressure present in the large intestine. A patient may suffer from symptoms of constipation or chronic diarrhea associated with changes in colonic motility that might be identified and diagnosed through colonic manometry. In fact, the Neurogastroenterology and Motility Society has issued a recommendation that patients who are constipated should undergo colonic manometry testing, particularly when they have not responded to other forms of testing and treatments. This means that the colonic manometry test can be very beneficial for patients affected by alterations in GI motility and that have not had any other clear answers about their conditions.45

The process of completing colonic manometry is somewhat similar to measuring pressure results of other portions of the gastrointestinal tract. With colonic manometry, however, the manometry tube is inserted into the patient’s anus and advanced through the rectum to reach the large intestine. Although colonic manometry has been shown to be beneficial in diagnosing nursece4less.com nursece4less.com nursece4less.com nursece4less.com 102 the cause of patient symptoms, the test can sometimes still not identify the actual condition causing the underlying clinical manifestations.

Researchers have discovered that when recording the frequency of colonic contractions through manometry, most patients will exhibit a certain number of contractions as evidenced by increases in colonic pressure during a 24- hour period. Increases in events have been shown following meal consumption as the body is digesting food. Alternatively, some patients who suffer from severe constipation have been shown to have very few or no periodic increases in colonic pressure during the time period measured, indicating a lack of movement in the large intestine, which contributes to constipation. However, the changes in pressure within the colon can be very subtle at times, because the manometry tube that measures these pressure changes is quite thin and could miss some of the very small movements in the wall of the large intestine; this means that the patient could still be experiencing colonic contractions but the test is not necessarily accurately measuring them.46

Nevertheless, manometry studies of the large intestine have been very useful in helping clinicians determine colonic function for some patients who experience GI motility problems. Because the manometry tube is placed within the colon, the manometry test itself allows the healthcare provider to gain better insight into what is going on inside the large intestine to better be able to analyze the patient’s GI motility problems and to diagnose the cause.

The colonic motility test can be done on an outpatient basis in a hospital or clinic that has endoscopy capabilities. Prior to the test, the patient will be in a fasting state and will need to have the colon cleansed to clear the

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 103 intestinal tract of stool and fecal matter. This is typically accomplished when the patient consumes a laxative or has an enema designed to stimulate stool excretion. The patient is sedated for the study, and a thin, flexible manometry tube, which is the pressure-monitoring device, is inserted into the anus and passed into the rectum and the large intestine. A guide wire is threaded through the manometry tube, which acts to direct and position the tube to obtain as accurate manometric measurements as possible until completion of the test. After the guide wire is removed, the manometric tube measures the pressure at various points along the colon and records the movements as a sequence of events on a monitor so that the medical provider can see the patterns of intestinal contractions through the test.

In some cases of colonic testing, the patient may be given a meal; after eating, the medical provider will then check the manometer to determine how the body is responding with colonic contractions during meal digestion. The actual testing period may vary but it is approximately three hours long after the tube is positioned in place and through the recording, with additional time required both before and after the test to prepare the patient and to recover from the procedure.

Colonic manometry testing is performed on both adults and children, although studies have shown that the procedure has been more successful when used in children. According to a study in the World Journal of Gastroenterology, there are few studies that indicate much success with this type of colonic study among adults, but when performed among children, the results of colonic manometry are much more likely to guide the provider’s treatment options. One study cited 88 percent of parents whose child underwent colonic manometry testing, and who then received treatment to manage the child’s condition, believed that the process was

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 104 helpful and improved their child’s health.45 Regardless of whether colonic manometry is used for an adult or for a child, this specific type of testing has been shown to be effective to detect changes in pressure levels within the large intestine of patients affected by GI motility problems. As a result, manometry testing remains a useful diagnostic tool to be considered whenever the need for GI motility testing arises.

Diagnostic Laparoscopy/Laparotomy

At times, surgery may be indicated for some patients who suffer from gastrointestinal motility problems, either to diagnose the condition that is causing the problems or to correct a health condition to facilitate normal motility once again. Laparoscopy and laparotomy are two types of surgical procedures that may be implemented for various conditions.

Laparoscopy is a minimally invasive surgery. The patient will need anesthesia and the surgeon will create a small opening in the skin but the procedure is performed using a scope or tube that is inserted into the opening. A camera on the end of the scope allows the surgeon to see inside of the abdominal cavity without needing to open the skin further. Laparoscopy can also allow the surgeon to take small amounts of tissue samples and to take pictures of the inside of the abdomen. Alternatively, laparotomy is an open procedure that involves a larger incision that can be pulled apart slightly to allow the surgeon to see inside of the abdominal cavity. Laparotomy may be exploratory, in which the surgeon is investigating the potential cause of the patient’s symptoms. It may also be done to correct a situation if the patient has had testing before the surgery and the cause of the problem has been identified.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 105 Surgical procedures may be part of diagnostic testing to take samples of gastrointestinal tissue to determine the potential cause of the motility problems. In many cases, diagnostic testing can be performed through various imaging studies and minimally invasive techniques that do not require surgery. Surgery may be necessary as part of treatment once the condition has been diagnosed and the cause of the motility problems identified, but laparoscopy or laparotomy may otherwise be indicated to collect tissue for biopsy to determine how well the cells and tissues of the GI tract are functioning.

Acquisition of tissues may be done as part of diagnostic testing; alternatively, tissue samples may be taken as part of another type of surgical procedure related to the patient’s symptoms and then the tissue is examined for biopsy. Tissue samples from the GI tract are often taken from the lining at various points along the tract, such as the lining of the esophagus, small intestine, or colon. Biopsy specimens from the intestinal lining may include tissue from the mucosal or submucosal surfaces, or even full thickness of tissue from the lining of the bowel.55 Alternatively, if there is an obstruction present, such as a polyp or lesion, a sample of this tissue may also be surgically removed for biopsy.

Natural orifice transluminal endoscopic surgery (NOTES) is a relatively new surgical technique that is minimally invasive and that allows the surgeon to manage or treat a GI condition without creating an external surgical incision. It may be performed as a type of surgical procedure to retrieve specimens for biopsy or to collect tissue cultures as well as to remove samples and specimens from within the body, whether as part of diagnosis or as a method of treatment.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 106 Normally, surgery to obtain tissue samples as part of diagnostic procedures requires puncturing the exterior skin of the abdomen to reach the internal cavity. When the surgeon is taking a tissue sample from an interior portion of an organ, such as with biopsy from the internal lumen of the intestinal tract, this could involve further perforation of the tract to reach the area needing to be biopsied. With NOTES, however, the surgeon may puncture the cavity of the intestinal tract to reach the interior portion, but the surgeon has approached the internal incision through a natural orifice.117 For example, the surgeon may take a sample of tissue from the stomach but is able to reach the interior tissue by passing a tube through the esophagus, rather than making an external incision.

The process of NOTES uses a combination of laparoscopic and endoscopic techniques to obtain tissue samples and to perform diagnostic procedures. According to a report in the Annals of the Royal College of Surgeons of England, the techniques utilized for a NOTES procedure must uphold certain principles of safe access, including minimal tissue injury, good exposure, avoidance of vascular and visceral injuries, and the ability to maintain a seal to manipulate the instrument.118 This information is important, as the NOTES procedure is designed to access those internal structures of the body, including the GI tract, which could otherwise be exposed and laid bare during surgical procedures. Any type of surgery places the patient at higher risk of infection because of the invasiveness of the process. When a surgical procedure is performed to diagnose a GI motility disorder, the surgery can place the patient at risk of other complications. The NOTES procedure may be performed as an alternative means of accessing the intestinal tract for diagnostic purposes but that also keeps the patient safe and that minimizes potential complications.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 107 Laboratory Testing

Complete Blood Count

The complete blood count (CBC) is a test of the health of the blood cells; and, it is often done to test the patient’s overall health and wellbeing. It can be used as part of diagnosis for a number of different medical conditions, including anemia, infection, cancer, or conditions that cause inflammation in the gut. Any of these disorders could lead to gastrointestinal motility problems. The CBC consists of various components as it tests different cells, each of which can be related to gastrointestinal motility changes. An alteration in the levels of certain blood cells as seen on the CBC results can indicate if there is a specific problem present that may be affecting the patient’s GI motility, such as the presence of an illness that affects intestinal function.

There are three main types of cells found in the blood and the CBC components test the amounts of each of these cells. The main cell types are white blood cells, red blood cells, and platelets. Each category can be further broken down into different elements that measure specific indicators within the blood sample.

The white blood cell components of the CBC include a test of the total number of white blood cells in the blood sample, as well as the white blood cell differential, which measures the type and amounts of the various types of white blood cells, including lymphocytes, monocytes, neutrophils, basophils, and eosinophils.41 The white blood cells are responsible for nursece4less.com nursece4less.com nursece4less.com nursece4less.com 108 fighting infection, so when they are elevated or decreased in the CBC sample, it can indicate that an infection is causing the GI motility problems. For example, a patient may develop nausea, vomiting, and diarrhea after suffering a viral gastrointestinal infection. The presence of infection can be detected through the CBC, even though it will not detect the specific virus causing the symptoms.

The patient who has an infection will most likely have an increased number of white blood cells in the CBC. The normal amount of white blood cells in a sample is 4,000 to 10,000/mm3; and, the differential portion of the CBC tells the clinician the specific amounts of each type of white blood cell. Since each type performs distinct functions in fighting off infection, it is important to check the white blood cell differential to help to determine the cause of infection. For example, if a patient complains of abdominal pain and increased GI motility and the CBC shows an elevated white blood cell count, the healthcare provider may consider that there is an infectious process causing the patient’s condition. When checking the differential, it may show that lymphocytes are elevated, which are important for fighting infection caused by viruses. This result may better help the healthcare provider to understand the cause of the infection.

The red blood cells are the second type of cells measured through the CBC. The red blood cells are responsible for oxygenation of body tissues because they contain hemoglobin and carry oxygen through the bloodstream. The red blood cell portion of the test is further broken down to test such elements as the total red blood cell count, hemoglobin, hematocrit, red blood cell indices, and the reticulocyte count.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 109 The normal red blood cell count is approximately 4.7 to 6.1 million cells/mcl for men and 4.2 to 5.4 million cells/mcl for women, which could be increased when a patient is dehydrated or has poor kidney function, or decreased in cases of anemia, hemorrhage, and severe infection. The red blood cell indices include components such as mean corpuscular volume (MCV), which measures the average size of a red blood cell. If the red blood cells are too large, they are considered macrocytic; this condition could occur because of certain vitamin deficiencies or with hypothyroidism. Alternatively, microcytic cells refer to those red blood cells that have an MCV result that is smaller than normal. Microcytic red blood cells typically develop if the patient is suffering from iron deficiency anemia. Other segments of the red blood cell test include the mean corpuscular hemoglobin (MCH), which measures the average amount of hemoglobin found within each red blood cell in the sample; mean corpuscular hemoglobin concentration (MCHC), which is the concentration of hemoglobin within a red blood cell; and, the red cell distribution width (RDW), which is a measurement of the various sizes of red blood cells found within the sample.42

The hemoglobin is the portion of the red blood cell that attaches to oxygen molecules in the bloodstream. The normal amount of hemoglobin varies between men and women but is typically 14 to 18 g/dL for men and 12 to 15 g/dL for women. Decreased levels of hemoglobin can indicate possible anemia, kidney disease, toxicity, or even cancer. The hematocrit is an indication of the volume of red blood cells within the blood sample. It is expressed in percentage form and the normal result is between 45 and 55 percent, although this may be slightly lower in women. A patient may have a low hematocrit if he or she has had excess fluid intake or if blood loss has occurred.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 110 The CBC may also include the reticulocyte count, which is a measurement of immature red blood cells found within the blood sample. The reticulocyte count is most often elevated in cases of anemia. If a patient has anemia and a high reticulocyte count, there may be another condition causing blood loss or a situation that would require the body to produce too many immature blood cells, such as in cases of hemolysis. The reticulocyte count may be decreased if there is a vitamin deficiency present, such as with vitamin B12 deficiency.41

Hypothyroidism, which is associated with a number of gastrointestinal motility problems, including constipation and malabsorption, can also lead to a drop in red blood cells and some kinds of anemia. Low thyroid levels can impact iron absorption, which could result in iron deficiency anemia.43 This could potentially create a negative cycle in which the intestines receive even less oxygenated blood than what they need when red blood cells and hemoglobin are lacking; which could then further perpetuate motility problems if the intestinal tract is not adequately oxygenated through circulation.

The final type of blood cells measured in the CBC is for platelet counts. Platelets are fragments of cells that support blood clotting. This may also be referred to as the thrombocyte count and it detects how well the patient is able to clot blood or is prone to blood loss. A normal platelet count is 150,000 to 450,000 mm3 among men and women.

Patients with some gastrointestinal disorders may have changes in platelet counts that range from minor variations in total counts to significantly low or high numbers. According to Houghton, et al., in the journal Neurogastroenterology & Motility, patients with irritable bowel syndrome

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 111 may have platelet changes. As discussed with irritable bowel syndrome, many patients suffer from GI motility changes that are regulated with administration of antidepressants that affect serotonin levels. This is because a significant amount of the body’s serotonin resides in the GI tract, where it regulates intestinal movements. Serotonin in the GI tract may also be referred to as 5-hydroxytriptamine (5-HT). The researchers in the study have shown that patients with irritable bowel syndrome typically have platelet-depleted 5-HT concentrations in the bloodstream.44 The study demonstrated that patients with constipation and diarrhea associated with irritable bowel syndrome had elevated levels of platelet-depleted 5-HT in serum samples, leading the researchers to believe there was a connection between these platelet-depleted cells and sigmoid colon motility.

A CBC is a very common blood test that can be easily performed within most healthcare facilities that have laboratory capabilities. This test should be ordered for any patient who presents with symptoms of a gastrointestinal motility problem that is potentially caused by infection, hemorrhage, or anemia. In some cases, the CBC may be ordered as part of diagnostic testing, but the results come back within normal limits. For example, a patient who presents with symptoms associated with irritable bowel syndrome may have completely normal laboratory studies, yet may continue to struggle with uncomfortable symptoms of increased or decreased GI motility.

When a patient receives treatment for a GI motility disorder, the CBC could also be performed to check the effectiveness of such treatment. If the GI motility problem is caused by another medical condition and the patient receives treatment, the CBC may be repeated after the treatment process to ensure that treatments are effective. The patient may also demonstrate a

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 112 lack of GI motility symptoms when the underlying condition is treated. Combined with the CBC, these signs are an indication that treatment measures are effective for the patient.

Treatment And Clinical Criteria

Treatment of gastrointestinal motility disorders is an individual course of action that considers the symptoms, medical history, and current health management strategies of each patient. One patient may need medication to control pain associated, for example, with achalasia, while another patient who takes the same drug for pain may experience drug side effects, such as severe constipation. The healthcare provider must consider the unique needs of the patient after diagnosing a GI motility disorder, utilizing standard interventions such as pharmacologic therapy, changes in lifestyle factors, and surgical approaches. Other more novel interventions may be considered as well, including stem cell therapy.

Neural Stem Cells

Stem cells are remarkable cellular bodies that are able to divide and develop into different types of cells. As a stem cell divides, it forms two new cells; each new cell can perform functions or it can remain a stem cell to divide again later. Stem cells are also important in that they may be able to repair certain defects in the body by replacing other cells because they can repeatedly divide and replenish them. On its own, a standard stem cell is non-specific; however, once it divides, it can take on the functions of cells in specialized areas of the body, including in the brain, the muscles, and the gastrointestinal tract.

Neural stem cells are also self-renewing, in that they are able to divide and then take on the characteristics and functions of cells of the brain and nursece4less.com nursece4less.com nursece4less.com nursece4less.com 113 nervous system. Neural stem cells form specific types of cells after they divide, including neurons and astrocytes, which are primary parts of the nervous system. Because nerves that serve various portions of the intestinal tract control GI motility, neural stem cells have been considered as part of treatment to replace damaged neurons that lead to GI motility disorders.

Neural cells are normally found in the submucosal or the muscular layers of the intestinal tract. These cells stimulate peristalsis after release of substances such as acetylcholine when nerve impulses reach the neuromuscular junction in the intestine. Normally, the release of neurotransmitters stimulates the muscles of the GI tract to contract and produce peristalsis in order to move digestible materials through the system. When a GI motility disorder develops, however, there may be damage to the nerves that stimulate peristalsis and the person may develop dysmotility.

In 2006, researchers were able to modify some of the actions of stem cells to essentially force certain stem cells into reproducing into specific types of tissue. These cells are known as induced pluripotent stem cells (iPSC). In essence, iPSC bodies can be directed to create new cells that specifically focus on one area where new cells are needed most, such as by creating new neurons to work in the GI tract when these cells have been damaged.

Treatment with neural stem cells involves transplanting the cells into the gastrointestinal tract where they can then divide and reproduce some of the neurons that affect muscular activity in the intestine. The researcher first reprograms fibroblasts to become iPSCs that will divide to form neural stem cells. The cells that result from this process are known as induced neural cells. Alternatively, stem cells for transplant could be taken from a healthy portion of the gut or from the brain.119 These cells are known as precursors,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 114 in that they eventually form the cells needed for regeneration into healthy neurons.

Transplantation of the cells may be performed through endoscopy, in which the intestine is visualized and the cells may be injected directly into the tissue. A study by Cheng, et al., in the journal Neurogastroenterology & Motility, worked with transplanting neural stem cells into the gut as a method of controlling Hirschsprung disease. The stem cells were injected using endoscopic procedures to directly reach the affected areas. The study showed that endoscopic transplantation of neural cells can be beneficial to deliver a large number of cells to a greater area, such as with cases of Hirschsprung disease, in which the bowel may be enlarged.120

When considering specific diseases of the gastrointestinal system, neural stem cell transplantation shows promise as a form of treatment. The transplant of neural stem cells into GI tissue has the potential to manage several forms of GI motility disorders that are caused by degenerative conditions of the nervous system, including achalasia, Hirschsprung disease, or congenital megacolon. Researchers are continuing to expand their work to include use of stem cells in the treatment of various other forms of GI motility disorders, particularly those that are unresponsive to other forms of therapy or that otherwise have no cure. The potential for technological advances that can create cells designated to treat certain GI disorders is an exciting thought that deserves continued study and future discussion.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 115 Dietary History and Assessment

For many patients with gastrointestinal motility disorders, changes in dietary habits alone can make a significant difference in the severity of symptoms. Unfortunately, many Americans have eating habits that include increased intake of high-fructose corn syrup, sugar alcohols, saturated fats and trans fats, and too few vitamins, minerals, and other important nutrients to maintain good health. During the health assessment, the nurse should include dietary history as part of the evaluation of the patient’s condition, as diet contributes significantly to the cause of many GI dysfunction symptoms.

There are many dietary changes that patients can make that will help to alleviate some symptoms, even if they do not actually cure the motility disorder. For symptoms of diarrhea, fluid and dietary changes can impact stool constitution and can resolve some symptoms of loose stools, as well as prevent excess fluid and electrolyte loss associated with diarrhea. The patient is at high risk of developing electrolyte imbalances in sodium and potassium with increased fluid loss through watery stool. It is important that the patient understands the significance of food and fluid intake when diarrhea is present, particularly when the condition has been happening for more than several days or is the result of another underlying medical condition that requires more extensive treatment. The patient should be encouraged to drink plenty of fluid, including at least one cup of fluid added for every loose stool.

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The BRAT diet, while often employed as part of dietary management of diarrhea, is not necessarily effective in managing symptoms of diarrhea in patients with GI motility disorders. BRAT stands for bananas, rice, applesauce, and toast, which are all relatively bland and soft foods that are said to calm the stomach and prevent indigestion. However, there is no evidence that states that this diet is effective in preventing diarrhea, and its recommended use seems to be purely anecdotal.54 The diet contains very little protein and is low in fiber, and, while it may offer some nutrients, it does not necessarily affect diarrhea; in fact, the BRAT diet was once recommended as part of treatment for diarrhea among children but it is now no longer suggested by healthcare providers as part of diarrhea management for children.60

Mild dehydration can be managed with intake of foods that provide calories and fluid but that are easy on the gastrointestinal tract, such as soda crackers, broth-based soup, and fruit juice. However, because of the potential for electrolyte imbalances that can occur with chronic diarrhea, the patient should be advised to continue to eat foods that are good sources of vitamins and minerals. Historically, a patient with chronic diarrhea was only given clear liquids and was not advised to eat solid foods for fear of worsening the condition. It is now understood that the cells of the intestinal tract are more likely to recover from damage when they are stimulated, such as through movement and digestion of food after eating.61

When eating, the patient should eat foods that are high in nutrients but should avoid excess sugar, caffeine, and alcohol. Some patients feel worse after consuming dairy products, so it is often best to avoid milk or cheese until diarrhea has resolved. Oral rehydration solutions that contain

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 117 electrolytes may prevent fluid loss and can provide balance in the intestinal tract. The patient may choose commercial preparations that can be taken as a drink to restore fluid and electrolytes; an example sometimes used for children with diarrhea is Pedialyte®. Alternatively, the patient may prepare his or her own mixture of oral rehydration solution, which should include salt, potassium chloride, bicarbonate of soda, and a small amount of sugar mixed with water.

Probiotics have been shown to be an effective preventive measure against some types of diarrhea and they may be incorporated into the patient’s diet through food intake that contain the bacteria or through specially designed supplements. Probiotics are microorganisms that support growth of healthy bacteria in the GI tract. They are effective in that, after ingestion, probiotics can destroy some toxins that contribute to illness-causing diarrhea, prevent harmful bacteria from infecting the gastrointestinal tract, stimulate increased mucus production in the intestinal tract, may help to decrease GI inflammation, and diminish the effects of gas and bloating.62

The two most common types of bacteria used as part of probiotics are Lactobacillus and Bifidobacterium. These bacteria can be purchased through supplements that the patient may buy over-the-counter to take. However, if the patient is suffering from diarrhea, he or she should consult with a healthcare provider about the best type of probiotic supplement to use. Alternatively, probiotics are also found in many foods; a patient with diarrhea may choose to include many foods that contain probiotics into the diet to help with GI motility and to potentially relieve some of the patient’s symptoms. Probiotics are found in foods such as yogurt and kefir, and in many fermented products, such as sauerkraut, sourdough bread, sour pickles, and tempeh.

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Based on information available, probiotics can potentially shorten the time period that a patient suffers from acute diarrhea, although the individual will need to take enough of a dose of probiotics to impact the digestive system. A minimum suggested amount to achieve positive effects is at least 5 billion per day.54 Although the efficacy of probiotics has been demonstrated in controlling symptoms of diarrhea among affected patients, they do not necessarily counteract diarrhea from all causes. A study in the Scandinavian Journal of Gastroenterology presented a summary of conditions that can be effectively managed by probiotic use, including diarrhea caused by antibiotic use, acute infectious diarrhea, diarrhea that developed as a healthcare associated infection, and persistent diarrhea.65 The evidence for probiotics continues to demonstrate that inclusion of foods with these beneficial microorganisms is helpful to patients with GI motility problems, particularly those with diarrhea.

While dietary changes are not always a complete cure for certain GI motility disorders and many patients suffer from symptoms due to damage of an underlying disease, a proper diet can make a significant difference in the patient’s symptoms. For the patient struggling with nausea, food may not sound appealing and it may be difficult to eat or prevent vomiting. However, food and fluid intake is important for patients who suffer from nausea and vomiting because of GI dysmotility, in order to best prevent anorexia and dehydration.

For the patient suffering from gastroparesis that causes nausea, there are several dietary suggestions that may help. The patient should be advised to monitor food consumption, not only in the kinds of foods eaten, but also how food is eaten. The patient should be advised to chew foods carefully and

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 119 thoroughly and to avoid taking large bites or swallowing pieces of food whole. Instead of eating three large meals a day, the patient would more likely benefit from six small meals each day, which can prevent stomach distention.

Many patients benefit from sitting at the table to eat and then sitting up or walking around for at least one hour after the meal is finished. Lying down after eating may slow the rate of stomach emptying and the patient may be more likely to experience nausea after the meal. The individual should also avoid greasy foods or those items that contain a lot of fat, as fat is slow to leave the stomach and enter the duodenum. If the patient is still unable to keep down solid food without vomiting, he or she may still try to take sips of liquids and consume foods that are less likely to lead to nausea, including broth, popsicles, or citrus juice. The patient may also be encouraged to blend foods with extra liquid to break them down so that they are in a liquid or semi-solid state, which could make them easier to tolerate.

Certain foods have been organized into a descriptive classification known as FODMAP: fermentable, oligo-, di-, and monosaccharides and polyols. These foods, when eaten in excess, could increase the risk of bacterial infection, may not be absorbed well, and may increase the amount of water pulled into the digestive tract. Examples of these types of foods include those with high fructose corn syrup, dairy products, foods containing wheat or rye, beans and legumes, honey; and those containing certain sweeteners, such as xylitol, sorbitol, and isomalt. Studies have shown that FODMAP foods tend to worsen symptoms of certain GI motility disorders, including irritable bowel syndrome.20 One element of dietary management is removing FODMAP foods or significantly limiting their intake to reduce symptoms of IBS. An article by

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 120 Halmos, et al., in the journal Gastroenterology explained that decreasing FODMAPs in the diet has been shown to help patients with IBS. The study examined the effects of a diet low in FODMAPs when compared to a standard diet; the subjects with IBS who followed a low FODMAP food diet suffered from fewer symptoms of bloating, gas, and abdominal pain when compared to those who followed standard fare diets.21 The study suggests that limited intake of FODMAP foods should be considered as first-line therapy for functional GI conditions such as IBS.

Not all symptoms associated with gastrointestinal motility disorders can be successfully managed with changes to the diet; however, managing dietary habits and choosing healthy foods in the right amount can make a difference for many people. Because the GI tract is responsible for digestion, absorption, and excretion of food and nutrients, it is essential to consider the effects of dietary intake when assessing patients who suffer from disorders of GI motility.

Activity and Exercise

Activity and exercise have been shown to be beneficial for many patients who suffer from gastrointestinal conditions, particularly those who are struggling with GI dysmotility. The healthcare provider may recommend increasing activity levels for some patients, as exercise can improve symptoms of some types of motility problems. Even when exercise does not directly impact GI dysmotility symptoms, the patient should be encouraged to continue with normal activities and to avoid immobility if possible, since exercise and activity are beneficial for organ systems beyond just the GI tract.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 121 Among patients who suffer from diarrhea, increasing activity levels may be undesirable, particularly if diarrhea is so severe that it impacts the person’s ability to participate in exercise or many other activities outside of the home. For instance, if a person is struggling with fecal incontinence in the form of diarrhea, he or she may have difficulties with leaving the house for fear of being incontinent of stool when away from home. It may be difficult to help a patient understand the importance of maintaining activity levels in this type of situation.

Normally, decreased activity levels and immobility are associated with slowed colonic motility and constipation, not necessarily diarrhea. In fact, strenuous exercise may actually increase GI motility and could contribute further to diarrhea when the body shunts blood away from the intestinal tract to meet the high needs of the muscles with activity. Some people struggle with activity-induced diarrhea when they exercise and then experience abdominal pain and an increased urge to have a bowel movement.

When a patient is suffering from diarrhea, rest and rehydration are typically recommended to cope with the situation, rather than encouraging an increase in activity levels. The healthcare provider can recommend the appropriate amount of exercise for a patient who is already accustomed to regular activity but who has developed diarrhea. Likewise, a patient who

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 122 suffers from fecal incontinence may be less likely to engage in regular exercise and may have difficulties with participating in any outside activities, so increasing activity levels is not always an option; however, the patient who suffers from overflow incontinence as a result of fecal impaction from constipation should avoid long periods of immobility, if possible, and strive to increase activity levels to prevent further constipation. While it is not necessary to take on a vigorous exercise regimen, an increase in activity levels in a previously sedentary person can help by improving circulation, stimulating peristalsis, and enhancing overall feelings of well being, which is important for the patient who feels embarrassed and humiliated because of fecal incontinence.

Similar to diarrhea or fecal incontinence, a patient with nausea and vomiting associated with pseudo-obstruction or gastroparesis may have reduced activity levels and may be less likely to participate in exercise or other activities. Movement sometimes worsens symptoms of nausea and the patient may experience dizziness, which can further increase the risk of vomiting. Some antiemetic drugs can cause drowsiness and may make the patient feel lethargic, such that he or she does not have enough energy to participate in extra activities.

However, exercise can be helpful in some situations in which the underlying cause of the nausea could be managed. In the case of gastroparesis, a patient may benefit from mild exercise to help improve GI motility; recommendations associated with eating and activity levels in this situation often advise taking a walk after eating to avoid lying down and to promote gastric emptying of stomach contents. Often, gastroparesis is associated with diabetes, a condition that can also benefit from regular exercise to control weight and to promote healthy blood circulation. It is therefore

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 123 important that the patient, who suffers from nausea as a result of intestinal dysmotility, whether it is due to gastroparesis or some other medical condition, consult with a healthcare provider for guidance about the appropriate amount of exercise and activity.

Surgery — A Palliative Approach

Surgical treatment of gastrointestinal motility disorders is palliative in nature in that the procedures are performed to keep the patient comfortable and to manage symptoms. Among patients who suffer from primary intestinal motility disorders, surgery is not necessarily an effective form of treatment to cure the situation.57 The exception is in cases of refractory constipation that has the potential to cause severe complications for the affected patient.

Surgical interventions for the management of GI dysmotility is done to relieve symptoms of distress and to help the patient to manage the condition despite its presence. Many GI motility disorders, particularly those caused by degenerative or congenital conditions, have no cure. However, complications that develop as a result of these disorders can cause painful and debilitating symptoms and may even shorten the life of the affected patient. For example, a patient who suffers from scleroderma may develop swallowing difficulties and slow peristalsis between the esophagus and the stomach. Surgery may be performed to eliminate some of the scar tissue present,

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 124 which will help the situation; however, the surgery is not able to cure the scleroderma.

Surgical treatment of esophageal conditions, such as in cases of achalasia, is primarily aimed at improving swallowing, peristaltic action of the esophagus, and muscular tone of the lower esophageal sphincter. Because achalasia is caused by nerve damage or lack of neurons that serve the esophagus, surgical treatment will not actually treat the condition. Instead, the goal of surgery is to relieve any obstructions that have developed in the esophagus and to alter the muscle tone of the LES so that it can allow food and fluids to pass into the stomach.121 Surgery does help to manage symptoms of achalasia, though, and will help to control the patient’s pain as well as prevent certain conditions that could develop as complications, such as malnutrition or dehydration.

Within the large intestine, disorders of motility can cause chronic diarrhea or constipation. When constipation is severe, or the patient suffers from a GI motility disorder because of a degenerative condition, surgical intervention may be required to remove part of the colon and to make the patient more comfortable. As with other types of surgical intervention for dysmotility, surgery may initially cause discomfort because of the procedure, but the ultimate goal is to improve the patient’s quality of life by reducing symptoms of disease and extending the patient’s life that may otherwise be shortened because of his or her condition.

Surgery may be indicated if a patient suffers from a GI condition that could cause such complications as to be life threatening, such as toxic megacolon. The condition occurs as a complication of inflammatory bowel disease or with colon infection. When infection develops in the gut, the large intestine swells

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 125 and expands, potentially leading to severe dehydration and even shock. Treatment of the inflammation is paramount to avoid critical consequences. An article by Autenrieth and Baumgart in Inflammatory Bowel Diseases explained that surgical intervention in cases of toxic megacolon is sometimes necessary to treat the underlying disorder causing the inflammation and swelling.122 In this case, surgery takes a palliative approach in that the patient will be more comfortable following the procedure, and it prevents widespread inflammation and possible septic shock.

Colectomy is one of the more common types of surgical procedures performed on the large intestine in order to treat some disorders of motility. Also called a colon resection, a colectomy involves removal of some or all of the large intestine when it is diseased and then rerouting the remaining portions so that stool exits outside of the body through a stoma. The surgery may be performed laparoscopically or it may be an open procedure. After removal of the diseased part of the bowel, the healthy ends of the bowel are then reattached. Depending on the amount of tissue removed, the colostomy may be temporary, requiring another surgery to restore normal bowel function, or it may be a permanent fixture.

Colectomy may be performed as a surgical procedure in a number of colonic conditions that affect gastrointestinal motility. A study in the Journal of Laparoendoscopic Surgeons demonstrated that a combination of subtotal colectomy, which is a procedure that removes most of the colon but leaves the rectum behind, combined with a modified Duhamel procedure, which involves anastomosis of lower and upper segments of the GI tract, could be used for the management of mixed constipation. Mixed constipation in this case is described as a combination of slow-transit constipation and outlet obstructive constipation. The study showed that when implemented into

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 126 adults who suffered from mixed constipation, combination subtotal colectomy with modified Duhamel, patients had favorable long-term effects, including improved constipation and bowel function, as well as improved quality of life.123

Because gastrointestinal motility disorders can arise from various pathologic processes and their symptoms can vary widely, there is not one surgical procedure designed to manage all types. In some cases of GI motility disorders, such as irritable bowel syndrome, surgery is not necessarily indicated at all. However, for those who have suffered from symptoms of GI dysmotility as the result of an underlying disease process, surgery could be an option that would reduce or even eliminate some uncomfortable symptoms. The goal of palliative care is to provide comfort for the patient and to improve quality of life. When surgery for GI dysmotility takes a palliative approach, the patient will not necessarily receive a cure for his or her condition but may benefit from control of symptoms, prevention of complications, and improved feelings of wellbeing.

Pharmacologic Therapy

Prescription and over-the-counter medication use has increased rapidly in recent decades, with almost one-half of Americans using some form of prescription drug on a daily basis. Medications are well known for their positive benefits in controlling symptoms associated with illness and disease, and yet medications are also

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 127 responsible for a number of unpleasant side effects that may prohibit some patients from taking them. Furthermore, some medications place certain patients at risk of complications that make their use too hazardous.

There are several classes of medications that cause gastrointestinal motility problems. While side effects of nausea or upset stomach are extremely common to many types of drugs and are listed on pharmaceutical packaging, there are a few medications that can cause significant motility problems in the GI tract. When these issues arise, patients often need to examine whether the drug is worth the GI motility problems it causes or if their conditions can be controlled through other means.

Opioids

One of the most well-known medication culprits that cause gastrointestinal motility problems is the opioid analgesic. Taken for pain and used widely in all manner of settings, including outpatient treatment centers, in-hospital intravenous administration, or home prescription use, opioids are often responsible for keeping patients comfortable and managing moderate-to- severe pain from procedures and from the complications of illness. Patients suffer from the effects of pain, whether it is chronic pain from a wound or due to illness, or acute pain as that from an injury.

Hospitals and healthcare centers have also increased their focus on improving pain relief for patients and ensuring that patients within their facilities gain control over their pain, and do not suffer when they are receiving treatment. As a result, use and administration of is more prominent than ever in the United States as healthcare providers continue to seek methods of best controlling patient pain and maintaining appropriate comfort levels.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 128 Analgesics are medications taken to control pain; they typically are differentiated between opioid and non-opioid analgesics, with the type and amount of the drug administered varying depending on the kind of pain the patient is experiencing. Mild-to-moderate pain is often controlled through non-opioid analgesics, while moderate-to-severe pain is more often managed with opioid analgesics. Drugs described as opioids are those that come from opium of the poppy plant; and, they may be natural or synthetic versions of the drug. After administration, opioid medications attach to certain receptors in the brain, producing a chemical response that induces feelings of pleasure by stimulating the brain to release dopamine. This attachment to receptors also produces feelings of calm and it blocks the sensation of pain.

Because of the increase in use of opioids within healthcare facilities and within the community, patients are also experiencing an increase in their side effects. Opioid medications have been known to cause neurological changes such as confusion or mental “fog,” may slow the breathing rate, sometimes to a dangerously low level; and, they produce gastrointestinal side effects, typically including nausea, vomiting, and constipation. Opioids can attach to various receptors, including the mu, kappa, and delta receptors, which affect different sites throughout the body, so they are able to control pain but also cause side effects in numerous locations in the body.

There are many opioid receptors in the gastrointestinal tract. When opioids are administered, they can affect these receptors and cause changes, including a decrease in mucus secretions, an increase in fluid reabsorption, and delayed gastric emptying. As a result, the patient who takes these drugs is more likely to suffer from GI complaints such as nausea and constipation. Approximately 25 percent of patients who are treated with opioids

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 129 experience nausea as a side effect.35 This effect can be worsened if the patient with nausea also experiences central nervous system changes that cause dizziness or that affect balance.

Even more common as a side effect, constipation may impact up to 95 percent of patients who use opioid analgesics.35 The development of hard, dry stools and slowed transit times in the large intestine results from decreased intestinal mucus production and increased reabsorption of fluid from the colon, thereby slowing GI motility and making stools difficult to pass. In some cases, constipation may also be worsened if the patient has gone for periods without eating, such as with anorexia that has developed because of nausea or because of requirements for certain medical procedures. In such cases, the patient does not have the food intake needed to stimulate the GI tract to promote motility.

Fortunately, the awareness and knowledge of the gastrointestinal side effects of opioid analgesics is so well known that healthcare providers can take measures to prevent these complications before they begin. For patients at risk of nausea because of slowed gastric motility, the provider may order antiemetic drugs to be administered prophylactically. Other measures to prevent or control nausea include distraction and relaxation techniques, as well as administration of other types of drugs to control dizziness or vertigo that may accompany the nausea, such as antihistamines and anticholinergic preparations.

For prevention and control of constipation, the provider may need to ensure that the patient maintains adequate fluid intake while taking opioid analgesics and that dietary fiber intake is adequate to prevent fluid reabsorption in the GI tract. For many patients, stool softeners are ordered

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 130 concomitantly with the opioid analgesics to help maintain normal bowel habits. Bulk forming and stimulant laxatives may also be needed to improve bowel function and to reduce constipation. Many patients reduce intake or even eliminate taking opioids because of the GI side effects; however, with the availability of these measures to treat nausea and constipation, the patient may not need to cut back on opioid medications to avoid their adverse effects.

Antidepressants

One of the most commonly prescribed medications in the United States, antidepressants are recommended for treatment of depression and some other forms of mental illness, as well as certain other chronic conditions that can cause pain or anxiety, including fibromyalgia and chronic fatigue syndrome. Antidepressants, while helpful to many, can also cause symptoms of gastrointestinal distress and can affect GI motility.

Antidepressants regulate levels of serotonin, which are found in the brain and in the GI tract. Serotonin is a neurotransmitter that affects human behavior and emotion; consequently, a person may take antidepressants to control depression or regulate anxiety. Since serotonin receptors are present in the GI tract and associated with pain from rectal distention, i.e., as occurs with irritable bowel syndrome (IBS), antidepressants are used as part of treatment for IBS, as well as depression.36 In fact, antidepressant prescription is part of routine management of irritable bowel syndrome. This may be because of the effects of these medications on serotonin in the GI tract; however, it could also be due to the psychological symptoms associated with IBS. Persons who suffer from chronic constipation or diarrhea associated with IBS may experience a worsening of symptoms during times of stress or emotional suffering. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 131 Antidepressants can cause a number of gastrointestinal side effects. Patients with IBS who take antidepressants, as part of treatment for IBS, should also be aware of the potential side effects associated with these drugs. Likewise, other individuals who take antidepressants but who have not necessarily been diagnosed with a gastrointestinal condition may also suffer the abnormal GI effects that these drugs can cause.

The most common offenders in these cases are tricyclic antidepressants and selective serotonin reuptake inhibitors. Tricyclics have the potential to slow intestinal transit because they have anticholinergic activity, in which they block the action of acetylcholine in the parasympathetic nervous system. As a result, the affected person is more likely to suffer constipation and slowed colonic transit due to decreased GI motility.70 These drugs also may diminish secretions in the stomach and intestines and salivation in the mouth, resulting in xerostomia, abdominal pain, bloating, and nausea. Alternatively, selective serotonin reuptake inhibitors (SSRIs) can have the opposite effect on the gastrointestinal system and may cause increased intestinal transit.70

As stated previously, serotonin is found in the GI tract and exerts some control over sensorimotor function. When food is digested and chyme passes through the intestinal tract, certain cells known as enterochromaffin cells release serotonin, which triggers peristalsis through nerve pathways. When a person takes a SSRI antidepressant, the availability of serotonin in the GI tract is prolonged, thereby potentially increasing the rate of peristalsis and intestinal motility.71 Selective serotonin reuptake inhibitors are often prescribed for patients who suffer from IBS with predominant constipation, as the increased GI motility associated with their use can reduce these symptoms. However, SSRI use may also cause the opposite effects and may

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 132 set off too rapid of peristaltic action, resulting in diarrhea. The affected individual may also suffer from abdominal pain and excess flatulence.

A study by Choung, et al., in the journal Neurogastroenterology & Motility, used questionnaires to examine patient responses to discern the effects of antidepressant use on the gastrointestinal system. The most common symptom reported by participants in the study was abdominal bloating and distention. The researchers in the study believed that this was possibly due to slowed GI motility, delayed gastric emptying, or that antidepressants promote bacterial overgrowth within the small bowel, leading to excess gas production and bloating.70 When a patient needs an antidepressant for support for mental health issues, or if these drugs are prescribed as adjunct medications for other conditions, affected patients should be counseled about the GI effects they can cause. Some effects may be transient and may cause minor symptoms; while other effects can be significant enough that affected patients may want to change prescriptions entirely.

Anticholinergics

Anticholinergic drugs are prescribed to work against the effects of the neurotransmitter acetylcholine within either the central or the peripheral nervous systems. There are a number of anticholinergic drugs available and their uses vary, depending on the body system involved. Anticholinergics are prescribed for respiratory disorders, as they act as bronchodilators in cases of asthma or chronic bronchitis; and, they may be prescribed for dizziness or insomnia, and they may also be used for some genitourinary conditions, such as when patients suffer from bladder dysfunction. Additionally, some anticholinergics are prescribed to control GI conditions and may be prescribed in cases of , , diarrhea, nausea, and vomiting. nursece4less.com nursece4less.com nursece4less.com nursece4less.com 133 There are two main types of cholinergic receptors in the body: nicotinic and muscarinic receptors. Nicotinic receptors are found in the neuromuscular junction between the nerve and the muscle, whereas muscarinic receptors are found in cell membranes of certain neurons. As a neurotransmitter, acetylcholine binds to both types of receptors. There are different sub-types of muscarinic receptors, which are found in specific locations throughout the body. For example, muscarinic-1 receptors are found in the brain, the salivary glands, and the stomach, while muscarinic-3 receptors are located in certain smooth muscles. Stimulation of muscarinic-3 receptors in the smooth muscle can lead to increased production of gastric acid.40 Within the gastrointestinal system, stimulation of muscarinic receptors has been shown to increase GI motility and to potentially cause nausea and vomiting. Alternatively, antagonism of muscarinic receptors has been shown to decrease both GI motility and gastric acid production.

When an anticholinergic medication is administered and the drug blocks the effects of acetylcholine, there is less of the neurotransmitter to bind to the nicotinic and muscarinic receptors in the body. A study in the journal BMC Geriatrics investigated defecation frequency among older adults with chronic obstructive pulmonary disease (COPD) who used muscle relaxant medications to control some of their respiratory symptoms. The study showed that those adults who used the drugs to control respiratory symptoms also had lower levels of defecation frequency and were more likely to suffer from constipation and slowed colonic transit.86 Because anticholinergic drugs are prescribed for so many different conditions, there is potential for patients to develop a number of gastrointestinal motility disorders with regular use of these drugs. As with other medications, patients should be counseled to understand the GI side effects associated with anticholinergic drugs when they begin taking them.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 134 Loperamide

There may be times when an individual takes medications specifically for symptomatic management of gastrointestinal motility problems but then ends up suffering adverse effects, sometimes because the medication seems to have too much of an effect on intestinal transit. An example of this is the use of antidiarrheal medications such as loperamide, which are often prescribed for the management of acute or chronic diarrhea, as well as traveler’s diarrhea among patients who are suffering from loose stools.

Antidiarrheal medications such as loperamide are typically indicated for use on a controlled or short-term basis, rather than being taken daily on a long- term basis. In general, many antidiarrheal drugs are not necessarily meant to be taken for an indefinite period of time; if a patient needs to take these types of drugs because of chronic diarrhea that is not responding to other medication, then the situation should be discussed with a healthcare provider first.

Loperamide works by decreasing gut motility to slow down the rate of intestinal transit so that the affected person is less likely to suffer from diarrhea. When colonic transit slows, more fluid is absorbed and the stools are less watery and become more formed. For some people, though, the effects of the drug can go in the opposite direction and can slow colonic transit so much that constipation develops. If excess fluid is reabsorbed in the colon to avoid watery stools, the body could ultimately absorb too much fluid from the intestinal tract, creating hard and dry stools associated with constipation.

The potential for constipation with loperamide use is enough that researchers sometimes induce constipation using the drug in lab animals in

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 135 order to study treatment options for constipation symptoms.87 For many, however, use of antidiarrheals such as loperamide is effective in treating diarrhea and controlling its unpleasant symptoms without causing constipation. Patients who want to use this type of drug for treatment of diarrhea should take it carefully and according to directions. Side effects can often occur when a person takes the drug incorrectly.

Anti-Parkinson Drugs

Although Parkinson’s disease (PD) was originally classified as a nervous system disorder, it is now considered a multi-organ syndrome, affecting various systems throughout the body.32 Gastrointestinal symptoms have been shown to worsen as Parkinson’s disease progresses; alternatively, a patient with PD who takes medication to control symptoms of the illness may be more likely to end up suffering from gastrointestinal effects as well.

Certain drugs used for management of disorders such as Parkinson’s disease have been shown to affect gastrointestinal motility, typically within the stomach, causing delayed gastric emptying. Parkinson’s disease is more common among older adults; this population of patients often suffers from symptoms of nausea, vomiting, constipation, and feelings of gastric fullness after taking medication. Levodopa is the most common agent prescribed for management of Parkinson’s disease. Levodopa is a precursor of dopamine. This drug may be more likely to slow GI motility because of its effects on dopamine receptors in the intestinal tract. Levodopa has also been shown to act on the stomach wall, decreasing movement of the pyloric sphincter and slowing the rate of gastric emptying.34

A person with Parkinson’s disease often develops neurological deficits including tremor, slow motor movements, and rigidity; and, these symptoms

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 136 are caused by lack of dopamine in the brain. After administration of levodopa, the brain converts it into dopamine, where it is stored until the body needs it to regulate its movement. Levodopa has been used successfully for management of PD for years. Its formulation has changed somewhat since the time of its initial release. Levodopa is now available in extended release forms that may have less of an effect on the GI system if the drug is released over a longer period of time.

The introduction of carbidopa, another medication used to enhance the effects of levodopa, results in a much lower dose requirement of levodopa when the two drugs are taken together.33 Carbidopa on its own has little to no therapeutic benefit, so it must be taken with levodopa for the patient to gain positive effects. Sinemet® is an example of a drug that is a combination of levodopa and carbidopa.

Dopamine cannot be administered to patients with PD because dopamine cannot cross the blood-brain barrier. Levodopa is the next best option because it is converted to dopamine in the body. However, because of its gastrointestinal side effects, there is a catch to taking this drug on its own; the patient often must either suffer from neuromuscular side effects associated with PD or must endure GI problems related to levodopa. Fortunately, the administration of carbidopa along with levodopa inhibits certain enzymes that affect levodopa’s conversion to dopamine, thereby reducing the amount of levodopa needed. The patient can still achieve the desired effects of the drug but with fewer instances of GI disturbances.

Medications used for the management of GI dysmotility may be administered to treat the underlying cause of the motility problems. Alternatively, they may also be given to counteract many of the negative symptoms the patient

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 137 with a motility disorder is experiencing. In many cases, drugs for symptom control and for treatment of the medical condition may be administered concomitantly.

Pharmacologic intervention for management of the symptoms of GI motility problems may make the patient more comfortable in terms of coping with his or her condition, but administering medication to counteract symptoms will not treat the underlying disease. Drugs are often given to work against some of the more common symptoms of dysmotility, including diarrhea, constipation, nausea and vomiting, and stool incontinence. Pharmacologic management of diarrhea is often administered in the form of antidiarrheal medications. These drugs slow peristalsis in the intestinal tract, thereby prolonging the time that food and waste is digested and absorbed. Some medications also allow more time for fluid to be absorbed in the intestinal tract so that stools are not liquid and watery.

Antidiarrheal medications are best indicated for conditions that cause increased GI motility and diarrhea, including irritable bowel syndrome with predominant diarrhea, for occasional use among patients who struggle with fecal incontinence, and with other situations that cause transient bouts of diarrhea. Antidiarrheals are available in prescription strength but they can be purchased over the counter as well. The patient who wants to consider using this type of drug should consult with a healthcare provider first to determine the most appropriate medication for use and to find out if the drugs would otherwise mask an illness that requires further treatment. Some common types of antidiarrheal medications that are available without a prescription include loperamide (Imodium®) and bismuth subsalicylate (Kaopectate®). In addition to controlling diarrhea, these drugs can also help to manage other unpleasant symptoms the patient may be experiencing as a result of

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 138 the illness. For example, the makers of Pepto Bismol, which is a brand name for bismuth subsalicylate, state that their product is also able to treat indigestion, nausea, and heartburn.53 Other drugs used for management of diarrhea and that may be available by prescription include diphenoxylate with atropine (Lomotil®), which can be also be accessed without a prescription but the dosage available as an over-the-counter product is lower than prescription strength. Note that this drug is considered to be a Schedule V controlled substance. Difenoxin with atropine (Motofen®) is another prescription antidiarrheal that has been discontinued in the United States and there is no generic equivalent.

Patients who take antidiarrheal medications should be aware that these drugs can sometimes work too well, and they may end up struggling with constipation and slowed GI motility instead of diarrhea. A patient who has had chronic diarrhea may or may not be an appropriate candidate for antidiarrheal therapy, at least not on a long-term basis. Antidiarrheals change the motility of the gastrointestinal tract but they are often not meant to be permanent additives to a therapeutic regimen. A patient who takes antidiarrheal medications on a long-term basis without the advice of a healthcare professional may only conceal underlying symptoms of illness without treating the actual disease. Long-term use may also lead to chronic constipation and the process should only be undertaken with the help of a healthcare provider.

When diarrhea is suspected of having an infectious cause, antibiotics may be administered to not only manage the symptoms of the diarrhea, but also to treat the underlying bacterial infection that is causing the GI motility problems. Antibiotics are not recommended in all cases, and they should not be used if the patient’s cause of diarrhea is because of viral infection. It

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 139 should also be noted that antibiotic use for treatment of diarrhea is less common than using other non-pharmacological forms of treatment, such as with fluid and electrolyte rehydration. However, there are some cases in which a patient who suffers from prolonged diarrhea because of a specific type of infection would benefit from the administration of antibiotics, including infection with Clostridium difficile, prolonged infection with Escherichia coli bacteria, and Salmonella infection in very young children.54

Antimicrobials are given to break down the infectious organism and prevent its further spread within the gastrointestinal tract. The type and brand of medication to use depends on the organism and the extent of the patient’s symptoms. Isolation of the specific kind of organism causing the infection may be necessary through serum or stool samples. Antibiotics manage bacterial infections; and, they may be broad spectrum, in which they harm many different strains of bacteria, or narrow spectrum, in which they target specific types of bacteria. The healthcare provider may prescribe a broad- spectrum antibiotic as coverage against the bacterial infection but may change to a specific drug when the exact organism has been isolated. Examples of antibiotics that may be prescribed for the management of infectious diarrhea include cefotaxime (Claforan®), vancomycin, and erythromycin.54

Parasitic infection may also lead to diarrhea, which should be treated with antiparasitic medications to control spread and to prevent worsening of symptoms. Antiparasitic drugs may target certain species or they may be broad-spectrum types that provide coverage against any number of parasitic organisms. An example of this type of drug is furazolidone (Furoxone®). It is important to remember that whenever a patient is suffering from infectious diarrhea, antimicrobial medications can help to manage symptoms

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 140 and to control the spread of the infection in the body, but the patient must still take precautions to prevent spreading the infection to others. Unfortunately, the nature of diarrhea excretion increases the risk of exposure to infectious microorganisms to caregivers and healthcare personnel, so the patient should be taught safety measures to practice good hygiene and prevent further spread of microorganisms.

There are several pharmacological treatment options available when the patient is suffering from prolonged constipation as a symptom of dysmotility. The slowed colonic transit may be best managed through certain types of drugs that are designed to speed up passage of stool through the intestinal tract; as with antidiarrheal medications, these drugs are often available without a prescription. Laxatives are commonly used for the intermittent management of constipation. Many laxatives can be purchased without a prescription, making them easy and inexpensive to use. Bulk-forming laxatives prevent and treat constipation, and are typically made up of products such as psyllium or methylcellulose; and, include Metamucil® and Citrucel®. Magnesium laxatives treat constipation by causing the colon to retain more fluid, thereby preventing the hardening of stool. An example of this type of laxative is Phillips Milk of Magnesia®. Stimulant laxatives (Senokot®, Ex-Lax®, Dulcolax®) manage constipation by stimulating the nerves that feed the large intestine, promoting colonic motility.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 141 Stool softeners are usually taken as oral medications or as liquid preparations to help some patients who are unable to strain while defecating. They are optimally for those who have pain with defecation because of obstruction or a medical condition, such as anal fissures. Examples include docusate (Colace®, Correctol®).25 When using medications to control constipation, the patient should be informed about the potential side effects that some of these drugs can cause. Most laxatives and stool softeners are able to adequately treat constipation, which can be further prevented with changes in lifestyle habits. However, if the patient takes too much of the medication, takes it unnecessarily out of fear of developing constipation, or otherwise uses the drug inappropriately, he or she could develop diarrhea and could be at risk of complications associated with that symptom. As with drugs to control any symptoms of GI motility disorders, the patient must always be educated about the correct use of the drug in order to best control his or her condition but also to stay safe while using medication.

Nausea and vomiting can develop as significant symptoms from GI motility disorders. These two common symptoms are most frequently seen with GI dysmotility conditions such as gastroparesis, intestinal pseudo-obstruction, and dumping syndrome. As a symptom, nausea may be treated with certain medications to control the unpleasant feeling and to prevent vomiting. Anti- nausea medications are designed to control nausea and motion sickness without necessarily treating the underlying disorder. If the patient has developed nausea as a result of a GI condition, antiemetic drugs will only be a temporary solution until the underlying cause is also controlled. There are various drugs available for treatment of nausea. These drugs may be accessible to the patient with or without a prescription. Some non- prescription medications that are used to symptomatically control diarrhea

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 142 may also be used to manage nausea, such as bismuth subsalicylate. Over- the-counter antihistamines can also control nausea by preventing the inner ear from sensing motion and sending the message about the sense of nausea to the brain. Prescription antiemetic medications can be used for more severe cases of nausea and they may be administered in other methods beyond the oral route, which can be particularly effective if the patient has been vomiting.

Prescription antiemetics may work in a manner similar to non-prescription drugs in that they can block messages to the brain that stimulate the sense of nausea. An example of this type of drug is promethazine (Phenergan™). Additionally, some prescription antiemetics work by increasing gut motility to speed up the rate that food moves through the intestine. Metoclopramide (Reglan®) is an example of this type of drug. In addition to oral preparations, antiemetics may be administered as rectal suppositories, transdermal patches, intramuscular injections, or as intravenous injections. Symptomatic management of fecal incontinence involves control of the rate at which the bowel moves stool through the intestinal tract. If a person suffers from diarrhea associated with fecal incontinence, he or she may benefit from antidiarrheal medication to reduce fluid loss and to retain stool bulk to avoid accidental loss of stool from the rectum. When overflow fecal incontinence occurs, the patient may need to try medications to control constipation without further inducing diarrhea. Medications such as loperamide will reduce stool frequency among patients with fecal incontinence, which can help them to achieve greater control. As with other symptomatic treatments, though, unless the underlying condition is managed, these medications may only temporarily control the situation.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 143 Certain drugs may be administered to manage not only the symptoms associated with a gastrointestinal motility disorder, but also to control the underlying cause of the condition. Cholinergic agonists are drugs that act in a manner similar to the neurotransmitter acetylcholine. The cholinergic system is also referred to as the parasympathetic nervous system; when this system is stimulated, the body responds through vasodilation, increased secretion of sweat and saliva, and increased mucus secretion. Studies have shown that patients who suffer from intestinal pseudo-obstruction may have excessive suppression of the parasympathetic system.57 Administration of cholinergic agonist medications may then change this response and help to alleviate some symptoms. Some cholinergic agonists that may be used specifically for the management of intestinal motility disorders include neostigmine (Prostigmin®) and bethanechol (Uricholine®).

Delayed gastric motility, such as that seen with gastroparesis, can lead to nausea that may well respond with antiemetic medications. However, these drugs only manage some of the symptoms of the condition but do not treat the underlying GI motility problems. Prokinetic medications can be administered to increase the speed of GI motility to move food through the intestinal tract at a faster rate. These drugs have been mentioned as treating nausea associated with gastroparesis, in that they facilitate faster gastric emptying, thereby reducing symptoms of nausea as well as other complications, such as abdominal distention, pain, and bloating.

Drugs known as dopamine antagonists are also useful when administered to some patients with GI motility disorders, namely those who suffer from delayed motility problems. Normally, dopamine inhibits certain activities within the gastrointestinal tract, such as the ability of the LES to close properly as well as the overall rate of motility.65 Dopamine antagonist

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 144 medications block dopamine receptors in the GI tract, although they may also be used for the management of some other conditions to prevent dopamine’s effects in other parts of the body. The main dopamine antagonist medications used for management of delayed GI motility are domperidone and metoclopramide, which has been mentioned as an antiemetic medication and is also called Reglan. Macrolides, which are drugs that are traditionally used as antibiotics, may also be administered for GI motility disorders, as they have been shown to increase the rate of transit in the GI tract. The most commonly used drug in this class is erythromycin, which may be administered intravenously or orally, depending on the patient’s condition. Erythromycin has been shown to accelerate the rate of gastric emptying in patients who suffer from gastroparesis in which they otherwise experience delayed gastric motility.64

Future Trends in Treatment

In earlier sections, Rome III Criteria to diagnose and treat varied functional gut disorders was discussed. The growing field of neurogastroenterology involves a unique body of research, and medical specialists have come together to form working committees to develop improved algorithms aimed at supporting clinicians to identify GI dysmotility symptoms, and to diagnose and to treat GI motility disorders. Presently, Rome IV guidelines are being developed related to novel treatments for gut microflora and the nature and severity of functional gut disorders. Additionally, the role of dietary nutrients is a major nursece4less.com nursece4less.com nursece4less.com nursece4less.com 145 area of clinical research focused on the development of new diagnostic criteria to treat gastrointestinal conditions. Clinicians are encouraged in newer treatment guidelines to utilize screening questionnaires and quality of life assessment tools when developing a plan of care for patients affected by a GI motility disorder. In addition to existing pharmacotherapy approaches to care, a systematic multidisciplinary approach to evaluate GI symptoms, chronicity and complexity of treatments to control symptoms, has evolved to assist primary care clinicians by clarifying important treatment questions and implementing up to date solutions for patients.

The burden of health care for patients affected by a GI motility disorder has been a major impetus in the development of multidisciplinary approaches to treatment to assist primary care providers to translate newer criteria into ways that better meet patient care needs. While this growing body of research is beyond the scope of this study, clinicians should know of newer helpful screening tools and algorithms to guide patient care. More diverse, cross-cultural influences in the treatment of a GI motility disorder that involves a growing body of research and practice guidelines have emerged. The field of neurogastroenterology has increasingly developed into multi- dimensional working committees of clinical researchers organized to develop improved therapeutic options for the wide spectrum of individuals suffering from functional gut disorders.

Summary

Gastrointestinal motility disorders comprise a complex grouping of conditions that affect the rate at which the intestinal system is able to process food and excrete waste. Motility disorders may produce mild symptoms or even no symptoms at all for some people. Alternatively, symptoms from pathologic processes that cause GI dysmotility may lead to pain and other debilitating

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 146 symptoms that can significantly decrease quality of life. Healthcare providers have many options for technological procedures that can successfully diagnose specific types of GI motility disorders. Furthermore, scientific advancements, new research developments, and proven methods of surgical intervention can all effectively assist patients who suffer with these conditions to be able to live normal and healthy lives despite having a GI motility disorder.

Clinicians are increasingly able to rely upon improved diagnostic classification systems and treatment approaches that capture a patient’s clinical profile more completely than in previous years. The burden on healthcare due to the chronicity and complexity of the nature of many GI motility disorders has been an impetus of many working groups to develop a diagnostic classification system that supports clinicians to diagnosis and treat conditions at various stages of progress. Patients with a diagnosis of IBS seen in primary care settings today may be treated quite differently according to newer practice guidelines, including greater consideration of psychological and physiological co-morbidities. The direction of future research and new clinical guidelines considers the multi-dimensional profile of patients, enabling clinicians to better identify and classify GI motility disorders than in prior years.

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nursece4less.com nursece4less.com nursece4less.com nursece4less.com 147 1. Ninety percent of absorption of nutrients occurs in the

a. stomach. b. duodenum. c. small intestine. d. large intestine.

2. True or False: The small intestine is referred to as “small” because it is the shortest segment of the GI tract.

a. True b. False

3. The junction between the small intestines and the colon is the

a. ileocecal valve. b. cecum. c. pyloric sphincter. d. duodenum.

4. When disorders of motility occur in the small intestine, the affected patient may suffer from

a. malnutrition. b. fluid and electrolyte imbalances. c. overgrowth of intestinal bacteria. d. All of the above

5. True or False: An opioid analgesic, a drug used to manage moderate-to-severe pain, may cause side effects, such as nausea, vomiting, and constipation.

a. True b. False

6. Within the gastrointestinal system, stimulation of muscarinic receptors has been shown

a. to decrease gastric acid production. b. to decrease gastrointestinal motility. c. to increase GI motility. d. slow colonic transit.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 148 7. Adults who use anticholinergic medication to control respiratory symptoms

a. may have lower levels of defecation frequency. b. may have increased colonic transit. c. may have improved gastrointestinal motility. d. will suffer from diarrhea as a side effect.

8. Intestinal neuropathy may occur as a result of

a. poorly controlled diabetes. b. Parkinson’s disease. c. spinal injury. d. All of the above

9. True or False: Carbidopa is a dopamine precursor.

a. True b. False

10. Loperamide is given to patients

a. to accelerate the rate of intestinal transit. b. as a treatment for diarrhea. c. as a treatment for constipation. d. None of the above

11. True or False: Carbidopa on its own has little to no therapeutic benefit, so it must be taken with levodopa for the patient to treat diarrhea.

a. True b. False

12. Scintigraphy is a diagnostic test that uses the following item(s):

a. radiographic isotopes. b. scrambled eggs. c. technetium or iodine. d. All of the above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 149 13. True or False: The term enteric dysmotility is used to describe motility disorders of the colon.

a. True b. False

14. Enteric dysmotility is demonstrated as abnormal contractions in the intestinal tract that typically lead to delays in the transport of food through

a. the small intestine. b. the large intestine. c. duodenum. d. anal canal.

15. In hypertensive lower esophageal sphincter,

a. there is decreased function of the excitatory nerves feeding the esophagus. b. the neurons in the esophagus work at a faster pace. c. a patient will have increased muscle contractions within the lower esophageal sphincter. d. All of the above

16. Anismus describes a condition in which the patient

a. swallows large amounts of air. b. is unable to control his pelvic floor muscles normally. c. passes stool through the anus with little to no control. d. swallowing food and then regurgitating it.

17. Hypothyroidism is associated with

a. weight loss. b. an decrease in thyroid hormone production. c. constipation. d. decreased sensitivity to cold.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 150 18. To reduce symptoms of IBS, a patient should remove or limiting FODMAP foods; FODMAP foods include

a. high fructose corn syrup. b. dairy products. c. foods containing wheat or rye. d. All of the above

19. True or False: Patients diagnosed with IBS cannot take tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs).

a. True b. False

20. If a patient increases dietary fiber intake to combat constipation, the patient should

a. increase daily fiber to 60 g per day all at once for immediate results. b. avoid insoluble fiber completely. c. increase fluid intake. d. avoid nuts and seeds.

21. Achalasia is a condition that affects how food is transitioned between the mouth and the stomach, and it typically

a. develops as an acute condition. b. develops over time. c. causes initial symptoms of mild reflux. d. Answers b., and c., above

22. Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that

a. results in poor intestinal motility. b. causes the bowel to become hyperactive. c. always involves a tumor. d. Answers b., and c., above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 151 23. Management of chronic intestinal pseudo-obstruction (CIP) is

a. palliative. b. curative. c. supportive (treat symptoms and prevent complications). d. None of the above

24. Examples of degenerative diseases that affect swallowing include

a. Huntington’s disease. b. Dementia. c. Creutzfeldt-Jakob disease. d. All of the above

25. One condition that may be more likely to develop with polymyositis is

a. chronic constipation. b. genetic predisoposition to polyp formation. c. gastroparesis. d. reflux disease.

26. Dumping syndrome is best managed with

a. changes in dietary practices. b. long-acting insulin. c. routine use of a prokinetic agent. d. Answers b., and c., above

27. Much of the peristalsis and transit of food occurs by

a. voluntary chewing action that stimulates chyme. b. involuntary control of smooth muscles in the GI tract. c. voluntary and involuntary actions. d. None of the above

28. True or False: A person with Hirschsprung’s disease has GI hypermotility.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 152 29. ______most often occurs because of motion sickness or as nausea during the first trimester of pregnancy.

a. Peristalsis b. Tachygastria c. Achalasia d. Gastroparesis

30. True or False: Too much glucose in the bloodstream damages parts of the GI system.

a. True b. False

31. Drugs that promote gastric emptying are

a. Metoclopramide (Reglan®). b. Erythromycin. c. Amitiza. d. Answers a., and b., above

32. Thyroid abnormalities may

a. later develop GI motility problems. b. have no correlation to GI motility conditions. c. cause constipation or diarrhea. d. Answers a., and c., above

33. Addison’s disease is also called

a. Cushing syndrome. b. hypocortisolism. c. hypercortisolism. d. hypothyroidism.

34. True or False: Brain-gut dysfunction describes a condition in which a patient may experience GI symptoms in response to emotions and psychological distress.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 153 35. A patient with IBS-C type may need medications that include

a. osmotic laxatives, stool softeners, and non-bulking agents. b. stool softeners and non-bulking agents. c. osmotic laxatives, stool softeners, and bulking agents. d. None of the above

36. Biofeedback helps patients with fecal incontinence and can be done with

a. manometric measures of the LES. b. an anorectral manometry procedure. c. both LES and duodenal manometry. d. Answers b., and c., above

37. Pelvic floor dysfunction affects the person’s ability to

a. pass stool regardless of transit time or stool consistency. b. pass stool due to transit time. c. pass stool due to stool dryness. d. Answers b., and c., above

38. Sarnelli, et al., in the World Journal of Gastrointestinal Pathophysiology, investigated

a. IBS. b. biliary stenosis. c. specific genes contributing to development of achalasia. d. gastroparesis.

39. A known risk factor for fecal incontinence include

a. ages 1 – 2. b. male gender. c. having a physical disability. d. nerve injuries affecting the LES.

40. True or False: Genes and familial tendencies are a large part of whether certain patients are at high risk of GI motility problems.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 154 41. Chronic megacolon may be

a. a congenital condition. b. an acquired condition because of illness. c. an acquired condition due to toxicity. d. All of the above

42. Tachygastria is a condition that causes

a. high-frequency electrical activity in the stomach with digestion. b. low frequency electrical activity in the stomach between meals. c. fainting spells. d. extreme hunger pains.

43. Rumination is a behavior disorder where a person

a. swallows food and then regurgitates it. b. thinks about food all the time. c. swallows large amounts of air and does not expel it. d. belches but does not vomit.

44. True or False: Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate.

a. True b. False

45. A person with aerophagia

a. has GERD. b. will experience increased flatulence, not belching. c. swallows large amounts of air. d. All of the above

46. True or False: Functional fecal retention is the most common behavioral disorder that causes motility problems in the large intestine, rectum, and anus.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 155 47. At an initial meeting with a patient, the nurse should question the patient about

a. symptoms, including history of pain. b. changes in stool output or toileting practices. c. feelings of pressure or bloating in the abdomen and lower pelvis. d. All of the above

48. A patient with diabetes who has uncontrolled blood glucose levels could develop neuropathy and gastroparesis to the point that the patient

a. develops high-frequency electrical activity in the stomach. b. develops low-frequency electrical activity in the stomach. c. is unable to detect the need to have a bowel movement. d. has regular, extreme hunger pains.

49. Scintigraphy is an X-ray that is performed

a. before meal consumption. b. after meal consumption. c. to help diagnose a GI motility disorder. d. Answers b., and c., above

50. True or False: Enterography is seldom done because it is more invasive than endoscopic procedures.

a. True b. False

51. A colonoscopy involves the following preparation

a. a clear liquid diet for 6 hours before the procedure. b. a clear liquid diet 1 day before the procedure. c. a clear liquid diet 3 days before the procedure. d. None of the above

52. Proctoscopy involves examination of

a. the rectum. b. the distal portion of the small bowel. c. the second portion of the small bowel to rule out inflammation. d. Answers a., and b., above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 156 53. True or False: Another name for an esophagography is the barium swallow test.

a. True b. False

54. True or False: The single-contrast technique describes application of contrast using a barium enema alone, while the double-contrast technique involves administering a barium enema and air into the large intestine.

a. True b. False

55. A drawback to capsule endoscopy is that it

a. only takes pictures of GI conditions in the bowel. b. is mostly designed to take pictures of only the large bowel. c. must be retrieved endoscopically. d. Answers b., and c., above

56. Electrodes used with EMG are often special types of ______that are placed within the muscle tissue.

a. electrodes b. needles c. calibrators d. sensors

57. Dyssynergic defecation may be defined and characterized as

a. a functional defecation disorder. b. paradoxical contractions of anal sphincter muscle. c. inability to relax the anal sphincter muscle. d. All of the above

58. Three main types of cells in the blood and CBC test are

a. white blood cells, absolute neutrophils and eosinophils. b. white blood cells, red blood cells and platelets. c. red blood cells, platelets and neutrophils. d. red blood cells, basophils and absolute neutrophils.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 157 59. Microcytic red blood cells typically develop if the patient

a. has an iron deficiency anemia. b. is suffering from a GI motility disorder. c. has hyponatremia. d. has a vitamin deficiency.

60. Hypothyroidism is a condition associated with

a. a number of GI motility problems. b. a possible drop in red blood cells. c. hyponatremia (low sodium). d. Answers a., and b., above

61. Normal platelet count in men and women is

a. 90,000 to 100,000 mm3. b. 150,000 to 450,000 mm3. c. 120,000 to 135,000 mm3. d. 60,000 to 100,000 mm3.

62. A standard stem cell is non-specific, but once it divides it can

a. take on the functions of cells in specialized areas of the body. b. no longer be of use and atrophies. c. only take on functions in the muscles. d. only take on functions in the liver and pancreas.

63. True or False: Induced pluripotent stem cells (iPSC) can create new cells that specifically focus on one area where new cells are needed most.

a. True b. False

64. Cheng, et al., published a study that worked with transplanting neural stem cells into the gut as a method of controlling

a. Crohn’s disease. b. Ulcerative colitis. c. Hirschsprung disease. d. Answers a., and b., above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 158 65. True or False: During the health assessment, the nurse should include dietary history as part of the evaluation of the patient’s GI condition.

a. True b. False

66. The BRAT diet is often employed as part of a dietary management of diarrhea

a. and it is recommended especially for children today. b. because evidence supports its efficacy. c. but its recommended use seems to be purely anecdotal. d. because it is high in protein.

67. ______have been shown to be an effective preventive measure against some types of diarrhea.

a. Antidiarrheal medications b. Probiotics c. Electrolytes d. Answer a., and c., above

68. ______can destroy some toxins that contribute to illness-causing diarrhea, among other benefits to GI motility.

a. Antibiotics b. Antidiarrheals c. Electrolytes d. Probiotics

69. True or False: The two most common types of bacteria used as part of probiotics are Lactobacillus and Bifidobacterium.

a. True b. False

70. Patients with gastroparesis that causes nausea should

a. monitor food consumption. b. chew foods carefully and thoroughly. c. eat six small meals each day. d. All of the above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 159 71. FODMAP foods, when eaten in excess, could

a. increase risk of bacterial infection. b. decrease risk of bacterial infection. c. decrease water in the digestive tract. d. None of the above

72. Activity-induced diarrhea can lead to

a. abdominal pain. b. increased urge to have a bowel movement. c. the need for rest and rehydration. d. All of the above

73. True or False: With gastroparesis, a patient is recommended to avoid even mild exercise due to GI dysmotility.

a. True b. False

74. True or False: Surgery for dysmotility is done with the goal to improve the patient’s quality of life by reducing symptoms of disease.

a. True b. False

75. Opioid receptors in the gastrointestinal tract affected by opioid medication can cause

a. increase in mucus secretions. b. decrease in fluid reabsorption. c. increased gastric emptying. d. None of the above

76. Approximately _____ percent of patients who are treated with opioids experience nausea as a side effect

a. 15 b. 25 c. 50 d. 70

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 160 77. ______are ordered concomitantly with the opioid analgesics to help maintain normal bowel habits.

a. Bowel preparations b. Purgatives c. Stool softeners d. Prokinetics

78. Antidepressant medication may be used as part of treatment for ______as well as depression.

a. irritable bowel syndrome b. inflammatory bowel disease c. diabetic gastroparesis d. None of the above

79. An upper endoscopy or EGD may be used

a. to insert biopsy forceps. b. to narrow down the cause of the motility issues. c. to look for inflammation in the gastrointestinal tract. d. All of the above

80. True or False: Endoscopy is a valuable process that helps to visualize the internal segments of the GI tract to better pinpoint a diagnosis when GI motility problems are present.

a. True b. False

81. Predominant forms of IBS are known as

a. IBS-C (IBS with constipation) or IBS-D (IBS with diarrhea). b. Irritable bowel syndrome or inflammatory bowel disease. c. IBS-S (IBS with fatty stools) or IBS-U (IBS untyped). d. IBS or IBS with brain-gut dysfunction.

82. A patient with dysphagia may be recommended the following to facilitate easier swallowing

a. thin liquids. b. thickening liquids. c. solid foods only. d. None of the above nursece4less.com nursece4less.com nursece4less.com nursece4less.com 161 83. Dysphagia can develop as a consequence of conditions, such as

a. stroke. b. carcinoma. c. degenerative disorders. d. All of the above

84. Choung, et al., reported the most common symptom experienced by participants using antidepressants was

a. diarrhea. b. constipation. c. abdominal bloating/distention. d. both diarrhea and constipation.

85. True or False: Two main types of cholinergic receptors in the body are nicotinic and muscarinic receptors.

a. True b. False

86. A study of older adults with chronic obstructive pulmonary disease (COPD) who used muscle relaxant medications also showed

a. higher levels of defecation frequency. b. lower levels of defecation frequency. c. constipation. d. Both b., and c., above

87. Loperamide works by ______gut motility to slow down the rate of intestinal transit and reduce diarrhea.

a. increasing b. both increasing and decreasing c. decreasing d. eliminating

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 162 88. Certain drugs used to manage Parkinson’s disease have been shown to affect GI motility, typically within the stomach, causing

a. tachygastria. b. delayed gastric emptying. c. globus. d. Both a., and c., above

89. ______cannot be administered to patients with Parkinson’s disease (PD) because it cannot cross the blood- brain barrier.

a. Dopamine b. Levodopa c. Reglan d. Both b., and c., above

90. True or False: Antidiarrheals are available only in prescription strength.

a. True b. False

91. Antibiotics are administered for infection

a. with Clostridium difficile. b. that is prolonged due to Escherichia coli bacteria. c. with Salmonella infection in very young children. d. All of the above

92. Examples of antibiotics that may be prescribed for the management of infectious diarrhea include

a. cefotaxime. b. vancomycin. c. augmentin. d. Both a., and b., above

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 163 93. ______is a broad-spectrum antiparasitic medication.

a. Furazolidone (Furoxone®) b. Augmentin c. Erythromycin d. Ampicillin

94. True or False: Psyllium or methylcellulose is given to treat diarrhea by causing the colon to retain more fluid, thereby preventing diarrhea.

a. True b. False

95. Nausea and vomiting are common symptoms most frequently seen with GI dysmotility conditions such as

a. gastroparesis. b. intestinal pseudo-obstruction. c. dumping syndrome. d. All of the above

96. Antiemetics can ______messages to the brain that stimulate the sense of nausea.

a. block b. send c. facilitate d. mimic

97. Antiemetics may be administered as

a. rectal suppositories. b. transdermal patches. c. intramuscular/intravenous injections. d. All of the above

98. True or False: Cholinergic agonists are drugs that act in a manner opposite to the neurotransmitter acetylcholine.

a. True b. False

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 164 99. Prokinetic medications can be administered to ______the speed of GI motility.

a. decrease b. moderate c. increase d. impair

100. ______is a growing medical field with working committees to develop improved algorithms to diagnose and treat GI motility disorders.

a. Gastroenterology b. Neuropsychiatry c. Neurogastroenterology d. Neurology

CORRECT ANSWERS:

1. Ninety percent of absorption of nutrients occurs in the

c. small intestine.

“Absorption occurs because of the microscopic projections on the surface of the small intestine; these projections, known as villi, are located on the mucosal surface and are where absorption takes place. Ninety percent of absorption occurs in the small intestine along its full length.”

2. True or False: The small intestine is referred to as “small” because it is the shortest segment of the GI tract.

b. False

“Although it is referred to as ‘small,’ the small intestine is actually the longest segment of the GI tract. Its description as being small refers to its diameter, which is less than that of the nearby colon.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 165 3. The junction between the small intestines and the colon is the

a. ileocecal valve.

“The ascending colon is connected to the small intestine at the ileocecal valve and is located on the right side of the body; undigested material travels through this portion of the colon first.”

4. When disorders of motility occur in the small intestine, the affected patient may suffer from

a. malnutrition. b. fluid and electrolyte imbalances. c. overgrowth of intestinal bacteria. d. All of the above [correct answer]

“Because the small intestine is responsible for much of the absorption that takes place in the GI tract, when motility disorders occur, the affected patient may then suffer consequences associated with malabsorption, including malnutrition, fluid and electrolyte imbalances, and overgrowth of intestinal bacteria.”

5. True or False: An opioid analgesic, a drug used to manage moderate-to-severe pain, may cause side effects, such as nausea, vomiting, and constipation.

a. True

“Taken for pain and used widely in all manner of settings, including outpatient treatment centers, in-hospital intravenous administration, or home prescription use, opioids are often responsible for keeping patients comfortable and managing moderate-to-severe pain from procedures and from the complications of illness ... Because of the increase in use of opioids within healthcare facilities and within the community, patients are also experiencing an increase in their side effects. Opioid medications have been known to ... produce gastrointestinal side effects, typically including nausea, vomiting, and constipation.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 166 6. Within the gastrointestinal system, stimulation of muscarinic receptors has been shown

c. to increase GI motility.

“Within the gastrointestinal system, stimulation of muscarinic receptors has been shown to increase GI motility and to potentially cause nausea and vomiting.”

7. Adults who use anticholinergic medication to control respiratory symptoms

a. may have lower levels of defecation frequency.

“The study showed that those adults who used the drugs to control respiratory symptoms also had lower levels of defecation frequency and were more likely to suffer from constipation and slowed colonic transit.”

8. Intestinal neuropathy may occur as a result of

a. poorly controlled diabetes. b. Parkinson’s disease. c. spinal injury. d. All of the above [correct answer]

“There are a number of systemic conditions that can cause enteric dysmotility within this section of the GI tract. Some examples include intestinal neuropathy, as with what occurs through poorly controlled diabetes, as well as Parkinson’s disease, scleroderma, and spinal injury.”

9. True or False: Carbidopa is a dopamine precursor.

b. False

“The introduction of carbidopa, another medication used to enhance the effects of levodopa, results in a much lower dose requirement of levodopa when the two drugs are taken together.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 167 10. Loperamide is given to patients

b. as a treatment for diarrhea.

“Some common types of antidiarrheal medications that are available without a prescription include loperamide ... In addition to controlling diarrhea, these drugs can also help to manage other unpleasant symptoms the patient may be experiencing as a result of the illness.”

11. True or False: Carbidopa on its own has little to no therapeutic benefit, so it must be taken with levodopa for the patient to treat diarrhea.

a. True

“Carbidopa on its own has little to no therapeutic benefit, so it must be taken with levodopa for the patient to gain positive effects. Sinemet® is an example of a drug that is a combination of levodopa and carbidopa.”

12. Scintigraphy is a diagnostic test that uses the following item(s):

a. radiographic isotopes. b. scrambled eggs. c. technetium or iodine. d. All of the above [correct answer]

“Scintigraphy utilizes radiographic isotopes that are transferred into the gastrointestinal tract to assess a patient’s motility and gastric emptying time. The patient eats a meal, typically scrambled eggs, which contain the isotopes needed for the study; the most common isotopes used are technetium and iodine.”

13. True or False: The term enteric dysmotility is used to describe motility disorders of the colon.

b. False

“The term enteric dysmotility is used to describe motility disorders of the small intestine.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 168 14. Enteric dysmotility is demonstrated as abnormal contractions in the intestinal tract that typically lead to delays in the transport of food through

a. the small intestine.

“The term enteric dysmotility is used to describe motility disorders of the small intestine.”

15. In hypertensive lower esophageal sphincter,

c. a patient will have increased muscle contractions within the lower esophageal sphincter.

“An example of a questionable entity associated with the esophagus is increased pressure found within the lower esophageal sphincter. The condition may be referred to as hypertensive LES, ... hypertensive LES occurs when there are changes to the nerves affecting the esophagus. In this case, there is increased function of the excitatory nerves feeding the esophagus, such that the neurons are working at a faster pace and are causing increased muscle contractions within the LES.”

16. Anismus describes a condition in which the patient

b. is unable to control his pelvic floor muscles normally.

“Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate.”

17. Hypothyroidism is associated with

c. constipation.

“Hypothyroidism is associated with slowing of many metabolic processes, and affected patients often struggle with symptoms of weight gain, fatigue, muscle and joint pain, depression, and increased sensitivity to cold. One of the most common GI complaints among patients with hypothyroidism is constipation ...”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 169 18. To reduce symptoms of IBS, a patient should remove or limiting FODMAP foods; FODMAP foods include

a. high fructose corn syrup. b. dairy products. c. foods containing wheat or rye. d. All of the above [correct answer]

“Certain foods have been organized into a descriptive classification known as FODMAP: ... Examples of these types of foods include those with high fructose corn syrup, dairy products, foods containing wheat or rye, beans and legumes, honey; and those containing certain sweeteners, such as xylitol, sorbitol, and isomalt.”

19. True or False: Patients diagnosed with IBS cannot take tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs).

b. False

“Antidepressants can cause a number of gastrointestinal side effects. Patients with IBS who take antidepressants, as part of treatment for IBS, should also be aware of the potential side effects associated with these drugs.”

20. If a patient increases dietary fiber intake to combat constipation, the patient should

c. increase fluid intake.

“As a patient increases dietary fiber intake, he or she should be counseled to increase fluid intake accordingly.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 170 21. Achalasia is a condition that affects how food is transitioned between the mouth and the stomach, and it typically

a. develops as an acute condition. b. develops over time. c. causes initial symptoms of mild reflux. d. Answers b., and c., above [correct answer]

“Achalasia typically does not develop all at once; instead, symptoms progressively worsen over time as the patient loses more ability to drink liquids and to eat solid food. The condition may initially cause symptoms of mild reflux that can eventually develop into severe pain any time that the individual tries to eat.”

22. Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that

a. results in poor intestinal motility.

“Chronic intestinal pseudo-obstruction (CIP) develops as a disorder that results in poor intestinal motility.”

23. Management of chronic intestinal pseudo-obstruction (CIP) is

c. supportive (treat symptoms and prevent complications).

“Management of CIP is usually not curative and the best approach is to treat the patient’s symptoms and to prevent complications, such as malnutrition or dehydration that may develop from the condition.”

24. Examples of degenerative diseases that affect swallowing include

a. Huntington’s disease. b. Dementia. c. Creutzfeldt-Jakob disease. d. All of the above [correct answer]

“Examples of degenerative diseases that affect neurological function and swallowing include such conditions as Huntington’s disease, dementia, or Creutzfeldt-Jakob disease.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 171 25. One condition that may be more likely to develop with polymyositis is

c. gastroparesis.

“One condition that may be more likely to develop with polymyositis is delayed gastric emptying, also called gastroparesis, which occurs when food moves too slowly from the stomach and into the small intestine.”

26. Dumping syndrome is best managed with

a. changes in dietary practices.

“Dumping syndrome is best managed with changes in dietary practices, including avoiding anything that would overstimulate the muscles of the stomach and cause it to contract too quickly.”

27. Much of the peristalsis and transit of food occurs by

b. involuntary control of smooth muscles in the GI tract.

“While some of the gastrointestinal tract utilizes the work of voluntary muscles, much of the peristalsis and transit of food and chyme is done through involuntary control of the smooth muscles lining the GI tract.”

28. True or False: A person with Hirschsprung’s disease has GI hypermotility.

b. False

“... patients with Hirschsprung’s disease are at risk of intestinal infection because of poor motility.”

29. ______most often occurs because of motion sickness or as nausea during the first trimester of pregnancy.

b. Tachygastria

“Tachygastria is a condition that causes high-frequency electrical activity within the stomach during digestion. The condition most often occurs because of motion sickness or as nausea during the first trimester of pregnancy.” nursece4less.com nursece4less.com nursece4less.com nursece4less.com 172 30. True or False: Too much glucose in the bloodstream damages parts of the GI system.

a. True

“... too much glucose in the bloodstream that circulates without being used for energy damages parts of the GI system, including the nerves that serve the intestinal tract, which may lead to severe GI motility disturbances.”

31. Drugs that promote gastric emptying are

a. Metoclopramide (Reglan®). b. Erythromycin. c. Amitiza. d. Answers a., and b., above [correct answer]

“Additionally, some prescription antiemetics work by increasing gut motility to speed up the rate that food moves through the intestine. Metoclopramide (Reglan®) is an example of this type of drug.... Erythromycin has been shown to accelerate the rate of gastric emptying in patients who suffer from gastroparesis in which they otherwise experience delayed gastric motility.”

32. Thyroid abnormalities may

a. later develop GI motility problems. b. have no correlation to GI motility conditions. c. cause constipation or diarrhea. d. Answers a., and c., above [correct answer]

“A commonly seen gastrointestinal motility disorder associated with hyperthyroidism is diarrhea, as the transit times in the intestine are increased due to the effects of the hormones.... One of the most common GI complaints among patients with hypothyroidism is constipation, as colonic motility slows with a decrease in thyroid hormone production.... Patients who suffer from thyroid abnormalities may not initially develop gastrointestinal motility problems. These difficulties may occur later in the course of thyroid disease, particularly when there is poor control over thyroid hormone secretion and poor management of thyroid disease.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 173 33. Addison’s disease is also called

b. hypocortisolism.

“Addison’s disease is most often caused by an autoimmune disorder in which the body attacks its own tissues and causes the adrenal glands to work inappropriately. Eventually, the damage from the autoimmune system destroys the adrenal cortex, which is the outer protective covering to the adrenal glands. The patient is no longer able to secrete sufficient amounts of cortisol and aldosterone needed to regulate various body functions, including weight control, the ability to fight infection, and control of heart rate and blood pressure. For this reason, Addison’s disease is also known as hypocortisolism.”

34. True or False: Brain-gut dysfunction describes a condition in which a patient may experience GI symptoms in response to emotions and psychological distress.

a. True

“Brain-gut dysfunction describes a condition in which a patient may experience gastrointestinal symptoms in response to emotions and psychological distress.”

35. A patient with IBS-C type may need medications that include

c. osmotic laxatives, stool softeners, and bulking agents.

“... a patient who struggles with IBS-C type may need medications and diet therapy that manages and prevents hard stools from forming, such as osmotic laxatives, stool softeners, and bulking agents.”

36. Biofeedback helps patients with fecal incontinence and can be done with

b. an anorectral manometry procedure.

“Biofeedback is a second method of controlling fecal incontinence. With biofeedback, the patient learns to consciously contract the muscles of the rectum that control defecation. The healthcare provider may perform biofeedback during a procedure known as anorectal manometry,...” nursece4less.com nursece4less.com nursece4less.com nursece4less.com 174 37. Pelvic floor dysfunction affects the person’s ability to

a. pass stool regardless of transit time or stool consistency.

“Pelvic floor dysfunction ... affects the person’s ability to pass stool at all, regardless of transit time or stool consistency.”

38. Sarnelli, et al., in the World Journal of Gastrointestinal Pathophysiology, investigated

c. specific genes contributing to development of achalasia.

“Sarnelli, et al., in their work published in the World Journal of Gastrointestinal Pathophysiology, investigated specific genes that may contribute to the development of achalasia among certain patients.”

39. A known risk factor for fecal incontinence include

c. having a physical disability.

“Known risk factors for fecal incontinence include advancing age, female gender, physical disabilities, and injury to the nerves affecting the anal sphincter, such as through childbirth.”

40. True or False: Genes and familial tendencies are a large part of whether certain patients are at high risk of GI motility problems.

a. True

“In some cases, genetic factors do not play a role in whether a patient will develop symptoms of a disorder; alternatively, genes and familial tendencies are a large part of whether certain patients are at high risk of GI motility problems.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 175 41. Chronic megacolon may be

a. a congenital condition. b. an acquired condition because of illness. c. an acquired condition due to toxicity. d. All of the above [correct answer]

“Chronic megacolon may be used as a term to describe the condition when it is congenital, although it can be later acquired because of illness or toxicity.”

42. Tachygastria is a condition that causes

a. high-frequency electrical activity in the stomach with digestion.

“Tachygastria is a condition that causes high-frequency electrical activity within the stomach during digestion.”

43. Rumination is a behavior disorder where a person

a. swallows food and then regurgitates it.

“Rumination refers to swallowing food and then regurgitating it; the patient may then repeatedly swallow the food or may vomit it.”

44. True or False: Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate.

a. True

“Anismus is a condition in which the patient is unable to control pelvic floor muscles normally in order to defecate.”

45. A person with aerophagia

c. swallows large amounts of air.

“Aerophagia is a rare type of disorder in which a person swallows large amounts of air. The air passes through the esophagus and enters the stomach but is then regurgitated, causing frequent belching.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 176 46. True or False: Functional fecal retention is the most common behavioral disorder that causes motility problems in the large intestine, rectum, and anus.

a. True

“... the purposeful holding of stool within the body leads to constipation when excess fluid is absorbed from feces held in the rectum ... The clinical entity in these situations is known as functional fecal retention; it is the most common behavioral disorder that causes motility problems in the large intestine, rectum, and anus.”

47. At an initial meeting with a patient, the nurse should question the patient about

a. symptoms, including history of pain. b. changes in stool output or toileting practices. c. feelings of pressure or bloating in the abdomen and lower pelvis. d. All of the above [correct answer]

“Upon the initial meeting, the patient may present with symptoms that vary according to the disorder present. Because the patient most likely will not know the cause of his or her symptoms upon arrival, it is up to the healthcare provider to make a diagnosis based on the information presented. The nurse should ask questions that focus not only on symptoms affecting the GI system, but also other symptoms that may be impacting different areas of the body. Starting with the GI system, the nurse should question the patient about symptoms, including history of pain, changes in stool output, feelings of pressure or bloating in the abdomen and lower pelvis, and any changes in toileting practices.”

48. A patient with diabetes who has uncontrolled blood glucose levels could develop neuropathy and gastroparesis to the point that the patient

c. is unable to detect the need to have a bowel movement.

“... a patient with diabetes who has uncontrolled blood glucose levels could develop neuropathy and gastroparesis to the point that he or she is unable to detect the need to have a bowel movement.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 177 49. Scintigraphy is an X-ray that is performed

a. before meal consumption. b. after meal consumption. c. to help diagnose a GI motility disorder. d. Answers b., and c., above [correct answer]

“Scintigraphy utilizes radiographic isotopes that are transferred into the gastrointestinal tract to assess a patient’s motility and gastric emptying time. The patient eats a meal, typically scrambled eggs, which contain the isotopes needed for the study; the most common isotopes used are technetium and iodine. After consuming the meal, the images are taken to detect the food as it passes through the patient’s GI tract.”

50. True or False: Enterography is seldom done because it is more invasive than endoscopic procedures.

b. False

“Enterography is beneficial because it is less invasive than endoscopic procedures ... Because of the non-invasive process involved with this type of study, and that it is sensitive enough to pick up changes in GI motility, enterography is a viable option for diagnostic treatment among patients who are suffering GI motility disturbances.”

51. A colonoscopy involves the following preparation

b. a clear liquid diet 1 day before the procedure.

“The colonoscopy is often used as a cancer screening tool [and] it may also be utilized to assess for potential obstructions in the large intestine, the presence of inflammation or polyps, bleeding, diverticulosis, or whenever the patient is suffering symptoms and is experiencing a change in bowel habits ... Prior to the procedure, the patient must undergo a bowel cleanse as preparation in order to remove any fecal matter in the intestine. This often requires a clear liquid diet for one day before the procedure and administration of a laxative that will empty the colon.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 178 52. Proctoscopy involves examination of

a. the rectum.

“Proctoscopy involves examination of the rectum. The process is similar to that of a colonoscopy or anoscopy in that the physician inserts a scope into the patient’s anus and advances it to the rectum to visualize the internal structures of this portion of the colon.”

53. True or False: Another name for an esophagography is the barium swallow test.

a. True

“The barium swallow is actually called an esophagography. It is referred to in simpler terms as a barium swallow because the patient actually drinks barium contrast that has been prepared as a mixture.”

54. True or False: The single-contrast technique describes application of contrast using a barium enema alone, while the double-contrast technique involves administering a barium enema and air into the large intestine.

a. True

“The single-contrast technique describes application of contrast through administration of barium enema alone, while the double- contrast technique involves administration of a barium enema and air into the large intestine.”

55. A drawback to capsule endoscopy is that it

a. only takes pictures of GI conditions in the bowel.

“A drawback to capsule endoscopy is that if it detects a problem within the gastrointestinal tract, it only takes pictures of it with the camera; the healthcare provider must still follow up with further testing to diagnose a condition or to obtain tissue samples.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 179 56. Electrodes used with EMG are often special types of ______that are placed within the muscle tissue.

b. needles

“Contrary to the surface electrodes used as part of cardiac testing, electrodes used with EMG are often special types of needles that are placed within the muscle tissue.”

57. Dyssynergic defecation may be defined and characterized as

a. a functional defecation disorder. b. paradoxical contractions of anal sphincter muscle. c. inability to relax the anal sphincter muscle. d. All of the above [correct answer]

“... dyssynergic defecation ... is defined as a functional defecation disorder characterized by impaired pushing forces, paradoxical contractions, or an inability to relax the anal sphincter muscle.”

58. Three main types of cells in the blood and CBC test are

b. white blood cells, red blood cells and platelets.

“There are three main types of cells found in the blood and the CBC components test the amounts of each of these cells. The main cell types are white blood cells, red blood cells, and platelets.”

59. Microcytic red blood cells typically develop if the patient

a. has an iron deficiency anemia.

“If the red blood cells are too large, they are considered macrocytic; this condition could occur because of certain vitamin deficiencies or with hypothyroidism. Alternatively, microcytic cells refer to those red blood cells that have an MCV result that is smaller than normal. Microcytic red blood cells typically develop if the patient is suffering from iron deficiency anemia.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 180 60. Hypothyroidism is a condition associated with

a. a number of GI motility problems. b. a possible drop in red blood cells. c. hyponatremia (low sodium). d. Answers a., and b., above [correct answer]

“Hypothyroidism, which is associated with a number of gastrointestinal motility problems, including constipation and malabsorption, can also lead to a drop in red blood cells and some kinds of anemia. Low thyroid levels can impact iron absorption, which could result in iron deficiency anemia. This could potentially create a negative cycle in which the intestines receive even less oxygenated blood than what they need when red blood cells and hemoglobin are lacking; which could then further perpetuate motility problems if the intestinal tract is not adequately oxygenated through circulation.”

61. Normal platelet count in men and women is

b. 150,000 to 450,000 mm3.

“A normal platelet count is 150,000 to 450,000 mm3 among men and women.”

62. A standard stem cell is non-specific, but once it divides it can

a. take on the functions of cells in specialized areas of the body.

“On its own, a standard stem cell is non-specific; however, once it divides, it can take on the functions of cells in specialized areas of the body, including in the brain, the muscles, and the gastrointestinal tract.”

63. True or False: Induced pluripotent stem cells (iPSC) can create new cells that specifically focus on one area where new cells are needed most.

a. True

“... iPSC bodies can be directed to create new cells that specifically focus on one area where new cells are needed most, such as by creating new neurons to work in the GI tract when these cells have been damaged.” nursece4less.com nursece4less.com nursece4less.com nursece4less.com 181 64. Cheng, et al., published a study that worked with transplanting neural stem cells into the gut as a method of controlling

c. Hirschsprung disease.

“A study by Cheng, et al., in the journal Neurogastroenterology & Motility, worked with transplanting neural stem cells into the gut as a method of controlling Hirschsprung disease.”

65. True or False: During the health assessment, the nurse should include dietary history as part of the evaluation of the patient’s GI condition.

a. True

“During the health assessment, the nurse should include dietary history as part of the evaluation of the patient’s condition, as diet contributes significantly to the cause of many GI dysfunction symptoms.”

66. The BRAT diet is often employed as part of a dietary management of diarrhea

c. but its recommended use seems to be purely anecdotal.

“The BRAT diet, while often employed as part of dietary management of diarrhea, is not necessarily effective in managing symptoms of diarrhea in patients with GI motility disorders.... there is no evidence that states that this diet is effective in preventing diarrhea, and its recommended use seems to be purely anecdotal.”

67. ______have been shown to be an effective preventive measure against some types of diarrhea.

b. Probiotics

“Probiotics have been shown to be an effective preventive measure against some types of diarrhea and they may be incorporated into the patient’s diet through food intake that contain the bacteria or through specially designed supplements.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 182 68. ______can destroy some toxins that contribute to illness-causing diarrhea, among other benefits to GI motility.

d. Probiotics

“Probiotics are microorganisms that support growth of healthy bacteria in the GI tract. They are effective in that, after ingestion, probiotics can destroy some toxins that contribute to illness-causing diarrhea, prevent harmful bacteria from infecting the gastrointestinal tract, stimulate increased mucus production in the intestinal tract, may help to decrease GI inflammation, and diminish the effects of gas and bloating.”

69. True or False: The two most common types of bacteria used as part of probiotics are Lactobacillus and Bifidobacterium.

a. True

“The two most common types of bacteria used as part of probiotics are Lactobacillus and Bifidobacterium.”

70. Patients with gastroparesis that causes nausea should

a. monitor food consumption. b. chew foods carefully and thoroughly. c. eat six small meals each day. d. All of the above [correct answer]

“For the patient suffering from gastroparesis that causes nausea, there are several dietary suggestions that may help. The patient should be advised to monitor food consumption, not only in the kinds of foods eaten, but also how food is eaten. The patient should be advised to chew foods carefully and thoroughly and to avoid taking large bites or swallowing pieces of food whole. Instead of eating three large meals a day, the patient would more likely benefit from six small meals each day, which can prevent stomach distention.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 183 71. FODMAP foods, when eaten in excess, could

a. increase risk of bacterial infection.

“Certain foods have been organized into a descriptive classification known as FODMAP: ... These foods, when eaten in excess, could increase the risk of bacterial infection ...”

72. Activity-induced diarrhea can lead to

a. abdominal pain. b. increased urge to have a bowel movement. c. the need for rest and rehydration. d. All of the above [correct answer]

“Some people struggle with activity-induced diarrhea when they exercise and then experience abdominal pain and an increased urge to have a bowel movement. When a patient is suffering from diarrhea, rest and rehydration are typically recommended to cope with the situation, rather than encouraging an increase in activity levels.”

73. True or False: With gastroparesis, a patient is recommended to avoid even mild exercise due to GI dysmotility.

b. False

“In the case of gastroparesis, a patient may benefit from mild exercise to help improve GI motility; recommendations associated with eating and activity levels in this situation often advise taking a walk after eating to avoid lying down and to promote gastric emptying of stomach contents.”

74. True or False: Surgery for dysmotility is done with the goal to improve the patient’s quality of life by reducing symptoms of disease.

a. True

“As with other types of surgical intervention for dysmotility, surgery may initially cause discomfort because of the procedure, but the ultimate goal is to improve the patient’s quality of life by reducing symptoms of disease and extending the patient’s life that may otherwise be shortened because of his or her condition.” nursece4less.com nursece4less.com nursece4less.com nursece4less.com 184 75. Opioid receptors in the gastrointestinal tract affected by opioid medication can cause

a. increase in mucus secretions. b. decrease in fluid reabsorption. c. increased gastric emptying. d. None of the above [correct answer]

“There are many opioid receptors in the gastrointestinal tract. When opioids are administered, they can affect these receptors and cause changes, including a decrease in mucus secretions, an increase in fluid reabsorption, and delayed gastric emptying.”

76. Approximately _____ percent of patients who are treated with opioids experience nausea as a side effect

b. 25

“Approximately 25 percent of patients who are treated with opioids experience nausea as a side effect.”

77. ______are ordered concomitantly with the opioid analgesics to help maintain normal bowel habits.

c. Stool softeners

“For many patients, stool softeners are ordered concomitantly with the opioid analgesics to help maintain normal bowel habits.”

78. Antidepressant medication may be used as part of treatment for ______as well as depression.

a. irritable bowel syndrome

“Since serotonin receptors are present in the GI tract and associated with pain from rectal distention, i.e., as occurs with irritable bowel syndrome (IBS), antidepressants are used as part of treatment for IBS, as well as depression. In fact, antidepressant prescription is part of routine management of irritable bowel syndrome. This may be because of the effects of these medications on serotonin in the GI tract; however, it could also be due to the psychological symptoms associated with IBS.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 185 79. An upper endoscopy or EGD may be used

a. to insert biopsy forceps. b. to narrow down the cause of the motility issues. c. to look for inflammation in the gastrointestinal tract. d. All of the above [correct answer]

“Upper endoscopy, also called esophagogastroduodenoscopy or EGD, involves insertion of a tube into the patient’s mouth and then advancing it down the esophagus.... The test is beneficial to look for conditions that may be causing the patient’s symptoms of pain, nausea, or vomiting, which may or may not be related to GI motility problems. It may also be done to rule out another condition and narrow down the cause of the motility issues. The upper endoscopy is more accurate than traditional X-rays when looking for certain issues within the gastrointestinal tract, such as inflammation. The endoscope can also be used to insert biopsy forceps through the channel to remove small tissue samples from the GI tract if the endoscopist determines it is necessary to perform a tissue pathology test.”

80. True or False: Endoscopy is a valuable process that helps to visualize the internal segments of the GI tract to better pinpoint a diagnosis when GI motility problems are present.

a. True

“... endoscopy is a valuable process that helps the endoscopist to visualize the internal segments of the GI tract, which can better pinpoint a diagnosis when GI motility problems are present.”

81. Predominant forms of IBS are known as

a. IBS-C (IBS with constipation) or IBS-D (IBS with diarrhea).

“Irritable bowel syndrome can cause symptoms that predominantly involve diarrhea or constipation, although some patients suffer from both. It is classified according to the predominant forms of stool that occur with symptoms, and may be considered IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), IBS mixed (IBS- M), or IBS unsubtyped (IBS-U) in which the stool consistency does not meet the criteria for the other forms of the condition.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 186 82. A patient with dysphagia may be recommended the following to facilitate easier swallowing

b. thickening liquids.

“The healthcare provider who works with a patient with dysphagia may provide some interventions that would facilitate easier swallowing. As mentioned, this may involve thickening liquids and otherwise modifying food textures and consistencies.”

83. Dysphagia can develop as a consequence of conditions, such as

a. stroke. b. carcinoma. c. degenerative disorders. d. All of the above [correct answer]

“Dysphagia can develop as a consequence of a number of conditions, including physical disabilities, stroke, and carcinoma, and, it may also develop because of difficulties related to certain types of degenerative disorders.”

84. Choung, et al., reported the most common symptom experienced by participants using antidepressants was

c. abdominal bloating/distention.

“A study by Choung, et al., in the journal Neurogastroenterology & Motility, used questionnaires to examine patient responses to discern the effects of antidepressant use on the gastrointestinal system. The most common symptom reported by participants in the study was abdominal bloating and distention.”

85. True or False: Two main types of cholinergic receptors in the body are nicotinic and muscarinic receptors.

a. True

“There are two main types of cholinergic receptors in the body: nicotinic and muscarinic receptors.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 187 86. A study of older adults with chronic obstructive pulmonary disease (COPD) who used muscle relaxant medications also showed

a. higher levels of defecation frequency. b. lower levels of defecation frequency. c. constipation. d. Both b., and c., above [correct answer]

“A study in the journal BMC Geriatrics investigated defecation frequency among older adults with chronic obstructive pulmonary disease who used muscle relaxant medications to control some of their respiratory symptoms. The study showed that those adults who used the drugs to control respiratory symptoms also had lower levels of defecation frequency and were more likely to suffer from constipation and slowed colonic transit.”

87. Loperamide works by ______gut motility to slow down the rate of intestinal transit and reduce diarrhea.

c. decreasing

“Loperamide works by decreasing gut motility to slow down the rate of intestinal transit so that the affected person is less likely to suffer from diarrhea.”

88. Certain drugs used to manage Parkinson’s disease have been shown to affect GI motility, typically within the stomach, causing

b. delayed gastric emptying.

“Certain drugs used for management of disorders such as Parkinson’s disease have been shown to affect gastrointestinal motility, typically within the stomach, causing delayed gastric emptying.

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 188 89. ______cannot be administered to patients with Parkinson’s disease (PD) because it cannot cross the blood- brain barrier.

a. Dopamine

“Dopamine cannot be administered to patients with PD because dopamine cannot cross the blood-brain barrier.”

90. True or False: Antidiarrheals are available only in prescription strength.

b. False

“Antidiarrheals are available in prescription strength but they can be purchased over the counter as well.”

91. Antibiotics are administered for infection

a. with Clostridium difficile. b. that is prolonged due to Escherichia coli bacteria. c. with Salmonella infection in very young children. d. All of the above [correct answer]

“However, there are some cases in which a patient who suffers from prolonged diarrhea because of a specific type of infection would benefit from the administration of antibiotics, including infection with Clostridium difficile, prolonged infection with Escherichia coli bacteria, and Salmonella infection in very young children.”

92. Examples of antibiotics that may be prescribed for the management of infectious diarrhea include

a. cefotaxime. b. vancomycin. c. augmentin. d. Both a., and b., above [correct answer]

“Examples of antibiotics that may be prescribed for the management of infectious diarrhea include cefotaxime (Claforan®), vancomycin, and erythromycin.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 189 93. ______is a broad-spectrum antiparasitic medication.

a. Furazolidone (Furoxone®)

“Antiparasitic drugs may target certain species or they may be broad-spectrum types that provide coverage against any number of parasitic organisms. An example of this type of drug is furazolidone (Furoxone®).”

94. True or False: Psyllium or methylcellulose is given to treat diarrhea by causing the colon to retain more fluid, thereby preventing diarrhea.

b. False

“Bulk-forming laxatives prevent and treat constipation, and are typically made up of products such as psyllium or methylcellulose...”

95. Nausea and vomiting are common symptoms most frequently seen with GI dysmotility conditions such as

a. gastroparesis. b. intestinal pseudo-obstruction. c. dumping syndrome. d. All of the above [correct answer]

“Nausea and vomiting can develop as significant symptoms from GI motility disorders. These two common symptoms are most frequently seen with GI dysmotility conditions such as gastroparesis, intestinal pseudo-obstruction, and dumping syndrome.”

96. Antiemetics can ______messages to the brain that stimulate the sense of nausea.

a. block

“Prescription antiemetics may work in a manner similar to non- prescription drugs in that they can block messages to the brain that stimulate the sense of nausea.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 190 97. Antiemetics may be administered as

a. rectal suppositories. b. transdermal patches. c. intramuscular/intravenous injections. d. All of the above [correct answer]

“In addition to oral preparations, antiemetics may be administered as rectal suppositories, transdermal patches, intramuscular injections, or as intravenous injections.”

98. True or False: Cholinergic agonists are drugs that act in a manner opposite to the neurotransmitter acetylcholine.

b. False

“Cholinergic agonists are drugs that act in a manner similar to the neurotransmitter acetylcholine.”

99. Prokinetic medications can be administered to ______the speed of GI motility.

c. increase

“Prokinetic medications can be administered to increase the speed of GI motility to move food through the intestinal tract at a faster rate.”

100. ______is a growing medical field with working committees to develop improved algorithms to diagnose and treat GI motility disorders.

c. Neurogastroenterology

“The field of neurogastroenterology has increasingly developed into multi-dimensional working committees of clinical researchers organized to develop improved therapeutic options for the wide spectrum of individuals suffering from functional gut disorders.”

nursece4less.com nursece4less.com nursece4less.com nursece4less.com 191 References

The reference section of in-text citations include published works intended as helpful material for further reading.

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