GIT in Hemodialysis

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GIT IN HEMODIALYSISBy: Ahmed EldeepMD

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AGENDA 1- Common gastrointestinal (GI) symptoms among HD patients.2-Abdominal pain in Dialysis patient.3- Are dialysis patients at an increased risk of GI bleeding? 4- Hemodialysis-associated ascites.

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Common gastrointestinal (GI) symptoms

The CVS complications like hypotension & arrhythmia were at the top with frequency of 79.3%. The GIT complications like nausea, vomiting abdominal pain followed the CVS complication in decreasing order of frequency. The other major proportion of complications was Hematological complications

1-Nausea and vomitingOccurs in up to 10% of routine dialysis treatments. Etiology The cause is multifactorial.Inadequate dialysis. HypotensionEarly manifestation of disequilibrium syndrome.Dialyzer reactions.Fluid and electrolyte changes during the dialysis treatment.Non-dialysis causes(outside of the dialysis setting) e.g: Hypercalcemia Cerebral causes or GI causes

Prior to the initiation of dialysis, patients may complain of nausea and vomiting. These symptoms usually disappearwith dialysis and removal of uremic toxins.

Etiology. Nausea or vomiting occurs in up to 10% of routine dialysis treatments. The cause is multifactorial.Most episodes in stable patients are probably related to hypotension. Nausea or vomiting also can be an earlymanifestation of the so-called disequilibrium syndrome described in II.A. Both type A and type B varieties ofdialyzer reactions can cause nausea and vomiting. Non-dialysis causes must always be considered when nauseaand vomiting occur outside of the dialysis setting, as discussed in Chapter 34. For example, hypercalcemia maymanifest as (primarily interdialytic) nausea and vomiting, and should be looked for when no other explanation is athand.2. Management. The first step is to treat any associated hypotension. If nausea persists, an antiemetic (seeTable 6-5) can be administered.3. Prevention. Avoidance of hypotension during dialysis is of prime importance. In some patients, reduction ofthe blood flow rate by 30% during the initial hour of dialysis may be of benefit. However, the treatment time mustthen be lengthened accordingly.6

Dyspepsia.

Dyspepsia. Dyspepsia is defined as persistent or recurrent abdominal discomfort centered in the upper abdomen(epigastrium). Dyspepsia and indigestion are terms that are frequently interchangeable. Symptoms may includeepigastric pain or discomfort, bloating, belching, eructations, and flatulence. Dyspepsia may be due to a true GIpathologic process, such as peptic ulcer disease, gastroesophageal reflux disease, gastritis, duodenitis, orgastroparesis, as seen in diabetic patients. Alternatively, dyspepsia may be related to medications that dialysispatients are required to take, such as phosphate binders (e.g., calcium carbonate or aluminum salts) or ironsupplements. Evaluation for organic lesion is warranted if the history and physical examination are suggestive of suchlesions. Prokinetic agents, antacids, and histamine H2 receptor antagonists are the most widely used agents in themanagement of dyspepsia. Dosing of these drugs in renal failure is discussed below in Section II.A.3. (prokineticdrugs) and Section II.B.3. (H2-blockers).7

2-Dyspepsia. Persistent or recurrent abdominal discomfort centered in the upper abdomen epigastric pain or discomfort, bloating, belching, eructations, and flatulence. EITIOLOGYTrue GI pathologic process, such as peptic ulcer disease, GERD, gastritis, duodenitis, or gastroparesis. Medications as phosphate binders (e.g., calcium carbonate or aluminum salts) or iron supplements. TTT: Prokinetic agents, antacids, and histamine H2 receptor antagonists.

Dyspepsia. Dyspepsia is defined as persistent or recurrent abdominal discomfort centered in the upper abdomen(epigastrium). Dyspepsia and indigestion are terms that are frequently interchangeable. Symptoms may includeepigastric pain or discomfort, bloating, belching, eructations, and flatulence. Dyspepsia may be due to a true GIpathologic process, such as peptic ulcer disease, gastroesophageal reflux disease, gastritis, duodenitis, orgastroparesis, as seen in diabetic patients. Alternatively, dyspepsia may be related to medications that dialysispatients are required to take, such as phosphate binders (e.g., calcium carbonate or aluminum salts) or ironsupplements. Evaluation for organic lesion is warranted if the history and physical examination are suggestive of suchlesions. Prokinetic agents, antacids, and histamine H2 receptor antagonists are the most widely used agents in themanagement of dyspepsia. Dosing of these drugs in renal failure is discussed below in Section II.A.3. (prokineticdrugs) and Section II.B.3. (H2-blockers).8

3-Constipationcommon complaint among dialysis patients. The causes of constipation are multifactorial. Patients' fluid intake is limited. Dietary restriction of high-potassium fruits and vegetables. Medications : calcium- or aluminum-containing phosphate binders and iron supplements. Patient inactivity and underlying medical conditions.

Constipation may result in obstruction, fecal impaction, and even bowel perforation, diverticular disease, as well as hemorrhoids.

Constipation. Constipation is not an uncommon complaint among dialysis patients. The causes of constipationare multifactorial. Patients' fluid intake is limited. Dietary restriction of high-potassium fruits and vegetables decreasesthe fiber content of ingested food. Medications such as calcium- or aluminum-containing phosphate binders and ironsupplements cause constipation. Patient inactivity and underlying medical conditions may contribute to constipation.Narcotics given as an analgesic, such as codeine and meperidine, can cause constipation, as well as mental statuschange in patients with end-stage renal disease (ESRD).Constipation may result in obstipation with obstruction, fecal impaction, and even bowel perforation. Long-termcomplications of constipation are thought to contribute to the etiologic process of diverticular disease, as well ashemorrhoids. In patients treated with peritoneal dialysis, decreased bowel motility can cause dialysate outflowobstruction through the peritoneal catheter.9

Senna lax labImportal sachLactulose Laxel sachEnemax Picolax drops

Management Increase the fiber content in food usually corrects constipation. If constipation persists, the following agents may be used: Emollient: docusate sodium (egycusate) 100 mg PO qd to tid , Stimulant: bisacodyl (Dulcolax) 13 tablets; and senna(senna lax lab purgation).Hyperosmotic: sorbitol ( importal sach )70% 30 mL PO qhs, lactulose 30 mL PO qhs. Sodium polystyrene sulfonate resin plus sorbitol (Kayexalate) has been associated with intestinal necrosis in ESRD patients, either given by enema or by the oral route ( Dardik et al, 2000).

Dietary changes to increase the fiber content in food usually corrects constipation. If constipation persists, thefollowing agents may be used: Emollient: docusate sodium (Colace) 100 mg PO qd to tid prn, casanthranol anddocusate sodium (Peri-Colace) 12 capsules or 12 tablespoons PO qhs prn; Stimulant: bisacodyl (Dulcolax) 13tablets PO qd prn; and Hyperosmotic: sorbitol 70% 30 mL PO qhs, lactulose (Chronulac) 30 mL PO qhs. Sodiumpolystyrene sulfonate resin plus sorbitol (Kayexalate) has been associated with intestinal necrosis in ESRD patients,either given by enema or by the oral route ( Dardik et al, 2000). It is not clear if the sorbitol component alone is equallydangerous. Whereas the combination is still widely used to treat hyperkalemia, use of sorbitol to treat constipation,where there are alternatives available, may not be wise. Soap suds, mineral oil, and tap water enemas or bisacodyl orglycerin suppositories once daily may be used for more immediate results. Colyte or GoLYTELY may be used forbowel preparation for endoscopy or radiology studies despite the high electrolyte content and the large volumeingested.Medicinal fiber in the form of psyllium (Metamucil) should be avoided. Both sodium and potassium are present in thepreparation, and a large volume of liquid is required in preparation. Laxatives containing magnesium, citrate, orphosphate should be avoided (e.g., milk of magnesium, magnesium citrate, and Fleet's products containingphosphate). Magnesium is poorly handled by patients with ESRD. Hypermagnesemia can result in development ofneurologic disorders. Citrate, in general, should be avoided in patients with ESRD because it increases absorption ofaluminum from the GI tract. Hyperphosphatemia from phosphate intake can upset the delicate calcium/phosphorusbalance and contribute to the sequela of secondary hyperparathyroidism.11

Medicinal fiber in the form of psyllium (Regmucil sach) should be avoided. Both sodium and potassium are present in the preparation. and a large volume of liquid is required in preparation.Laxatives containing magnesium, citrate, or phosphate should be avoided (e.g., milk of magnesium, magnesium citrate, and Fleet's products containing phosphate). Magnesium is poorly handled by patients with ESRD.

Hypermagnesemia can result in development of neurologic disorders. (laxel sach- Epico-eff. Sach)Citrate, in general, should be avoided in patients with ESRD because it increases absorption of aluminum from the GI tract.(Mg citrate) Hyperphosphatemia from phosphate intake can upset the delicate calcium/phosphorus balance and contribute to the sequela of secondary hyperparathyroidism.(Enemax- Laxel sach)Mg sulphate )Epsom salt- laxel sach)Na picosulphate (picolax drops)

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Senna lax labImportal sachLactulose Laxel sachEnemax Picolax drops

4-DiarrheaAn episode of diarrhea.Diarrhea following a period of constipation.An acute episode of bloody