Gastroenterologydistribution NOT for SALE OR DISTRIBUTION

SECTION V © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR GastroenterologyDISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Constipation 1,2,3,4 © Jones & Bartlett Learning, LLC Definition © Jones & Bartlett Learning, LLC Constipation is a disturbance in bowel function, characterized by NOT FOR SALE OR DISTRIBUTIONinfrequent or difficult defecation.NOT FOR SALE OR DISTRIBUTION

Causes1 ,2,3,5,6,7 • Functional disorders • Normal colonic transit, slow transit constipation, © Jones & Bartlettdyssynergic Learning,defecation (e.g., LLC anismus or pelvic fl oor © Jones & Bartlett Learning, LLC NOT FOR SALEdysfunction) OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Medications • Opioids, anticholinergics, calcium channel blockers, iron supplementation, antacids • Neurological disorders © Jones & Bartlett Learning,• Parkinson’s LLC disease, multiple sclerosis, spinal© Jones cord injury, & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONdementia NOT FOR SALE OR DISTRIBUTION • Metabolic disorders • Hypothyroid, diabetes, hypercalcemia • Blockages of the colon • Colon cancer, stricture or narrowing • Mood-related disorders © Jones & Bartlett Learning, LLC • Depression, anxiety © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Risk Factors1 ,2,3,6,7 Risk factors of constipation coincide with causes, • Advanced age • Female sex © Jones &• Bartlett More than twiceLearning, as common LLC than men © Jones & Bartlett Learning, LLC NOT FOR• Reduced SALE mobilityOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Low-fluid intake

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Gastroenterology

© Jones & Bartlett Learning,• Low-fiber LLCdiet © Jones & Bartlett Learning, LLC • Low socioeconomic status NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Signs & Symptoms1,2,3,4,6 • Have ≤ three stools/week. • Rectal fullness or feeling of inadequate bowel emptying. • Straining with defecation. © Jones & Bartlett Learning, LLC • Hard or lumpy stools. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONTests1,2,3,4,6,7 NOT FOR SALE OR DISTRIBUTION Tests are warranted if constipation has no clear etiology. • Complete blood count (CBC) • The presence of anemia suggests a secondary cause and © Jones & Bartlettshould be investigated. Learning, LLC © Jones & Bartlett Learning, LLC • Thyroid-stimulating hormone (TSH) NOT FOR •SALE Checks ORfor the DISTRIBUTION presence of hypothyroidism (secondary NOT FOR SALE OR DISTRIBUTION cause of constipation). • Basic metabolic panel (BMP), magnesium, and fasting glucose • Checks for electrolyte imbalance (hypercalcemia, low magnesium, and/or potassium) and hyperglycemia, which © Jones & Bartlett Learning,are secondary LLC causes of constipation. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Plain abdominal radiography NOT FOR SALE OR DISTRIBUTION • Checks for significant stool retention. • Colonoscopy • Recommended if warning signs are present (e.g., anemia, unexplained weight loss, positive fecal occult blood, gastrointestinal [GI] bleeding, or constipation refractory to © Jones & Bartlett Learning, LLC treatment). © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Treatment & Management1,2,3,4,6,7 • Nonpharmacological and nursing interventions: • Identify and treat potentially reversible causes of constipation. © Jones & Bartlett• Increase dietaryLearning, fiber to LLC25–35 g per day. © Jones & Bartlett Learning, LLC • Encourage adequate fluid intake (goal of 1.5–2 L/day). NOT FOR SALE• Increase OR physical DISTRIBUTION activity. NOT FOR SALE OR DISTRIBUTION

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Gastroenterology

© Jones & Bartlett Learning,• Monitor LLC for warning signs of possible malignancy.© Jones & Bartlett Learning, LLC • Constipation presenting acutely, anemia, abdominal NOT FOR SALE OR DISTRIBUTIONpain, unintentional weight loss, rectal bleeding,NOT FOR or a SALE OR DISTRIBUTION family history of colorectal cancer. • Schedule bathroom time. • Make time to have a bowel movement and ensure privacy. • Remind patients that the best potential for a bowel © Jones & Bartlett Learning, LLC movement is in the© morning Jones and &about Bartlett 45 minutes Learning, fol- LLC NOT FOR SALE OR DISTRIBUTION lowing a meal. NOT FOR SALE OR DISTRIBUTION • Do not postpone having a bowel movement if there is an urge to defecate. • Educate patients on constipation. • If there are minimal to no constipation symptoms, in- © Jones & Bartlettstruct patient Learning, to stop taking LLC laxatives. © Jones & Bartlett Learning, LLC • Being obsessed over bowel movements is not good; NOT FOR SALEhaving OR a daily DISTRIBUTION bowel movement is not necessary. NOT FOR SALE OR DISTRIBUTION • Patients need to engage in exercise and increase their fiber intake. • Biofeedback • Effective treatment for dyssynergic defecation. © Jones & Bartlett Learning,• Pharmacological LLC and other interventions:© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONConsider discontinuing medications that NOThave a sideFOR effect SALE OR DISTRIBUTION of constipation (if appropriate). • Bulking agents (e.g., psyllium [Metamucil]). • Example: psyllium 1 tsp (3.4 g) QD-TID with fluids PRN. • Promotes softer stool by increasing the bulk of the stool. © Jones & Bartlett Learning, LLC Will need to drink plenty© Jones of water & for Bartlett a better outcome. Learning, LLC NOT FOR SALE OR DISTRIBUTION • Not recommended NOTas first-line FOR agent SALE in patients OR onDISTRIBUTION high-dose opioids or with dysphagia. • May cause bloating or flatulence. • Stool softeners (e.g., docusate sodium [Colace]). • Example: Colace 100 mg PO BID. © Jones & Bartlett• Not to be Learning, used as chronic LLC treatment or in patients tak- © Jones & Bartlett Learning, LLC ing opioids. NOT FOR SALE• Well toleratedOR DISTRIBUTION and can be combined with a bulking agent. NOT FOR SALE OR DISTRIBUTION

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Gastroenterology

© Jones & Bartlett Learning,• Osmotic LLC agents (e.g., lactulose [Kristalose],© polyethyleneJones & Bartlett Learning, LLC glycol [Miralax], magnesium citrate) NOT FOR SALE OR DISTRIBUTION• Example: lactulose 15–30 mL PO QD-BID.NOT FOR SALE OR DISTRIBUTION • Lactulose recommended in those residing in nursing homes. • Consider when bulking agents and stool softeners are ineffective. © Jones & Bartlett Learning, LLC • May cause bloating© and/or Jones flatulence. & Bartlett Magnesium Learning, ci- LLC NOT FOR SALE OR DISTRIBUTION trate should be avoidedNOT with FOR renal impairment.SALE OR DISTRIBUTION • Stimulants (e.g., senna [Peri-Colace, Senokot], or bisacodyl [Dulcolax]) • Example: bisacodyl 5–15mg PO QD. • Should be used short term and avoided with bowel ob- © Jones & Bartlettstruction. Learning, Used when osmotic LLC agents are ineffective. © Jones & Bartlett Learning, LLC • Increases peristaltic contractions and can have unfa- NOT FOR SALEvorable OR side DISTRIBUTION effects such as abdominal cramping. NOT FOR SALE OR DISTRIBUTION • Secretagogues (i.e., lubiprostone [Amitiza] and linaclotide [Linzess]) • Example: lubiprostone 24 mcg PO BID. • Recommended as monotherapy and not with other © Jones & Bartlett Learning,laxatives. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• They are usually well-tolerated; howeverNOT may causeFOR GI SALE OR DISTRIBUTION disturbances (e.g., nausea, abdominal distention). Di- arrhea is the main side effect of linaclotide. • Alvimopan (Entereg) or methylnaltrexone (Relistor) • Treats opioid-induced constipation. • Enemas (used when there is evidence of fecal impaction) © Jones & Bartlett Learning, LLC • Soapsuds enemas should© Jones not be given& Bartlett to older adults. Learning, LLC NOT FOR SALE OR DISTRIBUTION • Tap water enemas areNOT the safestFOR for SALE regular use.OR DISTRIBUTION • Phosphate enemas are associated with hyperphospha- temia and should be avoided in renal disease. • Gastroenterology consultation/referral • To guide treatment when the above regimen is © Jones & Bartlettineffective. Learning, LLC © Jones & Bartlett Learning, LLC • Nutritionist consultation/referral NOT FOR •SALE To aid in OR dietary DISTRIBUTION changes NOT FOR SALE OR DISTRIBUTION

148 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 148 11/6/18 12:55 PM

Gastroenterology

1,3,4,7 © Jones & Bartlett Learning, Differential LLC Diagnosis © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Colon cancer: Will have warning signs suchNOT as weight FOR loss, SALE OR DISTRIBUTION positive occult blood, hematochezia, and change in bowel habits (e.g., increased frequency of bowel movements, loose stools). If there are concerns for colon cancer, consider colonoscopy or other tests (e.g., computer tomography [CT] scan of abdomen/pelvis). © Jones & Bartlett Learning, LLC • Irritable bowel syndrome© withJones constipation & Bartlett (IBS-C): Learning, More LLC NOT FOR SALE OR DISTRIBUTIONcommon in those ≤ ageNOT 50 years FOR and SALEwill have OR recurrent DISTRIBUTION abdominal pain, relieved by defecation. It can be difficult to differentiate between the two; however abdominal pain is not a feature of constipation by itself. Chronic constipation is exceptionally common in older adults, whereas there are © Jones &lower Bartlett rates of IBSLearning, diagnosed inLLC individuals ≥ age 50 years. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CLINICAL PEARLS2 • Consider the possibility of a bowel obstruction if constipation is severe or comes on suddenly. • Some patients are obsessive–compulsive regarding their constipation and should be reminded that daily bowel movements are not © Jones & Bartlett Learning,required; the LLC bowel needs a chance to work, and© daily Jones laxatives or& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONenemas is not the answer. NOT FOR SALE OR DISTRIBUTION • The Rome III Criteria is used to diagnose constipation ( Table 5-1 ) .

Table 5 - 1 Rome III Diagnostic Criteria: Functional Constipation and IBS-C © Jones & Bartlett Learning, LLC• Symptoms 3 mo; onset 6 ©mo Jones prior to diagnosis & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONFunctional ConstipationNOT IBS-C FOR SALE OR DISTRIBUTION • Must include >2 of the • IBS: Recurrent abdominal following: pain/discomfort 3 d/mo for • Straining* the past 3 mo, associated with • Lumpy or hard stools* 2 of the following: • Sensation of incomplete • Improvement with © Jones & Bartlettevacuation* Learning, LLCdefecation © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION (Continues) NOT FOR SALE OR DISTRIBUTION

149 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 149 11/6/18 12:55 PM

Gastroenterology

© Jones & Bartlett Learning,Functional Constipation LLC IBS-C © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Sensation of anorectal • Onset associatedNOT with FOR SALE OR DISTRIBUTION obstruction/blockage* change in stool frequency • Manual maneuvers to • Onset associated with facilitate defecation (eg, change in stool form digital evacuation, support • IBS is subtyped by of the pelvic floor)* predominant stool pattern © Jones & Bartlett Learning, LLC • <3 defecations/wk © Jones• IBS-C: & har Bartlettd or lumpy stools Learning,† LLC NOT FOR SALE OR DISTRIBUTION• Loose stool rarely present w/oNOT FOR≥ 25% SALEof defecations; OR loose DISTRIBUTION use of laxatives or watery stools‡ <25% of • Insufficient criteria for IBS-C defecations§ *25% of defecations. †Bristol Stool Form Scale 1–2: separate, hard lumps like nuts (difficult to pass); or lumpy, sausage- shaped stool. ‡Bristol Stool Form Scale 6–7: fluffy pieces of stool with ragged edges; mushy stool; or watery w/out solid pieces (entirely liquid). §In the absence of use of antidiarrheals or laxatives. © JonesBased & on: LongstrethBartlett GF et al. Gastroenterology Learning,. 2006; 130:1480-1491. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION References 1. Rao, S., & Sharma, A. (2017, August 4). Constipation in Adults. Epocrates. Retrieved from https://online.epocrates.com/diseases/154/Constipation-in-adults. Accessed December 10, 2017. 2. Greenberger, N. J. (2016, March). Constipation – Gastrointestinal Disorders. Merck Manuals: Professional. Retrieved from https://www.merckmanuals.com/professional © Jones & Bartlett Learning,/gastrointestinal-disorders/symptoms-of-gi-disorders/constipation. LLC © Jones Accessed & Bartlett Learning, LLC December 10, 2017. NOT FOR SALE OR DISTRIBUTION3. Acosta, A., Tangalos, E. G., & Harari, D. (2017). Constipation.NOT In Hazzard’s FOR Geriatric SALE OR DISTRIBUTION Medicine and Gerontology (7th ed.). New York, NY: McGraw-Hill. Retrieved from http://accessmedicine.mhmedical.com/content.aspx?bookid=1923§ionid =144526800. Accessed December 10, 2017. 4. Markland, A. (2014). Constipation. In Current Diagnosis & Treatment: Geriatrics (2nd ed.). New York, NY: McGraw-Hill. Retrieved from http://accessmedicine.mhmedical.com /content.aspx?bookid=953§ionid=53375660. Accessed December 10, 2017. © Jones & Bartlett Learning, LLC5. Wald, A. (2017, February 1). Management© Jones of Chronic & Constipation Bartlett in Older Learning, Adults LLC (Talley, N. J., & Grover, S., Eds.). UpToDate. Retrieved from https://www.uptodate NOT FOR SALE OR DISTRIBUTION.com/contents/management-of-chronic-constipation-in-adults?sourceNOT FOR SALE OR= searchDISTRIBUTION _result&search=constipation&selectedTitle=1~150#H30890925. Accessed December 10, 2017. 6. Mayo Clinic. (2016, October 19). Constipation. Retrieved from https://www.mayoclinic .org/diseases-conditions/constipation/symptoms-causes/syc-20354253. Accessed December 10, 2017. 7. Moyer, D., & Tierney, A. (2015, May). Outpatient Management of Constipation in © Jones &Older Bartlett Adults. Elder Care.Learning, Tucson, AZ: University LLC of Arizona. Retrieved from https:// © Jones & Bartlett Learning, LLC nursingandhealth.asu.edu/sites/default/files/constipation.pdf. Accessed December NOT FOR10, SALE 2017. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

150 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 150 11/6/18 12:55 PM

Gastroenterology

Types2,5,7 Oropharyngeal dysphagia (transfer): impaired movement of a food © Jones & Bartlett Learning, LLCbolus or liquid from the oropharynx© Jones to upper & Bartlettesophagus Learning, LLC NOT FOR SALE OR DISTRIBUTIONEsophageal dysphagia (transit):NOT FORimpaired SALE movement OR of DISTRIBUTIONfood bolus through the esophagus distal to the upper esophageal sphincter (most common)

Causes2,3,4,5,7

© JonesOropharyngeal & Bartlett Dysphagia Learning, EsophagealLLC Dysphagia © Jones & Bartlett Learning, LLC NOT FORNeurologic: SALE stroke, OR Parkinson’s DISTRIBUTION Mechanical obstruction: NOT FOR SALE OR DISTRIBUTION disease, dementia, multiple esophageal cancer, esophageal sclerosis, mass lesion stricture (gastroesophageal reflux), Schatzki ring Muscular: myasthenia gravis, Motility disorders: diffuse © Jones & Bartlett Learning,polymyositis LLC esophageal spasms,© Jonesachalasia & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONMetabolic: thyrotoxicosis, Cushing Esophageal carcinomaNOT (Consider FOR SALE OR DISTRIBUTION disease squamous cell if there is a history of smoking or alcohol abuse.) Infection: syphilis, oral mucositis Radiation to the oral cavity or neck © Jones & Bartlett Learning, LLC Oropharyngeal tumors © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONXerostomia (e.g., anticholinergicNOT FOR SALE OR DISTRIBUTION drugs) Poor dentition or poor fitting dentures © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

151 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 151 11/6/18 12:55 PM

Gastroenterology

Signs & Symptoms2,3,4,5,7

© Jones & Bartlett Learning, LLC Oropharyngeal Dysphagia© Jones Esophageal & Dysphagia Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONDysphagia is noted within a NOTDysphagia FOR isSALE noted several OR DISTRIBUTION second of attempting to swallow. seconds after initiating a swallow. Coughing during meals. Feeling of food or liquids “catching” in the throat (usually worse with solids). © JonesGagging. & Bartlett Learning, Regurgitation.LLC © Jones & Bartlett Learning, LLC NOT FORAspiration. SALE OR DISTRIBUTIONHeartburn. NOT FOR SALE OR DISTRIBUTION Odynophagia. Chest pain (seen with esophageal spasm). Change in voice (e.g., hoarseness).

© Jones & Bartlett Learning,• Unintentional LLC weight loss and anemia © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Needs to be investigated; sign of potentialNOT underlying FOR SALE OR DISTRIBUTION malignancy.

Tests2,3,5,6,7 • Modified barium swallow (MBS) or videofluoroscopy © Jones & Bartlett Learning, LLC • MBS is typically the first© Jones test ordered & Bartlettin the workup Learning, of LLC dysphagia. NOT FOR SALE OR DISTRIBUTION• An alternative to videofluoroscopy:NOT FOR FiberopticSALE ORendoscopic DISTRIBUTION evaluation of swallowing (FEES) commonly used in long-term care facilities. • Esophagogastroduodenoscopy (EGD) • Can take biopsies and allows for dilation of strictures. © Jones• & Esophageal Bartlett manometry Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR •SALE Used to ORidentify DISTRIBUTION neuromuscular disorders; ordered if the NOT FOR SALE OR DISTRIBUTION above tests are negative and dysphagia persistent.

152 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 152 11/6/18 12:55 PM

Gastroenterology

1,2,3,4,5,6,7,8 © Jones & Bartlett Learning,Management LLC & Treatment © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Nonpharmacological and nursing interventions:NOT FOR SALE OR DISTRIBUTION • Identify and treat the underlying cause of dysphagia. • Performing a full neurological examination can as- sist in determining the underlying cause of dysphagia (e.g., rigidity or shuffling gait can indicate Parkinson’s disease). © Jones & Bartlett Learning, LLC • Implement measures to© prevent Jones malnutrition & Bartlett and aspiration. Learning, LLC NOT FOR SALE OR DISTRIBUTION • This includes diet modification,NOT FOR slowing SALE the rateOR of DISTRIBUTIONeat- ing, eating in an upright posture, and reducing bolus size. • Ensuring thickened-liquids and avoiding liquids to avoid aspiration pneumonia. • Teach the Heimlich maneuver. © Jones & Bartlett• This is crucial Learning, for staff and LLC family members. © Jones & Bartlett Learning, LLC NOT FOR •SALE Medication OR modifications. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Consider switching PO meds to liquid form, if able. Teach patients if medications can be crushed to make administration easier. • Ensure adequate fluid intake when taking medications to avoid esophageal damage. © Jones & Bartlett Learning,• Encourage LLC proper oral hygiene. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Poor oral care is a risk factor for pneumonia;NOT encourage FOR SALE OR DISTRIBUTION routine dental visits. • Encourage products that alleviate dry mouth. • Pharmacological and other interventions: • Medications in select patients may include: © Jones & Bartlett Learning, LLC • Botulinum toxin injection.© Jones & Bartlett Learning, LLC • Reserved in individuals who are poor surgical NOT FOR SALE OR DISTRIBUTION candidates. NOT FOR SALE OR DISTRIBUTION • Nitrates, calcium channel blockers. • Reserved in individuals with motility disorders (achalasia, esophageal spasms). • Speech therapy consultation/referral © Jones & Bartlett• Certain tests Learning, are coordinated LLC by a speech language pa- © Jones & Bartlett Learning, LLC NOT FOR SALEthologist, OR such DISTRIBUTION as the MBS, which can identify which NOT FOR SALE OR DISTRIBUTION foods are better swallowed.

153 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 153 11/6/18 12:55 PM

Gastroenterology

© Jones & Bartlett Learning,• Will makeLLC suggestions regarding eating© and Jones drinking & Bartlett Learning, LLC aids to improve swallowing safety. NOT FOR SALE OR DISTRIBUTION• Dietitian consultation/referral NOT FOR SALE OR DISTRIBUTION • To ensure patient is on the proper diet. • Rehabilitative exercises • To strengthen swallowing muscles. • Percutaneous endoscopic gastrostomy tube © Jones & Bartlett Learning, LLC • Considered when nutritional© Jones status & isBartlett poor and/ Learning, LLC NOT FOR SALE OR DISTRIBUTION or recurrent aspirationNOT (risks FOR vs benefi SALE ts should OR fi DISTRIBUTIONrst be discussed, especially in patients with advanced dementia). • Surgical intervention • Endoscopic dilatation recommended with strictures. © Jones Note: & BartlettBeers listed items, Learning, as mentioned LLC above, include nondihydropyri- © Jones & Bartlett Learning, LLC NOT FORdines SALE calcium channelOR DISTRIBUTION blockers NOT FOR SALE OR DISTRIBUTION

CLINICAL PEARLS1 ,2,6 • If dysphagia is not treated, it can lead to pulmonary complications (e.g., silent aspiration, pneumonia), malnutrition, and death. It is the © Jones & Bartlett Learning,third leading LLC cause of infection-related death in adults© Jones > age 85. & Bartlett Learning, LLC • Dysphagia is an independent risk factor for aspiration pneumonia NOT FOR SALE OR DISTRIBUTIONand malnutrition. NOT FOR SALE OR DISTRIBUTION • Dysphagia to liquids and solids is usually due to an underlying neuromuscular disorder. If due to solids alone, this is refl ective of an underlying mechanical obstruction.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC References NOT FOR SALE OR DISTRIBUTION1. Rogus-Pulia, N., Barczi, S., & Robbins,NOT J. (2017). FOR Disorders SALE of swallowing. OR InDISTRIBUTION Haz- zard’s Geriatric Medicine and Gerontology (7th ed.). New York, NY: McGraw-Hill. Retrieved from http://accessmedicine.mhmedical.com/content.aspx?bookid =1923& sectionid= 144520375. Accessed December 16, 2017. 2. Gastrointestinal and abdominal complaints. In Current Diagnosis & Treatment: Geri- atrics (2nd ed.). New York, NY: McGraw-Hill. Retrieved from http://accessmedicine .mhmedical.com/content.aspx?bookid = 953§ionid = 53375659. Accessed © Jones &December Bartlett 16, 2017. Learning, LLC © Jones & Bartlett Learning, LLC 3. Gyawali, C. P. (2010, November). Dysphagia. American College of Gastroenterology. NOT FORRetrieved SALE from ORhttp://patients.gi.org/topics/dysphagia/. DISTRIBUTION Accessed December 16, 2017. NOT FOR SALE OR DISTRIBUTION

154 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 154 11/6/18 12:55 PM

Gastroenterology

4. Charous, S. J. (2016, September 12). Evaluation of Dysphagia. Epocrates. Retrieved © Jones & Bartlett Learning,from https://online.epocrates.com/diseases/226/Evaluation-of-dysphagia. LLC © Jones Accessed & Bartlett Learning, LLC December 16, 2017. NOT FOR SALE OR DISTRIBUTION5. Gastrointestinal disorders. In Current Medical Diagnosis & TreatmentNOT 2018. FOR New York, SALE OR DISTRIBUTION NY: McGraw-Hill. Retrieved from http://accessmedicine.mhmedical.com/content.aspx ?bookid=2192§ionid=168013478. Accessed December 16, 2017. 6. Azimi, E., Carnahan, J., Denson, K., & Kuester, J. (n.d.). Clinical Skills Workshop: Dysphagia Evaluation & Treatment. Milwaukee, WI: Medical College of Wisconsin. Retrieved from https://geriatricscareonline.org/application/content/products/M002 /slide/day2/R1445_27_Kathryn_Denson.pdf © Jones & Bartlett Learning, LLC 7. Lembo, A. J., & Robson, K. M. (2015,© Jones June 2). Oropharyngeal & Bartlett Dysphagia: Learning, Clini- LLC NOT FOR SALE OR DISTRIBUTIONcal Features, Diagnosis, and ManagementNOT (Talley, FOR N. J., SALE Ed.). UpToDate. OR Retrieved DISTRIBUTION from https://www.uptodate.com/contents/oropharyngeal-dysphagia-clinical -features-diagnosis-and-management?search=dysphagia risk factor&source=search _result&selectedTitle=2~150&usage_type=default&display_rank=2. Accessed December 20, 2017. 8. American Geriatrics Society 2015 Beers Criteria Update Expert Panel, Fick, D. M., Semla, T. P., Beizer, J., Brandt, N., & Dombrowski, R. . ..Steinman, M. (2015, October 8). American Geriatrics Society 2015 updated Beers criteria for potentially © Jones &inappropriate Bartlett medication Learning, use in older adults. LLC Journal of the American Geriatrics Soci- © Jones & Bartlett Learning, LLC NOT FORety, SALE 63(11), 2227–2246. OR DISTRIBUTION Retrieved from http://onlinelibrary.wiley.com/doi/10.1111 NOT FOR SALE OR DISTRIBUTION /jgs.13702/abstract. Accessed October 8, 2017.

Fecal Incontinence Definition1,4,6 © Jones & Bartlett Learning,Fecal incontinence LLC (FI) is the loss of bowel control,© Jones resulting & in Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONthe involuntary passage of feces. NOT FOR SALE OR DISTRIBUTION Note: FI is the second leading cause of nursing home placement.

Types1,4,6 Passive incontinence: unaware of passing small amount of stool. © Jones & Bartlett Learning, LLC Urge incontinence: aware© ofJones the need & to Bartlettdefecate; however Learning, LLC NOT FOR SALE OR DISTRIBUTIONhas leakage of stool due to inabilityNOT toFOR get to theSALE restroom OR in time.DISTRIBUTION Fecal leakage: the leakage of stool following incomplete bowel movement.

Causes1,2,4,6 © Jones• & Idiopathic Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Neurological conditions (e.g., dementia, multiple sclerosis, NOT FOR stroke)SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

155 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 155 11/6/18 12:55 PM

Gastroenterology

© Jones & Bartlett Learning,• Inflammatory LLC conditions (e.g., inflammatory© bowel Jones disease, & Bartlett Learning, LLC radiation proctitis) NOT FOR SALE OR DISTRIBUTION• Infectious diarrhea NOT FOR SALE OR DISTRIBUTION • Dysfunction of the anorectal sphincters • Fecal impaction • Excessive laxative use • Diabetes © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1,2,4,6 NOT FOR SALE OR DISTRIBUTIONRisk Factors NOT FOR SALE OR DISTRIBUTION • Advanced age • Nursing home patient • Female sex • Immobility © Jones• & Rectal Bartlett trauma Learning, LLC © Jones & Bartlett Learning, LLC • History of pelvic radiation therapy NOT FOR• DepressionSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Renal disease • Urinary incontinence

Signs & Symptoms1,2,4,5 © Jones & Bartlett Learning,• Urinary incontinence LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Constipation NOT FOR SALE OR DISTRIBUTION • Skin irritation • Hemorrhoids • Anal fissures • Perineal scarring (can indicate prior trauma or surgery) © Jones & Bartlett Learning, LLC • Weakened sphincter tone© Jones & Bartlett Learning, LLC • Patulous anus NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tests1,2,4,5,6,7 Diagnosis is made clinically • CBC, C-reactive protein (CRP) © Jones &• BartlettNot ordered Learning, routinely, ordered LLC if concern for underlying © Jones & Bartlett Learning, LLC infection or inflammation. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

156 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 156 11/6/18 12:55 PM

Gastroenterology

© Jones & Bartlett Learning,• Abdominal LLC plain film © Jones & Bartlett Learning, LLC • Ordered if there is a concern for fecal impaction. NOT FOR SALE OR DISTRIBUTION• Anorectal manometry NOT FOR SALE OR DISTRIBUTION • Ordered in select patients to determine rectal resting and squeeze pressures. • Anal ultrasonography • Evaluates for damage of the anal sphincters. © Jones & Bartlett Learning, LLC • Colonoscopy or flexible ©sigmoidoscopy Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• To determine if a mechanicalNOT FORcause is SALE present (e.g.,OR coDISTRIBUTION- lonic mass).

Management & Treatment1,2,4,5,6,7,8,9 • Nonpharmacological and nursing interventions: © Jones &• BartlettInvestigate andLearning, treat the underlying LLC reversible causes of © Jones & Bartlett Learning, LLC NOT FOR SALEfecal incontinence, OR DISTRIBUTION such as: NOT FOR SALE OR DISTRIBUTION • Treat the infectious source. • Treat the fecal impaction. • Encourage mobility. • Biofeedback and pelvic floor exercises. © Jones & Bartlett Learning,• Patient LLC must be cognitively intact and cooperative© Jones for & Bartlett Learning, LLC biofeedback to be effective. NOT FOR SALE OR DISTRIBUTION• Encourage dietary changes. NOT FOR SALE OR DISTRIBUTION • Make one food change at a time and keep record of this in a food diary, with goal to determine if symptoms change. • Foods that are known to contribute to loose stools © Jones & Bartlett Learning, LLC include, but not ©limited Jones to: prunes, & Bartlett figs, artificial Learning, LLC NOT FOR SALE OR DISTRIBUTION sweeteners, caffeine,NOT and FOR some vegetables.SALE OR Remove DISTRIBUTION any offending foods. • Encourage increased consumption of dietary fiber (this creates bulk and bulky stools stimulates peristalsis). • Schedule bathroom time. • Encourage using the bathroom following a meal, and © Jones & Bartlettensure privacy. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

157 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 157 11/6/18 12:55 PM

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© Jones & Bartlett Learning,• Offer emotional LLC support (fecal incontinence© Jonescan be so- & Bartlett Learning, LLC cially embarrassing). NOT FOR SALE OR DISTRIBUTION• Manual disimpaction. NOT FOR SALE OR DISTRIBUTION • An option in older adults with fecal impaction and laxative ineffective. • Implement measures to prevent skin breakdown (FI can lead to pressure ulcers). © Jones & Bartlett Learning, LLC • Frequent turning and© useJones of barrier & creamBartlett (e.g., zincLearning, LLC NOT FOR SALE OR DISTRIBUTION oxide). NOT FOR SALE OR DISTRIBUTION • Use of a stool collection system. • Preferred over pads or diapers; use of pouches or rectal tubes prevent exposure of perianal skin to stool and reduces odor and embarrassment. These are a good op- © Jones & Bartletttion in bedbound Learning, older adults. LLC © Jones & Bartlett Learning, LLC • Pharmacological and other interventions: NOT FOR •SALE Rid of excessive OR DISTRIBUTION laxative use. NOT FOR SALE OR DISTRIBUTION • Bulking agent (e.g., psyllium [Metamucil] or methylcel- lulose [Citrucel]). • Example: psyllium 1 tsp (3.4 g) QD-TID with fluids PRN. © Jones & Bartlett Learning,• Improves LLC stool consistency and reduces© the Jones frequency & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONof defecation; should be gradually introducedNOT toFOR avoid SALE OR DISTRIBUTION bloating. • Antidiarrheal agents (e.g., loperamide [Imodium], codeine). • Example: loperamide 2–4 mg PO following loose stools (max 16 mg/day). © Jones & Bartlett Learning, LLC • Rule out infection before© Jones starting medication.& Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • These agents slow downNOT bowel FOR motility. SALE Can ORbe used DISTRIBUTION with radiation proctitis and inflammatory bowel disease. • Loperamide recommended as first-line treatment (may cause xerostomia, dizziness, or abdominal cramps). If © Jones & Bartlettnot tolerated, Learning, switch to codeine LLC or low-dose amitripty- © Jones & Bartlett Learning, LLC NOT FOR SALEline (Elavil) OR DISTRIBUTION (10–25 mg QHS). NOT FOR SALE OR DISTRIBUTION

158 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 158 11/6/18 12:55 PM

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© Jones & Bartlett Learning,• Enemas LLC and/or suppositories (e.g., phosphate© Jones enema, & Bartlett Learning, LLC glycerin rectal, bisacodyl [Dulcolax]). NOT FOR SALE OR DISTRIBUTION• Example: glycerin rectal 2 g suppository NOTonce daily FOR PRN. SALE OR DISTRIBUTION • Used if fecal impaction is the underlying cause of FI and in those with spinal injury. • Rectal preparation is used as fi rst-line treatment but, if not effective, can switch to an oral laxative (e.g., lactu- © Jones & Bartlett Learning, LLC lose [Generlac, Enulose]© Jones or sennosides & Bartlett [Senokot]). Learning, LLC NOT FOR SALE OR DISTRIBUTION • Suppositories may causeNOT perianal FOR irritation SALE whereas OR DISTRIBUTION enemas used chronically can lead to fl uid and electrolyte imbalance. • Wound, ostomy continence (WOC) nurse consultation/referral • Enhances the care for patients suffering from FI; re- © Jones & Bartlettsearch has shownLearning, agencies withLLC WOC nurses have signif- © Jones & Bartlett Learning, LLC icantly better outcomes than those without WOC nurses. NOT FOR• Gastroenterology SALE OR DISTRIBUTION consultation/referral NOT FOR SALE OR DISTRIBUTION • Can guide medical decision making and determine if surgery is the right option, especially if fecal incontinence is refractory to medical therapy. © Jones & Bartlett Learning, Note: Beers listed LLC items, as mentioned above, include© amitriptyline. Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Differential Diagnosis1 NOT FOR SALE OR DISTRIBUTION • Colorectal cancer: Will have warning signs, such as rectal bleeding and/or anemia, and/or family history of colon cancer. Symptoms come on quickly. A colonoscopy can confirm colonic mass. © Jones & Bartlett Learning, LLC • Inflammatory bowel disease© Jones (IBD): May & haveBartlett rectal bleeding Learning, LLC NOT FOR SALE OR DISTRIBUTIONand abdominal pain; lab NOTstudies FORmay reveal SALE leukocytosis OR DISTRIBUTION and/ or elevated inflammatory markers.

CLINICAL PEARLS3 • Fecal incontinence is distressing physically, psychologically, and © Jones &socially, Bartlett placing Learning,older adults at risk LLC for nursing home placement © Jones & Bartlett Learning, LLC and poor health. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

159 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 159 11/6/18 12:55 PM

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© Jones & Bartlett Learning,References LLC © Jones & Bartlett Learning, LLC 1. Brown, S. (2016, July 29). Fecal Incontinence in Adults. Epocrates. Retrieved from NOT FOR SALE OR DISTRIBUTIONhttps://online.epocrates.com/diseases/840/Fecal-incontinence-in-adults.NOT FOR Accessed SALE OR DISTRIBUTION December 11, 2017. 2. Ansari, P. (2016, October). Fecal Incontinence – Gastrointestinal Disorders. Merck Manuals: Professional. Retrieved from http://www.merckmanuals.com/professional /gastrointestinal-disorders/anorectal-disorders/fecal-incontinence. Accessed December 11, 2017. 3. Acosta, A., Tangalos, E. G., & Harari, D. (2017). Constipation. In Hazzard’s Geriat- © Jones & Bartlett Learning, LLC ric Medicine and Gerontology (7th ©ed.). Jones New York, NY: & McGraw-Hill. Bartlett Retrieved Learning, from LLC http://accessmedicine.mhmedical.com/content.aspx?bookid=1923§ionid NOT FOR SALE OR DISTRIBUTION=144526800. Accessed DecemberNOT 11, 2017. FOR SALE OR DISTRIBUTION 4. Hall, K. E. (2014). Gastrointestinal and abdominal complaints. In Current Diagnosis & Treatment: Geriatrics (2nd ed.). New York, NY: McGraw-Hill. Retrieved from http:// accessmedicine.mhmedical.com/content.aspx?bookid=953§ionid=53375659. Accessed December 11, 2017. 5. Ferzandi, T. R. (2016, May 5). Fecal Incontinence (Talavero, F., Isaacs, C., & Strohbehn, K., Eds.). Medscape. Retrieved from https://emedicine.medscape.com © Jones &/article/268674-overview Bartlett Learning,. Accessed December LLC 11, 2017. © Jones & Bartlett Learning, LLC 6. Shah, B. J., Chokhavatia, S., & Rose, S. (2012, July 8). Fecal Incontinence in the NOT FORElderly: SALE FAQ. AmericanOR DISTRIBUTION Journal of Gastroenterology, 107(11). Retrieved from http:// NOT FOR SALE OR DISTRIBUTION gi.org/wp-content/uploads/2012/10/7-ajg2012284a.pdf. Accessed December 11, 2017. 7. Gulanick, M., & Myers, J. L. (2017). Nursing Care Plans: Diagnoses, Interventions, & Outcomes. St. Louis, MO: Elsevier. 8. American Geriatrics Society 2015 Beers Criteria Update Expert Panel, Fick, D. M., Semla, T. P., Beizer, J., Brandt, N., & Dombrowski, R. . ..Steinman, M. (2015, Octo- © Jones & Bartlett Learning,ber 8). American LLC Geriatrics Society 2015 updated Beers criteria© forJones potentially inap&- Bartlett Learning, LLC propriate medication use in older adults. Journal of the American Geriatrics Society, NOT FOR SALE OR DISTRIBUTION63(11), 2227–2246. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111NOT FOR SALE OR DISTRIBUTION /jgs.13702/abstract. Accessed October 3, 2017. 9. Westra, B. L., Bliss, D. Z., Savik, K., Hou, Y., & Borchert, A. (2014). Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care. Home Healthcare Nurse, 32(2), 119–127. DOI: 10.1097 /NHH.0000000000000030.

© Jones & Bartlett Learning, LLCGastroesophageal© Reflux Jones Disease & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONDefinition1,4,5 NOT FOR SALE OR DISTRIBUTION Gastroesophageal reflux disease (GERD) is defined as the reflux of gastric contents into the esophagus.

Causes1,2,4,5 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Incompetent lower esophageal sphincter (LES) muscle relaxation. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

160 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 160 11/6/18 12:55 PM

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1,2,4,5 © Jones & Bartlett Learning,Risk Factors LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Family history of heartburn NOT FOR SALE OR DISTRIBUTION • Advanced age • Truncal obesity • Hiatal hernia • Tobacco smoking • Alcohol © Jones & Bartlett Learning, LLC • Some foods © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• May include caffeinatedNOT beverages, FOR spicy SALE foods OR (limited DISTRIBUTION evidence). • Some medications • Includes nitrates, calcium channel blockers, antihista- mines, antidepressants, anticholinergics, NSAIDs. © Jones• & Gastroparesis Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR• SclerodermaSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Signs & Symptoms1,2,3,4,5 • Heartburn • 30–60 min after eating and reclining. © Jones & Bartlett Learning,• Sour regurgitation LLC © Jones & Bartlett Learning, LLC • Dysphagia NOT FOR SALE OR DISTRIBUTION• May indicate development of esophageal NOTstricture. FOR SALE OR DISTRIBUTION • Chronic cough • Sore throat • Atypical chest pain • Worsening asthma © Jones & Bartlett Learning, LLC • Nausea or vomiting © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tests1,2,3,4,5 • A trial round of a proton pump inhibitor (PPI) • Further workup recommended if no improvement noted after 2 months. © Jones &• BartlettPositive response Learning, indicates 78%LLC sensitivity and 54% © Jones & Bartlett Learning, LLC specificity for GERD. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

161 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 161 11/6/18 12:55 PM

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© Jones & Bartlett Learning,• Upper endoscopy LLC (esophagogastroduodenoscopy)© Jones & Bartlett Learning, LLC • Safe procedure, including in very frail elderly patients; NOT FOR SALE OR DISTRIBUTIONshould be done if reflux symptoms continueNOT despite FOR SALE OR DISTRIBUTION medication. • Determines severity of reflux disease and evaluates for complications such as esophageal cancer or Barrett’s esophagus. © Jones & Bartlett Learning, LLC • Ambulatory pH monitoring,© Jones 24-hour & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Not usually performedNOT but is FORan option SALE if upper OR endos- DISTRIBUTION copy is negative and GERD symptoms are persistent despite PPI therapy. It will determine if symptoms are related to acid or not. • Esophageal manometry © Jones &• BartlettNot usually Learning,a benefit in older LLC adults unless planning for © Jones & Bartlett Learning, LLC antireflux surgery. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Treatment & Management1,2,3,4,5,6 • Nonpharmacological and nursing interventions: • Encourage dietary changes • Avoid greasy or spicy foods, fats, caffeine, and/or alco- © Jones & Bartlett Learning,holic LLCbeverages. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Eat smaller, more frequent meals. NOT FOR SALE OR DISTRIBUTION • Avoid eating 3 hours before going to bed (if nocturnal symptoms present). • After eating, sit upright for about 3 hours and avoid reclining. • Encourage weight loss, if obese. © Jones & Bartlett Learning, LLC • Avoid smoking and secondhand© Jones smoke. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Advise against wearingNOT tight clothing.FOR SALE OR DISTRIBUTION • Pharmacological and other interventions: • Antacids (e.g., aluminum hydroxide/magnesium hydroxide/simethicone [Mylanta], calcium carbonate/magnesium hydroxide [Rolaids], calcium carbonate [Tums]) © Jones & Bartlett• Example: Learning,Rolaids 2–4 chewable LLC tabs PO PRN (max: © Jones & Bartlett Learning, LLC 12 tabs/24 hrs). NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

162 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 162 11/6/18 12:55 PM

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© Jones & Bartlett Learning,• Provides LLC rapid relief of GERD symptoms;© Jonesrecom- & Bartlett Learning, LLC mended with symptoms that occur less than once NOT FOR SALE OR DISTRIBUTIONweekly. NOT FOR SALE OR DISTRIBUTION • Monitor for adverse effects: diarrhea, hypercalcemia, hypo-hypermagnesium, nephrolithiasis. • Proton-pump inhibitors (e.g., esomeprazole [Nexium], lansoprazole [Prevacid], omeprazole [Prilosec]) © Jones & Bartlett Learning, LLC • Example: omeprazole© 20Jones mg PO &QD-BID, Bartlett 30 min- Learning, LLC NOT FOR SALE OR DISTRIBUTION utes before breakfastNOT for 8 weeksFOR (some SALE may needOR thisDISTRIBUTION longer). • Not to be given concomitantly with clopidogrel (Plavix). • Offers quick symptom relief and promotes healing in © Jones & Bartletterosive esophagitis. Learning, LLC © Jones & Bartlett Learning, LLC • Preferred over H2 blockers in the short- and long-term NOT FOR SALEtreatment OR ofDISTRIBUTION GERD. NOT FOR SALE OR DISTRIBUTION • Adverse reactions include risk of osteoporosis, fracture, low magnesium, infectious gastroenteritis (Clostridium difficilie), pneumonia, and vitamin B12-deficiency with long-term use. © Jones & Bartlett Learning,• Histamine-2 LLC receptor antagonists (e.g., famotidine© Jones [Pep- & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONcid AC], ranitidine [Zantac]) NOT FOR SALE OR DISTRIBUTION • Example: ranitidine 150 mg PO QD or BID (may re- quire decreased dose based off renal function). • Cimetidine (Tagamet) avoided in older adults given increased risk of delirium and drug interactions. • Provides heartburn relief for about 8–12 hours. © Jones & Bartlett Learning, LLC • Can be used as an adjunct© Jones to proton-pump & Bartlett inhibitor Learning, LLC NOT FOR SALE OR DISTRIBUTION (PPI) therapy if symptomsNOT FORare still SALEpresent. OR DISTRIBUTION • Caution use in patients with delirium (or high risk of delirium). Adverse reactions include headache, constipation or diarrhea, dizziness, and xerostomia. • Gastroenterology consultation/referral © Jones & Bartlett• Refer when Learning, patients do not LLC respond to the typical © Jones & Bartlett Learning, LLC NOT FOR SALEtreatment. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

163 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 163 11/6/18 12:55 PM

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© Jones & Bartlett Learning,• Can determineLLC if surgery is the right option,© Jones especially & Bartlett Learning, LLC if medications control symptoms but patient not will- NOT FOR SALE OR DISTRIBUTIONing to take long-term PPI therapy or if GERDNOT symp-FOR SALE OR DISTRIBUTION toms continue despite PPI therapy. Surgery is unlikely to be benefi cial if PPIs are ineffective. Note: Beers listed items, as mentioned above, include proton-pump © Jones & Bartlett Learning, LLC inhibitors (avoid use beyond 8 weeks)© Jones and H2-receptor & Bartlett antagonists. Learning, LLC NOT FOR SALE OR DISTRIBUTION Differential DiagnosisNOT1 ,2,3 FOR SALE OR DISTRIBUTION • Peptic ulcer disease (PUD): Endoscopy would show an ulcer and patient typically will have nocturnal symptoms that awaken them at night. Compared to GERD, an upper endoscopy would show the severity or extent of tissue damage; © Jones &about Bartlett one-third Learning, will have erosion LLC or ulcers in the esopha- © Jones & Bartlett Learning, LLC NOT FOR gus.SALE GERD OR does DISTRIBUTION not typically cause nighttime symptoms NOT FOR SALE OR DISTRIBUTION or disrupt sleep. Heartburn as the main symptom indicates GERD, not PUD. • Malignancy: Will have other symptoms such as anemia, worsening dysphagia, GI bleeding, and/or unintentional weight © Jones & Bartlett Learning,loss. May LLChave abnormal blood work, such ©as anemiaJones or &el- Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONevated LFTs. NOT FOR SALE OR DISTRIBUTION CLINICAL PEARLS1 ,2,3 • Complications of GERD after the age of 65 years include Barrett’s esophagus, esophageal adenocarcinoma, esophagitis, bleeding, and peptic stricture. © Jones & Bartlett Learning, LLC • The mainstay of treatment© includes Jones lifestyle & changesBartlett (e.g., Learning,head LLC NOT FOR SALE OR DISTRIBUTIONof bed elevation, losing weight)NOT and FOR controlling SALE symptoms OR withDISTRIBUTION acid-suppressing therapy.

References 1. Zuckerman, M. J., & Othman, M. O. (2017, February 7). Gastroesophageal Reflux Disease. Epocrates. Retrieved from https://online.epocrates.com/diseases/82/GERD © Jones &-gastroesophageal-reflux-disease. Bartlett Learning, Accessed LLC December 9, 2017. © Jones & Bartlett Learning, LLC 2. McQuaid, K. R. (2018). Gastrointestinal disorders. In Current Medical Diagnosis & NOT FORTreatment SALE 2018. ORNew York,DISTRIBUTION NY: McGraw-Hill. Retrieved from http://accessmedicine NOT FOR SALE OR DISTRIBUTION

164 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 164 11/6/18 12:55 PM

Gastroenterology

.mhmedical.com/content.aspx?bookid=2192§ionid=168013478. Accessed © Jones & Bartlett Learning,December 9, 2017.LLC © Jones & Bartlett Learning, LLC 3. Hall, K. E. (2014). Gastrointestinal and abdominal complaints. In Current Diagnosis & NOT FOR SALE OR DISTRIBUTIONTreatment: Geriatrics (2nd ed.). New York, NY: McGraw-Hill.NOT Retrieved FORfrom http:// SALE OR DISTRIBUTION accessmedicine.mhmedical.com/content.aspx?bookid=953§ionid=53375659. Accessed December 9, 2017. 4. Mayo Clinic. (2017, November 1). Gastroesophageal Reflux Disease (GERD). Retrieved from https://www.mayoclinic.org/diseases-conditions/gerd/symptoms -causes/syc-20361940. Accessed December 9, 2017. 5. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2014, © Jones & Bartlett Learning, LLC November 1). Definition & Facts for© GER Jones & GERD. U.S.& BartlettDepartment of Health Learning, and LLC Human Services, National Institute of Health. Retrieved from https://www.niddk.nih NOT FOR SALE OR DISTRIBUTION.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults/definition-factsNOT FOR SALE OR DISTRIBUTION. Accessed December 9, 2017. 6. American Geriatrics Society 2015 Beers Criteria Update Expert Panel, Fick, D. M., Semla, T. P., Beizer, J., Brandt, N., & Dombrowski, R. . ..Steinman, M. (2015, Octo- ber 8). American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227–2246. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111 © Jones &/jgs.13702/abstract Bartlett. AccessedLearning, October 8, 2017.LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

165 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 165 11/6/18 12:55 PM

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 166 11/6/18 12:55 PM