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Vomiting Diarrhea And Constipation

Constipation Vomiting, diarrhea, and constipation are among the most common complaints of patients presenting to emergency departments. Gastrointestinal dysfunction is the final common pathway for a variety of diseases. Therefore, many patients complaining of vomiting, diarrhea, or constipation have a cause for their symptoms remote from the gastrointestinal system. Emergency physicians must consider not only the gastrointestinal emergencies manifested as vomiting, diarrhea, or constipation but also the nongastrointestinal emergencies manifested as gastrointestinal dysfunction. An important and often difficult step in the evaluation of patients with vomiting, diarrhea, or constipation is having the patient define the illness. The layperson's definitions of vomiting, diarrhea, and constipation often differ tremendously from the medical definitions. For example, patients often say vomiting when they really mean coughing up sputum. Some patients complain of constipation and mean that...

Docusate sodium Colace

Senna (Senokot, Senna-Gen) 10-20 mg kg PO PR qhs prn (max 872 mg day) granules 362 mg teaspoon supp 652 mg syrup 218 mg 5mL tabs 187, 217, 600 mg F. Sennosides (Agoral, Senokot, Senna-Gen), 2-6 yrs 3-8.6 mg dose PO qd-bid 6-12 yrs 7.15-15 mg dose PO qd-bid > 12 yrs 12-25 mg dose PO qd-bid granules per 5 mL 8.3, 15, 20 mg liquid 33 mg mL syrup 8.8 mg 5 mL tabs 6, 8.6, 15, 17, 25 mg

TABLE 1235 Acute and Chronic Constipation

In older children, one should not automatically think that the cause is functional. Constipation is seen in children who are anorexic or who have cerebral palsy, neuromuscular disease, dehydration, hypercalcemia, hypokalemia, hypothyroidism, or depression or who have ingested drugs such as diuretics, antihistamines, anticholinergics, or narcotics. A thorough history and physical examination, including rectal, are necessary. An empty rectal vault does not rule out constipation. If there are signs of bowel obstruction, tumor, or serious illness, one should consult an appropriate specialist. Acute constipation is treated by increased oral fluids and possibly a stool softener or milk of magnesia. Chronic constipation is treated in three separate steps, and follow-up with a primary care specialist is important. The steps are cleanout, maintenance, and behavior modification.

Functional Anorectal Disorders Constipation

There is a large variation in stool frequency between individuals and infrequent bowel actions in the absence of symptoms can be regarded as part of the normal spectrum of bowel function. However, constipation is a symptom that may affect a quarter of the population at some time and patients with decreased bowel frequency or impaired rectal evacuation have impaired quality of life and consume a large amount of healthcare resources. Many different processes can result in the final common symptoms of constipation and no single treatment will be effective across the board. The multidiscipli-nary team approach is valuable in the management of difficult constipation. For people with mild longstanding constipation investigations are not required, and dietary management is usually sufficient to relieve symptoms. When chronic constipation is more severe, detailed consideration of likely causes and other treatments is warranted. Psychological morbidity, such as depression is commonly...

Constipation and Hemorrhoids

Pregnant women often develop constipation, most frequently during the latter stages of pregnancy. It is caused by reduced gut motility, physical inactivity, and the pressure exerted on the bowel by the enlarged uterus. The weight of the fetus and the downward pressure on the veins can lead to hemor-rhoid formation. These conditions can be treated with increased consumption of high-fiber foods and dried fruits and higher fluid intake. Bulk-forming laxatives can also be used however, there is a risk of alterations in electrolyte absorption with chronic use of laxatives.

TABLE 794 Medicinal Adjuncts Used in the Treatment of Constipation

In its extreme form, functional constipation can result in a variety of potentially life-threatening complications. Fecal impaction and intestinal pseudo-obstruction are two sequelae of which the emergency physician should be acutely aware. Fecal Impaction Patients with fecal impaction must be disimpacted manually prior to leaving the emergency department. Manual disimpaction is not a glamorous procedure, and, as a result, many physicians avoid doing it. This is unfortunate, since enemas the alternative therapy rarely work for fecal impaction. It must be remembered that manual disimpaction can be a painful procedure for which patients at times require sedation. After disimpaction, a host of medicines may be used to assist the patient in achieving normal fecal flow ( T ble 79 4). The agents listed in the table start with the least potent and end with the most potent. Intestinal Pseudo-Obstruction Intestinal pseudo-obstruction is a condition seen in patients with a long-standing history...


Constipation occurring after birth but within the first month of life suggests Hirschsprung disease, hypothyroidism, or anal stenosis. The diagnosis of Hirschsprung disease is supported by absence of feces on rectal examination and abrupt change in bowel luminal size on barium enema and is confirmed by a rectal biopsy demonstrating absence of ganglion cells. Infants with hypothyroidism present with feeding problems a weak, hoarse cry hypothermia hypotonia and peripheral edema. The child should be admitted for further evaluation and treatment.27

Finding endometriosis in unexpected places

I have seen some strange cases where pelvic endometriosis causes seemingly unrelated symptoms. A patient had right-side pain at the level of her umbilicus (belly button) and multiple intestinal symptoms, such as nausea, constipation, and pain after eating. She had a previous diagnosis of irritable bowel syndrome (IBS) or some other inflammatory bowel disease, but when she didn't receive any relief from other

Physical Examination 231

The urologist will be better able to make use of modern diagnostic tools and management algorithms in a purposeful manner once the urologic history and physical examination are complete. They should not be bypassed. A prospective controlled study addressing the predictive value of abdominal examination in the diagnosis of abdominal aortic aneurysm, for instance, reported a negative predictive value higher than 90 for aneurysms of 4 cm and a positive predictive value over 80 for those larger than 5 cm (Vendatasubramaniam et al. 2004). Another group (van den Berg et al. 1999) compared the detection of groin hernia by different diagnostic tools and physical examination. Interestingly, physical examination achieved a sensitivity of 75 and a specificity of 96 . In patients with acute abdominal pain (Bohner et al. 1998), the variables with the highest sensitivity for bowel obstruction were distended abdomen, decreased bowel sounds, history of constipation, previous abdominal surgery,...

TABLE 2314 Symptoms and Signs of Hypercalcemia

A mnemonic sometimes used for the signs and symptoms of hypercalcemia is stones (renal calculi), bones (osteolysis), moans (psychiatric disorders), and groans (peptic ulcer disease and pancreatitis). The most common gastrointestinal symptoms are anorexia and constipation, but these are very nonspecific.

Table 22 Important clinical factors in the diagnosis of thyroid cancer

Past medical history include symptoms of pheochromocytoma or hyperparathyroidism, long-standing constipation and or diarrhea, hypertension and or episodes of nervousness. These should alert the clinician to the possibility of thyroid carcinoma in association with a familial MEN syndrome.

Chronic Pain in the Elderly

Elderly patients frequently complain of chronic pain. Unfortunately, many of the commonly used medications for pain have higher complication rates in the elderly. In particular, the nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with higher rates of gastrointestinal bleeding and renal disease in the elderly. Opioids also may cause debilitating sedation and or constipation in the elderly however, opioids may have less debilitating side effects than NSAIDs. Doses of many agents should be reduced when treating the elderly, to avoid side effects, and it is essential that a follow-up plan be in place at the time of discharge. There is a perception that the elderly are undermedicated for pain control. While this may be true, the elderly do not seem to be undermedicated more than other age groups. 14

Practical Management of Eating Difficulties

Anorexia (loss of appetite) is often associated with other eating difficulties, such as nausea, taste changes, and constipation, and addressing these problems may improve the patient's appetite. Pain may also contribute to anorexia, and regular analgesia for pain may in turn help improve appetite, as may dietary alterations (Table 2). For patients who have severe anorexia, an appetite stimulant should be considered, such as dexamethasone, medroxyproes-terone acetate, or megestrol acetate.

Natural Infections

Although infection may be asymptomatic, symptomatic disease typically follows a predictable course. Clinical signs at the onset of disease in horses and sheep are nonspecific excited or depressed behavior, hyper-thermia, anorexia, jaundice, constipation, and colic. Classical disease becomes apparent within 1 or 2 weeks. Animals maintain an upright, wide-based stance with their heads extended. Repetitive behaviors are common and may include vacuous chewing, circular ambulation, and running into obstacles. Horses become paretic in the terminal phases of disease. A distinctive decubitus posture associated with paddling movements of the legs has been described. Frequently, in late disease, the virus migrates centrifugally along the optic nerve to cause retinopathy and visual impairment. Acute mortality may be as high as 80-100 in horses and 50 in sheep. Sheep that survive may have permanent neurologic deficits. Recurrence of acute disease has been described in sheep. Natural symptomatic...

Clinical Presentation

Celiac disease may present in a wide variety of ways (Table 1). In children, the onset of celiac disease is classically described as occurring within the first to seventh year of life with the introduction of cereals to the diet. Symptoms may vary with the age of the child at onset of disease. Young children may develop chronic diarrhea, failure to thrive, muscle wasting, abdominal distension, vomiting, and abdominal pain. Older children may present with anemia, rickets, behavioral disturbances, or poor performance in school. In some children constipation, pseudo-obstruction, and intussusception may be seen. It has been estimated that 2-8 of children with unexplained short stature may have celiac disease. Dental enamel defects involving secondary dentition as well as Monosymptomatic - anemia, diarrhea, lactose intolerance, constipation

Pharmacological management

The two single dose studies of diamorphine and dihydrocodeine respectively in patients with chronic heart failure suggest improvement in abnormal ventilatory patterns. The pilot study was a randomized placebo controlled cross-over study of 10 patients with NYHA III IV symptoms.43 Patients were recruited from a heart failure clinic and randomized to receive oral morphine or placebo. Patients were given 5mg of morphine four times a day in the active arm, or dose reduced to 2.5mg four times a day if the serum creatinine was greater than 200mcmol l. Patients with a peak flow less than 150l min or a serum creatinine greater than 300mcmol l were excluded. On morphine, median breathlessness score (Visual Analogue Score 0 - 100mm) fell by 23mm (p 0.022) by day 2, and this improvement was maintained. Sedation scores increased until day 3, reducing on day 4. Four patients reported constipation on morphine compared with one on placebo, but there were no other differences between the two arms in...

Large Bowel Obstruction

A carcinoma is the leading cause of large bowel obstruction, while volvulus and diverticulitis account for most of the remaining cases. All of these precipitating conditions are more common in the elderly. The overall mortality rate approximates 40 percent. Distention is common, vomiting and constipation are reported in about half the patients. Importantly, a significant percentage (up to 20 percent) will report diarrhea. A history of rectal bleeding, altered bowel habits, or weight loss may be present with underlying carcinoma.12 The pain is usually gradual in onset however, cecal volvulus can present with the acute onset of severe, colicky pain. 17 Sigmoid volvulus is two to three times more frequent than cecal volvulus and more commonly presents with a gradual onset of pain.18 Fever or the presence of peritoneal irritation suggests a perforation or gangrenous bowel.

Clinical Features

The most common symptom of diverticulitis is pain. This is commonly described as a steady, deep discomfort in the left lower quadrant. Patients will frequently complain of a change in the bowel habits, either in the form of diarrhea or increasing constipation. Tenesmus is another common symptom. The involved diverticulum may irritate the bladder or ureter, causing the patient to have urinary frequency, dysuria, or pyuria. If a fistula develops between the colon and the bladder, the patient may present with recurrent urinary tract infections or pneumaturia. Paralytic ileus with abdominal distention, nausea, and vomiting may develop secondary to intraabdominal irritation and peritonitis. Small bowel obstruction may also occur as adjacent loop of small bowel becomes kinked or narrowed in the inflammatory mass.

Differential Diagnosis

Symptoms of irritable bowel syndrome include diffuse crampy or colicky abdominal pain, brought on by meals or emotional upset. The patients may also describe a bloated or distended sensation in the abdomen. The symptoms are usually intermittent and chronic. The passage of flatus or a bowel movement may bring relief. The disease is characterized by alternating bouts of constipation and diarrhea. On physical examination, the patient is afebrile and a cordlike mass may be appreciated in the left lower quadrant corresponding to the sigmoid colon. Signs of localized or generalized peritonitis are not seen. Laboratory studies are normal. Patients who have colon carcinoma may present with a change in bowel habits, either diarrhea or constipation, and or abdominal pain that can mimic symptoms of diverticular disease. There may be blood mixed with the patient's stools, and weight loss. Physical examination may reveal a palpable mass, usually nontender. Fever and chills are less common, and...

Chapter References

Sonnenberg A, Koch TR Physician visits in the United States for constipation 1958 to 1986. Dig Dis Sci 34 606, 1989. 21. Romero Y, Evans JM, Fleming KC, et al Constipation and fecal incontinence in the elderly population. Mayo Clin Proc 71 81, 1996. 22. Abyad A, Mourad F Constipation Common-sense care of the older patient. Geriatrics 51 28, 1996.

TABLE 827 Diagnosis and Treatment of Spontaneous Bacterial Peritonitis

To appreciate the presence or worsening of baseline encephalopathy, one must determine the patient's underlying functional status. Questions related to changes in personality, worsening dementia, alterations in level of consciousness, and neuromuscular function should be pursued. The staging of hepatic encephalopathy is outlined in Table.82-8. Asterixis characterizes stage II and is a manifestation of neuromuscular weakness made evident when the patient tries to maintain a certain posture. Typically, the hands begin to flap when the patient is asked to hold the hands up and extended at the wrist (stop traffic). Alternately, the tongue moves back and forth like a snake when the patient is asked to keep his or her tongue extended. Serum ammonia level is often measured in this setting and is frequently significantly elevated. However, this is a nonspecific finding, and ammonia levels are notoriously inaccurate. Thus ammonia may serve as a marker but not as an index of encephalopathy. The...

Dietary Fiber Obesity and the Etiology of Diabetes

Constipation, diverticular disease, and laxation Unquestionably, fiber is of direct benefit in relieving the symptoms of constipation and diverticular disease but there is little information about its role in the etiology of these conditions. Numerous interventions have shown that foods high in insoluble NSPs (e.g., certain cereal brans) and some soluble NSP preparations (e.g., psyllium) are very effective at controlling constipation and diverticular disease and enhancing laxation. The actual effect can vary with source. Wheat bran increases undigested residue, and fiber from fruits and vegetables and soluble polysaccharides tend to be fermented extensively and are more likely to increase microbial cell mass. Some NSP (and OS) preparations retain water in the colon. The physical form of the fiber is also important Coarsely ground wheat bran is a very effective source of fiber to increase fecal bulk, whereas finely ground wheat bran has little or no effect and may even be constipating....

Biliary Complications

Biliary problems account for a significant proportion of complications, and incidence may be as high as 29 percent. 5 Leaks, strictures (ductal narrowing), and obstruction (ductal blockage) account for 80 percent of these complications. In general, leaks occur early, with 38 percent in the first 30 days and most (80 percent) within the first 6 months.6 Early leaks tend to be more severe owing to duct disruption and higher immunosuppression and are notoriously difficult to treat. Leaks after the first month are invariably associated with either elective or inadvertent removal of an indwelling biliary catheter. 7 In children, stricture and obstruction are responsible for 90 percent of complications.6 For patients with Roux-en-Y, the leak tends to occur at the anastomosis, whereas for the majority of patients who have choledochocholedochostomy, the leak is at the anastomosis early or the T-tube site later.8 The cause of biliary injury is either immunologic or preservation injury,...

Laboratory Investigations

Electrolyte abnormalities, particularly low serum potassium values, occur only where there is self-induced vomiting or abuse of diuretics or laxatives. stimulating hormone, and estradiol. Increased growth hormone levels with decreased levels of insulin-like growth factor 1 (somatomedin C) in the serum. Plasma renin activity and aldosterone levels may be very high in patients who abuse laxatives or diuretics (pseudo-Bartter's syndrome). Electrocardiography shows sinus bradycardia, flat

Dietary Management

Binge vomit laxatives Comment feelings Vomited and took 10 laxatives If the bulimic is used to keeping his or her stomach empty, even a normal amount of food may seem excessive and may trigger the urge to vomit. They should be informed that stomach distension is a normal consequence of eating and reassured that they will get used to the feeling in time. Similarly, if someone has been abusing laxatives, he or she may suffer from constipation and should be encouraged to have a reasonable fiber intake along with plenty of fluids.

Physiologic And Metabolic Effects

Burkitt and Trowell (2) were the first to report the physiological importance of dietary fiber consumption. Based on epidemiological studies, they showed associations between low-fiber diets and chronic disorders such as constipation, diverticulosis, colon cancer, diabetes, and cardiovascular disease. Since the 1970s research has been carried out that, for the most part, confirms the role of dietary fiber in disease prevention. Normal laxation is an important health benefit of dietary fiber consumption. Certain varieties of dietary fiber have been shown to increase stool weight and frequency, soften feces, increase fecal bulk, and reduce gastrointestinal transit times. This is particularly true of insoluble dietary fibers such as cellulose, found in large quantities in wheat bran, and of soluble but nonfer-mentable fibers such as psyllium gum. Constipation may be prevented, or successfully treated, by increasing dietary fiber intake. Various hypotheses have been suggested as to how...

Step 3 Strong opioids

The commonest complications of morphine administration are nausea, vomiting, constipation, drowsiness and confusion. Difficulty with micturition, ureteric spasm and antidiuresis and a variety of autonomic effects may also occur. Large doses of morphine can cause respiratory depression and hypotension, leading to circulatory failure and deepening coma. Unless there is a definite reason for not doing so, a laxative should be prescribed for all patients receiving morphine. Best is a combination of a contact laxative (e.g. senna) and a faecal softener (e.g. docusate). Some patients may develop severe faecal retention and require suppositories, enemas or manual evacuation.

Bladder Rupture Postaugmentation

Undergo augmentation are neurologically impaired therefore, lower abdominal sensation is diminished and signs and symptoms may be nonspecific. Patients may complain of nausea, vomiting, fever, obstipation, gross hematuria, and oliguria physical examination demonstrates a distended rigid abdomen with positive peritoneal signs.

TABLE 791 Vomiting and Diarrhea The Gastroenteritis Mnemonic

PHYSICAL EXAMINATION Clinical clues may also assist in making the diagnosis. In addition to evaluating the ABCs, much of the physician's initial attention should be directed toward the assessment of hydration status. Severely volume-depleted patients require immediate intervention, lest circulatory collapse be imminent. The abdominal, genitourinary, and pelvic examinations are often revealing. Physicians should search carefully for tenderness, peritoneal signs, hernias, masses, and evidence of obstruction or torsion. The findings of a careful physical examination may point toward unsuspected causes of vomiting, such as bulimia (scars on the dorsum of hands), pneumonia (consolidative findings on lung examination), or Addison's disease (hyperpigmentation). The rectal examination is important. An anal fistula may be the only clue to Crohn's disease in an otherwise healthy teenager with vomiting, or may demonstrate fecal impaction.

NonST Segment Elevation Myocardial Infarction Nstemi and Unstable Angina

-Morphine sulfate 2-4 mg IV push prn chest pain. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache. -Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate (Colace) 100 mg PO bid. -Ondansetron (Zofran) 2-4 mg IV q4h prn N V. -Famotidine (Pepcid) 20 mg IV PO bid OR -Lansoprazole (Prevacid) 30 mg qd.

Irritable Bowel Syndrome IBS

IBS is manifested in about 8 to 19 of the population and is associated with symptoms of abdominal pain, constipation and or diarrhea, and gas. About 85 of those with IBS have an increase in symptoms when experiencing stress. Therefore, the treatment of choice is relaxation therapy and research has shown that relaxation therapy combined with finger temperature biofeedback is the most effective. Although more direct forms of feedback have been tried, such as colonic motil-ity sounds, rectal feedback using rectal balloons, and feedback of the electrical activity of the lower gut, these techniques have not proven effective and at this time are not used in general practice. The biofeedback is usually combined with client education about the relationship between stress and symptoms.

TABLE 1222 Assessment of Dehydration

Bacteria that invade the mucosa of the terminal ileum and colon can cause dysentery, which is characterized by frequent bowel movements that contain blood, mucus, or pus. The diarrhea is often accompanied by fever, tenesmus, and painful defecation. Infants and children who have bloody or mucousy diarrhea after having received antibiotics may have antibiotic-associated pseudomembranous colitis due to infection with cytotoxigenic C. difficile. Infestations with Entamoeba histolytica may also cause dysentery. Table 122-3 lists the enteric infections that cause children to have bloody diarrhea.

Meningomyelocele Myelomeningocele

Children with meningomyelocele have multiple, complex medical problems due to impairment of nerves at or below the site of the lesion. There is variable impairment of sensory and motor nerves controlling voluntary and autonomic functioning. Associated medical concerns include neurogenic bowel and bladder function, contractures, scoliosis, club feet, hydrocephalus, Chiari II malformation, tethering of the spinal cord, spinal cord syrinx, vesicoureteral reflux, decubitus ulcers, constipation, encopresis, recurrent urinary tract infections, growth failure, latex allergy, gastroesophageal reflux, apnea stridor syndrome, seizures, partial agenesis of the corpus callosum, strabismus, visual acuity impairment, precocious puberty, and osteoporosis. Individuals also may have cognitive impairments. Mild forms of cognitive impairment may affect visual motor functioning. More severe cognitive impairment has been associated with sparing of verbal skills and a cocktail party syndrome, in which the...

Gastrointestinal Zoonotic Infections

Zoonotic gastroenteritis often presents with fever, headache, and abdominal pain often localizing to the right lower quadrant. Patients may have diarrhea or constipation. Laboratory findings may consist of electrolyte and acid-base abnormalities if diarrhea is severe. Leukocytosis may be seen if an interstitial invasion has occurred, and eosinophilia is often a finding with intestinal parasitic infestation. Most cases of zoonotic gastroenteritis are self-limiting and require only fluid hydration. However, specific pathogens may require specific therapy (Table 145-6).

Nutrient and Fluid Needs

Fluid needs are based on body size rather than calorie intake. Table 3 demonstrates how to calculate fluid needs. Constipation is a chronic problem for most children with CP and is related to muscle tone, loss of sensation, limited physical activity, medication side effects, and inadequate dietary fiber and or fluid intake. Oral motor dysfunction results in diminished intake as well as in food and fluid loss. Modified food and fluid textures result in less free water and fiber in the diet. Discomfort associated with constipation may decrease appetite and increase gastroesophageal reflux. Dietary intervention may therefore be limited and medical management may be necessary.

Repeated Orthopedic Surgeries

These are common in children with CP, and each surgery must be preceded by an evaluation of nutritional status and assessment of the child's ability to physically heal and recover quickly from the trauma. Many children who are marginal oral feeders will decompensate, lose weight, and have a difficult time healing because of a cascade of events including pain, poor positioning for safe feeding, worsening constipation, minimal intake, lethargy, and increased medications for pain that may have a sedative effect. They may require supplemental feedings prior to surgery or during the postoperative period.

Appendix Information on Recommended Measures Child Health Questionnaire

The GSRS is a clinical symptom rating scale originally designed for patients with irritable bowel syndrome and peptic ulcer disease 122 . It has subsequently been evaluated in patients with GERD 105, 123 . GSRS for use with GERD patients contains 15 items, each assessed on a 1-point to 7-point scale, with 7 representing extreme discomfort. The items combine into five syndromes labeled reflux, abdominal pain, indigestion, diarrhea, and constipation. Mean scores are calculated from the items in each syndrome. The measure may be administered as a self-report or by an interviewer. The GSRS has been used in UK, Scandinavian, and US populations. It demonstrates acceptable reliability, both internal consistency and stability, evidence of construct and discriminative validity, as well as responsiveness to change. A copy of the US version of the GSRS is included in the article by Revicki and colleagues 105 .

Autonomic Dysreflexia

Autonomic dysreflexia is dramatic paroxysmal hyperactivity of uninhibited sympathetic and parasympathetic nerves in children with spinal cord lesions proximal to thoracic level 6. It is caused by stimulation below the level of the lesion by bladder overdistention, fecal impaction, skin breakdown, or fractures. Presentation is sweating, flushing, pounding headache, hypertension, bradycardia, and piloerection above the level of the lesion. Death or cerebral vascular accident may result. 17

Hormonal versus nonhormonal

Pelvic pain associated with severe dysmenorrhea and or pain at the time of ovulation is likely due to endometriosis or adenomyosis. Women with endometriosis report premenstrual spotting, dyspareunia, dyschezia, poor relief of symptoms with nonsteroidal anti-inflammatory drugs, progressively worsening symptoms, inability to attend work or school during menses, and the presence of pelvic pain unrelated to menses more often than women with primary dysmenorrhea.

History and Physical Examination

The medical history should assess diabetes, stroke, lumbar disc disease, chronic lung disease, fecal impaction and cognitive impairment. The obstetric and gynecologic history should include gravity parity the number of vaginal, instrument-assisted and cesarean deliveries the time interval between deliveries previous hysterectomy and or vaginal or bladder surgery pelvic radiotherapy trauma and estrogen status.

Physical Examination

While performing the bimanual examination, levator ani muscle function can be evaluated by asking the patient to tighten her vaginal muscles and hold the contraction as long as possible. It is normal for a woman to be able to hold such a contraction for five to 10 seconds. The bimanual examination should also include a rectal examination to assess anal sphincter tone, fecal impaction, occult blood, or rectal lesions.

Intraabdominal Masses

Every child should have a careful abdominal examination because intraabdominal masses grow silently at first until they cause obstruction, bleeding, or hemorrhage into the tumor or until a parent sees a mass protruding in the abdomen. The child should be supine with his or her head turned toward the parent, and one should carefully palpate all quadrants of the abdomen. If a mass is palpated, the child should be referred to a pediatric surgeon and diagnostic imaging studies obtained. A careful rectal examination, especially if the child has constipation or a gait abnormality, must be done to check for a presacral teratoma and for ovarian masses both of these tumors can show calcifications on plain film x-rays in approximately 50 percent of cases.

Postoperative Urinary Retention

Bladder that then becomes overdistended, with resultant detrusor dysfunction that can lead both acute and chronic retention. In some patients, especially those undergoing pelvic surgery, there is a risk of direct neurological damage as a cause of abnormal detrusor function. Other causes of postoperative UR include immobility, constipation, pain, local edema and preexisting BOO.

Clinical Manifestations

Primary hyperparathyroidism may present in a variety of ways. Patients may be asymptomatic and the disease may be recognized through routine screening laboratory tests. Other patients may present with severe renal or bone disease. Because calcium affects nearly every organ system, calcium dysregulation may present clinically with a multitude of signs and symptoms. The most common symptoms include fatigue, weakness, depression, arthralgia and constipation. Conditions associated with hyperparathyroidism include kidney stones, chondrocalcinosis, osteitis fibrosa cystica, osteoporosis, hypertension, gout, peptic ulcer disease and pancreatitis. Patients with excess PTH production may experience progressive loss of bone mineralization. This is manifested as subperiosteal resorption, osteoporosis and pathologic fractures. Skeletal involvement is most readily demonstrated by radiographic films.

The Renointestinal Relationships Normal and Pathologic Anatomy

Many patients with renal disease present with symptoms that seem to arise from the digestive tract. Practically every case of urinary tract disease is known to be accompanied by some gastrointestinal complaint of a transitory or permanent character, particularly nausea, vomiting, epigastric distress, constipation, or diarrhea.1 Gastrointestinal symptoms alone have been noted in up to 43 of patients. Since clinical investigation of such patients is often started with barium contrast studies, it is important to recognize that characteristic effects on specific portions of the bowel may uncover the primary renal disease and redirect the course of evaluation.2

Management of Hypercalcemia Based on Severity

Hypercalcemia in the moderate range may be associated with symptoms such as polyuria, polydipsia, anorexia, constipation, and various degrees of obtundation. In this setting, it is prudent to embark upon a more aggressive approach to the hypercalcemia as described below. The therapy, however, has to be adapted to the actual level of the serum Ca and is not ordinarily as vigorous as it is when the serum Ca is much higher.

Lambert Eaton myasthenic syndrome

This disorder is much less common than myasthenia gravis. It is characterized by proximal muscle weakness, depressed tendon reflexes, post-tetanic potentiation and autonomic changes, including dry mouth and constipation. Onset can be in adolescence, but is usually after 40 years of age. Other autoimmune diseases may associate, notably thyroid disease and vitiligo, and other autoantibodies occur at increased frequency.

Emergency Diagnosis and Management

Emergency therapy is directed at minimizing the complications of acute MS exacerbations. Fever must be reduced in order to minimize the weakness caused by elevated temperature. Seizures can be treated with the standard benzodiazepine, phenytoin, and barbiturate regimen. Optic neuritis, severe constipation, and worsening muscle weakness also may complicate an MS exacerbation.

Selfassessment case histories

A 52-year-old man underwent an elective colonoscopy for investigation of constipation. Two hours later he developed severe abdominal pain and vomiting. The duty doctor diagnosed colonic perforation, which was confirmed by x ray film. The surgical team was informed and part of his large bowel was resected at laparotomy. Later, the patient's observations are as follows temperature 38 C, pulse 110 per minute, RR 30 per minute, BP 90 50 mmHg and poor urine output. He is mildly confused. Investigations show Hb 10-5 g dl-1, WBC 20 x 109 litre-1, platelets 70 x 109 litre-1, Na 135 mmol litre-1, K 4-7 mmol litre-1, urea 15 mmol litre-1 (BUN 41-6 mg dl-1), and creatinine 150 mol litre-1 (1-8 mg dl-1). Arterial blood gases on 5 litres per minute via a simple face mask showed pH 7-26, PO2 8-2 kPa (63 mmHg), PCO2 5-3 kPa (40-7 mmHg), bicarbonate 17-5 mmol l, BE - 8. A CVP line has been inserted after 1500 ml colloid. The initial reading is 12 mmHg. What is your further management

Nutrient and Drug Interactions

In Europe, 83 of 'apparently healthy' people in the previously mentioned SENECA study use an average of two types of drugs, with antihypertensives (33 ), analgesics (31 ), diuretics (24 ), sleeping pills (18 ), and psychotropic drugs (17 ) taken most often. Many drugs taken by the elderly can interfere with nutritional status. The possible effects include suppression or stimulation of appetite and impaired nutrient absorption and metabolism. For example, lisdiuretics can have adverse effects on calcium metabolism, salicylates can increase the need for vitamin C, and some types of antihypertensives act as antagonists of vitamin B6. Negative consequences of laxatives, often taken by the elderly, include interference with nutrient absorption. Dietary interventions may help to reduce the intake of drugs. There is evidence that moderate sodium restriction prevents or delays the development of hypertension. Also, limiting alcohol intake provides protection...

Endocrine Abnormalities

THYROID HORMONE The most common findings of hypothyroidism include lethargy, fatigue, dry coarse skin, facial and extremity swelling, hoarseness, constipation, and weakness. Oral manifestations are related to the accumulation of glycosaminoglycans in the oral tissues, causing macroglossia and thickened lips. If hypothyroidism occurs in childhood, teeth may fail to erupt, although tooth formation is unimpaired. 19

Tricyclic Antidepressants

Introduced in 1959, the tricyclic antidepressants (TCAs) constituted the first line of treatment for depression until the appearance of the selective serotonin reuptake inhibitors in the 1980s. The first TCA to be introduced was imipramine, which was found to have antidepressant actions instead of sedative effects that were expected based on its structure analogous to phenothiazine. Currently, there are nine TCAs (imipramine, amitriptyline, desipra-mine, nortriptyline, clomipramine, trimipramine, dox-epine, protriptyline, and amoxapine) and one tetracyclic (maprotiline) drug marketed in the United States. Central nervous system side effects are mostly due to their antimuscarinic action. Sedation, confusion, or seizures resulting from lowering of seizure threshold occur in about 15 of patients. Peripheral side effects include significant antimuscarinic effects on the cardiovascular system (arrhythmias and tachycardia) as well as blurred vision, dry mouth, constipation, and urinary...

Delivery of the placenta

Acetaminophen codeine (Tylenol 3) 1-2 tab PO q3-4h prn OR Oxycodone acetaminophen (Percocet) 1 tab q6h prn pain. Milk of magnesia 30 mL PO q6h prn constipation. Docusate Sodium (Colace) 100 mg PO bid. Dulcolax suppository PR prn constipation. A and D cream or Lanolin prn if breast feeding. Breast binder or tight brazier and ice packs prn if not to breast feed. Labs Hemoglobin hematocrit in AM. Give rubella vaccine if titer < 1 10.

Symptomatic Treatments Of Dystonias

Side effects of anticholinergic drugs are central and peripheral. Central effects include confusion, memory impairment, hallucinations, restlessness, insomnia, nightmares, and sedation. Peripheral side effects (such as dry mouth, blurred vision, exacerbation of acute angle glaucoma, urinary retention, and constipation) may be controlled by peripheral cholinergic drugs, such as pyridostigmine or pilocarpine. Side effects

Food labelling for the consumer

In 1998, the MAFF advised that, for the purpose of food labelling, fibre be defined as NSP in line with COMA's recommendations and that claims relating to fibre should also be based on this definition and on COMA's recommendation of a DRV of 18 g day. In raising the fibre intake in the diet, there can be potential side effects in the first few months. These can be excessive wind, bloating and abdominal cramps which will gradually lessen, with many patients and consumers finding that constipation is relieved and that it is worth carrying on with the increased fibre intake. In increasing the fibre intake in the diet there are some points that should be followed When fibre in the diet is increased, the fluid intake should increase correspondingly, drinking six to eight cups of water per day along with other fluid that is consumed normally. Most people drink inadequate amounts of water every day and often inadequate amounts of fluid in general, which can lead to headaches and constipation.

Endometriosis may even cause intestinal contractions and hypoglycemia

Some studies have shown that deep endometriosis most often affects the area along the nerves in the large intestine, which may be the reason for the common symptoms of cramping and contractions of the intestines. These cramps and contractions are the cause of constipation and diarrhea that often accompany a patient's period.

Excipients For Overthecounter Drugs

(eventually the number of therapeutic classes reached approximately 80). During this review, the FDA attempted to keep the task at a manageable level by not reviewing specific marketed products, but rather by creating various monographs (standards) for OTC active ingredients in numerous therapeutic classes. Expert Panels were advised only to consider excipients (or complete product formulations) when such excipients or formulations materially impacted the drug's efficacy or diminished its safety. In therapeutic classes such as antacids, laxatives, antidiarrheals, expectorates, antitussives (cough suppressants), sleep aids, and numerous oral products, excipients such as lactose, starch, methylcellulose, magnesium stearate, etc., had long been used in the manufacturing of OTC finished products without raising safety concerns, and were therefore not examined. However, there were a number of exceptions where inactive ingredients had a noticeable (and usually detrimental) impact on safety...

Clinical Conditions in Prepubertal Children

CONGENITAL VAGINAL OBSTRUCTION Vaginal obstruction can be secondary to a transverse vaginal septum or imperforate hymen. Imperforate hymen is found in 1 in 1000 of full-term female neonates, and a transverse vaginal septum is found in 1 in 2000 to 1 in 84,000 females. Diagnosis is made by careful examination of the perineum. Infants may go undiagnosed for weeks until they develop an abdominal mass, difficulty with urination, or a visible bulging membrane at the vagina introitus. In severe forms, children may have constipation, hydronephrosis, respiratory compromise, and edema of the lower extremities. The treatment of hydrocolpos is surgical excision of the obstruction.

Tolerance and Dependence

Tolerance can be defined as a state of decreased responsiveness to the pharmacological effects of a drug resulting from previous exposure. Tolerance to most effects of opioids is seen, excluding constipation and miosis. The tolerance shows selectivity so that tolerance to one opioid is not necessarily accompanied by tolerance to others and the mechanism is ill-defined. Mechanisms such as down regulation or decoupling of receptors have been suggested but the underlying mechanism is probably adaptive changes of the effector system in response to the opioid inhibitory effects. Dependence may have two components, physical and psychological. Withdrawal or antagonism of the drug leads to pathophysiological disturbances collectively known as 'the withdrawal syndrome' whose symptoms include Morphine is a potent analgesic with good sedative and anxiolytic properties. It usually produces euphoria but dysphoria may occur if given in the absence of pain. Miosis is a common feature of overdose....

Controlled clinical trials morphine varying aetiologies for breathlessness

Other than constipation, there was no excess of symptoms in the treatment group. Withdrawals from the study that were attributable to morphine included three people with nausea and one with sedation. Sedation as a side-effect peaked on the second day. Respiratory depression was not seen and the majority of patients continued on some form of opioid in the longer term.

Early Postoperative Bowel Obstruction

Early postoperative bowel obstruction refers to mechanical bowel obstruction, primarily involving the small bowel, which occurs in the first 30 days following abdominal surgery. The clinical picture may frequently be mistaken for ileus, and these clinical conditions can overlap. The clinical presentation of early postoperative bowel obstruction is similar to bowel obstruction arising de novo crampy abdominal pain, vomiting, abdominal distension, and obstipation. The incidence of early postoperative bowel obstruction has been variable in published series, due to difficulty in differentiating ileus from early postoperative bowel obstruction, but the reported range is from 7 to 9.5 of abdominal operations. more early surgical correction, and should be suspected in the setting of complete obstipation, or when abdominal CT suggests internal hernia or complete bowel obstruction.

Current Vegetarian Eating Patterns and Practices

Cholesterol and high in complex carbohydrates, dietary fiber, magnesium, potassium, folic acid, and antioxidant nutrients such as vitamins C and E. They also tend to be relatively low in energy. Thus, the diet-related risks for a number of chronic degenerative diseases associated with intakes of these nutrients may be decreased on vegetarian diets. Some risks are clearly lower for example, vegetarians generally tend to have lower weight for height than do nonvegetarians. Constipation tends to be less of a problem in this group, perhaps due in part to the higher intake of dietary fiber.

Acquired anorectal disorders

Anal fissure is the most common cause of minor rectal bleeding in infants and toddlers, and is associated with constipation and painful defaecation. The tear in the anal mucosa is typically located in the posterior midline. Chronic fissure is sometimes associated with a sentinel skin tag at 12 o'clock position. Treatment consists of stool softener, sitz bath and local anaesthetic gel application. Occasionally a chronic fissure requires topical nitroglycerin therapy or lateral Rectal prolapse usually occurs in the toilet training age group and is often associated with constipation. The prolapse usually involves the mucosa only and responds to conservative treatment. Persistent prolapse may require hypertonic saline injection or Thiersch procedure using a strong nylon suture. The possibility of cystic fibrosis should be considered.

Immobilization Hypercalcemia

Most cases of immobilization hypercalcemia are seen in adolescent boys following recent spinal cord injuries. 16 Risk factors include age less than 21 years, complete neurologic injuries, cervical injuries, prolonged immobilization, and dehydration. 16 Presenting symptoms include anorexia, nausea, headache, malaise, and depression in mild cases. In more severe cases, patients may have persistent nausea and vomiting, gastric dilatation, fecal impaction, and abdominal pain. Microscopic calcium deposition in the kidney may impair its ability to concentrate urine, leading to polyuria and polydipsia. Patients may also develop cardiac dysrhythmias and seizures.16

Psychiatric Disorders

Psychiatric disorders are estimated to afflict up to 50 percent of the developmentally disabled population. Although mood disorders, particularly depression, are most frequent, they are relatively unlikely to precipitate ED evaluations. Instead, emergency visits are usually precipitated by aggression or extreme agitation. In such cases, benzodiazepines or low-dose, low-potency antipsychotics, such as chlorpromazine, may be acutely helpful in controlling the patient's behavior sufficiently to proceed with an evaluation. However, it is essential to try to identify the underlying etiology of these behaviors and changes in their frequency or intensity. Undiagnosed, painful medical problems, including severe constipation, often lead to exacerbation. 16 Sleep apnea can also be manifest as increased irritability. In addition, anxiety may be manifest primarily as agitation. Often environmental factors can be identified that are increasing the patient's anxiety. Such factors may include...

Gastrointestinal Disorders

Mentally retarded individuals frequently present to the ED with gastrointestinal bleeding and it is the most common reason for hospital admission. In 70 percent of cases studied, erosive esophagitis was the diagnosis.20 A large number of developmentally disabled individuals also have ulcers, usually duodenal. Such conditions respond well to aggressive treatment with proton pump inhibitors and H 2 blockers. In addition, perhaps as many as 40 percent of mentally retarded individuals have a neurogenic bowel with resulting constipation, overflow diarrhea, and infrequent rectal tears. It is important to carefully evaluate for constipation. Treatment must include both acute and long-term measures, including establishment of a regular stool pattern and provision of adequate fluid and fiber intake. It is also important to determine whether the patient has pica and may have developed bezoars. About 10 percent of individuals with pica will develop intestinal obstruction. 21 While surgery is...

Bile acid sequestering agents resins

The biggest proportional reduction in lipid levels occurs at low doses and in those who have moderately elevated levels of cholesterol.54 Careful selection of the vehicle and logistics used in resin administration will promote long-term patient adherence. Premixing with cold water (taking advantage of the resin's hygroscopic nature) and drinking the preparation slowing is by far the most frequent and successful method of administration. Still, some patients prefer mixing with a heavily textured juice. Pre-existing gastrointestinal symptoms should be addressed before resin therapy is started. Bloating, belching and increased flatus are related to rapid ingestion. Dyspepsia and increased stool consistency or frank constipation can be managed with increases in fluids or dietary fiber intake. as 25 , have also been reported.56 Colesevelam does not cause constipation, which is likely to improve patient adherence,55 and is formulated as a tablet, which should eliminate the palatability...

Gastrointestinal Complications

Anorectal disease is common in AIDS patients. Proctitis is characterized by painful defecation, rectal discharge, and tenesmus. Common causative organisms include Neisseria gonorrhoeae, Chlamydia trachomatis, syphilis, and herpes simplex. Proctocolitis includes the same symptoms in the presence of diarrhea, and multiple bacterial organisms may be responsible (most commonly Shigella, Campylobacter, and Entamoeba histolytica). Diagnostic evaluation should include anoscopy, with microscopic examination, Gram stain, and culture of pus and or stool.

Sacrocaudal dysgenesis in Manx cats

Rectal Deformity Kittens

The prognosis for severely affected cats is frequently hopeless and treatment is not available. Cats with urinary and faecal incontinence may be managed with manual bladder expression and faecal softening agents, but recurrent urinary tract infection, megacolon and chronic constipation are common problems. Meningocoele in cats with minimal neurological deficits may be surgically correctable. Many tailless cats do not have neurological signs, and sacral and caudal deformities often are incidental radiological findings.

The History of Diverticular Disease

In 1927, Spriggs and Marxer suggested that the term 'diverticulum' originated from the word 'divertikel' which was said to have been used by Fleischman in 1815 in describing this anomaly in the colon. Between 1815 and 1869 many writers of medical articles were stating that they all believed that these 'divertikel' were not nascent but acquired later in life - thought to be caused by constipation. Even at this early stage in medical history, it was recognized that a fistula could be one of the associated complications of diverticular disease (Jones, 1859).

TABLE 751 Common Causes of Intestinal Obstruction

Tables Bowel Obstruction

Colonic obstruction is almost never caused by hernia or surgical adhesions. Neoplasms are by far the most common cause of large bowel obstruction. 45 Therefore, anyone who has symptoms of colonic obstruction should be evaluated for a neoplasm. Diverticulitis may create significant secondary obstruction and mesenteric edema. Stricture formation may occur with chronic inflammation and scarring. Fecal impaction is a common problem in elderly, debilitated patients and may present with symptoms of colonic obstruction. The next most frequent cause of large bowel obstruction after cancer and diverticulitis is sigmoid volvulus. Elderly, bedridden, or psychiatric patients who are taking anticholinergic medication are most often subject to this mechanical problem. A history of constipation may precede the volvulus and presenting symptoms. Radiographic appearance is usually classic ( F,i,g,.,,,,,,7,,5, ,,l). Finally, although much less common, cecal volvulus may also cause large bowel...

Hasan Aziz and Zarin Mogal

In developing countries epilepsy still remains in the shadows of myths, superstitions and stigma. Fear, shame and mysticism surrounds epilepsy even today. Families of patients with epilepsy often make references to black magic, witchcraft, voodoo or evil ancestral spirit possession, a divine punishment, and poisoning.26,27,36,37 The mysterious stormy events of an epileptic seizure have compelled many to associate it with a supernatural cause.36-39 In Pakistan, only 3.1 population surveyed associated epilepsy to a supernatural cause as against 71 in Turkey.40 In traditional Africa epilepsy is linked to the evil eye. The curative rituals range from complete shaving of entire body with glass and affliction of burns to banishment of the person causing the evil influence.38,41 The saliva, flatus, breath, and other secretions of the patient are thought to be highly contagious.38,42 Epileptic seizure is thought to signify escaping of a demon or an evil spirit and hence one is not allowed to...

Acquired neuropathies

Feline dysautonomia is a polyneuropathy of unknown cause that affects autonomic ganglia, resulting in failure of the autonomic nervous system. The disease was first reported in the UK in the 1980s but has since been uncommon until increased numbers of cases were diagnosed in the early 2000s. There is usually a rapid onset of clinical signs, developing over 48 h, but slower progressive development can occur. Clinical signs include dilated pupils, prolapsed nictitating membranes, bradycardia, dry mucous membranes, megaoesophagus, regurgitation, constipation, bladder atony, dysuria, urinary incontinence, loss of anal tone and reflex, and anorexia. Cats become dehydrated and without nursing support and fluid replacement will deteriorate rapidly. Treatment is palliative and consists of fluid therapy, parenteral feeding (nasal or gastrostomy feeding tubes), laxatives, artificial tears, pilocarpine eye drops (one drop to both eyes every 12 h). The bladder should be emptied manually or by...

Disorders of the Labia

LICHEN SCLEROSIS ATROPHICA Although uncommon in prepubertal girls, lichen sclerosis is being increasingly recognized by emergency physicians and pediatricians. This increased recognition is in some measure a reflection of increased concern about and awareness of sexual abuse and the subsequently increased frequency of perineal examination of prepubertal girls. The affected girl complains of itch, irritation, dysuria, perineal and or perianal pain, and bleeding. There may be a coexistent vaginal discharge. As perianal pain persists, the girl may develop problems with painful defecation, stool retention, constipation, and encopresis.

General Considerations

Presenting symptoms of ileus include nausea, vomiting, obstipation, constipation, abdominal distention, and abdominal pain. When these symptoms are present in the first few days after surgery, they are most often due to adynamic ileus. The symptoms of adynamic ileus are most often mild and respond to nasogastric suction, bowel rest, and intravenous hydration. However, in cases of prolonged ileus, the physician must always look for an underlying cause. Evaluation of patients with suspected ileus includes abdominal radiographs to identify air-fluid levels, chest x-ray, CBC, electrolytes, and urinalysis for secondary causes of ileus. Mechanical ileus of the bowel is most often secondary to adhesions. Small bowel obstruction above the ligament of Treitz is associated with frequent bouts of bilious emesis. In cases of more distal obstruction, pain and distention become more severe, the frequency and volume of vomiting decrease, and emesis becomes more feculent. Abdominal radiographs...

Storage Sites Plasma Proteins

Effect Food Irradiation

Diarrhea is an unpleasant physiological effect of toxicant ingestion. It is important to understand the factors and mechanisms responsible for the effect in order to better understand the toxic response and how treatment can be devised. Diarrhea is the frequent evacuation of watery feces. The term is derived from Late Latin diarrhoea and Greek diarrhoia, from diarrhein, which means to flow through. Food poisoning, laxatives, and alcohol ingestion can cause acute diarrhea, but it is usually caused by an acute infection with bacteria such as Salmonella, Staphylococcus aureus, and Escherichia coli. Acute diarrhea is usually self-limiting in infants and the major concern to influence the prognosis is prevention of dehydration. Travelers' diarrhea is very common and affects up to half of those traveling to developing areas of the world. Decreases in solute absorption can result from overeating, deficiencies in gut enzymes or bile flow, or ingestion of poorly absorbed ions such as...

Psychotropic Drug Structure

Amantadine Parkinson

Of those in current clinical use), but all are associated to some degree with the typical peripheral anticholinergic effects of blurred vision, dry mouth, urinary retention and constipation. The popularity of benzhexol lies in its additional ability to inhibit striatal dopamine reuptake.

TABLE 325 Equianalgesic Opioid Doses

The opioids include the phenanthrene derivatives (e.g., morphine, codeine, and hydromorphone), the phenylpiperidine derivatives (e.g., meperidine and fentanyl), and the diphenylheptane derivative (methadone). When they are used in equianalgesic doses, there is no compelling evidence to recommend one opioid over another. Accumulation of the toxic metabolite of meperidine (normeperidine) has been shown to cause CNS toxicity in patients with compromised renal function or those taking monoamine oxidase inhibitors (MAOIs).13 Morphine, in contrast to meperidine, has an active rather than a toxic metabolite. Adverse effects of opioids include nausea, vomiting, constipation, pruritus, urinary retention, and respiratory depression.

Marsha M Linehan and Eunice Y Chen

An ED, as defined by current clinical classification systems, the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV, APA, 1994) and International Classification of Disorders-10 (ICD-10 WHO, 1992), involves extreme forms of eating behavior accompanied by an extreme dependence on weight and shape as a means of self-evaluation. This leads to a significant impairment of health and psychosocial functioning and significant mortality in AN. ED diagnoses are classified into AN and BN, and for those who meet neither criteria, eating disorders not otherwise specified (ED-NOS DSM-IV) or atypical eating disorders (ICD-l0). The ED-NOS criteria include those meeting the BED research criteria (DSM-IV). AN is marked by amenorrhea and low weight (body mass index BMI < 17.5 or a body weight 85 of expected) due to dieting, vomiting, overexercise, and the abuse of laxatives, diuretics, or diet pills. BN is marked by a preoccupation with thinness despite being a healthy weight...

Antidepressants Elavil and Relatives

These drugs date from 1958, when the parent compound, imip-ramine (Tofranil), was invented. It is still in wide use today, along with a close relative, amitriptyline (Elavil), and a number of other similar drugs. Some depressed patients respond very well to these medications but not until after at least two weeks of regular use. On the other hand, the toxic effects begin right away sedation, dry mouth, blurred vision, constipation, difficulty in urinating. Normal people are likely to notice only these side effects'' without any positive mood changes. A newer antidepressant drug is fluoxetine (Prozac), unrelated to the older members of this group. It is currently very popular in psychiatric medicine. Fluoxetine is an effective antidepressant, but some patients cannot tolerate it, because it makes them very anxious.

TABLE 2833 Physiologic Changes Associated with Eating Disorders

Laxative abuse produces weight loss mainly by dehydration and hypokalemia. Common nonspecific complaints of laxative abuse include constipation, diarrhea, abdominal cramping, and bloating. Severe potassium depletion due to chronic laxative abuse and intense physical exercise may contribute to myonecrosis. Specific effects include melanosis coli and cathartic colon. In carthartic colon, the colon is converted into an inert tube incapable of propelling the fecal stream without large doses of laxatives. This condition is not entirely reversible and may require colectomy. Brownish gray hyperpigmented areas on the skin are reported as complications of phenolphthalein-containing laxatives (e.g., Correctol and Ex-Lax).

Normal Bowel Rectosphincteric Reflex

Increased or decreased time of passage or transit of material through the colon can lead to the common symptoms of constipation or diarrhea. Delayed transit and constipation are primarily dietary in origin and can be corrected by the addition of fiber or bulk to the diet. Increased speed of transit may result in diarrhea, although diarrhea can be the result of many diseases or conditions unrelated to colonic motility. centers of the CNS have on motility. The final effects of stress on colonic motility vary greatly from individual to individual. Most students are familiar with diarrhea previous to an important examination. The severity of the problem is usually related inversely to how well the student knows the material to be covered by the test. Prolonged, extreme responses of anger, anxiety, hostility, or resentment may result in irritable bowel syndrome. In these individuals constipation may alternate with diarrhea, and abdominal pain or cramping and flatulence are often present as...

Competence To Refuse Psychotropic Medication

Managing a person's refusal of psychotropic medication (e.g., antipsychotic or antidepressant medication), once he or she has been hospitalized, has been one of the most controversial issues in mental healthcare in recent years. Before the 1980s, many rejected the notion of a psychiatric patient's right to refuse medication, suggesting that the purpose of psychiatric hospitalization would be defeated if patients were permitted to refuse treatment with medication (Appelbaum, 1988). In part, the controversy about involuntary treatment of psychiatric inpatients with medication arose from the nature and effects of psychotropic medication. Psychotropic medications have been viewed somewhat inaccurately as powerful and dangerous substances whose use is akin to mind control. Their risks, whether short-term dry mouth and constipation or long-term involuntary movement disorders, relative to their benefits, the treatment of the mental disorder, have been greatly exaggerated, at least by many...

Epidemiology And Classification Of Dm1

In the classical form, which is the most common, symptoms become evident between the second and the fourth decade of life, showing a slow progression over time (table 36.1). The key feature of the disease is myotonia, which is characterised by delayed relaxation after muscular contraction (fig 36.1A,B) progressive muscular weakness (dystrophy) and wasting are also typical findings facial, axial, semi-distal, and distal compartments are predominantly involved. DM1 is, however, a multisystem disorder indeed, affected patients can manifest abnormalities of other organs and systems including the eye (cataract), the endocrine system (diabetes, thyroid dysfunction, hypogonadism), the central nervous system (cognitive impairment, mental retardation, attention disorders), the gastrointestinal system (dysphagia, constipation, gallbladder stones, pseudoobstruction), and the heart (table 36.2).

Folklore and Evidence Fact or Fiction Totality of the Evidence

Has more fiber than white bread Effective cure for constipation prevents cancer lowers cholesterol Oatmeal and oat bran can prevent heart disease Prevents scurvy helps to heal ulcers causes constipation unpasteurized milk has more nutrients than pasteurized a glass of milk before bed causes drowsiness mothers who drink a lot of milk have colicky babies milk and other dairy products are fattening and should be avoided on a low-fat diet the calcium in milk and other foods causes kidney stones Prevents vaginal yeast infections cures vaginitis, constipation, and diarrhea yoghurt applied topically heals a sunburn

TABLE 846 Complications of Laparoscopy

RECIAL SURGERY Patients who have undergone hemorrhoidectomy frequently have problems with postoperative urinary retention, the management of which has been previously discussed. Ihree other problems that can occur are constipation, rectal hemorrhage, and rectal prolapse. Ihe management of constipation in a patient who has undergone rectal surgery is no different from that of any other patient with constipation. Gentle rectal examination is indicated, and enemas can still be used. Posthemorrhoidectomy rectal hemorrhage can occur immediately postoperatively but may also be delayed (4 2 days).15 Proposed causes of delayed bleeding include sepsis of the pedicle, disruption of a clot, and sloughing of tissue. 16 Ihe patient may present with minimal bleeding or massive hemorrhage. While ligation of the affected vessel is needed, a temporary tamponade with a Foley catheter may be helpful.

Clinical evaluation

Endometriosis should be considered in any woman of reproductive age who has pelvic pain. The most common symptoms are dysmenorrhea, dyspareunia, and low back pain that worsens during menses. Rectal pain and painful defecation may also occur. Other causes of secondary dysmenorrhea and chronic pelvic pain (eg, upper genital tract infections, adenomyosis, adhesions) may produce similar symptoms. Gastrointestinal tract (constipation,

Description Of Treatment Processes

Comprehensive treatment for eating disorders generally requires attention to four distinct features of these disorders (1) biological aspects, particularly nutritional status and the deleterious consequences of semistarva-tion and undernutrition on the one hand, or serious obesity on the other (2) eating disorders related behaviors including restrictive and idiosyncratic eating patterns, eating binges, purging, ordinarily by means of vomiting or use of laxatives, and excessive, compulsive exercise (3) eating disorder related thoughts, attitudes, and emotions, which may include distorted self-perceptions, overvalued ideas, and self-disparagement, all related to shape and weight, diminished cognitive complexity and increased obsessionality and perfectionistic thinking accompanying malnutrition, and increased nutrition-related emotional fragility with mood and anxiety symptoms and (4) associated psychopathological and interpersonal problems, the frequent comorbid conditions of mood,...

Hypercalcemia Of Malignancy

Approximately 40 percent of patients with multiple myeloma will have hypercalcemia, often accompanying the clinical triad of back pain, anemia, and lethargy. Hypercalcemia from any cause may produce nausea, vomiting, anorexia, and constipation. Altered mental status, confusion, and coma are consistent with rapid and or high levels of hypercalcemia. Elevated ionized calcium is responsible for neuromuscular dysfunction, and therefore, serum calcium levels should be interpreted in conjunction with serum phosphorus, albumin, and blood pH determinations. The QT interval of the electrocardiogram may shorten as the serum calcium rises.

Probiotics and Prebiotics

Prebiotics are nondigestible food ingredients that stimulate the growth or modify the metabolic activity of intestinal bacterial species that have the potential to improve the health of their human host. Criteria associated with the notion that a food ingredient should be classified as a prebiotic are that it remains undigested and unabsorbed as it passes through the upper part of the gastrointestinal tract and is a selective substrate for the growth of specific strains of beneficial bacteria (usually lactobacilli or bifidobacteria), rather than for all colonic bacteria, inducing intestinal or systemic effects through bacterial fermentation products that are beneficial to host health. Prebiotic food ingredients include bran, psyllium husk, resistant (high amylose) starch, inulin (a polymer of fructofuranose), lactulose, and various natural or synthetic oligosaccharides, which consist of short-chain complexes of sucrose, fructose, galactose, glucose, maltose, or xylose. The best-known...

Health Effects of Carbohydrates

High intakes of NSP, in the range of 4-32 gday-1, have been shown to contribute to the prevention and treatment of constipation. Population studies have linked the prevalence of hemorrhoids, diverticular disease, and appendicitis to NSP intakes, although there are several dietary and lifestyle confounding factors that could directly affect these relationships. High-carbohydrate diets may be related to bacterial growth in the gut and subsequent reduction of acute infective gastrointestinal disease risk.

Key Questions in Evaluating Patients for Urinary Incontinence

Retention, constipation, sedation (OAB and overflow) C. Because fecal impaction has been linked to urinary incontinence, a history that includes frequency of bowel movements, length of time to evacuate and whether the patient must splint her vagina or perineum during defecation should be obtained. Patients should be questioned about fecal incontinence.

Answers To Some Questions People Commonly

Dietary restrictions modifications are inevitable for the persons suffering from such disorders like colds, cough, constipation, piles, high B.P., diabetes, liver ailments, kidney ailments, heart ailments and obesity. A diabetic who continues to eat sweets cannot hope to improve with Reflex Zone Therapy.

Nausea Vomiting and Hyperemesis Gravidarum

Findings upon physical examination are usually normal except for signs of volume depletion. Rectal examination should be performed to rule out fecal impaction and occult blood. A pelvic examination should be performed if there is pelvic pain, vaginal bleeding, or discharge.

The elderly

There is a decrease in intestinal motility (Bitar and Patil, 2004) and mucosal immune function (Fujihashi and McGhee, 2004) with aging. Fecal impaction may result from loss of smooth muscle contractility, but it is not clear if prolonged exposure of pathogens to intestinal epithelium is a risk factor for pathogen infection. However, studies have found that the elderly are at greater risk of infection from the senescence of gut-related immune tissues (Fujihashi and McGhee, 2004).


Free perforation is an indication for immediate surgical intervention. Patients with perforation will often present with peritoneal signs secondary to leakage of enteric contents into the peritoneal cavity with resulting inflammation and abscesses. The most common reasons for perforation are peptic ulcer disease or diverticulitis. The history should be focused to help differentiate these. A change in bowel habits and frequent constipation can suggest a colonic source. Nonsteroidal drug use and tobacco abuse are associated with peptic ulcers. Perforation from either source can be contained or freed within


SIDE EFFECTS AND CONTRAINDICATIONS The most common side effects include dry mouth, drowsiness, and constipation. Rarely, bradycardia can occur in patients with sick sinus syndrome. Clonidine may interact with other drugs, causing adverse effects such as orthostatic hypotension in patients taking diuretics, decreased antihypertensive effects with cyclic antidepressants, increased sedation with alcohol, and bradyarrhythmias or other dysrhythmias with negative inotropic agents. When high doses of clonidine are abruptly stopped, the well-documented phenomenon of clonidine withdrawal with severe rebound hypertension, tachycardia, flushing, and abdominal symptoms may be seen. If this syndrome occurs, the patient should be given clonidine therapy promptly. The use of b blockers should be avoided because they may worsen the withdrawal symptoms.

Colonic Motility

The gastrocolic reflex, an anterograde postperis-taltic process, occurs following a meal, originating proximally and propagating anterograde. Both the caloric content and the fat composition of the meal influence colonic peristalsis. Gastric distention by food contents, water, or gas also has a stimulatory effect. Gastrointestinal hormones secreted in response to a meal, such as cholecystokinin, are thought to mediate peristaltic responses to a (fatty) meal. Irritant laxatives also stimulate peristalsis, even when administered rectally. Opiates are

Anorexia Treatment

Relationship and adequate motivation have been established, the therapist educates the client about a healthy body mass index and instructs the client to record her weight weekly. In addition, the client is instructed in self-monitoring and is given daily food records on which to log everything eaten or purged, laxatives taken, as well as thoughts and feelings elicited by these behaviors. Steady increases in the type, amount, and frequency of food eaten are then undertaken. Daily calorie intake guidelines (no lower than 1500 calories day) and weekly weight gain goals (typically 1-2 pounds week) are set and worked toward until the client reaches a weight at which menses resumes and dieting is not needed to maintain the weight. Some methods used for eating pattern modification include well-planned exposure to forbidden food types and amounts, delaying purging behaviors, distraction from disturbing thoughts while eating, and engagement in pleasant activities following eating. Treatment...

The Large Intestine

The beneficial effects of dietary fiber on the alimentary tract were emphasized by another of the founders of the dietary fiber hypothesis, Denis Burkitt, who based his arguments largely on the concept of fecal bulk, developed as a result of field observations in rural Africa, where cancer and other chronic bowel diseases were rare. His hypothesis was that populations consuming the traditional rural diets, rich in vegetables and cereal foods, produced bulkier, more frequent stools than persons eating the refined diets typical of industrialized societies. Chronic constipation was thought to cause straining of abdominal muscles during passage of stool, leading to prolonged high pressures within the colonic lumen and the lower abdomen. This in turn was thought to increase the risk of various diseases of muscular degeneration including varicose veins, hemorrhoids, hiatus hernia, and colonic diverticulas. Colorectal neoplasia was also thought to result from infrequent defecation, because...

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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