ITEMS IN AFP WITH MESH TERM:
ABSTRACT: In addition to pain, patients who are approaching the end of life commonly have other symptoms. Unless contraindicated, prophylaxis with a gastrointestinal motility stimulant laxative and a stool softener is appropriate in terminally ill patients who are being given opioids. Patients with low performance status are not candidates for surgical treatment of bowel obstruction. Cramping abdominal pain associated with mechanical bowel obstruction often can be managed with morphine (titrating the dosage for pain) and octreotide. Delirium is common at the end of life and is frequently caused by a combination of medications, dehydration, infections or hypoxia. Haloperidol is the pharmaceutical agent of choice for the management of delirium. Dyspnea, the subjective sensation of uncomfortable breathing, is often treated by titration of an opioid to relieve the symptom; a benzodiazepine is used when anxiety is a component of the breathlessness.
Evaluation of Constipation - Article
ABSTRACT: Constipation is the reason for 2.5 million physician visits per year in the United States, with more than one half of these visits to primary care physicians. Patients and physicians frequently define constipation differently. To determine the underlying cause of constipation, it is important to evaluate the patient's general health, psychosocial status, medical illnesses, dietary fiber intake, and use of constipating medications. The differential diagnosis of constipation and the approach to its evaluation differ in adults and children. Tests of physiologic function are usually reserved for constipation that does not respond to conventional therapy. Family physicians can effectively manage most patients who have constipation.
Management of Irritable Bowel Syndrome - Article
ABSTRACT: Irritable bowel syndrome is the most common functional disorder of the gastrointestinal tract and is frequently treated by family physicians. Despite patients' worries about the symptoms of irritable bowel syndrome, it is a benign condition. The diagnosis should be made using standard criteria after red flags that may signify organic disease have been ruled out. An effective physician-patient relationship is vital to successful management. Episodes of diarrhea are best managed with loperamide, while constipation often will respond to fiber supplements. Antispasmodics or anticholinergic agents may help relieve the abdominal pain of irritable bowel syndrome. Refractory cases are often treated with tricyclic antidepressants. Newer agents such as tegaserod and ondansetron target neurotransmitter receptors in the gastrointestinal tract Some forms of psychologic treatment may be helpful, and gastroenterology consultation is occasionally needed to reassure the patient. Comorbid conditions such as depression or anxiety should be investigated and treated.
ABSTRACT: Diagnosing a patient who presents with abdominal pain and altered bowel habits can be challenging. Although serious organic illnesses can cause these symptoms, irritable bowel syndrome is commonly responsible. It can be difficult to properly evaluate these patients without overusing diagnostic tests and consultation. A practical approach for diagnosing irritable bowel syndrome is suggested, using the Rome II criteria and the presence of alarm symptoms such as weight loss, gastrointestinal bleeding, anemia, fever, or frequent nocturnal symptoms as starting points. If there are no alarm symptoms and the Rome II criteria are not met, it is acceptable to reevaluate the patient at a later date. If there are no alarm symptoms and the Rome II criteria are met, the patient should be categorized on the basis of age: patients 50 years or younger can be evaluated on the basis of predominant symptoms--constipation, diarrhea, or abdominal pain. Patients older than 50 years should be fully evaluated and considered for gastroenterology referral. If alarm symptoms are present, a full evaluation should be performed (and gastroenterology referral considered), regardless of the patient's age.
ABSTRACT: Constipation is a common complaint in older adults. Although constipation is not a physiologic consequence of normal aging, decreased mobility and other comorbid medical conditions may contribute to its increased prevalence in older adults. Functional constipation is diagnosed when no secondary causes can be identified, such as a medical condition or a medicine with a side effect profile that includes constipation. Empiric treatment may be tried initially for patients with functional constipation. Management of chronic constipation includes keeping a stool diary to record the nature of the bowel movements, counseling on bowel training, increasing fluid and dietary fiber intake, and increasing physical activity. There are a variety of over-the-counter and prescription laxatives available for the treatment of constipation. Fiber and laxatives increase stool frequency and improve symptoms of constipation. If constipation is refractory to medical treatment, further diagnostic evaluation may be warranted to assess for colonic transit time and anorectal dysfunction. Alternative treatment methods such as biofeedback and surgery may be considered for these patients.
ABSTRACT: Constipation in children usually is functional and the result of stool retention. However, family physicians must be alert for red flags that may indicate the presence of an uncommon but serious organic cause of constipation, such as Hirschsprung's disease (congenital aganglionic megacolon), pseudo-obstruction, spinal cord abnormality, hypothyroidism, diabetes insipidus, cystic fibrosis, gluten enteropathy, or congenital anorectal malformation. Treatment of functional constipation involves disimpaction using oral or rectal medication. Polyethylene glycol is effective and well tolerated, but a number of alternatives are available. After disimpaction, a maintenance program may be required for months to years because relapse of functional constipation is common. Maintenance medications include mineral oil, lactulose, milk of magnesia, polyethylene glycol powder, and sorbitol. Education of the family and, when possible, the child is instrumental in improving functional constipation. Behavioral education improves response to treatment; biofeedback training does not. Because cow's milk may promote constipation in some children, a trial of withholding milk may be considered. Adding fiber to the diet may improve constipation. Despite treatment, only 50 to 70 percent of children with functional constipation demonstrate long-term improvement.
ABSTRACT: Persons with mental retardation are living longer and integrating into their communities. Primary medical care of persons with mental retardation should involve continuity of care, maintenance of comprehensive treatment documentation, routine periodic health screening, and an understanding of the unique medical and behavioral disorders common to this population. Office visits can be successful if physicians familiarize patients with the office and staff, plan for difficult behaviors, and administer mild sedation when appropriate. Some syndromes that cause mental retardation have specific medical and behavioral features. Health issues in these patients include respiratory problems, gastrointestinal disorders, challenging behaviors, and neurologic conditions. Some commonly overlooked health concerns are sexuality, sexually transmitted diseases, and end-of-life decisions.
ABSTRACT: Opioid analgesics are useful agents for treating pain of various etiologies; however, adverse effects are potential limitations to their use. Strategies to minimize adverse effects of opioids include dose reduction, symptomatic management, opioid rotation, and changing the route of administration. Nausea occurs in approximately 25 percent of patients; prophylactic measures may not be required. Patients who do develop nausea will require antiemetic treatment with an antipsychotic, prokinetic agent, or serotonin antagonist. Understanding the mechanism for opioid-induced nausea will aid in the selection of appropriate agents. Constipation is considered an expected side effect with chronic opioid use. Physicians should minimize the development of constipation using prophylactic measures. Monotherapy with stool softeners often is not effective; a stool softener combined with a stimulant laxative is preferred. Sedation and cognitive changes occur with initiation of therapy or dose escalation. Underlying disease states or other centrally acting medications often will compound the opioid's adverse effects. Minimizing unnecessary medications and judicious use of stimulants and antipsychotics are used to manage the central nervous system side effects. Pruritus may develop, but it is generally not considered an allergic reaction. Antihistamines are the preferred management option should pharmacotherapy treatment be required.
ABSTRACT: As death approaches, a gradual shift in emphasis from curative and life prolonging therapies toward palliative therapies can relieve significant medical burdens and maintain a patient's dignity and comfort. Pain and dyspnea are treated based on severity, with stepped interventions, primarily opioids. Common adverse effects of opioids, such as constipation, must be treated proactively; other adverse effects, such as nausea and mental status changes, usually dissipate with time. Parenteral methylnaltrexone can be considered for intractable cases of opioid bowel dysfunction. Tumor-related bowel obstruction can be managed with corticosteroids and octreotide. Therapy for nausea and vomiting should be targeted to the underlying cause; low-dose haloperidol is often effective. Delirium should be prevented with normalization of environment or managed medically. Excessive respiratory secretions can be treated with reassurance and, if necessary, drying of secretions to prevent the phenomenon called the "death rattle." There is always something more that can be done for comfort, no matter how dire a situation appears to be. Good management of physical symptoms allows patients and loved ones the space to work out unfinished emotional, psychological, and spiritual issues, and, thereby, the opportunity to find affirmation at life's end.