Pharmacology for Chronic Gastroenterology Diseases

Pharmacology and Nursing Interventions for Patients with Chronic Gastroenterology

• A presentation by Cydnee Seneviratne, Catherine Fox, Kaleigh McCartney, Shelley de Boer, and Twyla Ens.

Topics Covered

• Celiac Disease
• Ulcerative Colitis
• Crohn's Disease
• Irritable Bowel Syndrome
• Chronic Pancreatitis
• Hepatitis C
• Advanced Cirrhosis
• Esophageal Varices
• Hepato-Renal Syndrome

Learning Objectives

• Pharmaceutical interventions and nursing considerations/interventions for patients with chronic hematological disorders and conditions that affect men and women are explored

Celiac Disease Diagnosis

• Confirmed with a small intestinal biopsy or a skin biopsy in patients with dermatitis herpetiformis, which is done before starting a gluten-free diet.
• Symptom presentation is a key diagnostic factor.
• Monitor for symptoms disappearing when a gluten-free diet is introduced.
• Irritable bowel syndrome must be ruled out because symptoms are similar.

Celiac Disease Management

• A lifelong gluten-free diet must be maintained.
• Wheat, barley, oats, and rye products must be avoided; pure oats do not contain gluten, but oat products do.
• Treatment includes fluids; serum electrolytes and osmolality should be monitored for dehydrated patients to determine hydration status.
• Monitor intake/output, skin turgor, mucous membranes, and urine specific gravity.
• Assess children's growth and development at each visit.
• Consult a dietician who is familiar with the management of celiac disease.
• Provide education to the family.
• Lifelong compliance to a strict gluten-free diet is essential.
• Identify and treat any nutritional deficiencies
• Multivitamins may be required
• Daily vitamin D and calcium are needed through food and/or supplements.
• Utilizing local, provincial, and national support groups could be beneficial.
• Continuous follow-up with healthcare providers is important.
• Pharmacological nutritional management includes a combination of corticosteroids and a gluten-free diet.

Celiac Disease: Patient Teaching and Planning for Care

• Provide written and verbal instructions on a gluten-free diet.
• Teach parents and clients to read labels, as gluten is found in some medications and many food additives, preservatives, and stabilizers.
• Encourage patients to consume a healthy, balanced diet.
• Avoid cross-contamination when preparing gluten-free food.
• Seek medical advice if a patient develops a celiac crisis.
• Compliance with diet and lifestyle is important.

Celiac Disease: Nutritional Teaching - Gluten-Containing Foods

• Foods to avoid include: barley (flakes, flour, pearl), beer, ale, lager, bread stuffing, brewer's yeast, couscous, dextrin, farro, graham flour, modified wheat starch, oatmeal, oat bran, oat flour, whole oat groats, pastas, rye bread and flour, semolina, and wheat bran.
• Items that may contain gluten: broth, soup, soup bases, burgers, meatloaf, flavored coffee and teas, imitation bacon bits and imitation seafood, medications, sausages, hot dogs, deli meats, sauces, marinades, gravies, seasonings, and soy sauce.

Celiac Disease: Nutritional Teaching - Gluten-Free Foods

• Consume beef, pork, poultry, fish, eggs, milk, cream, cheese, vegetables, fruit, rice, corn, gluten-free wheat flour, puffed rice, corn flakes, and cornmeal.

Disorders of the Lower Gastroenterology Tract

• Irritable Bowel Syndrome
• Inflammatory Bowel Disease
  • Ulcerative Colitis
  • Crohn's Disease

Irritable Bowel Syndrome (IBS): Diagnosis

• Accurate diagnosis through history and physical examination.
• Rule out other disorders via testing, like colorectal cancer, peptic ulcer disease, inflammatory bowel disease, and malabsorption disorders.
• Standardized symptom criteria based on Rome Criteria (Rome III in text).
• Rome IV criteria: Recurrent abdominal pain for at least one day per week in the last three months, associated with two or more of the following: symptoms related to defecation, changes in stool frequency, and/or changes in stool form.

Irritable Bowel Syndrome: Management

• Treatment depends on whether the patient has pain, diarrhea, or constipation.
• Antispasmodic medications reduce muscle spasms, abdominal pain, and cramping.
• Low-dose antidepressant medications may help relieve depression and anxiety.
• Antidiarrheal medications (like Loperamide) can reduce stool frequency and gastric movement.
• Laxatives can improve constipation.
• Prosecretory and analgesic agents increase fluid in the digestive tract and reduce pain sensitivity.
• Prokinetic agents stimulate bowel movement and contractions.
• Dietary fiber intake of 30-40 grams/day may help regulate bowels and reduce diarrhea and constipation.
• Over-the-counter therapies include osmotic laxatives, bulk-forming laxatives (psyllium), and stool softeners.

Irritable Bowel Syndrome: Patient Teaching and Planning for Care

• Identify food triggers by keeping a food diary.
• Inform patients that high-fat foods can worsen symptoms.
• Avoid alcohol and reduce caffeine intake..
• Sorbitol sweeteners may exacerbate symptoms.
• Maintain hydration by drinking water.
• Probiotic supplements may reduce symptoms such as abdominal pain, bloating, and bowel movement irregularity.
• Reduce stress.
• Eat smaller meals.
• Introduce fiber to reduce symptoms.
• Use stress-reduction techniques like acupuncture, deep breathing, visualization, meditation, and yoga.
• Promote a healthy lifestyle and encourage exercise.
• Promote sleep and healthy sleep patterns.
• Peppermint oil may be helpful.

Ulcerative Colitis and Crohn's Disease: Diagnosis of Ulcerative Colitis

• Diagnosis through history and physical examination.
• Procedures include colonoscopy, sigmoidoscopy, and barium enema.
• Lab tests include CBC, ESR, electrolytes, BUN, creatinine, and albumin.
• Stool culture and sensitivity can rule out C. difficile.
• Stool samples are tested to rule out occult blood.

Crohn's Disease: Diagnosis

• Diagnosis through history and physical examination.
• Include CBC and ESR, serum chemistries, and testing of stool for occult blood
• Testing also includes barium enema and sigmoidoscopy, along with a colonoscopy with biopsy

Ulcerative Colitis and Crohn's Disease: Management

• Treatment goals include resting the bowel, controlling inflammation, managing fluids and nutrition, managing patient stress, providing education, and providing symptomatic relief.
• Pharmacological therapy includes:
  • Sulfasalazine
  • Corticosteroids (oral prednisone for mild-moderate cases; proctitis treated with hydrocortisone enemas, rectal foams, and suppositories; monitor for Cushing's syndrome, HTN, hirsutism, and mood swings)
  • Immunosuppressant therapy with cyclosporine and biologics like Infliximab (Remicade)

Ulcerative Colitis: Management - Surgical Interventions

• Surgery is indicated if the patient fails to respond to treatment, has frequent and debilitating exacerbations, massive bleeding, perforation, strictures, or obstruction, tissue changes suggesting dysplasia, or carcinoma develops.
• Surgical procedures can include total proctocolectomy with permanent ileostomy or with ileoanal reservoir.

Ulcerative Colitis: Post-Operative Care

• Involves routine observations for patients who have abdominal surgery.
• Monitor stoma viability, mucocutaneous border (area where the mucous membrane of the bowel is sutured to the skin) and peristomal skin integrity.
• Stoma output may reach 1500 to 2000 mL per 24 hours.
• Intravenous fluid support is important to replace ileostomy losses (more than 1200 ml/24 hours).
• Watch for signs of hemorrhage, abdominal abscesses, small bowel obstruction, dehydration, etc.
• Remove NG tube when bowel function returns.
• Systemic antibiotics are discontinued within 24 hours of operation, and corticosteroids are tapered post-procedure.
• Inform the patient that transient incontinence of mucus may occur following an Ileoanal Reservoir procedure.
• Kegel exercises are recommended to strengthen the pelvic floor and sphincter muscles when safe.
• Perform perianal skin care from the first bowel movement.

Postoperative Colostomy Care

• Assess the stoma, protect the skin around it, select the appropriate pouch, and provide patient education on ostomy self-care to help the patient adjust psychologically.
• Key characteristics of the stoma include color, edema, and bleeding.
• Record the volume, color, and consistency of the drainage.
• Differentiate between ileostomy and colostomy drainage based on the type of liquid.
• Irrigate the stoma, but avoid wiping it to prevent a vasovagal response.
• Teach the patient how to change the stoma, control odor, and recognize signs and symptoms of complications.

Ulcerative Colitis and Crohn's Disease: Nutritional Therapy

• Nutritional advice from the Crohn's and Colitis Canada website:
  • Identify and eliminate trigger foods from the diet.
  • Choose safe foods.
  • Eat smaller, more frequent meals throughout the day.
  • Consider lactose-free products.
  • Reduce sugar and artificial sweeteners.
  • Avoid drinking a lot of fluid during a meal; wait until after eating.
  • Reduce fat intake.
• Patients may require enteral or parenteral nutrition.
• Monitor fluids and electrolyte losses for malabsorption, potentially requiring parenteral nutrition or enteral feeds with high calories and nutrients, lactose-free, and absorbed in the proximal small intestine.
• Patients may require supplemental iron.

Ulcerative Colitis and Crohn's Disease: Patient Teaching and Planning of Care

• Encourage exercise, sports, and activities during remission.
• Manage commitments and encourage patients not to over-commit.
• Find support from a community of individuals or a support group.
• If patients have diarrhea, support them by encouraging them to be clean, dry, and free of odor, facilitate bowel movement management, provide a deodorizer, and encourage meticulous perianal hygiene.
• Reduce stress by using meditation, yoga, and mindfulness.

Other Chronic Gl Disorders

• Chronic Pancreatitis
• Hepatitis C
• End-Stage Liver Disease
  • Cirrhosis
  • Esophageal Varices
  • Hepato-Renal Syndrome

Chronic Pancreatitis Diagnosis

• Diagnosis based on symptoms and includes laboratory studies:
  • Serum and lipase levels.
  • Bilirubin and alkaline phosphatase tests.
  • Presence of mild leukocytosis.
  • Elevated sedimentation rate.
• Stool samples are tested to assess fecal fat content.
• Deficiencies of fat-soluble vitamins, cobalamin, glucose intolerance, and possible diabetes may be found.
• ERCP is used to assess the ductal system.

Chronic Pancreatitis: Management and Planning of Care

• Focus is on controlling, preventing, and managing pancreatic attacks.
• Pain management.
• Control of pancreatic exocrine and endocrine insufficiencies.
• Dietary modifications.
• Pancreatic enzymes supplementation
• Control of diabetes.
• Eliminating alcohol from the diet.
• Encourage smoking cessation.
• Surgery may be needed to remove any duct obstruction.

Hepatitis C: Management

• Prompt treatment initiation may need to occur in patients with advanced liver fibrosis and cirrhosis.
• Direct-acting antiviral agents (DAAs) have fewer adverse effects and are more tolerated, which results in better patient compliance.
• Sofosbuvir (Sovaldi)
• Sofosbuvir/ledipasvir (Harvoni)
• Ombitasvir/paritaprevir/ritonavir/dasabuvir (Holkira pak)
• Daclatsvir (Daklinza)
• Elbasvir/grazoprevir (Zepatier)

Hepatitis C: Patient Teaching and Planning of Care

• There is no vaccine available for hepatitis C.
• Primary measures are aimed at preventing transmission and encouraging early testing if there is concern about exposure.
• Teach patients about universal/standard precautions in high-risk groups.
• Condom use is advised during sexual intercourse with an individual with the Hepatitis C Virus (HCV).
• Do not share personal items.

Advanced Cirrhosis of the Liver

• Esophageal Varices
• Hepatic Encephalopathy

Advanced Cirrhosis of the Liver: Esophageal Varices

• Diagnosed with upper endoscopy.
• Avoid alcohol, ASA, and NSAIDs.
• Nonselective beta blockers (propranolol) reduce bleeding risk by decreasing portal venous pressure.
• treatment for actively bleeding esophageal varices is esophageal balloon tamponade.

Advanced Cirrhosis of the Liver: Management

• Diuretics, such as spironolactone (Aldactone), amiloride (Apo-Amilzide), furosemide (Lasix) and triamterene (Teva-Triamterene).
• Propranolol (Inderal or Nadalol)
• Proton Pump Inhibitor
• Rifaximin (Zaxine)
• Neoyomycin sulphate
• Vasopressin
• Octreotide (Sandostatin)
• Vitamin K

Hepatic Encephalopathy Grades

• Grade 0 (Minimal HE): No clinical manifestations, but some abnormalities on psychometric testing.
• Grade 1 (Mild HE): Alterations in behavior, mild confusion, slurred speech, and disordered sleep.
• Grade 2 (Moderate HE): Lethargy, moderate confusion.
• Grade 3 (Severe HE): Stupor, incoherent speech, and sleeping.
• Grade 4 (Coma): Coma and unresponsiveness.

Advanced Cirrhosis of the Liver: Patient Teaching and Planning of Care

• Health promotion and prevention strategies for the causes of cirrhosis include avoidance of alcohol, management of viral hepatitis and biliary obstruction, as well as addressing obesity and right-sided heart failure.
• Ascites: Patients with ascites who cannot breathe may require paracentesis and albumin infusion.
• Dyspnea: Patients with dyspnea should be placed in semi-Fowler's or high Fowler's position for improved respiratory efficiency.
• Diuretics: Patients taking diuretics need monitoring for serum sodium, potassium, chloride, bicarbonate, and creatinine levels.
• Maintain good skin hygiene.
• Supportive interventions include addressing patient anxiety, monitoring for bleeding in patients with esophageal varices (with preparation for balloon tamponade if needed), and monitoring swallowing and performing oral/nasal care.
• Lab values to watch for in hepato-renal patients.
• Nutritional support should include higher caloric intake with high carbs and moderate-to-low fat levels.
• There may be a protein restriction.
• Sodium restrictions should be in place for patients with ascites and edema.
• Foods high in sodium should be avoided, such as canned soup/vegetables, salted snacks, smoked meats/fish, crackers, breads, olives, pickles, ketchup, antacids and carbonated beverages.
• Patients should be encouraged to read food labels for more info.