DIGESTIVE SYSTEM-PART-V-HEMORRHOIDS

HEMORRHOIDS-TREATMENTS

Hemorrhoids in which piles or clusters of dilated blood vessels in the lower rectum (internal piles) or in the anus (external piles) are formed. Pile is a traditional name used by many people for hemorrhoids.

The piles or clusters of the dilated blood vessels known as arteriovenous anastomoses present in the rectum and anus cause downward displacement of the rectal and anal cushions to form the internal and external piles respectively.

Although hemorrhoids are common and considered minor medical problems hey produce considerable discomfort and anxiety.

A proper diagnosis must be carried out before taking a conclusion for the treatments of hemorrhoids as many other pathological conditions can mimic the symptoms of hemorrhoids such as,

1.Anal abscess a small inflamed reddish boil which is caused by an infection usually of  Staphylococcus 

2.Cryptitis which is inflammation of the crypts usually seen in inflammatory bowel disease and Crohn's disease.

3.Anal fissure which is a small tear in the lining of the anus.

4. An anal fistula is an abnormal contact of the rectal mucosa with the skin of the anus adjacent to it.

5.A polyp which a tumor of the large intestine.

6.Colorectal cancer

All the above conditions also can cause bleeding which is similar to hemorrhoids.

Fortunately, patient reassurance and the proper administration of a few simple treatments usually improve the conditions of hemorrhoids.

Types of Hemorrhoids

1. Internal hemorrhoid is an exaggerated vascular cushion with an engorged internal hemorrhoidal plexes located above the dentate line and covered with a mucus membrane

2. An external hemorrhoid is a dilated vein of the inferior hemorrhoidal plexus located below the dentate line and covered with squamous epithelium

Causes

Hereditary may be a primary cause. But there are other acquired causes also such as

1.Situations that result in increased venous pressure in the hemorrhoidal plexes such as chronic straining of defecation during constipation; small hard stools; prolonged sitting on the toilet; heavy weight lifting jobs; and pregnancy.

2. The dilated hemorrhoidal veins are pushed downward during defecation or straining a with increase venous pressure they dilate and become engorged.

Over time the fibers that attach the hemorrhoidal veins to their underlying mucosa stretch which results in Prolapse

Symptoms 

1. Painless bleeding is the most common symptom occur during defecation or bowel movements

2. Prolapse is the second most common symptom whether it may be temporary or permanent.

3. Pain is usual if thrombosis involving external tissue is present.

4. Other symptoms are discomfort; soreness; pruritus; swelling and discharge 

Groups of internal hemorrhoids

1. A first degree (Grae-1) hemorrhoid does not descend or prolapse during straining during defecation.

2. A second degree (Grade-2) hemorrhoid descend but return automatically with relaxation

3. A third-degree (Grade-3) hemorrhoid require manual replacement into the rectum after prolapse

4. A fourth degree (Grade-4) hemorrhoid is permanently prolapsed.

Treatments

All treatments of hemorrhoids are based on breaking a cycle of events such as the protrusion of vascular submucosal cushion through a tight anus which becomes congested and hypertrophic which causes the mucosa to protrude further.

Treatments for minimal bleeding 1st and 2nd Grades:-

1.Advise the patient to reduce straining during defecation and to avoid sitting longer time on the toilet

2. Avoid constipation by the intake of high fiber diet, increased water drinking, use of bulk laxatives stool softeners such as docusate.

3. Use sitz baths (a bath in which a person can sit in water up to his hips) to soothe the anal mucosa by using warm water mixed with Epsom salt or ice cubes. Avoid prolonged bathing by increasing the frequency of bathing.

 doctors' supervision and special procedures.

4.OTC hemorrhoidal ointments, creams, foams and suppositories can also help to relieve symptoms

Treatments of Higher Graded Hemorrhoids

It usually requires a doctor's supervision and special procedures.

1. Anoscope ligation watches the video above.

A rubber band ligation is employed for symptomatic hemorrhoids of grades 2 and 3.In this procedure a rubber band ligature is inserted into the anus by using an anoscope and placed on the rectal mucosa above hemorrhoid well above the dentate line. The ligated area sloughs off in a few days.

2. Infrared coagulation can be used for Grade-2, but it is less effective than the banding with large hemorrhoids. Watch the video above.

3. Sclerotherapy is the procedure in which a sclerosing agent is injected into hemorrhoids.

4.Cryotherapy in which freezing the hemorrhoids are performed.

5.Surgical hemorrhoidectomy. Watch the above video.

This invasive procedure is reserved only for Grades 3 and 4.

The main disadvantages are after this surgery performed whether by traditional or by laser, the patients often have significant discomfort and post-operative disabilities.

An external thrombosed hemorrhoid can be completely excised in an office setting, clinic, or in an operation theatre.

OTC Treatments

FDA has approved some OTC medications to alleviate the discomforts of hemorrhoids such as pain; irritations; burning; inflammations; itching and swelling. But they are not curative and their use may produce any unwanted symptoms stop them and consult the doctor.

1. Generally, ointments and creams are preferable than suppositories which may bypass the affected area.

2. Local anesthetics work by blocking the pain impulses. They can be used at the anus and the perianal level but not deep up to the rectum.

e.gs

1.Benzocaine 5% to 20%

2.Zinc sulfate monohydrate and Pramoxine HCl 1%(Anusol Plus)

3.Benzyl Alcohol 1% to 4%

4.Dibucaine HCl 0.25% to 1%

5.Dyclonine HCl 0.5% to 1%

6.Lidocaine 2% to 5%

7.Xylocaine and Tetracaine 05% to 1%

3. Vasoconstrictors have been shown to decrease mucosal perfusion in the anorectal area after topical application. However, because bleeding in this area is a sign of more serious conditions other than hemorrhoid vasoconstrictors are not approved for minor bleeding. These agents may give local anesthetic effects also for relieving itching burning etc.

e.g.

a.Ephedrine sulfate 0.1 to 0.125%

b.Ephedrine HCl 0.005% to 0.01%

c.Phenylephrine HCl 0.25%

All the above are in aqueous solutions.

Vasoconstrictors are highly contraindicated in those who have cardiovascular disease, high blood pressure, hyperthyroidism, and diabetes mellitus.

Protectants

These agents provide a physical barrier forming a protective coating over the mucosa to give a temporary comfort.

e.gs

a.Absorbents 

b.Adsorbents

c.Demulcents

d.Emollients

 

DIGESTIVE SYSTEM PAR-IV-GERIAIC CONSTIPATION

CONSTIPATION IN ELDERLY PATIENTS

Constipation is common in elderly patients above 80 years who are at bed rest.

These geriatric patients tend to be at risk for tight motion or constipation due to insufficient intake of dietary fiber, fluids, failure to establish a regular bowel habit, and excessive use of inappropriate laxatives such as stimulant or osmotic laxatives which results in loss of bowel smooth muscle tone.

Laxative Abuse often happens in elderly patients and young women when they chronically use stimulant laxatives or osmotic laxatives in order to promote bowel movements and to shed their excess weight.

In some medical practices, the elderly patients with anorexia nervosa or bulimia(an obsessive desire to lose weight) are often advised to take high doses of stimulant laxatives several times per day which may result in serious laxative abuses with unwanted consequences such as loss of bowel tone, and bowel perforation, etc.

Elderly patients should be thoroughly examined for such drug abuse including uses of opiates, and anticholinergics along with their medical history for other underlying diseases such as Hypothyroidism.

Cough suppressants and some pain killers commonly contain opiates such as codeine, meperidine, and dextromethorphan, etc. Anticholinergics are commonly used in anti-allergic medications such as all antihistamines preparations, belladonna extract(for diarrhea), and hyoscyamus and stramonium plant products(for stomach pain). Hence care should be taken when elderly patients with constipation are to take the above medication.

A major concern with geriatric patients is the possible loss of digestive fluids if they take stimulant and saline laxatives on a long time basis. Enemas should be given on doctor's supervision only. Magnesium containing laxatives such as Epsom Salt should not be used for those who have kidney problems.

Geriatric patients can be treated for acute constipation at home by Glycerine Suppositories with Bulk Laxatives. For chronic constipation Lactulose, a prescription drug can be used under a doctor's advice. 

DIGESTIVE SYSTEM-PART III-CONSTIPATION DURING PREGNANCY

PREGNANCY- CONSTIPATION-TREATMENT

Constipation relief at pregnancy

During pregnancy, period constipation is common and often annoying but the etiology is not similar to normal constipation.

Constipation in pregnancy is often caused by the compression of the intestinal tract by the enlarged uterus.

Pregnancy patients should avoid any laxatives like stimulant laxatives as they are absorbed systemically. Also, stimulant laxatives such as castor oil may cause premature labor.

They should avoid any laxatives such as mineral oil(Liquid Paraffin) which will interfere with the systemic absorption of fat-soluble vitamins.

The safe medicines for pregnancy patients are bulk laxatives or stool softeners.

Examples are Psyllium, Malt extract soup, and Methylcellulose (Bulk laxatives)

Fiber enriched fruits as stool softeners

 

DIGESTIVE SYSTEM-PART-II-DIARRHEA

DIARRHEA-TREATMENTS

Diarrhea is a frequent disturbing physiologic event in our routine life. It is one of the body languages by which the body tries to express that some unwanted things have been ingested into it. It is an involuntary action of expelling unwanted things out by our bodies without our concern.

Hence diarrhea can be defined as an abnormal increase in the frequency and loosening of the stools.

In general, the amount of stool may increase to above 200 gm or ml/day and its water content increased to above 60% to 99%.

Diarrhea persists due to some disturbing physiologic factor prevents or blocks the absorption of the water content of the stool by the small intestine.

Classifications of Diarrhea

1.By Mechanism of Actions:-

a. Osmotic Diarrhea occurs when a nonabsorbable substance present in the foods pulls excess water into the intestinal lumen.

(e.g.)1.Overeating

2.Ingestion of nonabsorbable substances such as sorbitol, glycerin, etc.

3.Enzyme deficiencies (e.g.)Deficiency of Lactase a disaccharidase enzyme to breakdown the nonabsorbable disaccharide sugar Lactose into absorbable monosaccharides.

b.Secretory Diarrhea occurs when the intestinal wall is damaged results in increased secretion and decreased absorption of water and electrolytes by the intestine.

(e.g.)

1.Bacterial endotoxins (E.coli;Vibrio cholerae,Shigella,S.aureus)

2.Bacterial infections (Shigella, Salmonella)

3.Viral infections (Rotavirus, Norwalk virus)

4.Protozoal infections (Giardia lamblia, Entamoeba histolytica)

5.Miscellaneous causes such as inflammatory bowel disease, and medications like prostaglandins, antibiotics, colchicine, and chemotherapeutic drugs.

c.Motility Disorders occurs when there is an insufficient contact of the stool with the intestinal wall so that less water is absorbed by the intestine

(e.g.)

1.Irritable bowel syndrome, scleroderma, diabetic neuropathy, gastric/intestinal incompatibility, and vagotomy.

2. Medications that can induce motility disorders include cholinergic agents (metoclopramide, bethanechol,), digitalis quinidine, and antibiotics.

Antibiotics cause diarrhea by intestinal irritations, increased bowel motility, and destroying intestinal bacterial flora. These symptoms can be minimized by taking antibiotics after food.

2.By etiology

a.Acute Diarrhea(Less than 2 weeks)

1.Infections

A.Viral infections due to Rota and Norwalk viruses

Rotavirus usually affect children under 2 years of age. The infection onset by 1 to 2 days and lasts for 5 to 8 days. Vomiting, fever, and mild dehydration are common symptoms. There is usually no pus or blood in the stool

Norwalk virus usually affects older children and adults. It has an onset of 1to2 days and lasts for 24 to 48 hours. Mild fever, vomiting, and dehydration are the symptoms and without pus or blood in the stool.

B.Bacterial Infections

Due to the consumption of contaminated water and food and the onset occur after 8 to several days.

Toxigenic Bacteriae These includes E.coli;V.cholerae;S.aureus.which spread their endotoxins. Symptoms are excretion large watery and greasy stools leads to severe dehydration.

Invasive Bacterias such as E.coli; Shigella; Salmonella; Campylobacter; and Clostridium difficile ane invading the intestinal mucosa. This results in dysentery like diarrhea which is experienced by an extreme urgency to defecate, stomach cramping, tenesmus(a false feeling of passing stool), fever, chills, blood, or pus in the stool.

Protozoa such as G.lamblia; E.histolytica; and Cryptosporidium causes explosive foul-smelling large volume of watery stool. This is due to the extreme invasion of the intestine by destroying its villi. Symptoms are severe loss of water and extreme dehydration. Though it is self-limiting it may persist for several months until complete eradication of the organisms.

C. Diet-induced diarrhea is commonly induced by food allergies, high fiber diets, fatty or spicy foods, large amounts of stimulants like caffeine, or milk. Avoiding such foods are the best treatment

TREATMENTS

A.Non-Medical Treatments

It is most advisable normal feeding of food or milk should not be stopped as the recent researches show that a normal diet or breastfeeding during diarrhea does not make it worse and may actually improve diarrhea.

Fluids in large quantities should be taken as electrolyte solution in order to prevent dehydration in acute diarrheal episodes. Oral and intravenous rehydration should be engaged as per the severity.

A homemade rehydration solution can be prepared as follows 

Sodium chloride(Table salt)     ---0.5 teaspoon

Potassium chloride                   ---0.25 tsp

Sodium bicarbonate (backing

                                    salt)      ---0.5 tsp

Glucose                                    ---2 tablespoon

Water add up to 1 liter.

Recommended dosages as follows

Adult (= or > 10 yrs)              ---2000to3000ml/day

Children (5 to 10 yrs)             ---1000to2000ml/day

Children (below 5 yrs)           ---40to75ml/kg for -  

                                                  - the first 6 hrs.or -

5 to 10 ml every 10 to 15 min for 30 min then-

15 to 20 ml every 10 to 15 mins for 30 mins then-

30 ml  every 30 minutes to complete the first 6 hours

60 ml (1/4 cup) every 30 minutes for the next 12 hours

Fluids to be avoided include hypertonic fluids such as apple juice; powdered drink mixes; gelatin water and carbonated drinks.

B.Medical Treatments

Up to date, the American FDA has allowed three agents as a category -I (i.e.safe and effective) medicines such as activated attapulgite (Aluminium and Magnesium silicates); calcium polycarbophil and loperamide.

1.Antiperistaltic drugs

These medicines acting by reducing the peristaltic movements of the gut. The frequency of the bowel movement is decreased and stool consistency is increased.

This medication is contraindicated in bacterial diarrhea as it prevents the clearance of the bacteria from the body and opens the way for the organism to enter into the system. But much information tells that this not serious and often proves no harm however care should be taken during the colitis diarrhea as it may cause serious megacolon.

Children <2 years should not be treated with these medications.

The following medicines are dispensed under prescription such as opiates related diphenoxylate/atropine (Lomotil); difenoxin/atropin(Metofen) as antiperistaltic agents.

Loperamide(Imodium); Kaopectate-II; are the nonprescription drugs.

Antiperistaltic drugs should not be used for more than 48 hours.

Side effects

1.Abdominal Pain

2.Stomach discomfort or distention

3.Drowsiness

4.Dizziness

5.Dry mouth 

Dosage

For adults 4 mg followed by 2 mg after each loose motion and not exceed 16 mg/day

For children 1 to 2 mg three times daily as per the weight and age.

2.Adsorbents

These drugs adsorb the toxins, bacteria gases, and water content of the stool on its surface of exposure. They are not absorbed systemically.

They are used only to give symptomatic relief and not a cure for severe symptoms. They should be given in large doses immediately following a loose stool.

a.Activated attapulgite. For adults a dose of 1200 mg after each stool.

For children 300 to 600 mg after each stool

Side effects are almost nill

b. Calcium Polycarbophil For adult 1 gm 1 to 4 times daily

For children 0.5 gms 1 to 4 times daily.

Side effects are nill

3.Miscellaneous

1.Bismuthsubsalicylate for an adult 2 tablets or 30 to 60ml every hour as needed to a maximum of 8 doses per day. The child's dose is half of the adult dose.

Side effects 

It can cause harmless grayish black stools or tongue and ringing in the ear.

Contraindicated in children recovering from chickenpox, or flu because of the possible Rye's syndrome.

2. Lactobacillus is used to replace the normal bacterial flora.

3. Lactase a disaccharidase they can breakdown diarrhea producing nonabsorbable disaccharides like lactose (in milk) into absorbable glucose and galactose.

The adult dose is 1 to 2 capsules taken with dairy products

4. Anticholinergics like atropine and scopolamine are producing antidiarrheal effects by slowing the bowel movements and increasing fluid absorption.

Side effects are dry mouth, blurred vision, urinary retention, and tachycardia.

5. Antiinfectives The infective diarrheas can be treated by the administration of antibiotics

Ciprofloxacin                             500 mg twice/day

Doxycycline                                100mg twice/day

Norfloxacin                                 400mg twice/day

Tetracycline                                   250mg 4times/day

Septran-DS                                   1 tab 2 times/day

The above are treatments should be under a doctors supervision

 

DIGESTIVE SYSTEM-PART-1-CONSTIPATION

CONSTIPATION-TREATMENTS

Because of our modern lifestyle, our eating styles and the method of cooking are all changed. Even the natural edibles such as fruits, grains, nuts, and herbs are all grown in chemically fertilized fields. The days are modernized in such a way that everybody whether they are poor or rich has to rely on foods with slow poisonings to satisfy their hunger.

Because of this everybody becomes sick and somehow relies on medicines which are also chemicals as an added tragedy of self-poisoning. Even animals, birds are not escaped from this moral tragedy.

Simply we are self-poisoning in the name of food drinks and medicines with a moral just.No another way to escape.

Stomach distress is a common discomfort with many people in this modern world because our eatings are first dumped into this part only. Some people because of their careless eating behavior do not give respect to their stomach instead they use it as a dustbin by dumping into it mercilessly with whatever they saw and whenever they feel to munch something as fast foods. The result is stomach distress like upset, constipation, or diarrhea.

Constipation is defined as the difficult or infrequent passage of stool. Normal passage of stool must range in frequencies from 1 or 2 times daily or 2 to 3 times weekly.

Constipation may generally give a discomfort of headache, stomach bloating, or an abnormal rectal fullness.

Causes

1.Insufficient dietary fibers

2.Lack of movements

3.Poor bowel habits such as not responding to the defecatory urge, or hurried and incomplete evacuation.

4.Stress

5.Fever

6.Medicines such as opium, marijuana, nicotine, anticholinergics like antidepressants, antihistamines, phenothiazines antispasmodics, and calcium-containing antacids.

7.Pathological conditions like intestinal obstructive tumors, diabetes, and hypothyroidism.

 Diverticulitis a condition in which small pouches are formed at the bowel wall.

Counsellings

1.Normal stool frequencies

2.Duration of the constipation

3. Amount of dietary fibers taken

5.Medicines in use

6.Presence of other symptoms.

7.Chronic medical history. 

Treatments

A.Non-Medical 1.Advice to increase intake of fluids and fibers such as cereals, fruits, green vegs, potatoes

2.Increase exercise to increase bowel movements

3. Bowel training to increase regularity

B.Medical

1.Laxatives: Laxatives generally should not be taken if nausea, vomiting, or stomach pain is present.

a)Bulk Laxatives  

Bulk laxatives are natural or synthetic polysaccharides that work in both small and large intestines.

Because their onset of action is slow(24 to 72 hrs) they are better to be used as a preventive rather than as a curative.

Bulk laxatives should be taken at least with a minimum of 5 ounces of water otherwise they may cause constipation. Some bulk forms may contain sugar hence care must be taken by diabetics.

Bulk laxatives are contraindicated in obstructive bowel syndrome, intestinal tumors or Crohn's disease(a type of inflammatory disease that affects any part of the digestive system)

Examples of Bulk Laxatives 

1.Natural

a)Psyllium (The adult dose is 3.7 to 7 gms/day, child dose is 1/2 of the adult dose)

b)Malt extract (Adult 16 gms 4 times/day;child dose 16 gms 2 times/day)

2.Synthetic

a)Methylcellulose (Adult dose 1to 2 gms 1to 2 times/day; child dose 05 gms 1 to 3 times/day)

b) Polycarbophil (Adult dose 1 gm 1 to 4 times/day;child .05 gm 1 to 3 times/day)

Tetracyclines should not be taken with any calcium compounds like calcium polycarbophil.

b)Saline and Osmotic Laxatives

These laxatives work by forming an osmotic gradient to pull water into the lumen of the intestine and thereby form a bulky feeling to promote the peristalsis and motility.

These laxatives also the activity of an enzyme known as cholecystokinin a pancreatic enzyme that increases the fluid secretion of the GI tract.

Available as rectal enemas and suppositories work within 5 to 30 minutes and the oral preparations work within 4 days. 

A.Saline Laxatives

1.Magnesium citrate

2.Magnesium hydroxide

3.Magnesium sulfate

4.Sodium phosphate.

B.Osmotic Laxatives

1. Glycerin is available in suppositories or enema liquid.

An adult dose is 3 gm as suppository or 5 to 15 ml as an enema

A child dose is 15 gm as suppository or 2 to 5 ml as an enema

2. Lactulose is available as prescription medicine.

This may cause flatulence or cramping and must be taken with fruit juice, water, or milk.

The adult dose is 15 to 30 ml 2 to 3 times daily;

A child dose is 2.5 to 5 ml 2 to 3 times daily.

3. Sorbitol is a nonabsorbable sugar similar in efficacy and action with lactulose. It can be given orally as a 70% solution or rectally as a 25% solution. At the beginning of the first few days, sorbitol will give stomach flatulence, cramps, and pains similar lactulose but these will disappear on continued use.

An adult dose is 15ml orally (70% solution) or 120ml rectally (25% solution)

A child dose is 15 ml orally (70% solution) or 30 to 60 ml rectally (25% solution)

C.Stimulant Laxatives

These drugs work both in the small and large intestines by stimulating their motility. Their major drawback is abdominal cramping. Continuous use may produce numbness and reduced sensitivity of the bowel.

Oral preparations have the onset of action in 6 to 10 hours while the rectal preparations have the onset within 30 to 60 minutes.

1. Anthraquinone Laxatives include senna, cascara sagrada, and Castrol.

Long time use may cause melanosis coli a condition in which a dark pigmentation of the colonic mucosa occurs which disappears in 12 months after discontinuation of the drug. There are no other serious side effects.

Urine becomes colored as pink/red, brown, or yellow.

Cascara sagrada may be excreted in the milk.

a)Senna an adult dose is 300 to 1200mgs/day and for children 100 to 600mgs/day.

b)Cascara sagrada adult dose is 300 to 1000mgs/day.

2.Diphenhydramine derivatives
a)Phenolphthalin
These preparations may cause allergies in some people.
The adult dose is 60 to 200 mg/day.
alkaline urine
discoloration of the urine to pink/red, yellow or brown.
b)Bisacodyl (Dulcolax)
The tablets are enteric-coated and they should not be crushed or chewed. 
Bisacodyl should not be taken within 1 hour of ingesting antacid or milk.
3.Castor Oil
It has an onset of action within 2 to 6 hours. It works mainly at the small intestine. Hence it produces strong cathartic effects such as excess fluid and electrolyte loss. Cause dehydration. Contraindicated in pregnancy.
Adult dose 15 to 60ml
The child's dose is 5 to 15ml.
4.Emollient Laxatives
They cause surfactant effects and allow absorption of water by the stool to soften. They are very useful to heart patients to avoid them in straining to pass the hard stool.
The onset of action is very slow. (24 to 72 hours)
a)Docusate sodium
b)Docusate calcium
c)Docusate potassium
The adult dose is 100 to 300 mg/day
Child dose is 50 to 150 mg/day
Large quantity of water (8oz) water should be consumed after each dosage
This product should not be given with mineral oils as they may cause systemic absorption of mineral oils
5.Lubricant Laxatives 
Mineral oil-like liquid paraffin can be included in this category. They form fine lubrication of the bowel wall and thereby produce laxative effects.
The onset of action is 6 o 8 hours.
The adult dose is 15 to 45 ml/day
Child dose is 10 to 15 ml/day
Cautions 
1. Mineral oil may interfere with the absorption of fat-soluble vitamins like vitamin-A, D, E, and K.
2. Debilitated and dysphagia patients are at the risk of lipid pneumonitis from mineral oil aspirations.
3. Emollients like docusate should not be used concurrently as it may cause the absorption of mineral oil into the system.
4.May cause seepage
5.Should be taken in an empty stomach. 

 
 

 

WEIGHT CONTROL AND SLEEP AIDS-PART-V

SLEEP LOSS- TREATMENTS

In the previous post, we have seen a comprehensive encyclopedia of sleep and insomnia and their maps. In this emotional modern lifestyle insomnia with its various forms becomes a common problem. Even after lying in the bed getting a night of good sleep is a difficult procedure for many individuals.

Hence this post is dedicated to being guidance and treatment to tackle the problems of insomnia.

Guidances

The following general procedures are helpful to have a good hygienic sleep. The followings are the nonmedical approaches:-

1.Establishing a regular bedtime

2.Going to bed when tired and ready to sleep

3. If anxiety interferes get out of the bed and have a relaxed short walk, read some relaxing books, have a warm bath, or do some relaxing exercises.

4. Avoid hard exercises at bedtime.

5. Avoid alcohol because it will break sleep into fragments.

6. Avoid stimulants such as coffee, PPA, nicotine, and pseudoephedrine

7. Make sure that bedroom and bed are comfortable

8. Avoid small afternoon naps.

Treatments

Drug Treatments of Transient and Short term Insomnia:-

In general wakefulness and sleep, are antagonizing each other to control brain activities. Several nerve transmitters are involving in these antagonizing activities.serotonin and gamma-aminobutyric acid is the two known central neurotransmitters that slowly promote sleep.

Acetylcholine a central transmitter is maintaining REM sleep.

Catecholamines such as noradrenaline, adrenaline, and dopamine are the central neurotransmitters that cause wakefulness and antagonizing sleep.

Individuals may vary greatly in their natural levels of neurotransmitters and their sensitivity to these chemicals.

These theories are helpful to describe the actions of some medications on sleep patterns.

Hypnotics have their effects by modifying the secretions and receptor responses of serotonin, GABA, acetylcholine histamine and catecholamines

The goals of the hypnotic treatments of short term and transient insomnia are to restore day time work capacity and to eliminate the self-induction of anxiety-provoking thoughts.

The general norms of the hypnotic treatments are advising the patients not to take hypnotic drugs to more than three consecutive nights followed by one-night medicine free. This is to minimize tolerance and habit formation and to have a self-practice to control the stress that night. 

Prescription hypnotic agents

Benzodiazepines are the drugs of choice for treating transient and short term insomnia.

The mechanism of action is by acting on its receptors situated adjacent to the GABA receptors, they facilitate and enhance the actions of GABA the sleep-promoting hormone on its own receptor.

Benzodiazepines are available as follows

Short-Acting (2 to 8 hours)

1.Oxazepam

2.Clonazepam

3.Midazolam

4.Triazolam 

Intermediates (10 to 20 hours)

1.Temazepam

3.Lorazepam

4.Alprazolam

Long Actings(1 to 3 days)

1.Chlordiazepoxide

2.Diazepam

3.Flurazepam

The route of administration of benzodiazepines are both oral and by I.V or i.m. injections

Since benzodiazepines are metabolized in the liver and excreted through urine caution should be taken while using these medications during renal and liver insufficiencies. 

Many of the metabolites of benzodiazepines are very active.

Drug dependence 

Prolonged use can produce dependence.

Sudden withdrawal may cause confusion, anxiety, and agitation.

Side Effects

1.Drowsiness and confusion (the most common side effects)

2.Ataxia (dysfunctions and noncooperative nerve movements)

3.Dizziness

4.If taken with other CNS depressants benzodiazepines will cause respiratory depression and death.

Flumazenil is the antidote for benzodiazepine poisoning its effects lasts for 1 hour only and hence repeated dose is necessary for heavy poisoning.

Zolpidem

It is a newer drug and has an advantage over benzodiazepines by having minimum side effects and withdrawal symptoms.

Even though it is not a benzodiazepine it acts on the benzodiazepine receptor to produce the effects.

Side effects

1.Nightmares

2.Agitations

3.Headaches

4.GI distress

5.Dizziness

6.Daytime drowsiness

Barbiturates are less commonly prescribed to treat insomnia because of its serious and excessive respiratory depressing effects.

OTC DRUGS

The FDA has approved two antihistamines such as Diphenhydramine and Doxylamine

These antihistamines are commonly used in cough syrups and because of their serious anticholinergic effects caution should be taken by those who have extrapyramidal effects such as tardive dyskinesia, Akathesia, and Parkinson disease. Also, it should be taken with caution by those who have Prostatic enlargement.

 

   

WEIGHT CONTROL AND SLEEP AIDS- PART IV

SLEEP AIDS

Sleep is the healthy process of the body to keep it healthier. So many healthier procedures are performed during the process of sleep, such as growth, preparation of waste products like creatinine, urea, and lactic acid to be excreted in the urine. sleep maintains our body's metabolism and growth in a normal way. The digestive system is regulated. During sleeping the workloads of all our involuntary smooth muscles like heart, lungs, and visceral organs are minimized in order to boost them with fresh energy. Sleep refreshes our nervous system. Our blood is cleaned from waste and toxic products by healthy sleep.

Sleep time and quality vary among individuals. The usual range of sleep time per night is 5 to 10 hours.

Sleep requirements are changing according to the person's age. Newborns may sleep up to 18 hours. Preteens usually fall asleep within 5 to 10 minutes with deep sleep. By adulthood, 7 to 8 hours of sleep gives good rest. In the old age, six hours may suffice. In general, according to the modern theory, it is not the length of the sleep but it is the deepness of the sleep is more important.

Polysomnography includes Electro Encephalo Gram (EEG), the Electro Oculo Gram (EOG) and the Electro Myo Gram (EMG) recordings to note the changs during sleep 

Stages

By using polysomnography the scientists discovered five stages of sleep

1.One rapid eye movement (REM) stage

2.Four nonrapid eye movement (NREM) stages.

In normal sleep, REM occupies 25% by leaving the remaining 75% in the NREM stages.

In the NREM stages, the last third and fourth stages are considered as deep sleep stages or collectively known as delta sleep stages.

Most dreams occur during the REM stage and the degree of the restfulness of sleep depending on the amount of REM stage.

Most medications used to treat sleeplessness including the OTC medicines interfere with some parts of the sleep stages especially with the REM stage.
INSOMNIA
Insomnia is the interrupted sleep cycle or insufficient sleep that results in impaired daytime performances. Insomnia must be defined more with the depth of the sleep than with the length of the sleep.
Insomnia should be diagnosed with the deficiencies in the day time performances and not the number of hours  slept as the primary determinant of the diagnosis
Occasional one or two sleepless nights or with insufficient sleep is not important to be considered as insomnia. The pathologically concerning the situation with long time sleeplessness if it contains frequent microsleeps or extreme tiredness otherwise no need to worry.
Patients after a restful night sleep if they wake up in the morning with full freshness and satisfactory and feel no need to have an afternoon nap can reassure themselves that they have no insomnia. It is not necessary to have a sleep of 8 hours. Oftentimes a simple reassurance can be a cure for insomnia.
Insomnia is of three types as follows:-
1.Transient 
In this case, if a person cannot have a night sleep in less than 7 days then it is known as transient insomnia. Causes include shift work or acute anxiety
2.Short -term
This type lasts for 1-3 weeks. Causes of short term insomnia can be usually identifiable and self-limiting such as grief, pain, noise, or a tension provoking situation.
3.Long- term  
This type of insomnia lasts for more than 3 weeks. Chronic insomnia is caused by some underlying diseases most probably such as Hyperthyroidism or Arthritis and requires a thorough diagnoses of patients' physical and mental health.

General causes of insomnia

1.Intrinsic causes 

A. Psychophysiologic insomnia is a condition in which the patient associated with increased wakefulness with the bedroom and the sleep time routine.

B. Restless legs syndrome is characterized by extremely uncomfortable sensations in the leg muscle at rest which are relieved by moving the legs up and around.

C. Sleep Apnea can be obstructive or centrally mediated. The hallmark is breathing that stops for short periods during sleep. Patients with sleep apnea should not use hypnotics or OTC medicines.

2.Extrinsic causes 

A. Adjustment sleep disorders are prompted by a stressful situation.

B. Inadequate sleep hygiene  is caused by a lifestyle that reduces the amount of quality sleep

C. Hypnotic, stimulant, or alcohol dependency is caused by dependence, tolerance, or over-reliance on a particular drug of abuse.

3.Circadian sleep disorders

A. Delayed sleep phase syndrome occurs in people whose natural sleep times are altered due to work.

e.g.If a person should be at work at 8 a.m but gets tired after 2 a.m. and wakes at 10 a.m.would be affected by this disorder.

B. The jet lag syndrome is a problem primarily for people who frequently travel across several time zones.

4. Psychiatric disorders

such as major depressive disorders result in poor sleep that usually improves on proper antidepressant treatments