O.+DIGESTION

=DIGESTION =



Pamela Wandry

__OVERVIEW __ The digestive system is the break down center for food in the body. The digestive system has several functions. Motility is the process of food moving through the digestive tract. Ingestion, mastication, deglutition, and peristalsis are all involved in motility. Ingestion is simply taking the food int o the mouth. Mastication is when the food is shewed and mixed with saliva. Deglutition is the swallowing of food. Finally, peristalsis is the moving of food through the digestive tract by small contractions. Secretions in the digestive tract are both exocrine secretions and endocrine secretions. Exocrine secretions include bicarbonate, water, hydrochloric acid, and digestive enzymes that get secreted in the lumen. The stomach can secrete as much as 2 to 3 liters a day of gastric juice. Endocrine secretions come from the small intestine and stomach and help regulation of the digestive system. Digestion is the process of food being broke down into absorbable subunits. Absorption is a release of digested products into lymph and blood. Storage and elimination are exactly what they say. The stomach stores the food and then it is eliminated. The digestive tract also serves as an immune barrier. There are simple columnar epithelium lining the intestine that prevent pathological organisms from entering. When you eat a big meal you never really think about how hard your digestive system has to work to get all that food broke down and absorbed for nutrients and then to get rid of the extra.

This chapter covers the digestive system starting with the Introduction to the Digestive System where the functions of the digestion system are explained which include motility, secretion, digestion, absorption, storage and elimination and immune barrier. Next this chapter goes into the layers iof GI tract which include the mucosa which lines the lmen of the GI tract and is the absorptive and major secretory layer. The submucosa which is thick and is a highly vascular layer of the connective tissue that serves the mucosa. Also consists of submucosal plexus aka Meissner's plexus that provides a nerve supply to the muscularis muosae of the small and large intestine. Next is the muscularis which is responsible for segmental contractions and peristaltic movement through the GI tract. This layer also includes the myenteric plexus aka Auerbach's plexus located between the two muscle layers and provides the major nerve supply to the entire GI tract. The last layer is known as the serosa which completes the wall of the GI tract. It is a binding and protective layer consisting of areolar connective tissue covered with a layer of simple squamous epithelium. This chapter also covers the regulation of the GI tract. Then goes on into the from the mouth into the stomach. Starts with definitions of mastication and degultition then goes into detail on how digestion occurs through the esophagus and into the stomach. Next Pepsin and Hydrochloric Acid Secretion is discussed. Describes the three functions of a strong acidy which is a pH less than 2. Also within this section digestion and absorption in the stomach is described and also disorders such as gastritis and peptic ulcers are described and how they can be treated. Next the small intestine is talked about that includes the villi and microvilli, intestinal enzymes and also the intestinal contractions and motility. Then the large intestine is discussed including the structure of the liver, functions of the liver, gallbladder and pancreas. next is the neural and endocrine regulation of the digestive system which includes the regulation of gastric function that consists of three phases; cephalic phase, gastric phase and intestinal phase, next is the regulation of intestinal function where the ENS is discussed and also the intestinal reflexes that include the gastroileal reflex, the ileogastric reflex and the intestino-intestinal reflexes, then the regulation of pancreatic juice and bile secretion, and lastly in the section trophic effects of GI hormones. Last in this chaper, digestion and absorption of carbohydrates, lipids and proteins are discussed. At the end of the chapter is interactions that the digestive system has with other body systems. Also a summary and review activities. AR

__ESSENTIAL QUESTION __ **Choose two organs of the digestive system. Explain how the structure of that organ contributes to the function of that organ.** **The three molecules, carbohydrates, proteins and lipids are important molecules in food that need to be physically and chemically digested by the digestive system. For each-carbohydrate, protein and lipid describe:****Where the nutrient is digested in the digestive system****The enzymes that help to hydrolyze the molecule****How the nutrient is absorbed****How the body uses the nutrient** Organ 1: The stomach is a J shaped organ that starts at the esophagus and ends at the duodenum or start fot eh small intestine. The stomach stores food, starts the process of digesting proteins, kills bacteria because of the acidic gastric juices, and moves food on into the small intestine. The first 2/3 of the stomach is made up of the upper fondus and lower body and is known as the cardiac region. The last 1/3 of the stomach is the pyloric region which consists of the atrium, a widened area, and the pyloric sphincter. The stomach is able to contract with mixes the chyme with gastric secretions and starts to move the partially digested food into the duodenum form the atrium and pyloric sphincter. There are long folds on the inside of the stomach that are called rugae. At the opening fo these folds there are openings called gastric pits. Deeper into the folds are gastric glands that secrete into the stomach. There are several different cells in the gastric glands that all secrete different products. Goblet cells secret cumus, parietal cells secrete HCl, G cells secret gastrin into the blood, and D cells secrete a hormone called somatostatin. Chief cells secrete the inactive form of pepsin, pepsinogen and enterochromaffin-like cells secrete histamine and 5-hydrooxytryptamine, also known as serotonin, that act as paracrine regulators in the digestive tract. Gastric mucosa is also responsible for secreting the polypeptide intrinsic factor. Intrinsic factor is necessary for absorbing vitamin B12. Vitamin B12 is an essential part of red blod cell production in the bone marrow. Recently, the stomach has also been found to secrete ghrelin. Ghrelin is a hormone that has been found to possibly help regulate hunger by rising before a meal and lowering after a meal. All of these secretions from the gastric glands cells along with water is what makes up the acidic gastric juices.

Organ 2: The small intestine is located between the pyloric sphincter and the ileoceccal valve which opens in to the large intestine. The small insteine is only called small because it doesn't have a very large diameter. It is, however, very long. It can measure up to 3m or 12ft. long in a living person. The first part, which extends from the pyloric sphincter, is ab out 20 to 30 cm long and is called the duodenum. Next comes the jejunum, which is the next 2/5 of the small intestine. Finally, the ileum makes up teh last 3/5 of the small intestine. Digested food is made easier by long length and a lot of surface area. The surface area is increased by the many folds and projections. Villi are tiny finger like projectinos and microvilli are hair-like projections. Epithelial cells along with goblet cells cover each villus. Lymphocytes, central lacteal, and capillaries can all be found on the inside of villus. Each epithelial cells apical surface has a brush border created by a layer of microvilli. The brush border contains enzymes that aide in the digestions of glucose, fructose, and maltose, along with producing fee amino acids, dipeptides, and tripeptides and aides in absorption of dietary Ca+ which is regulated by Vitamin D. The small intestine also experiences two types of contractions, peristalsis and segmentation. Peristalsis happens because of the difference in pressure between the pyloric end and the distal end and is slow and weak. Segmentation is a little bigger contraction of the circular smooth muscle and mixes the chyme. These contractions are automatic and caused by slow waves of graded depolarization.

A large majority of the carbohydrates that are ingested in the diet come from starches, which are most often lactose and sucrose. The digestion of these starches starts with the salivary amylase in the mouth. The salivary amylase looses most of it's power when it enters the stomach because the pH is too acidic. Most of starch digestion occurs in the duodenum due to the presents of pancreatic amylase. The starch is turned into trisaccharide maltriose and disaccharide maltose because of the cleaving of straight chains by the pancreatic amylase. Oligosaccharaides need to be used with the maltose and maltriose inorder to hydrolyse the bonds in the starch. Hydrolysis happens between the mono-saccharides and the maltose, maltriose, and oligosaccharides because of brush boder enzymes from the epi cells in the small intestine. Disaccharides sucrose and lactose are also hydrolyzed into mono-saccharides by the brush boder enzymes. Now the mono-saccharides can be transported across the epi cells by secondary active transport and finally into the blood capillaries in the intestinal villi.

Protein digestion starts with the pepsin in the stomach. Most of the products from the start of this digestion with pepsin are short-chain polypeptides. The majority of the protein digestion happens in the duodenum and jejunum of the small intestine. Trypsin, elastase, and chymostrypsin, pancreatic enzymes, are responsible for the cleaving of the peptide bonds. These enzymes can also be called endopeptidases. Exopeptidases, on the other hand, remove amino acids at the ends of the polypeptide chains. These enzymes include carboxypeptidase and aminopeptidase, both pancreatic enzymes. Now the polypeptide chains can be turned into free amino acids, dipeptides, and tripeptides. The free amino acids can now be absorbed into the epi cells and sent out into the blood capillaries by transport with Na+. The dipeptides and tripeptides can enter the epi cell's cytoplasm by secondary-active transport with H+ molecules. Here they are hydrolyzed to free amino acids and sent out into the blood stream.

Digestion of lipids happens in the small intestine. Bile is secreted when there are lipids present in the duodenum. Bile salt micelles emulisfies fat into droplets of fat that are then dissolved into the bile salt micelles. This increases the surface area that fat can be digested in. Triglycerides are hydrolyzed into free fatty acids and monoglycerides by pancreatic lipase. The phospolipids are broken down into fatty acids and lysolecithin by phosphaolipase A. When the fatty acids and monoglycerides are dissolved the turn into mixed micelles. Free fatty acids, monoglycerides, and lysolecithin enter into the epi cells after leaving the micelles. After they are inside the epi cell, they get re-synthesized and turned into triglycerides and phospholipids. From here the triglycerides and phospholipids hook up with protein and form chylomicrons. The chylomicrons are then secreted in the the central lacteal of the small intestines villi. When the chylomicrons are in the blood stream, apolipoproteins help them to bind with receptors on the capillaries in the fat and muscle.

Carbohydrates, proteins, and lipids are all used for energy in the body.

**The three molecules, carbohydrates, proteins, and lipids, are important** **molecules in food that need to be physically and chemically digested by the** **digestive system. For each nutrient (carbohydrates, proteins, and lipids):**

*** Describe where the nutrient is digested in the** **digestive system** *** Describe the enzymes that help to hydrolyze the** **molecules** *** Describe how the nutrient is absorbed** *** Describe how the body uses the molecule**
 * (nutrient)**


 * **Nutrient** || **Where Nutrient is Digested** || **Enzymes to Hydrolyze the Molecule** || **How Nutrient is Absorbed** || **How the Body Uses the Nutrient** ||
 * **Carbohydrates** || Digestion begins in the **mouth** but once swallowed stops due to the low pH of the stomach.

Digestion begins again in the **duodenum** where a majority of starch digestion occurs.

Digestion is completed in the **small intestine**. || ** Salivary Amylase ** from the saliva in the mouth cleaves some of the bonds between adjacent glucose molecules.

** Pancreatic Amylase ** released from the pancreatic juice in the duodenum cleaves the straight chain of starch to produce a maltose disaccharide, the maltriose trisaccharide and oligosaccharides (short, branched chains of glucose).

** Brush Border Enzymes ** on the microvilli of the epithelial cells in the small intestine hydrolyze the maltose, maltriose, and the oligosaccharies broken down by the duodenum as well as sucrose and lactose into monosaccharides. || Once the carbohydrates are broken down into monosaccharides they are moved across the epithelial cell membrane of the small intestine by secondary active transport, passively across the intestinal epithelium when intestinal glucose concentration is high, and is secreted from the epithelial cell into the capillaries in the intestinal villi. || Carbohydrates are used by the body for energy. They usually make up about 50% of the calories of the average American diet therefore providing 50% of our energy as Americans. ||
 * **Proteins** || Digestion begins in the **stomach** however the stomach is not essential for complete protein digestion that occurs in the small intestine.

Most protein digestion occurs in the **duodenum** and **jejunum** of the small intestine. || ** Pepsin ** begins breaking down proteins into short-chained polypeptides to create more homogeneous chyme.

** Trypsin **, **chymotrypsin**, and **elastase** are pancreatic juice enzymes that cleave peptide bonds in the interior of the polypeptide chains. **Carboxypeptidase** (removes amino acids from carboxyl-terminal end of polypeptide chains) a pancreatic juice enzyme and **aminopeptidase** (cleaves amino acids from amino-terminal end of polypeptide chains) a brush border enzyme that remove amino acids from the ends of the polypeptide chains. Polypeptide chains are digested into amino acids, dipeptides, and tripeptides. The || Free amino acids are absorbed by cotransport with Na+ into epithelial cells and secreted into capillaries. Dipeptides and Tripeptides enter epithelial cells by a single membrane carrier in secondary active transport using H+ gradient to transfer them into cell cytoplasm where they are hydrolyzed into free amino acids and secreted into the blood. || Proteins are used as a source of energy by the body and provide roughly 11-14% of our caloric intake therefore energy for Americans. ||
 * **Lipids** || Digestion of lipids in newborns begins in the **mouth** and **stomach**.

In adults lipid digestion greatly begins in the **duodenum**. || ** Lipases ** are produced by salivary glands and the stomach which begins the digestion of lipids in newborns.

<span style="display: block; font-size: 10pt; line-height: normal; margin-bottom: 0pt; text-align: justify;">The arrival of lipids in the duodenum stimulates **bile** secretion which break up the lipids into emulsification droplets of triglycerides. The digestion occurs at the surface of the droplets by **pancreatic lipase** and **colipase**. Lipase removes 2 of the 3 fatty acids from each triglyceride molecule and liberates free fatty acids and monoglycerides. **Phospholipase A** digests phospholipids into fatty acids and lysolecithin. Free fatty acids, monoglycerides, and lysolecithin enter the micelles of bile salts, lecithin, and cholesterol from bile and form mixed micelles which move to the brush border of the intestinal epithelium. || <span style="display: block; font-size: 10pt; line-height: normal; margin-bottom: 0pt; text-align: justify;">Free fatty acids, monoglycerides and lysolecithin either leave the micelles and pass through the microvilli into the intestinal epithelial cells or the micelles are transported into the epithelial cells where the parts are removed from the micelles. Once in the epithelial cells they are used to resynthesize triglycerides and phospholipids in the epithelial cells. <span style="display: block; font-size: 10pt; line-height: normal; margin-bottom: 0pt; text-align: justify;">Triglycerides, phospholipids, and cholesterol combine with protein in the epithelial cells and form chylomicrons. Chylomicrons are secreted into the lymphatic capillaries of the intestinal villi. Lipids pass through the lymphatic system and enter the blood through the thoracic duct. || <span style="display: block; font-size: 10pt; line-height: normal; margin-bottom: 0pt; text-align: justify;">Lipids are used by the body as a form of energy. Lipids make up the remainder of the average Americans caloric intake. || Chart by Jill Dunbar

__<span style="color: #800080; font-family: 'Arial Black',Gadget,sans-serif;">SUMMARY __ <span style="color: #800080; display: block; font-family: 'Arial Black',Gadget,sans-serif; text-align: center;">Pamela Wandry

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 180%;">Stomach



The stomach is the organ between the esophagus and the intestines, it is the digestive organ and stores and churns food into a pasty substance known as chyme. Food enters the stomach via the cardiac sphincter (esophageal sphincter) and this sphincter acts as a gate, preventing food from returning to the esophagus once in the stomach. Heart burn is common in many individuals and the cardiac sphincter is what is responsible for this occurrence, as it does not close properly and food + stomach acid is allowed into the esophagus, causing a burning and painful sensation. The stomach is very acidic in nature due to the release of hydrochloric acid from the parietal cells making the gastric juice have a pH of less than 2. Gastric juice consists of mucus from goblet cells, HCL from parietal cell, pepsinogen from chief cells, histamine and serotonin from ECL cells, gastrin from G cells, somatostatin from D cells, and approx. 2-4 Liters of H20 that we drink daily. The stomach is mainly a storage for food and breaks down food substances into smaller particles, most particles are absorbed in the small intestine, however, aspirin and alcohol are able to be absorbed in the stomach. The only life sustaining purpose for the stomach is for secretion of a substance called intrinsic factor. Intrinsic factor is needed for the absorption of Vitamin B12 in the end portion of the ileum in the small intestine. B12 is needed for RBC's to mature in bone marrow, without this intrinsic factor, pernicious anemia will occur and if not given to an individual via an injection, death will most likely occur within 3-5 years. Once food has gone through the stomach by involuntary contractions of the stomach, the food (now chyme) is sent to the pyloric sphincter, which is also gated to the first portion of the small intestine, where it will be further broken down and absorbed by the body for use.

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 180%;">Enteric Nervous System

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The ENS is organized into ganglia that are interconnected by two plexuses, the myenteric and submucosal plexi. The myenteric (Auerbach's) plexus is found along the entire length of the GI tract and the submucosal (Meissner's) plexus is located in the small and large intestine. The ENS has been referred to as the "gut brain" and contains about 100 million neurons, which is about the same as the number of neurons located the spinal cord (CNS). The ENS has inter-neurons, sensory neurons and autonomic motor neurons. The main functions of the ENS is to control GI motility (coordinates peristalsis movements), control of fluid and electrolyte transport (so that fluid and electrolytes are absorbed and not pushed through GI system too quickly), and mucosal protection. How the ENS controls peristalsis: When a bolus of food stimulates the sensory neurons, inter-neurons activate motor neurons. The motor neurons will then produce a relaxation of the smooth muscle in front of the bolus (food or chyme depending on where its located) and will stimulate contraction behind the bolus. As you can see this will push the food in the direction opposite which it started and by this peristalsis movement food particles are going to continue to move correctly through the GI tract.

<span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif; font-size: 180%;">Layers of the Gastrointestinal Tract

=<span style="color: #800080; display: block; font-family: 'Arial Black',Gadget,sans-serif; font-size: 140%; text-align: center;">[|4 layers of the gi tract] = The GI tract from the esophagus to the anal canal consists of four layers, each layer contains a main tissue type and perform specific functions in the digestion process. Mucosa is the layer directly on the outside of the lumen. It protects the GI tract wall, secretes substances and absorbs the end products of digestion. The mucosa consists of a simple columnar epithelium; outside this simple columnar epithelium is where the lamina propria which is composed of areolar connective tissue is located. The lamina propria contains many lymph nodules which protect the GI tract against diseases that may enter the blood stream. Outside the lamina propria (the outermost layer of the mucosa) is layer of smooth muscle called muscularis mucosae. The Muscularis mucosae contains many folds in certain areas of the GI tract, such as the stomach and small intestines. These many folds greatly increase absorption of substances (increase absorptive surface area). There are also specialized goblet cells that secrete mucus throughout the GI tract, which helps protect the GI tract from harsh substance, for example, goblet cells in the stomach secretes alkaline mucus which protects the stomach's lining from the harsh acidic environment in order to prevent damage to the cells of the stomach (otherwise the stomach would ultimately digest itself).

Submucosa consists of a highly vascular layer of connective tissue. It is located outside of the mucosa layer. It contains blood vessels, lymphatic vessels, and nerve plexuses. Absorbed molecules that pass through the mucosa layer enter the submucosa's blood and lympatic vessels. The submucosal plexus or Meissner's plexus provides a supply of nerves to the the layer of the mucosa called the muscularis mucosae of the small and large intestine.

Muscular is (muscularis externa) consists of smooth muscle which is responsible for the peristalsis movement of food through the digestive tract and of segmental contractions (muscular constrictions of the lumen, serves to mix chyme thoroughly). Between the muscularis and serosa called the myenteric plexus or Auerbach's plexus is a major supply of nerves which supply the entire GI tract. These nerves contain ganglia from the sympathetic and parasympathetic division of the ANS.

Serosa is the outer most layer of the GI tract wall. It is a binding and protective layer consisting of areolar connective tissue and simple squamous epithelium. This is the first layer of defense of the layers and is very important.

//__VITAMINS__// Vitamins are small organic molecules that serve as coenzymes in metabolic reactions or that have other highly specific functions. Vitamins must be obtained in the diet because the body either does not produce them or the body produces them in insufficient quantities, such as Vitamin D which is limitly produced by the skin and the B vitamins and vitamin K are produced by intestinal bacteria. The two classes of vitamins are: fat-soluble and water-soluble. __** FAT-SOLUBLE VITAMINS **__

__**Functions:**__
__** Vitamin E: **__consists of important antioxidant functions. __** Vitamin K: **__ required for the production of prothrombin and for clotting factors VII, IX and X. __** Vitamin A: **__an antioxidant vitamin important in vision and bone growth. __** Vitamin D: **__produced by the skin under the influence of UV light and is produced insufficiently and does not meet the body's needs.

__**Sources:**__
__** Vitamin E: **__ milk, eggs, meat, leafy vegetables. __** Vitamin K: **__green leafy vegetables. __** Vitamin A: **__ yellow vegetables and fruit. __** Vitamin D: **__fish liver.

__**Symptoms to Deficiencies in these Vitamins:**__
__** Vitamin E: **__ muscular dystrophy. __** Vitamin K: **__ hemorrahage; inability to form clot. __** Vitamin A: **__ night blindness and dry skin. __** Vitamin D: **__ rickets (softening of bones in children eventually leading to fractures and deformities), osteomalacia (softening of bones).

__** WATER-SOLUBLE VITAMINS **__

__**Functions:**__
__** Vitamin B1 (thiamine): **__cofactor for enzymes that catalyze decarboxylation. __** Vitamin B2 (riboflavin): **__part of the flavoproteins (FAD). __** Vitamin B6 (pyridoxine): **__coenzyme for decarboxylase and transaminase enzymes. __** Vitamin B12 (cyanocobalamin): **__coenzyme for amino acid metabolism, also needed for erythropoiesis (production of red blood cells). __** Biotin: **__ needed for fatty acid synthesis. __** Vitamin C: **__ needed for collagen synthesis in connective tissues. __** Folate: **__ needed for reactions that transfer one carbon. __** Niacin: **__ part of NAD and NADP. __** Pantothenic acid: **__ part of coenzyme A.

__**Sources:**__
__** Vitamin B1 (thiamine): **__liver, unrefined cereal grains. __** Vitamin B2 (riboflavin): **__liver and milk. __** Vitamin B6 (pyridoxine): **__liver, corn, wheat and yeast. __** Vitamin B12 (cyanocobalamin): **__liver, meat, eggs and milk. __** Biotin: **__ egg yolk, liver and tomatoes. __** Vitamin C: **__ citrus fruits, green leafy vegetables. __** Folate: **__ green leafy vegetables. __** Niacin: **__ liver, meat and yeast. __** Pantothenic acid: **__ liver, eggs and yeast.

__**Symptoms to Deficiencies in these Vitamins:**__
__** Vitamin B1 (thiamine): **__beriberi (nervous system ailment), neuritis (inflammation of a nerve or group of nerves, characterized by pain, loss of reflexes, and atrophy of the affected muscles). __** Vitamin B2 (riboflavin): **__glossitis (inflammation or infection of the tongue), cheilosis (a disorder of the lips marked by scaling and fissures at the corners of the mouth). __** Vitamin B6 (pyridoxine): **__convulsions. __** Vitamin B12 (cyanocobalamin): **__pernicious anemia. __** Biotin: **__ dermatitis (inflammation of the skin), enteritis (inflammation of the small intestine). __** Vitamin C: **__scurvy (characterized by spongy and bleeding gums, bleeding under the skin, and extreme weakness). __** Folate: **__ sprue (a chronic, chiefly tropical disease characterized by diarrhea, emaciation, and anemia), anemia (low RBC's). __** Niacin: **__ pellagra (characterized by skin eruptions, digestive and nervous system disturbances, and eventual mental deterioration). __** Pantothenic acid: **__ dermatitis, enteritis, adrenal insufficiency. Amanda Rolstad

<span style="font-family: 'Times New Roman','serif';">Fox, Stuart Ira. (2009). //Human Physiology//. New York, NY: McGraw-Hill. <span style="font-family: 'Times New Roman','serif';">http://04340.com/ross/medicalwiki/test/Physiology%20of%20GI%20tract%20-%20overview%20&%20salivary%20secretion.html

__<span style="color: #800080; font-family: 'Arial Black',Gadget,sans-serif;">APPLICATION __

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As a nursing student, one of my patients had diarrhea. Of course he had had a hemiarthroplasty, so we were up to the bedside commode quite a bit. He was on a liquid diet and progressed to fill liquids and then a bland diet. One of my instructors over heard me talking about not knowing what to order for his meals so his condition doesn’t worsen. She suggested to me not to order him dairy products and not too much fiber. I took it to heart and didn’t order any dairy at all. Slowly his diarrhea was better and he was able to go home. Well to make a long story short, I later found out I could have given him yogurt or cottage cheese. These types of dairy products contain flora that the digestive system needs to regulate itself. Needless to say, I was a little disappointed with not knowing this sooner, maybe my gentleman patient could have gone home a day earlier.

As a nurse I will monitor a patient with diarrhea closely because the loss of the extra fluid can cause dehydration. Diarrhea can be treated by giving Lomotil after loose stools, but any stool softeners or fiber medications should be held because they stimulate the intestine and can cause a worsening of the problem. I will also be aware of common drugs that may cause diarrhea such as IV antibiotics (this one happened to me in clinical too!) If I know the cause of the diarrhea I will be able to better treat the symptoms and get the problem under control.

LJ

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