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Gastrointestinal Disorders
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Tegaserod, a 5-HT4-receptor agonist that stimulates peristalsis and fluid secretion, has been withdrawn from the US market by the FDA, so it is no longer recommended for this indication
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GASTROINTESTINAL GAS Belching
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Belching (eructation) is the involuntary or voluntary release of gas from the stomach or esophagus It occurs most frequently after meals, when gastric distention results in transient lower esophageal sphincter relaxation Belching is a normal reflex and does not itself denote gastrointestinal dysfunction Virtually all stomach gas comes from swallowed air With each swallow, 2 5 mL of air is ingested, and excessive amounts may result in distention, flatulence, and abdominal pain This may occur with rapid eating, gum chewing, smoking, and the ingestion of carbonated beverages Chronic excessive belching is almost always caused by aerophagia, common in anxious individuals and institutionalized patients Evaluation should be restricted to patients with other complaints such as dysphagia, heartburn, early satiety, or vomiting Once patients understand the relationship between aerophagia and belching, most can deal with the problem by behavioral modification Physical defects that hamper normal swallowing (ill-fitting dentures, nasal obstruction) should be corrected Antacids and simethicone are of no value
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Management of Refractory Chronic Constipation
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Patients with refractory constipation not responding to routine medical management warrant referral to a specialist for further diagnostic studies, including colonic transit and pelvic floor function studies, in order to distinguish slow colonic transit from anorectal dysfunction Colon transit time is most commonly measured by performing an abdominal radiograph 120 hours after ingestion of 24 radiopaque markers Retention of greater than 20% of the markers indicates prolonged transit Rarely, surgery (subtotal colectomy) is required for patients with severe colonic inertia Anorectal disorders are assessed with balloon expulsion testing, anal manometry, and defecography Patients with anorectal dysfunction may benefit from biofeedback therapy
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Treatment of Fecal Impaction
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Severe impaction of stool in the rectal vault may result in obstruction to further fecal flow, leading to partial or complete large bowel obstruction Predisposing factors include severe psychiatric disease, prolonged bed rest and debility, neurogenic disorders of the colon, and spinal cord disorders Clinical presentation includes decreased appetite, nausea, and vomiting, and abdominal pain and distention There may be paradoxical diarrhea as liquid stool leaks around the impacted feces Firm feces are palpable on digital examination of the rectal vault Initial treatment is directed at relieving the impaction with enemas (saline, mineral oil, or diatrizoate) or digital disruption of the impacted fecal material Long-term care is directed at maintaining soft stools and regular bowel movements (as above)
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American College of Gastroenterology Task Force An evidencebased approach to the management of chronic constipation in North America Am J Gastroenterol 2005;100 (Suppl 1): S1 4 [PMID: 16008640] Chiarioni G et al Biofeedback is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia Gastroenterology 2006 Mar;130(3):657 64 [PMID: 16530506] Hsieh C Treatment of constipation in older adults Am Fam Physician 2005 Dec 1;72(11):2277 84 [PMID: 16342852] Kamm MA Clinical case: chronic constipation Clin Gastroenterol Hepatol 2006 Feb;4(2):233 48 [PMID: 16469685] McKeage K et al Lubiprostone Drugs 2006;66(6):873 9 [PMID: 16706562] Ramkumar D et al Efficacy and safety of traditional medical therapies for chronic constipation: systematic review Am J Gastroenterol 2005 Apr;100(4):936 71 [PMID: 15784043] Rao SS et al Clinical utility of diagnostic tests for constipation in adults: a systematic review Am J Gastroenterol 2005 Jul;100(7):1605 15 [PMID: 15984989] Wald A Constipation in the primary care setting: current concepts and misconceptions Am J Med 2006 Sep;119(9): 736 9 [PMID: 16945605] Wald A Severe constipation Clin Gastroenterol Hepatol 2005 May;3(5):432 5 [PMID: 15880311]
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Flatus
The rate and volume of expulsion of flatus is highly variable Flatus is derived from two sources: swallowed air and bacterial fermentation of undigested carbohydrate The majority of swallowed air not belched passes through the gut and leaves as flatus Swallowed air may contribute up to 500 mL of flatus per day (primarily nitrogen) Bacterial fermentation of undigested carbohydrates leads to the additional production of gas, particularly H2, CO2, and methane The majority of this fermentation takes place in the colon Under normal circumstances, a small substrate of fermentable substances reaches the colon These substances include fructose, lactose, sorbitol, trehalose (mushrooms), raffinose, and stachyose (legumes, cruciferous vegetables) Complex starches and fiber may also cause gas Gas production may be increased with ingestion of these carbohydrates or with malabsorption Determining abnormal from normal amounts of flatus is difficult An initial trial of a lactose-free diet is recommended Common gas-producing foods should be reviewed and the patient given an elimination trial These include beans of all kinds, peas, lentils, brussels sprouts, cabbage, parsnips, leeks, onions, beer, and coffee Fructose intolerance may be more common than previously appreciated Fructose is present not only in many fruits but is also used commonly as a sweetener or as fructose corn syrup in candy, fruit juices, and soda Foul odor may be caused by garlic, onion, eggplant, mushrooms, and certain herbs and spices For patients with persistent complaints, complex starches, and fiber may be eliminated, but such restrictive diets are unacceptable to most patients Of refined flours, only rice flour is gas-free The nonprescription agent Beano ( -d-galactosidase enzyme) reduces gas caused by foods containing raffinose
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