hello and welcome to part two of drugs that are going to be utilized to treat patients who have specific gastrointestinal disorders if you haven't watched part two uh part one of this lecture make sure you do that part one we really kind of Dove deep into the anatomy of the gastrointestinal system and the process of digestion and I won't spend time doing that here in this online lecture but one thing that I want to kind of make a note of is that the first part of this series really focus in on things that happen to the upper GI tract and so now what we're really going to be focusing in on are things that happen in the lower GI tract or diseases or situations that would plug the lower GI tract particularly the lower small intestine the large intestine the rectum and the colon so we're going to cover things like constipation and diarrhea for example irritable bowel syndrome inflammatory bowel disease just basic flatulence or or and or gas and then hemorrhoids these are all things that your patient may be um more hesitant to discuss or to talk about when compared to the items in the online lecture for lecture one right heartburn indigestion things like that are things that I would come to you and talk to you about and feel comfortable with but things like constipation or having diarrhea might make our patients a little bit more uncomfortable so I've tried to break this up in terms of patient sensitivity and and I will suggest some ways to kind of get our patients to open up about the things that they might be struggling with in this particular part of the online lecture so our first stop is going to be in the area of constipation if someone is constipated that typically means they are producing bowel movements less frequently the research suggests that as we think about how to Define constipation that anyone that has less than three bowel movements per week would be considered constipated now there are extreme versions of constipation where maybe you're not producing bowel movements at all that would be like almost a complete obstruction and so it's going to vary in it there's going to be a spectrum right so we shouldn't all get alarmed if a patient isn't producing more than three bowel movements in a week but there are other also other items to kind of add to that checklist do they have less than three bowel movements per week is that a stool the bowel movements that they are producing is it dry is it hard are they straining to create that bowel movement and do maybe when they finish evacuating do they still feel like there's some part of that left in in their colon that they just can't remove right these would all be checklists and signs and symptoms that a patient might actually be constipated and as you can tell and as I'm talking through this some of these things your patients aren't going to want to come in and talk to you about so it'll become important for you as a healthcare practitioner to create pre-participation physical exam forms that kind of help you get at some of these questions without having to have the direct conversation a question like how frequently do you produce a bowel movement might help you determine who might be at risk for suffering from constipation for example right when you go to the bathroom do you have to strain to produce a bowel movement right that could be a simple yes or no question and those can be ways to indirectly assess whether or not a patient is constipated or has is suffering from diarrhea as well so overall the most common sign and symptom of a patient who's constipated is abdominal discomfort and pain and then the obvious the inability to produce a bowel movement but I actually want to talk about the less obvious kind of signs and symptoms that a patient might present to us with one of those being a headache and then the other of those being low back pain so what we know about the GI tract right the the esophage esophagus is going to dump contents into the stomach the stomach is then go going to the pyloric speaker is going to relax and allow contents to move from the stomach into the Dual denim or a large percent of most of the nutrients are absorbed there and then the food will move progressively through the process of peristalsis and motility will move through the small intestine to the large intestine and then obviously the rectum and the column to be excreted right and so we can see that along the way depending on where the constipated episode actually happens you can your patient can traditionally present with pain anywhere in the abdominal region but most often it's usually in the lower left corner um because that's kind of where that bowel that colon is is actually going to sit at least the descending portion of that colon is actually going to sit but interestingly enough if we look at the anatomy of the patient we can also see that a lot of the abdominal organs or intestines kind of live at the lumbar region so it is possible that if a patient is is suffering from constipation that they could have referred low back pain that has nothing to do with injury and is a sign and a symptom that we're just not cognitively thinking about could be associated with with constipation and similarly your the headache is most often brought on by the backup in the gastrointestinal system so we have to think or rethink about how we might be asking quite historical questions one thing that I want to bring to mind is this image on the slide on the bottom right hand side of this PowerPoint slide some of the triggers for constipated moments not drinking enough water if a patient's dehydrated then the bowel itself isn't um loose it isn't wet and so it is harder to move a hard bowel through the system than it is a very soft very mobile very oily type of bowel right that'd be easier for the intestines to kind of push along so that it can be excreted so drinking water and making sure your patients are hydrated actually reduces the risk of developing constipation over time but stress is another triggering Factor stress has been linked to a decline in peristalsis or decline inactivity or motility of the small intestines and large intestines and so if you're stressed your less your intestines are less mobile which means we're moving things a lot slower through the process then pregnancy and obesity both have been linked to constipation constant pressure in the abdominal region sometimes we tend to move things a little bit slower in the area of pressure or things tend to get stuck in the area oppression so patients who are pregnant patients who are obese most often will suffer from constipation more than those that might be on the lighter side or aren't carrying an infant for example a diet um unhealthy diets have also been linked to the development of constipation so make sure you're eating diets that are high in fiber to kind of create a bulky stool which would move through the GI tract a little bit further uh one thing that we know is that inactivity which is linked to obesity has been linked to constipation activity like when we're running when we're jumping when we're walking it actually shakes right or jars the intestinal system so in essence it's kind of facilitating Mobility or peristalsis facilitating the movement of the kind of the stool to create or produce a bowel movement we know that medications can also be linked to constipation now codeine in particular most medications with codeine have been linked to to um to an adverse side effect which is the development of constipation so oftentimes when patients are taking medications that have Codeine in them their number one adverse side effect is going to be constipation so one of the things that um is great about diarrhea is we'll talk about this when we get there you can actually have patients take over-the-counter um coding based drugs that will then guess what cause the stool to become firmer but in this case in a patient in a patient who is already constipated we want to remove any coding like drugs because it will further facilitate the constipated moment make the stool even firmer making it more difficult to actually release and then last but not least are schedule changes so I'm going to give you an example let's think of your life right now this summer most of you are getting ready to move into an immersion most of you might be working in addition to that oh wait a minute most of you are taking a fully online course and then you might have a life outside of all of those other activities right those things that we add to your schedule make it very difficult for you to build in just social time let alone time to actually sit down on a toilet and to remove or evacuate all of the things that you've eaten for the day oftentimes you have patients who to maybe have packed their schedule so full that they can't go to the bathroom one of the things that I know about myself is I don't feel comfortable actually producing a bowel movement in public I want to be home when I do that right and you'll have patients that are like that too holding that bowel movement and resisting the urge actually increases the risk for development of constipation because you have to strain more right to remove that bowel once you can actually get into a comfortable space to produce a bowel movement so all of these variables are important they are things that are tangible things that we as Healthcare practitioners can certainly change most of these are going to represent Lifestyle Changes right I hope you're seeing that so let's talk we're going to be talking about medications to treat constipation um but before we even talk about medications that can be used to treat um constipation we kind of have to talk about what are the goals of the drug therapy for constipation first right what are the goals like why are we going to give a patient a drug well the the biggest goal is to do what to soften the stool to either make it more oily so it can slide or move through the GI tract more freely right that's ultimately the goal the goal of an oral drug is to do one of those two things add more water into the intestinal system so it can wrap around the substance that's there make it more fluid like and make it easier to move add some oil to that structure so it's more slimy or more gel like or more viscous like so it can move freely through right that's ultimately the goal of oral pharmacol pharmacological drugs but I just said on the opposite side that there are lifestyle changes that also have to kind of go in with the pharmacological treatment so I don't want you to think that the only thing we need to do is find an over-the-counter medication give that to the patient and their constipation goes away there's lifestyle changes that also need to be accounted for in this process and for those of you that wake up thinking you know lifestyle is medicine that life is holistic in nature we have to look at mental health we have to look at psychological stressors right we have to look at diet we have to look at whether or not they're hydrating we have to look at their day-to-day life routine too to see how that's contributing to the development of the constipation that the patient has but with that said the goal of treatment any treatment that we give our patient for constipation is to produce more normal or within normal limit bowel movements right so we want to get to a place to where the patient is at least producing three or more bowel movements a week right and we again we can do that in different ways so let's say pharmacological since this is a pharmacology class and that's why you're here there are three kind of drug categories that we're going to talk about your stool softeners which are probably most commonly used in surgical procedures or a post pregnancy your bulk forming laxatives and then last but not least your hyperosmotic agent so the first one the first category of drugs we're going to talk about are your bulk forming laxatives these are most often going to be powder-based laxatives um mostly comprised of fiber or non-digestible plant products um so example the probably prime example is going to be Metamucil so essentially what happens is you drink this with a lot of water in fact you take most of these bulk forming laxatives with at least eight ounces of water if in fact they are um powder based and so you're going to take it with about eight ounces of water most often if I'm using a bulk forming laxative I'll mix it into the water that the patient has to take if the patient has an aversion to water then I'll usually put it in some Gatorade or some apple juice for a child for example what happens is when we think about the physiology of bulk forming laxatives as the name implies bulk forming what they're going to do is in the presence of water which in the GI tract we have lots of fluid and lots of water they're going to kind of swell and they're going to create they're going to activate and create what's called a gel-like substance or like a viscose a viscous like substance that viscous like substance is going to kind of wrap around right um that the the contents in the stomach and make it kind of slippery for lack of better words and so when that stool is no longer dry and hard and it's wet and it's moist and it's like oily then what we know is through the process of peristalsis and motility it will move smoother through the GI tract right the other thing that bolt forming laxatives do in addition to creating that gel-like structure which will move into the actual bowel itself right the other thing that it does is it will stimulate peristosis and push the stool freely through the GI tract the great thing about forming laxatives is they have a decent onset of action they're more on the slower side so if you're looking to acutely relieve constipation this isn't the type of medication that you would use roughly around 12 to 24 hours before we'll see any movement of the bowel in other words we probably won't see a patient produce a bowel movement until about 12 to 24 hours after ingesting the the bulk forming laxative and again because it forms in the presence of fluid we want to make sure that that patient is taking this type of medication with at least eight ounces of fluid and that's key that's actually an exam question as it relates to your book forming laxatives right now the one key consideration is of all the drugs we're going to talk about today the bulk forming laxatives are the one drug category that have the most interactions with other drugs that we will take the three key drugs that we're going to refer to are the tetracycline the warfin which is a blood thinner and then the aspirin which is also a blood thinner in patients who have maybe high blood pressure cardiovascular disease and are taking one dose per day what this means is your bulk forming laxatives actually decrease the efficacy um and potency of these drugs so if you have a patient who it has a history of taking tetracycline's Warfarin or aspirin then this would not be a laxative for your patient to take does that make sense to wall so you have to ask those questions you know on that history um or physical exam you know how you're asking which drugs are you taking you want to look and see and if that's the case then Metamucil would not be a good drug of choice to relieve constipation in these patients it would but then you would lessen or dampen the effect of the tetracycline the warfarin or the aspirin so both forming laxatives are great they're gonna swell in the presence of fluid which is why we have to take it with a lot of water they're going to make create a gel like substance which will kind of infiltrate the stool make it more slimy or gel like and making it easier to move through the GI tract the next category of um of of us of what am I thinking the next category of drugs that we can use to relieve constipation are going to be stool softeners stool softeners are most often used post-surgically post abdominal surgery um surgery or if your Post delivery whether that's um vaginally or if you even have a cesarean section so stool softeners are the drug of choice in patients where we really don't want that patient straining to produce a stool right so what is a stool softener a stool softener is something that's going to do what what do you think soften the stool right that's the beautiful name of it it is a combination of oil and water so it's a surfactant that oil and water mix when the patient takes either that pill or as you can see down there that powder mixed with water they drink that the interaction of that particular drug with the acidic nature of the stomach will cause it to either rupture if it's a pill or a gel like a structure or will cause it to bind to the HCL and it will produce oil and water and what will happen is that oil and that water will move into the stool and we know oil makes things slippery and it also makes it very soft and so that facilitates movement through the GI tract stool softeners also have a very slow onset of action that are very similar to our our bulk forming um laxatives so we just want to be careful that if the goal is to have a patient produce a bowel movement quickly neither of these would be ideal but what I love about our stool softeners and our bulk forming laxatives is truly this one thing that they allow the body to naturally remove the the struct the the the stool without creating a lot of irritation or inflammation in the body so these are the two drug categories that I like to to naturally recreate um peristalsis and removal of the stool by producing a bowel movement so in my mind they're kind of like the least harmful laxatives on on the market now on this side I have kind of mineral oil question mark it is true if we have nothing else we can't get to the grocery store we can't get to Walmart and we need to kind of soften the stool mineral oil works just as well just keep in mind you don't want to give a patient too much mineral oil right because it can increase toxicity within the body but it's certainly like a little shot of mineral oil with water will do the trick right it's going to move through the GI tract part of that's going to get absorbed but then hopefully the other part that's left over will get absorbed by the stool it will soften the stool and simulate peristalsis and removal of that stool or at least movement of that stool through the GI tract right so that's just kind of a a quick clinical tool Jewel for you all next we have our hyperosmotic agents they really fall into kind of I'll call them two key categories your saline osmotics and and then glycerin the role of the hyperosmotic agents is actually to draw water into the intestinal Lumen into the rectum into the column colon so it's going to draw lots of water into the into those anatomical structures particularly just into the small intestine and when water kind of is allowed to be drawn into the small intestine that water the stool absorbs that water making it very soft and allowing it to become more mobile right through the process of parasol system motility your saline osmotics are very interesting two categories but your saline osmotics think of them as salt osmotics you're basically going to be taking some form of salt which would then attract water into that particular area the great thing about specific forms of saline osmotics is that they're not absorbed in the GI tract so they can sit there and act as a sponge does that make sense and so the three probably top saline osmotics at least saline structures that would be used in an over-the-counter medication that we might purchase would be magnesium citrate and phosphate those are the three that we most commonly see in the drugs that we would buy over the counter if we were using a hyperosmotic agent now one of the great things about hyperosmotic agents is if you need the medication to work quicker then it has a quicker onset of action between one to six hours most of the research that I read however said within an hour that patient's producing a bowel movement that really has to do with the fact that those salts are sitting there and they're just drawing tons of water into the intestinal tract and that water is being absorbed by the stool and that stool becomes softer making it easier to move through the actual di tract so really great um over-the-counter medication to use if you want to rapidly reduce constipation in a patient and then we have glycerin because is a little bit different it's the first drug that we're talking about that's actually a rectal suppository so this is not taken orally in fact we're going to be inserting an enema really the patient you're going to train the patient patient's going to insert the enema of Glycerin and you know glycerin is slippery it's like oil it's going to draw water directly into the rectum and anal region and guess what it's going to soften that stool and then the soils can be removed relatively easy onset of action for your glycerin is less than an hour so we're talking 30 minutes to 45 minutes now this can be very challenging though right number one it is an enema we have to apply it directly to the rectum ideal would be cleaning the rectal region making sure hands are sanitized and then inserting that enema into the rectum while the patient's laying on the left side facilitates kind of the circulatory movement the other challenge is if you're if for example you're traveling maybe you put the enema in before you leave for travel and then let's say you hit traffic well one of the scary things about glycerin is you can't hold it once you have the urge with these laxatives you cannot hold it so glycerin may not be the drug of choice if you're traveling right because you may not be able to get to a restroom in time so those longer onset of action versus shorter onset of action you have to decide what about environmental factors do we have a do we have a restroom available if they do get the urge to have a bowel movement all right next category are going to be your stimulant laxatives as you as the name implies it is going to have a direct effect on the intestinal wall it's going to stimulate or increase um GI tract motility it's going to increase peristalsis so it's going to cause those intestines to crumble up and move your your stool through the system right the thought is that these stimulant laxatives do so by causing increase of water and electrolytes into the intestinal wall again what do you think happens when water enters into the small and large intestines it gets absorbed by the stool the stool becomes soft couple that with increased motility and increase peristalsis and what do you have a bowel movement hopefully the onset of action for most stimulant laxatives is going to be about six to ten hours so somewhere in between right just going to depend it's going to be somewhere in between those kind of bulk forming la laxatives right and so we just have to decide given the timing which of these based on their onset of action would be beneficial for the patient that I have in front of me the most common stimulant laxative that we see over the counter is Ex-Lax and Dulcolax which you can see here on the slide but the inherent reality a few things is maybe we don't want to do a suppository and maybe our patient can't um orally swallow has a gag reflex and can't swallow so in the bottom left right hand corner of this slide what we can see is a stimulant laxative that's capable of being chewed and has flavor so they're chocolate there's vanilla just depends um kind of pick your poison I happen to think the chocolate stimuli stimulant laxative might be a little bit better than a suppository but again suppository you're going to get quick responses right away right so onset of action will vary um a little bit and we'll talk about that I think on the next slide when you see all of the drugs listed together the biggest concerns for your stimulant laxatives is they're the most abused among patients with eating disorders and I'll kind of hit that a little bit more um and they're not recommended for daily use because of how violent they are in terms of in increasing the motility and increasing the peristalsis in fact you can create a diuretic patient a patient who now has diarrhea so we want to be very careful when we're using our stimulant laxatives the other thing that we see is if we take too much of a stimulant laxative it will lead to abdominal cramps again maybe potentially diarrhea and then dehydration within our actual patients so overall what what concerns do we have when we're thinking about having a patient take a laxative whether that's a bulk forming laxative whether that's a hyperosmotic laxative or a stimulant laxative is that all of these because they're increasing gastrointestinal motility and peristalsis they and they the patient may feel abdominal cramping we might even see the development of gas and then the the end of the spectrum would be if they take too much of this diarrhea will develop and then we'll have a patient who's dehydrated over time long-term use of saline laxatives in in particular um because it because remember those saline laxatives are going to draw a lot of the water and the fluid into the gastrointestinal tract can also cause electrolyte disturbances and can lead to dehydration in patients so again your stimulant laxatives and your saline laxatives you just want to be very very careful because they do change water osmosity um throughout and then last but not least with these laxatives particularly the stimulant laxatives you just have to be careful if you have a bulimic patient one of the things that we know is oftentimes they'll eat with with the team for example but then they're like they feel guilty about maybe the number of calories that they had until one way to get rid of that if they don't want to vomit and draw attention is actually through a stimulant laxative right because it's normal for most patients to go to the bathroom not as normal for patients to just be vomiting right after they eat so we have to keep that in mind when we're working with patients who have Eating Disorders or who we suspect have eating disorders now here is a screenshot from your textbook I thought man your textbook does it great I keep saying this over and over again but it is actually a really good study tool for the board of certification examination we talked through really four kind of key classes of laxatives your bulk forming remember it's going to be more of your fiber base it's going to be more powder like for the most part certainly can be found in a tablet form but the one thing that we're concerned about with bulk forming is the onset of action it's relatively long so this isn't something a book forming laxative isn't something that we would use in if we need to relieve constipation acutely right most common bolt forming laxative is Metamucil for sure next we had our hyperosmotic um laxatives or your saline laxatives those are going to be comprised of like your phosphates do you remember that your your citrate would be another example and then you had glycerin which would be the suppository um we can see that those are going to be those are going to be more have a quicker onset of actions so can be used more for a more acute a case where we need to relieve the constipation sooner rather than later we have our stimulant laxatives we talked a lot about the Dulcolax and the Ex-Lax right we can also see that there is a Dulcolax tablet and suppository and we can see that if we put it in the rectum then the onset of Act of action drastically drops right so when we go directly to the area we can see the onset of action will drop completely and then we have our our stool softeners which again are going to be used mostly post-surgical whether that be delivery of a patient or a abdominal surgery we can see again your stool softeners depending on which one your Colace is going to take a little while to do some bowel movement which is okay after surgery you don't want necessarily after a um a very catastrophic abdominal surgery to have a bowel movement because we want to allow those muscles to relax a little bit but then you can see again that your enemies you can use an enema and then that stool will move quickly so what am I saying here with lots of laxatives available to us over over the counter we have to decide do we want something that's going to acutely increase motility and peristalsis and cause a bowel movement we have to consider the environment we're in do we want something that's going to be takes a slower time to have an onset of action but might mimic what would really happen in the body and cognitively allow us to process that and so these are the four categories and you'll have to decide the key thing for you as athletic trainers is knowing okay Metamucil that's a bulk forming it's going to take a little while it's going to Act Naturally within the body it's going to draw some water in and soften the stool oh a stool softener oh man probably would never really use that because that's really used post-surgically right your stimulants big concern is going to be patients with eating disorders making sure that if you have a patient taking a stimulant that they're actually using the stimulant laxative to decrease constipation not to get rid of good key nutrients that we actually need so those are the four categories of laxatives next we're going to talk about diarrhea the opposite of constipation so you have increased frequency of bowel movements but oftentimes it's not just about increasing the frequency of the bowel movements it also has to do with the consistency of the bowel movements right we know that the ideal would be a hydrated kind of firm bowel that gets excreted oftentimes with diarrhea usually diarrhea they really can't see any structural Integrity to the actual bowel that that they're producing right or stool that they're actually producing so we want to keep that in mind when we're looking at differentials it's not only just frequency but it's also consistency of the stool there are two different types of diarrhea there's acute which would occur one day after being exposed to a bacteria or a virus or some type of cold right and it will last two weeks after two weeks of treatment uh two two weeks of maybe being on a brat diet we'll talk about that the the diarrhea should resolve itself so if it doesn't then we move into something called chronic diarrhea which lasts lasts longer than than two weeks right some of the potential causes for diarrhea are I mean there's a lot but in what we typically will see is a bacterial infection so food for example maybe went out of the country and you ate food and you got Salmonella poisoning right or you drink water right um what we see is that that bacteria will produce toxins those toxins will then impact the gastrointestinal wall and guess what increased peristalsis and motility and that's protective right in other words we have this pathogen invading our gastrointestinal tract what do I want to do I want to get it out so guess what motility increases um you have peristalsis increasing and we move things quick too quickly so we don't have enough nutrients being absorbed but we're getting everything out of the system and that's protective in nature so what are the signs and symptoms of diarrhea obviously increased frequency of stool but what we also see is um burning in the rectal region especially if what's coming out is extremely acidic right abdominal cramping maybe even gas can also be associated with that now we're going to talk about medications that can medication classes that can be used to treat diarrhea but before we even do that what are the goals of treating diarrhea that's really what it boils down to big thing in diarrhea that we're not necessarily concerned with in constipation is dehydration of the patient because not only are they losing water but they're also losing electrolytes and that's going to impact their acidic basic kind of um homeostasis so we have to keep that in mind like really we're not concerned with the actual stool that they're losing but with that you all know I'm sure most of us have had diarrhea at some point in time in our life as it comes out there's water and there's electrolytes that are being lost and so the real goal is to restore hydration in our patient while we're trying to also combat um combat the diarrhea at the same time so we want to identify the threat and the cause if that's bacterial we want to put them on an antibiotic right away right if that's antiviral then it just has to live its course and then we want to provide symptomatic relief and that's where drug therapy is going to to come in right we have to figure out what the cause is and then we have to use drug therapy to treat the patients so the first class of drugs are the opioids you'll remember in the constipation section I talked a lot about how opioids would contribute to constipation so in a patient who has diarrhea we actually want to give them opioids because one of the things that your gastrointestinal tract has are these EU opioid receptors and so these opioids attach to the EU opioid receptors mu opioid receptors and they slow down the motility of the gastrointestinal tract what does that mean it means that if we're slowing down how fast something is moving through the digestional tract we have more time for it to become firmer right or more solid in nature and that reduces the diuretic moment and creates a stool that would be considered normative per se now the difference between the opioids used to treat diarrhea and those used to treat pain is that these particular opioids aren't designed to kind of cross the blood brain barrier in other words they're not going to travel to the brain and have an impact there so we're not concerned about abuse of these particular medications or addiction to these particular medications the most common type of opioid anti-diuretic medication that we see on the over-the-counter is imodium but lomatil as well and the biggest side effects associated with the opioids in in terms of antidiuretic medications going to be dry mouth so make sure you're drinking a lot of water and dizziness and then obviously skin rash Now problem probably the most commonly used over-the-counter medication for diarrhea is going to be Pepto-Bismol or bismuth sub salicylate say that a few times Pepto-Bismol was often utilized in patients who have diarrhea interestingly enough one of the things that they're finding in the research is that Pepto-Bismol kind of has to it some type of like antibiotic effect and so it helps fight off bacterial infections associated with like food poisoning for example example the other thing that we know is that when Pepto-Bismol comes in contact with acid it's broken down into salicylic acid and that salicylic acid is an anti-inflammatory so it also helps reduce any inflammation within the gastrointestinal tract so it kind of has this kind of two twofold kind of treatment it's helping with any bacteria that may have been invaded and it also has an anti-inflammatory effect so all in all Pepto-Bismol is a safe drug to use a safe safe drug of choice to use for patients who have diarrhea the other thing that we know about Pepto-Bismol is it has a short onset of action and a short half-life and so it can be taken almost up to eight times per day one of the things that I experience in the clinical setting particularly with the Pepto-Bismol tablets and I put this on there intentionally to remind me to tell you that when a patient chews the tablets oftentimes there may be an acidic reaction that's happening in the throat region posterior tongue region and it may tongue the turn the patient's tongue black and so patients will like panic and you'll will forget forgotten that you gave them Pepto-Bismol and you'll send them to the ER and then the physician will be laughing at both of you so all that to say sometimes when Pepto-Bismol gets broken down into salicylic acid if that happens before it hits the pharynx if it happens in the posterior throat or posterior tongue you may see a black kind of tongue and that is well within normal limits we do not have to amputate all right moving forward to um two kind of syndromes or diseases that we want to talk about the first one is irritable bowel syndrome there are kind of really if we look at it three different types or forms of irritable bowel syndrome we have irritable bowel syndrome D which is for diarrhea irritable bowel syndrome C which is for constipation and irritable bowel syndrome mix which means the patient wavers between states of constipation and diet diarrhea the moral of the story is the bowel is irritated right so for some reason in this particular group of patients the colon is more sensitive to stimuli that stimulates peristalsis that stimulates movement or motility and so you see a patient who suffers from diuretic impulses and the in what's interesting about this is it's linked to several different things and so there isn't one causative Factor it can be diet it can be hormonal then I'm going to spend maybe a second talking about this we know about irritable bowel syndrome is that females tend to suffer from that more and that's linked to hormonal changes in the female cycle so if you if you look at patients that have irritable bowel syndrome most of them are going to be female the other thing that we see associated with the development of irritable bowel syndrome is it's linked to psychological and emotional stress so patients who suffer from anxiety and or depression or other mental health diseases oftentimes this triggers the bowel to become irritable right there's maybe more motility um and more movement or peristalsis and so you have diarrhea or the opposite let's say you're depressed and it slows down the motility and then you have a constipated moment Foods also have been linked to irritable bowel syndrome D or diarrhea particularly those that are inflammatory in nature I love onions like I can put onions on every single thing in the world just about and but what I do know is that when the GI tract breaks down onions it produces kind of an inflammatory effect now the great thing is that most of the time if your GI tract is intact it will move those onions through the system relatively quick but foods that are really produce acids and become inflammatory onions for example caffeine for example and then you have alcohol and dietary fat which actually may slow down the motility of your GI tract so we can see there are certain food triggers that would would cause an irritable bowel and create irritable bowel syndrome so we can treat this different ways right it depends if the patient has ibsd and diarrhea then we're going to use anti-diuretics right the patient has irritable bowel syndrome constipation then we're going to use a laxative so it's really going to depend on the signs and symptoms that a patient is actually presenting with now irritable bowel syndrome isn't something that goes away most often it is a lifelong kind of syndrome that the patient has to figure out how to navigate if we go back to some of the slides we would then say what lifestyle modifications do we need to make for this particular patient to make sure they have a less episodes of diarrhea or constipation or a wavering of of the tube the next disease we'll talk about is inflammatory bowel disease so let me move my face out of the way so we're talking inflammatory bowel disease which is different than irritable bowel syndrome and here's how with irritable bowel syndrome that is treatable in other words we can give medications and the signs and symptoms will go away most often sometimes if we can make the lifestyle modifications we can resolve irritable bowel syndrome but with inflammatory bowel disease this is a lifelong disease that sometimes actually requires surgery and also lifestyle modifications and there isn't one drug per se that the patient's going to take that will resolve this issue right so this is why it's termed inflammatory bowel disease because that's a lifelong syndrome we can usually resolve a disease most often we can't so the two that we're going to talk about the two that fall into this category are Crohn's disease and ulcerative colitis and as her name implies they are different different disease processes what we do know is they most often have been linked to genetics and then also to a deficiencies and so will we think they're linked to are different autoimmune inefficiencies so with crohn's disease this is an inflammation of the actual digestive tract is going to impact both the small and the large intestine and it will impact all of the layers of the actual intestinal wall one of the things that Physicians look at to kind of rule out Crohn's disease or ulcerative colitis is they also look at whether or not the the lesions right the little craters in the anatomical regions are continuous and consistent or not in Crohn's disease think C Crohn's continuous they are not continuous so what does that mean it means when you maybe do an MR and you're looking for um craters in the gastrointestinal wall you might have some that maybe start in the ascending colon you have a few here then you have some in the transverse colon then you have some in the descending colon so forth and so forth so on they're not continuous in Crohn's disease which makes it such a challenging disease to care for so we can isolate it it's easy surgically we can kind of remove just a little piece and move forward but when a patient has Crohn's disease and has several different lesions in different regions it makes it hard because then we have to remove some of the transverse colon some of the ascending calling and some of the descending colon so Crohn's not continuous ulcerative colitis on the opposite end of that is impacting a different anatomical region colitis the colon and the rectum so it's the most descending part of the the colon it's right where we're getting ready to expel our stools right this part becomes impacted and unlike Crohn's disease believe it or not the lesions are very continuous which means they're in the same region so you might have lesions on this side or you might have lesions here you might have lesions here but they're continuous they're connected making it easier to treat surgically right because we can cut out a piece of the colon or the rectum right and hopefully resolve the the issue now these two diseases are lifelong diseases I've said that and yes we can use drugs to kind of treat the lesions maybe even if we were to go back to the sulf crates where we could have them take a drug that would kind of seal in right that the hole that might resolve some of it but for the most part patients you typically have to have surgery to cut out the lesions so this is um a rare disease most often not diagnosed right away because it presents like stomach pain or abdominal cramping right or maybe they're assuming they have constipation or diarrhea and so sometimes it gets missed until there's actual Imaging involved so if you have a patient this is what we say if a patient who's been taking laxatives or antidiarrheal drugs for more than two to four weeks then you kind of want to refer out and just make sure we're not missing either an irritable bowel syndrome or an inflammatory bowel disease right so what are some of the drugs that are going to be used to treat the irritable bowel syndrome first the Mainstays of irritable bowel syndrome treatment are going to be listed here so it's going to be a combination of antidiar diarrheal meds and constipation mids right it's going to depend on which form of irritable bowel syndrome the patient actually has right if it's D then we want to take those anti diarrheal meds that opioids the absorbance right if it's C constipation then the forming laxatives tend to be pretty good you can do a stool softener and in some ways the antidepressants reduce motility reduce motility but more importantly not even just the reducing of motility which would facilitate constipation one of the things we know is that depression is often linked to constipational moments and irritable bowel syndrome so we want to resolve the depressional moment first so that the GI tract can do what it's supposed to do on this side of the slide we have drugs that are going to be utilized to treat the um bowel disease right so the inflammatory bowel disease so if we were to go back to this slide we said inflammatory bowel disease lifelong so because there's an inflammatory response happening whether that's Crohn's disease or ulcerative colitis we have to do something to drop the inflammatory response right and so you'll see a lot of the drugs listed here for inflammatory bowel disease have what in them some sort of anti-inflammatory medication to reduce the inflammation in the injured areas of the GI tract right so most common drug used to treat inflammatory bowel disease is going to be Humera the other one is Flagyl those two are the most commonly prescribed drugs used to treat inflammatory bowel diseases now let's talk about exercise induced problems most Runners long distance Runners are going to be more apt to suffer from exercise induced um problems particularly diarrhea seems to be the number one side effect of patients who run for distance at a fast pace um so why is that it's because most Runners typically will run in the morning to avoid the Heat and so they haven't emptied their bow yet until you have all of your stool just sitting there waiting to be released you start shaking it and it just wants to to come out the other thing that we know about racing is when we race when we exercise a lot of the blood is drawn away from the intestines into the musculoskeletal system seems to make sense but then when we stop guess what happens oh that blood goes back to the area that was deprived the GI tract so we'll see and sometimes in great cross-country Runners they'll lose their bow after the race for example and so that will happen and that is absolutely normal we just have to figure out how to manage that right what if we need to have them take some type of anti-diar diuretic medication prior to running if this happens constantly and then the other thing that we've seen is the development of GERD in patients that um run a lot occurs more frequently during exercise than at rest so what's the reason for that think about it we're running we're jumping we're hopping we're doing all these things and so we'll start to see is um that will apply pressure to the lower esophageal sphincter it might cause the lower esophageal sphincture to relax just a little bit and so then you get a little bit of a backsplash from the stomach of the stomach contents into the actual esophagus itself so it's possible what am I saying when patients exercise even though exercise is great it can cause some of these GI tract uh problems we just have to be able to identify them and baseball I don't have to educate our patients that these this is a normal process right okay let's talk hemorrhoids yay hemorrhoids first we have to know Anatomy the beautiful thing about the anatomy is we can see this here we have veins that kind of surround we have veins and arteries that surround the rectum and give it great blood flow right when we think about hemorrhoids we have hemorrhoidal kind of veins that's what we call them hemoridal veins we have internal and we have external veins right it would make sense we have to supply the skin um of the area that we sit on right so when we think about hemorrhoids hem the hemorrhoids are inflammation of or engorgement of those hemroidal veins either internally and or externally if it's internally you'll see the the polyp develop inside of the rectum and then if it's external hemorrhoids then you know the more common form of hemroids we'll see the polyps developing on the outside or the external portion of the rectum those are the ones that are actually visible to the human eye what are some of the common causes I'm going to summarize this and just say it's pressure any type of pressure are being placed on the rectum that would kind of squeeze the vascular system is going to cause hemorrhoids or straining right so heavy weight lifting for example I'm sure you've seen a few commercials where you have those Olympic weight lifters who then go to squat and then hemorrhoids just drop out right um so any type of straining the other thing that we see is a patient who's constipated it'll sit in the rectal area kind of increasing and causing engorgement and stimulating hemorrhoids what we see most often is patients with diarrhea the acid irritates the rectal pathway and stimulates in swelling in the hemroidal region and so you'll start to see the development of hemorrhoids all that to say hemorrhoids are no fun if you haven't had them they are not they if they're external they bleed they're very painful if they're on the external surface they get really itchy and dry some of them will protrude the internal ones if they the polyps get large enough will protrude externally and so you'll start to see seepage right on the undergarments of the patient so hemorrhoids are an extension of the rectum so in and of itself that already creates an environment that isn't sterile because you're going to have some feces on those hemorrhoids so it makes it when you're thinking about how to treat them corticosteroids are going to be extremely important over-the-counter sometimes we see patients put over-the-counter lubricant or anti-inflammatory kind of gels and rub it to reduce but most often sometimes you can't resolve it with your over-the-counter creams or oral cortical steroids or anti-inflammatories and so Physicians will have to go in and surgically excise some of those polyps so you'll have to decide now you're all probably thinking like well do we have to look at our patient's rectum most often we can have the patient feel but yeah there may be a time where you may have to or if you feel uncomfortable refer it out right okay the last drugs on our stop are drugs used to treat gas or flatulence right that flatulence that also happens too so when we think about intestinal gas that could be belching that could be flatulence or passing gas right there are many ways that we excrete gas in our body the two most common ways are going to be belching and then also flatulence right those are the two most common ways we see gas most often happen after we drink some type of gaseous structure substance example would be like a soda we see flatulence happen most often after meals and we're going to talk about specific foods that would probably increase flatulence I.E beans or broccoli right green like substances but how does gas arise most often we can swallow it gulp it right that would be an example we also have just inter um interluminal gas production that just happens naturally and then we have diffusion of gases across blood so some of this is going to happen naturally some of this is going to happen um from us doing things that we probably shouldn't be doing so swimming for example you take a deep breath you go underwater you're trying to stay underwater and you start to swallow your own air right we've all done that that produces gas in the body but what do we do when the gas makes us uncomfortable when our stomach starts to hurt right or if we're holding our flatulence because we don't want to let it go and our stomach starts to hurt so what do we do with people who are more gassy than not there are two over-the-counter types of drugs that a patient can use and you have to understand the difference between the two there's gas X and there's bino I'm going to start with bino first because it's actually the more intuitive one for us to understand be no as the name implies b-e-a-n being associated with food so when the gas is associated with food when a patient's gas is associated with food then bino is the drug of choice most often it's usually associated with green leafy vegetables beans and peanuts whole grains like whole wheat so anytime a patient has gas after eating something then most often you're going to give them or ask them to take bino it's going to help prevent gas associated with ingestion of food Gas-X on the other end of the spectrum is the opposite it's a degasser so if the gas isn't associated with food and then maybe it's associated with the fact that you're producing gas bubbles or you're gulping air for example it's gonna it's an anti-foaming agent which will break down the gas bubbles and reduce the the flatulent or um burping episodes that we have so those are the two different types both are available over the counter you'll have to decide you can do pill form you can do as you can see here a liquid form where you drop it into a drink before eating most of these are going to be taken before eating or before a meal specifically your Beano to reduce gas after eating a meal it's kind of like lactose in some regards so all of this to say we're concluding this lecture of gastrointestinal drugs and I hope that this has been helpful I hope it makes you see things from a different perspective what I'm also hoping is that it makes it easier for you to have these kind of I don't know awkward conversations that our patients probably wouldn't want to have with us but what are you supposed to do you have to rule out any other underlying disease right an example of that would be inflammatory bowel disease right cancer for example we want to figure out what the frequency and duration is of that GI complaint when's the last time they've had a bowel movement how often do they have bowel movements what is the context structuring of their stool when they do have a bowel movement right then we want to get a complete patient history we want to find out if there's any history of autoimmune disease right any history of gastric intestinal ulcers are they taking NSAIDs which would contribute to peptic ulcer disease and then if a patient has been medicating for more than a week or so then we want to refer out to make sure we aren't missing anything all in all most of the things that we talked about in these two online lecture lectures can be treated over the counter in fact what we know I'll end with this one little nugget the most utilized over-the-counter drugs we just covered the anti-inflammatory drugs guess what the second most utilized over-the-counter drug is you got it it is your laxatives your anti-diarrheal and your gas medications so while you don't have to be experts at knowing dosing what you do have to be experts at knowing are the groups or the categories of drugs and which ones might be better given the environmental setting I hope this has been helpful thank you so much for following along have a wonderful week