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## Complete Summary

#### GUIDELINE TITLE

Gastrointestinal disorders.

#### BIBLIOGRAPHIC SOURCE(S)

American Medical Directors Association (AMDA). Gastrointestinal
disorders. Columbia (MD): American Medical Directors Association (AMDA);
2006. 28 p. \[24 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Gastrointestinal disorders most commonly seen in the long-term care
population, including abdominal pain, gastroesophageal reflux disease
(GERD), constipation, diarrhea, and gastrointestinal bleeding

**Note**: Hepatobiliary and pancreatic diseases are beyond the scope of
this guideline.

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Prevention\
Risk Assessment\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Gastroenterology\
Geriatrics\
Internal Medicine\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Nurses\
Pharmacists\
Physician Assistants\
Physicians\
Social Workers

#### GUIDELINE OBJECTIVE(S)

-   To improve the quality of care delivered to patients in long-term
    care settings

-   To offer care providers and practitioners in long-term care
    facilities a systematic approach to recognizing, assessing,
    treating, and monitoring patients with common gastrointestinal
    disorders

#### TARGET POPULATION

Elderly individuals and/or residents of long-term care facilities with
common gastrointestinal disorders

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Recognition/Assessment**

1.  Identifying presence of gastrointestinal (GI) disorders by
    evaluating signs and symptoms and asking questions

2.  Assessing risk factors for GI disorders

3.  Determining the nature and severity of GI disorders using such tools
    as American Medical Directors Association (AMDA)\'s *Protocols for
    Physician Notification* and the PQRST Mnemonic

4.  Identifying the cause of GI disorder (comprehensive history,
    physical examination, and laboratory tests)

5.  Determining if a referral for a specialty consultation is
    appropriate

**Management/Treatment/Prevention**

1.  Managing the GI disorder and its underlying cause

2.  Identifying and implementing measures to prevent or minimize the
    risk of GI disorders

**Monitoring**

1.  Monitoring the patient\'s response to treatment and adjusting
    interventions as necessary

2.  Monitoring the status and treatment of underlying causes of GI
    disorders and reviewing relevant medications

3.  Monitoring the facility\'s management of GI disorders

#### MAJOR OUTCOMES CONSIDERED

-   Signs and symptoms of gastrointestinal (GI) disorders

-   Risk factors for GI disorders

-   Use of medications to treat GI disorders

-   Number of specialist referrals and invasive testing

-   Morbidity, mortality, and incidence of complications of GI disorders

-   Incidence of GI disorders

-   Quality of life

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

This guideline was developed by an interdisciplinary workgroup, using a
process that combined evidence and consensus-based approaches.
Workgroups include practitioners and others involved in patient care in
long-term care facilities. Beginning with a general guideline developed
by an agency, association, or organization such as the Agency for
Healthcare Research and Quality (AHRQ), pertinent articles and
information, and a draft outline, each group works to make a concise,
usable guideline that is tailored to the long-term care setting. Because
scientific research in the long-term care population is limited, many
recommendations are based on the expert opinion of practitioners in the
field.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Guideline revisions are completed under the direction of the Clinical
Practice Guideline Steering Committee. The committee incorporates
information published in peer-reviewed journals after the original
guidelines appeared, as well as comments and recommendations not only
from experts in the field addressed by the guideline but also from
\"hands-on\" long-term care practitioners and staff.

All American Medical Directors Association (AMDA) clinical practice
guidelines undergo external review. The draft guideline is sent to
approximately 175+ reviewers. These reviewers include AMDA physician
members and independent physicians, specialists, and organizations that
are knowledgeable of the guideline topic and the long-term care setting.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The algorithm [Common Gastrointestinal Disorders in the Long-Term Care
Setting](http://www.guideline.gov/algorithm/5026/NGC-5026_1.html) is to
be used in conjunction with the clinical practice guideline. The numbers
next to the different components of the algorithm correspond with the
steps in the text. Refer to the \"Guideline Availability\" field for
information on obtaining the full text guideline.

#### CLINICAL ALGORITHM(S)

A clinical algorithm is provided for [Common Gastrointestinal Disorders
in the Long-Term Care
Setting](http://www.guideline.gov/algorithm/5026/NGC-5026_1.html).

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

The guideline was developed by an interdisciplinary work group using a
process that combined evidence- and consensus-based thinking.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**Outcomes that may be expected from implementation of this clinical
practice guideline include**:

-   Reduced incidence of some acute gastrointestinal (GI) disorders and
    greater stability of chronic GI disorders

-   Appropriate use of medications to treat GI disorders

-   Appropriate use of acute care facilities to assess and treat GI
    disorders if indicated

-   Appropriate use of specialist referrals and invasive testing in the
    management of GI disorders

-   Reduced morbidity, mortality, and incidence of complications (e.g.,
    fecal impaction, dehydration) of GI conditions

-   Improved palliative care outcomes in residents with a poor prognosis

#### POTENTIAL HARMS

**Adverse Effects of Treatments and Medications**

-   Table 12 in the original guideline document lists adverse effects
    that should be monitored for.

-   Both an increased relative risk for community-acquired pneumonia and
    an increased risk of community-acquired *Clostridium
    difficile*-associated disease have been reported in patients taking
    protein pump inhibitors (PPIs). It is uncertain whether the
    association with pneumonia is caused by the drug or is coincidental
    to increased use of PPIs in patients with chronic pulmonary
    conditions who are at increased risk for pneumonia.

-   Prokinetic agents such as metoclopramide may cause excessive
    sedation, depression, and tardive dyskinesia.

-   Any opioid can exacerbate ileus that is causing abdominal pain and
    should be used with caution.

-   Both patients and dispensing staff are at some risk of allergy to
    psyllium.

-   Because fiber can increase flatulence and fecal incontinence, dosing
    should be individualized.

-   Excessive long-term use of stimulant laxatives (e.g., senna,
    bisacodyl) may be associated with the development of \"cathartic
    colon,\" that is, a poorly functioning colon caused by the chronic
    abuse of stimulant laxatives.

-   The most common side effects of metronidazole are headache,
    dizziness, GI discomfort, nausea and vomiting, metallic taste,
    diarrhea, vaginitis, pelvic discomfort, a disulfiram-like reaction
    to alcohol, seizures, and peripheral neuropathy. An elevated white
    blood cell count has also been reported.

-   Tetracycline may cause a photosensitivity reaction.

-   Amoxicillin may cause diarrhea or allergy.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Morphine is contraindicated to treat pain caused by cystic duct
    obstruction or spasm.

-   Sucralfate is contraindicated if potential exists for significant
    drug-drug interactions (e.g., phenytoin, thyroid hormone, warfarin)

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This clinical practice guideline is provided for discussion and
    educational purposes only and should not be used or in any way
    relied upon without consultation with and supervision of a qualified
    physician based on the case history and medical condition of a
    particular patient. The American Medical Directors Association and
    the American Health Care Association, their heirs, executors,
    administrators, successors, and assigns hereby disclaim any and all
    liability for damages of whatever kind resulting from the use,
    negligent or otherwise, of this clinical practice guideline.

-   The utilization of the American Medical Director Association\'s
    Clinical Practice Guideline does not preclude compliance with State
    and Federal regulation as well as facility policies and procedures.
    They are not substitutes for the experience and judgment of
    clinicians and care-givers. The Clinical Practice Guidelines are not
    to be considered as standards of care but are developed to enhance
    the clinician\'s ability to practice.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The implementation of this clinical practice guideline (CPG) is outlined
in four phases. Each phase presents a series of steps, which should be
carried out in the process of implementing the practices presented in
this guideline. Each phase is summarized below.

I.  **Recognition**

    -   Define the area of improvement and determine if there is a CPG
        available for the defined area. Then evaluate the pertinence and
        feasibility of implementing the CPG

II. **Assessment**

    -   Define the functions necessary for implementation and then
        educate and train staff. Assess and document performance and
        outcome indicators and then develop a system to measure outcomes

III. **Implementation**

     -   Identify and document how each step of the CPG will be carried
         out and develop an implementation timetable

     -   Identify individual responsible for each step of the CPG

     -   Identify support systems that impact the direct care

     -   Educate and train appropriate individuals in specific CPG
         implementation and then implement the CPG

IV. **Monitoring**

    -   Evaluate performance based on relevant indicators and identify
        areas for improvement

    -   Evaluate the predefined performance measures and obtain and
        provide feedback

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Clinical Algorithm\
Tool Kits

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Medical Directors Association (AMDA). Gastrointestinal
disorders. Columbia (MD): American Medical Directors Association (AMDA);
2006. 28 p. \[24 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006

#### GUIDELINE DEVELOPER(S)

American Medical Directors Association - Professional Association

#### GUIDELINE DEVELOPER COMMENT

Organizational participants included:

-   American Association of Homes and Services for the Aging

-   American College of Health Care Administrators

-   American Geriatrics Society

-   American Health Care Association

-   American Society of Consultant Pharmacists

-   National Association of Directors of Nursing Administration in
    Long-Term Care

-   National Association of Geriatric Nursing Assistants

-   National Conference of Gerontological Nurse Practitioners

#### SOURCE(S) OF FUNDING

Funding was supported by the following: Bristol-Myers Squibb Company,
Eisai Inc., Forest Laboratories, Janssen, Mallinckrodt Pharmaceuticals,
Novartis, Pfizer Inc., Sanofi-Adventis, Sepracor Inc., Wyeth

#### GUIDELINE COMMITTEE

Steering Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Marjorie Berleth, MSHA, RNC, FADONA; Lisa Cantrell,
RN, C; Charles Cefalu, MD, MS; Sandra Fitzler, RN; Joseph Gruber, RPh,
FASCP, CGP; Susan M. Levy, MD, CMD; Harlan Martin, RPh., CCP, FASCP;
Evvie F. Munley; Jonathan Musher, MD, CMD; Mary Tellis-Nayak RN, MSN;
Barbara Resnick, PhD, CRNP; William Simonson, PharmD., FASCP

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: None available

Print copies: Available from the American Medical Directors Association,
10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone:
(800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site:
[www.amda.com](http://www.amda.com/)

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Guideline implementation: clinical practice guidelines. Columbia,
    MD: American Medical Directors Association, 1998, 28 p.

-   We care: implementing clinical practice guidelines tool kit.
    Columbia, MD: American Medical Directors Association, 2003

Electronic copies: None available

Print copies: Available from the American Medical Directors Association,
10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone:
(800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site:
[www.amda.com](http://www.amda.com/)

Additionally, process and quality indicators can be found in Table 16 of
the original guideline document.

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on June 23, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the American Medical Directors Association (AMDA) and the
American Health Care Association. Written permission from AMDA must be
obtained to duplicate or disseminate information from the original
guideline. For more information, contact AMDA at (410) 740-9743.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008