11/19/2012 Increased risk of GI motility issues: Cerebral palsy Rett syndrome Two Common 22q- (velocardiofacial syndrome) Gastrointestinal Problems Cornelia de Lange syndrome, Degenerative neuromuscular disorders in Persons with DD: (muscular dystrophies, mitochondrial cytopathies) Gastroesophageal Reflux & Trisomy 18 Constipation Chromosomal translocations Terry Broda, RN, BScN, NP-PHC, CDDN Gastro-esophageal Reflux GERD Reflux of acid from the stomach into the Reflux esophagitis: 5-7% in general esophagus population In persons w/ DD Due to defective or Overall prevalence is 10-15% stretched sphincter But w/ known risk factors: 30-50% (LES) between the stomach & esophagus, 70% in those w/ severe/profound DD! a hiatal hernia or i motility Risk factors Symptoms In persons w/ DD Additional factors Burning pain in throat Scoliosis Hiatal hernia (90%!) & esophagus Cerebral palsy Obesity Abdominal pain Severe & profound DD Diabetes Thoracic (chest) pain Non-ambulatory Pregnancy Certain Rx Scleroderma But … Older age what if the person is non-verbal? T.Broda, Solution-s 1 11/19/2012 GERD or CB? A word about food refusal.. Refuses to eat or food avoidance Breathing vs eating? Refusal to sleep, lay down(on their back) Taste & texture Depressive behaviors (isolates oneself) Nausea & vomiting Irritability after meals & during the night Food & Rx interaction? Screaming, aggression & SIB Medical procedures (spoon vs. scope!) (head-banging, hand-mouthing/biting) Stripping (pants, belt, bra): too tight? Dental pain Excessive water drinking (pica?) Dysphagia Constipation, obstruction (pica/feces) Signs & Symptoms Signs & Symptoms Wt loss, poor growth, FTT in children Regurgitation and rumination 1-2 hours Arched back with difficulty sitting after meals (p.c.) or overnight Recurrent vomiting/aspiration N & V, burping, coughing, wheezing, Recurrent episodes of pneumonia, throat clearing, yawning, hiccups asthma exacerbations Sinusitis, pharyngitis, otitis Hoarseness Abdominal distension Dental caries Constipation (as a contributing factor) Aphthous ulcers When is it GERD? Monitoring Predisposing risk factors along with Scatter plot occurrence of any of those behaviors, Calendar a minimum of 4 times per month: A-B-C sheets SHOULD RAISE SUSPICION Food diary TO Breau pain scale HIGHEST LEVEL for GERD! MEDINA (2010) T.Broda, Solution-s 2 11/19/2012 Red Flags (Alarm symptoms) Risk factors: Meds (**notify MD ASAP!) Chest pain (cardiac type) ASA Calcium channel blockers Choking (coughing, hoarseness & SOB) Alpha-blockers Anti-cholinergics Narcotics Dysphagia (?strictures) Anticonvulsants Nicotine Vomiting (hematemesis) Benzodiazepines Nitrates Pain on swallowing (odynophagia) Beta-blockers NSAIDs & COX-2 inhibitors Anemia d/t GI bleeding (melena stool) Bisphosphonates Theophylline Bloody vomit or coffee grains** Weight loss >5% Complications Diagnosis Esophageal strictures Mild Severe Recurrent inflammation S/S less often (<3/wk) S/S more frequent =>erosion Low intensity Present for > 6 months Not at night More intense => Barrett's esophagitis ( if s/s > 5yrs) No interference w/ life Wakes at night, or Increased risk of esophageal cancer with Heartburn pain rated 1- restless nights Barrett’s ( if s/s > 5yrs) 3/10 Interferes w/ life No major complications Pain rated 7/10 + Complications Gray, p.721 Dx Tests Other possibilities? Blood/urine testing (r/o anemia) Dyspepsia Cardiac pain X-ray (fluoroscopy: barium swallow) to Pyloric stenosis Lactose intolerance check for hiatal hernia. Peptic ulcer disease Esophageal cancer Hirschsprung’s Biliary tract disease Ambulatory 24-hour pH monitoring* Esophagitis Upper endoscopy (not conclusive?)* secondary to Esophageal motility studies* esophageal motility *for refractory esophagitis or structural issue **Diagnosis can be made without endoscopy based on history. T.Broda, Solution-s 3 11/19/2012 Planning Therapeutic Goals Relieve S/S Review & modify risk factors (if possible) Improve QoL Have MD assess for comorbid dx Promote healing of esophagus Have MD assess if problematic Rx can Prevent complications (strictures, be adjusted or D/C’ed bleeds & Barrett’s) Adopt an individualized plan Prevent recurrences Lifestyle modifications Treatment: Rx Avoid exercising/ Fill in food diary Mild Moderate/severe bending on a full Avoid trigger foods: Antacids (Aluminum stomach chocolate, tomato- PPI (proton pump hydroxide, Magnesium Stop smoking based foods, alcohol, inhibitor) (see next salts, Calcium carbonate Limit ETOH peppermint, onions, slide for examples) caffeinated products, or combos: Rolaids, Tums, (heal up to 90% by 12wks) Attain healthy weight Maalox) citrus fruits and drinks, Step-down Tx (PPI Avoid lying down for 3 high fat meals Alginates (Gaviscon) first, then H2RA after hours p.c. or eating H2-RA (histamine receptor healed before hs Avoid tight clothing around waist/chest antagonist) Avoid large meals Elevate head of bed (10 (see next slide) May even require Sx: cm, 6-8 inches, (BID dosing of H2RAs fundiplication or use 2-3 pillows) relieves s/s in 60%, heals tissue in 40%) Meds: considerations CYP450 interactions & AEDs (cimetidine & omeprazole) Prokinetic (domperidone?) T.Broda, Solution-s 4 11/19/2012 Constipation: How serious a problem? 50-85% of older people w/ DD suffer from constipation (2005, Australia, Management Guidelines: a symptom Developmental Disability) Up to 70% of persons with dx of NOT moderate to profound MR have it (2001, Netherlands, JIDR) a disease! *Especially for non-ambulatory residents What exactly is Normal? Transit times Frequency: Mouth: 1 min 3 X per week to 3X per day! Esophagus: 4-8 secs Average passage time: Stomach: 2-4 hrs 50 (men) to 57 hrs (women), but Small intestine: can vary from 20-100hrs! 3 to 5hrs Average weight: Colon: 10 hrs to several days 100g = 3.5 oz. What exactly is Normal? Usual color: Brown but can vary from reddish or Constipation: greenish dark brown to lighter mustard brown how it can Consistency: happen 70-75% actually H2O! (in bacteria & undigested plant cells) 50-66% bacteria 33-50% undigested plant foods (fiber) T.Broda, Solution-s 5 11/19/2012 Cause & Effect: Risk factors Kids & adults? Female > Male (2-3X); Age over 65 Similar prevalence so likely is present IQ < 50 (moderate/severe/profound MR) early in life & does not necessarily Diagnoses: CP, hypothyroidism (DS), WS, develop over time DM, comorbid GERD Intrinsic motility problem rather than Inadequate food/caloric & fluid intake overstretching (functional retention) Inadequate dietary fiber Immobility/non-ambulatory Medications Meds Anticholinergics; or meds w/ antiCH SE Anti-psychotics, antidepressants, Anticonvulsants, benzodiazepines, Antiparkinsonians, antispasmodics Ca+ channel blockers Diuretics Antacids (Al hydroxide, Tums, Maalox) Fe+, Ca carbonate Opioids (narcotic analgesics) & NSAIDs Rome II criteria: Behavioral Signs: 2 or > for at least 12 weeks in last year: For >25 % of defecations: SIB/aggression Straining Irritability Lumpy or hard stools Positioning : legs bent at the knee, Sensation of incomplete evacuation with thighs elevated to h pressure Sensation of anorectal obstruction on the abdomen (crouching) Use of manual maneuvers to facilitate evacuation of stool (rocking on the toilet seat) Less than 3 defecations per week Loose stools are not present Insufficient criteria for IBS Dx T.Broda, Solution-s 6 11/19/2012 Red Flags (Alarm Symptoms) Other concerns? (**notify MD ASAP!) Abdominal pain Cholecystitis (4Fs!) N & V Melena, rectal bleeding, rectal pain Gastritis & PUD Fever H. Pylori Weight loss Meds G-tube placement Monitoring Dx tests? Measure abdominal girth? Scatter plot Abdominal X-ray (flat plate) Calendar Distended abdomen & masses LLQ A-B-C sheets TFTs Food diary Pb screening if pica Bristol Stool form Planning Therapeutic Goals Regular BM within 48-72 hours Review & modify risk factors (if possible) Have MD assess for comorbid dx Appropriate laxative use Have MD assess if problematic Rx can Avoid complications: be adjusted or D/C’ed From straining: hemorrhoids, hernia, GERD, coronary & cerebrovascular Adopt an individualized plan dysfunction in elderly Long Term: hemorrhoids, incontinence, impaction, obstruction, rectal prolapse, anal fissures, megacolon T.Broda, Solution-s 7 11/19/2012 Hemorrhoids (symptoms) Hemorrhoids Intermittent pain in rectum, during Causes: unknown, but several bowel movements aggravating factors( heredity ): Blood stains in underwear, shorts Diarrhea Various complaints such as burning, Spicy foods itching, swelling Alcohol Protrusion of internal hemorrhoid Dehydration noted Pregnancy Chronic constipation Hemorrhoids Tx Options: laxatives Bulk-forming Interventions: Hyper-osmotic agents Try to eliminate constipation Lubricants Cream to i pain & Osmotic saline agents inflammation Stool softeners Observe for any bleeding** Stimulants Please see chart… Health Education Continued monitoring Normal BM: frequency, type Dietary modifications: Frequency: scatter plot Increase calories Bristol Stool form Increase fiber, fruits & vegetables Improvements in behavior Increase fluids Breau pain scale Lifestyle modifications Food diary Increase exercise T.Broda, Solution-s 8 11/19/2012 Questions? Thank you! T.Broda, Solution-s 9 .