Gastrointestinal Tract Disorders

Key Points

∙ Vomiting, the expulsion of gastric contents, has a multitude of causes. Nausea, a queasy
sensation, may or may not precede the expulsion.
∙ The cause of the vomiting must be identified. Antiemetics can mask the underlying cause
of vomiting and should not be used until the cause has been determined.
∙ Two major cerebral centers—the chemoreceptor trigger zone (CTZ), which lies near the
medulla, and the vomiting center in the medulla—cause vomiting when stimulated.
∙ Nonpharmacologic measures should be used first when nausea and vomiting occur. If the
nonpharmacologic measures are not effective, antiemetics are combined with
nonpharmacologic measures.
∙ The nonpharmacologic methods of decreasing nausea and vomiting include
administration of weak tea, flat soda, gelatin, Gatorade, and Pedialyte. Crackers and dry
toast may be helpful.
∙ When dehydration becomes severe, intravenous (IV) fluids are needed to restore body
fluid balance.
∙ Nonprescription antiemetics can be purchased over the counter. These drugs have
minimal effect on controlling severe vomiting resulting from anticancer drugs, radiation,
and toxins.
∙ Selected antihistamine antiemetics can be purchased without a prescription to prevent
nausea, vomiting, and dizziness caused by motion. These drugs inhibit vestibular
stimulation in the middle ear.
∙ The side effects of antihistamine antiemetics are similar to those of anticholinergics:
drowsiness, dry mouth, and constipation.
∙ Several nonprescription drugs, such as bismuth subsalicylate, act directly on the gastric
mucosa to suppress vomiting.
∙ Phosphorated carbohydrate solution, a hyperosmolar carbohydrate, decreases nausea and
vomiting by changing the gastric pH; it may also decrease smooth-muscle contraction of
the stomach.
∙ Antiemetics that were once frequently used for the treatment of nausea and vomiting
during pregnancy are no longer recommended because they may cause harm to the fetus.
Instead, nonpharmacologic methods are used when possible to alleviate nausea and
vomiting during pregnancy.
∙ Many prescription antiemetics act as antagonists to dopamine, histamine, serotonin, and
acetylcholine, which are associated with vomiting.
∙ Antihistamines and anticholinergics act primarily on the vomiting center; they also act by
decreasing stimulation of the CTZ and vestibular pathways.
○ Side effects include drowsiness, which can be a major problem; dry mouth;
blurred vision caused by pupillary dilation; tachycardia; and constipation.
∙ Phenothiazines and the miscellaneous antiemetics, such as metoclopramide and
trimethobenzamide, act on the CTZ center.
○ Phenothiazines have antihistamine and anticholinergic properties. The side effects
of phenothiazine antiemetics are moderate sedation, hypotension, extrapyramidal
 symptoms, central nervous system (CNS) effects, and mild anticholinergic
symptoms.
∙ Dopamine antagonists suppress emesis by blocking dopamine2 receptors in the CTZ.
○ Common side effects of dopamine antagonists are extrapyramidal symptoms.
∙ Droperidol block the dopamine2 receptors in the CTZ. They are used to treat
postoperative nausea and the vomiting and emesis associated with toxins, cancer
chemotherapy, and radiation therapy.
○ Droperidol is likely to cause extrapyramidal syndrome (EPS) if used for an
extended time.
∙ Selected benzodiazepines indirectly control nausea and vomiting that may occur with
cancer chemotherapy.
∙ Serotonin antagonists suppress nausea and vomiting by blocking the serotonin receptors
(5-HT3) in the CTZ and the afferent vagal nerve terminals in the upper GI tract.
○ Common side effects include headache, dizziness, hypotension, palpitations,
constipation, edema, and fatigue.
∙ Dexamethasone and methylprednisolone are two agents that are effective in suppressing
emesis associated with cancer chemotherapy.
∙ Cannabinoids alleviate nausea and vomiting resulting from cancer treatment.
Cannabinoids can be used as an appetite stimulant for patients with acquired
immunodeficiency syndrome.
○ Side effects occurring as a result of cannabinoid use include mood changes,
euphoria, drowsiness, dizziness, headaches, depersonalization, nightmares,
confusion, incoordination, memory lapse, dry mouth, orthostatic hypotension or
hypertension, and tachycardia.
○ Trimethobenzamide suppress impulses to the CTZ. The side effects and adverse
reactions are hypotension, blurred vision, and extrapyramidal symptoms.
∙ Metoclopramide suppresses emesis by blocking the dopamine receptors in the CTZ. It is
used in the treatment of postoperative emesis, cancer chemotherapy, and radiation
therapy.
○ High doses can cause sedation and fatigue. With this agent, the occurrence of EPS
is more prevalent in children than in adults.
∙ Emetics are drugs used to induce vomiting. When an individual has consumed certain
toxic substances, induced vomiting may be indicated to expel the substance before
absorption occurs.
∙ Vomiting should not be induced if caustic substances have been ingested. Activated
charcoal is given when emesis is contraindicated.
∙ Diarrhea (frequent liquid stool) is a symptom of an intestinal disorder. Diarrhea can be
mild to severe. Antidiarrheals should not be used for more than 2 days and should not be
used if fever is present.
∙ Because intestinal fluids are rich in water, sodium, potassium, and bicarbonate, diarrhea
can cause minor or severe dehydration and electrolyte imbalances.
∙ The cause of diarrhea should be identified. Nonpharmacologic treatment for diarrhea is
recommended until the underlying cause can be determined. This includes use of clear
liquids and oral solutions and IV electrolyte solutions.
∙ Traveler’s diarrhea is usually caused by E. coli. It ordinarily lasts less than 2 days;
 however, if it becomes severe, fluoroquinolone antibiotics are usually prescribed.
Loperamide may be used to slow peristalsis and decrease the frequency of defecation, but
it can also slow the exit of the organism from the GI tract.
∙ Opiates decrease intestinal motility, thereby decreasing peristalsis. Constipation is a
common side effect of opium preparations. Diphenoxylate and difenoxin are combined
with atropine to decrease abdominal cramping, intestinal motility, and hypersecretion.
With prolonged use of these drugs, physical dependence may occur.
∙ Loperamide is structurally related to diphenoxylate but causes less CNS depression.
∙ Adsorbents act by coating the wall of the GI tract and adsorbing bacteria or toxins that
cause diarrhea. Adsorbent antidiarrheals include kaolin and pectin.
∙ Bismuth subsalicylate is considered an adsorbent because it adsorbs bacterial toxins.
∙ Colestipol and cholestyramine are prescription drugs that have been used to treat diarrhea
due to excess bile acids in the colon. They are effective, although they have not been
approved by the U.S. Food and Drug Administration for that purpose.
∙ Constipation, the accumulation of hard fecal material in the large intestine, is a relatively
common complaint and a major problem for older adults. Insufficient water intake and
poor dietary habits are contributing factors.
∙ Nonpharmacologic management of constipation includes a diet high in fiber, water,
exercise, and routine bowel habits.
∙ A “normal” number of bowel movements ranges between one to three a day to three a
week. What is normal varies from person to person; the nurse should determine what
normal bowel habits are for each patient.
∙ Laxatives and cathartics are used to eliminate fecal matter. Laxatives promote a soft
stool; cathartics result in a soft to watery stool with some cramping. Purgatives are harsh
cathartics that cause a watery stool with abdominal cramping.
∙ Laxatives should be avoided if there is any question that the patient may have intestinal
obstruction, if abdominal pain is severe, or if symptoms of appendicitis, ulcerative colitis,
or diverticulitis are present.
∙ Most laxatives stimulate peristalsis. Laxative abuse from chronic use is a common
problem, especially in older adults. Laxative dependence can become a problem, so
patient teaching is an important nursing responsibility.
∙ Osmotics, hyperosmolar laxatives, include salts or saline products, lactulose, and
glycerin. Saline products consist of sodium or magnesium, and a small amount is
systemically absorbed. Serum electrolytes should be monitored to avoid electrolyte
imbalance.
∙ Lactulose, another saline laxative that is not absorbed, draws water into the intestines to
form a soft stool. It decreases the serum ammonia level and is useful in liver diseases,
such as cirrhosis.
∙ Glycerin acts like lactulose, increasing water in the feces in the large intestine.
∙ The bulk that results from the increased water in the feces stimulates peristalsis and
defecation.
∙ Patients who have renal insufficiency should avoid magnesium salts. Hypermagnesemia
can result from continuous use of magnesium salts, causing symptoms such as
drowsiness, weakness, paralysis, complete heart block, hypotension, flush, and
respiratory depression.
∙ The side effects of excess lactulose use include flatulence, diarrhea, abdominal cramps,
nausea, and vomiting. Patients who have diabetes mellitus should avoid lactulose,
because it contains glucose and fructose.
∙ Stimulant laxatives increase peristalsis by irritating sensory nerve endings in the
intestinal mucosa.
∙ Castor oil is a harsh laxative (purgative) that acts on the small bowel and produces a
watery stool.
∙ Side effects of stimulant laxatives include dizziness, nausea, abdominal cramps,
weakness, and reddish brown urine caused by excretion of phenolphthalein, senna, or
cascara.
∙ Castor oil should not be used in early pregnancy because it stimulates uterine
contractions, and spontaneous abortion may result.
∙ Prolonged use of senna can damage nerves, which may result in loss of intestinal
muscular tone.
∙ Bulk-forming laxatives are natural fibrous substances that promote large, soft stools by
absorbing water into the intestine, increasing fecal bulk and peristalsis. These agents are
nonabsorbable. Defecation usually occurs within 8–24 h.
∙ This group of laxatives does not cause laxative dependence and may be used by patients
with diverticulosis, irritable bowel syndrome (IBS), and ileostomy and colostomy.
∙ Bulk-forming laxatives are not systemically absorbed; therefore, there is no systemic
effect.
∙ If bulk-forming laxatives are excessively used, nausea, vomiting, flatulence, or diarrhea
may occur. Abdominal cramps may occur if the drug is used in dry form.
∙ Selective chloride channel activators are laxatives used to treat idiopathic constipation in
adults. The drug activates chloride channels in the lining of the small intestine, leading to
an increase in intestinal fluid secretion and motility, thereby enhancing the passage of
stool.
∙ Adverse effects of selective chloride channel activators include nausea, diarrhea,
headache, abdominal distention, and flatulence.
∙ Emollients are lubricants and stool softeners used to prevent constipation. These drugs
decrease straining during defecation. Stool softeners work by lowering surface tension
and promoting water accumulation in the intestine and stool.