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Constipation Flashcards

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1
Q

healthcare definition

A

<3/week
straining associated with defecation
hard dry stool

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2
Q

patient perception of constipation

A

small stool
feeling of incomplete evacuation
decreased stool frequency

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3
Q

patho

A

slower than normal movement thru the gi tract. Tonic contractions (stomach), peristaltic waves (intestines)
internal anal spincter relaxation (rectum)

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4
Q

secondary causes:
systemic
neuro
pshychological

A
  1. systemic: electrolyte imbalances, thyroid disorders, IBS
  2. neurological: autonomic neuropathy, MS, parkinsons, cerebrovascular accidents, dementia
  3. psychological: depression, eating disorders, situational stress
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5
Q

contributing meds

A 
OPIATES *morphine and oxycodone*
antacids
anticholinergics 
antidepressents 
antihistamines 
benzodiazepines 
beta blockers 
calcium channel blockers 
diuretics
iron supplements 
muscle relaxants 
statins
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6
Q

risk factors

A

age > 65
female
pregnancy and post birth
secondary causes

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7
Q

clinical presentation

A

complains: reduced stool frequency, straining, hard/dry stools, feeling of incomplete evacuation

additional symptoms: anorexia, headache, low back pain, abdominal discomfort, bloating, flatulence

complications: hemorrhoids, bleeding, rectal ulcers, anal fissures

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8
Q

rome criteria

A

2 or more of the following:
- less than 3 bowel movements / week
- straining during > 25% of defecations
sensation of incomplete evacuation in >25%
-sensation of anorectal obstruction / blockage for >25
- manual maneuvers to facilitate >25%

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9
Q

exclusions to self care

A

severe ab pain, distention, cramping, or unexplained flatulence
concomitant fever, nauseu, and or vomiting
unexplained changes in bowel habits (esp if weight loss)
blood in the stool or dark tarry stool or changes in stool character
symtoms persisting >2 weeks or recur over a period of 3+ months, or after dietary/lifestyle changes
daily laxitive use (not including fiber based therapy)
Age <2 years
conditions precluding laxatve self treatment (paraplegiz/ quadriplegiz, colostomy)
history of inflammatory bowel disease, anorexia

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10
Q

nonpharmacologic

A

diet and excersize
- increase fluid 2L / day
increase fiber (25g in women 38 for men)
fruits (prunes) vegetables, whole grains.
limit foods with little fiber content
- meats cheese and processed foods
effects seen in 3-5 days

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11
Q

how should you increase fiber?

A

slowly over 1-2 weeks

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12
Q

what is bowel retraining

A

it is heed the urge, allow sufficent toilet time

attempt upon waking or 30 minutes post meal

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13
Q

what are some daily fiber supplements

A

Inulin (fiberchoice, metamucil, clear and natural)
partiallly hydrolyzed guar gum (sunfiber)
powdered cellulose (unifiber)
wheat dextrin (benefiber)

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14
Q

pharmacologic laxative types

A 
bulk forming
hyperosmotic 
emollient
lubricant
saline 
stimulant
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15
Q

Bulk forming laxatives indiciation

A

RECOMMENDED CHOICE for most instances of constipation
- useful for patients on low fiber diets, post partum, older adults, patients w colostomies, IBS
propylaxis for those who should refrain from straining

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16
Q

bulk forming - MOA

A

dissolves or swells in the intestinal fluid -> forms emollient gel -> stimulates peristalsis -> facilitates passage of intestinal contents

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17
Q

Bulk forming - SAFETY

A
  • CHOKING RISK - avoid if difficult studying, esopheal strictures, fluid restrictions ( heart failure)
  • OBSTRUCTION, fecal impaction - avoid if palliative care, OPIOID-INDUCED constipation, intestinal ulcerations
  • HYPERCALCEMIA – older adults, renal impairment
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18
Q

Bulk forming - TOLERABILITY

A

Abdominal cramping, flatulence

increased flatulence or risk of obstruction if recommended dose exceeded

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19
Q

Bulk forming - efficacy

A

Closely mimic the physiologic mechanism in promoting evacuation
Onset: 12-24 hours (may be delayed up to 72 hours)

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20
Q

Bulk forming - DI

A

Decreased absorption
- Physical binding of medications in GI tract
- Chelation with calcium-containing laxatives
- Oral tetracyclines,
quinolones
Separate administration by 2 HOURS

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21
Q

Hyperosmotic Laxatives - Indication

A

Polyethylene glycol (PEG) 3350 - short term treatment for occasional constipation for patiens 17+ years

Glycerin - lower bowel evacuation for patients of all ages

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22
Q

Hyperosmotic Laxatives - MOA

A

large, poorly absorbed ions that draw water into the colon or rectum via osmosis

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23
Q

Hyperosmotic Laxatives - Safety

Study These Flashcards
A

PEG3350- consult pcp in renal disease and IBS

Glycerin: innappropriate for patients with rectal irritation
hypokalemia with chronic use

24
Q

Hyperosmotic Laxatives - Tolerability

Study These Flashcards
A

Peg 3350: bloating, abdominal discomfort, cramping, flatulence
diarrhea/excessive stool frequency with higher doses

Glycerin: rectal irritation

25
Hyperosmotic Laxatives - Efficacy
PEG 3350- onset 12-72 hours (up to 96 hours in some patients) Glycerin - onset 15-30 minutes
26
Hyperosmotic Laxatives - DI
minimally absorbed - none sig
27
Emollient laxatives - stool softeners indication
prevention of straining and painful defecation patients with anorectal disorders, severe hypertension, cardiovascular disease, recent surgery, postpartum women prevention of opioid induced constipation in combination with a stimulant laxative treatment of occasional constipation `
28
Emollient laxatives - MOA
anionic surfactant that softens fecal mass | - increases the wetting efficiency of intestinal fluid -> mixture of aq and fatty substances
29
Emollient laxatives - safety
weakness, sweating, muscle cramps, irregular heartbeat with excessive doses
30
Emollient laxatives - tolerability
diarrhea, mild cramping
31
Emollient laxatives - efficacy
onset 12 - 72 hours (up to 3-5 days in some patients)
32
Emollient laxatives - DI
minimally absorbed | increased systemic absorption of mineral oil - avoid combination
33
Emollient laxatives - examples of meds
docusate sodium | docusate calcium
34
Lubricant Laxatives - indication
prevention of straiing or painful defecation | USE IN SELF CARE STRONGLY DISCOURAGED DUE TO SAFER ALTERNATIVES
35
Lubricant Laxatives - MOA
softens fecal contents by coating stool and preventing colonic absorption of fecal water
36
Lubricant Laxatives - Safety
lipid pneumonia - avoid in patients < 6 years, older adults, pregnant, bedridden, difficulty swallowing
37
Lubricant Laxatives - Tolerability
abdominal cramps, diarrhea, nausea, vomiting, anal leakage with larger doses
38
Lubricant Laxatives - efficacy
onset 6-8 hours (oral) 5-15 minutes (rectal) | use is similar to emollient laxatives
39
Lubricant Laxatives - DI
Increased systemic absorption - avoid combination with docusate products decreased absorption of vitamins - increased bleeding risk in patients taking warfarin
40
Lubricant Laxatives - product
Mineral oil - oral liquid or enema
41
Saline Laxatives - indication
Treatment of occasional constipation | Pre-operative bowel evacuation (e.g. colonoscopy)
42
Saline Laxatives - MOA
Ions that are retained in the intestinal wall | Draw in water via osmosis -> increased intraluminal pressure and intestinal motility
43
Saline Laxatives - Safety
Dehydration – avoid in patients who cannot tolerate fluid loss Magnesium products – avoid in newborns, older adults, renal impairment Sodium phosphate products – avoid in congestive heart failure, caution in renal impairment
44
Saline Laxatives - tolerability
Cramping, nausea, vomiting | Dehydration – consume 8 oz. water following administration of magnesium products
45
Saline Laxatives - Efficacy
Onset 30 min. – 6 hours (oral magnesium hydroxide) Onset 30 min. – 3 hours (oral magnesium citrate, sodium phosphate) Onset 2-15 min. (rectal magnesium citrate, sodium phosphate)
46
Saline Laxatives - DI
Oral anticoagulants, digoxin, chlorpromazine Decreased absorption Chelation with magnesium-containing laxatives Oral tetracyclines, quinolones
47
Saline Laxatives - products
Magnesium citrate magnesium hydroxide sodium phosphate magnesium sulfate
48
Stimulant Laxatives - indication
Pre-operative bowel evacuation (e.g. colonoscopy) Prevention or treatment of opioid-induced constipation in combination with docusate
49
Stimulant Laxatives - MOA
Increase intestinal motility by local irritation of the mucosa or action on the intramural nerve plexus of intestinal smooth muscle Increase secretion of water and electrolytes into the intestine
50
Stimulant Laxatives - safety
Severe cramping, electrolyte and fluid deficiencies, protein loss, malabsorption, hypokalemia, excessive loss of fluid during evacuation Subject to overuse (patients with disordered eating, elderly, misconceptions about normal BM frequency)
51
Stimulant Laxatives - tolerability
Vomiting, nausea, diarrhea, severe cramping with excessive doses; 
red/violet/brown-colored urine (senna)
52
Stimulant Laxatives - efficacy
Onset 6-10 hours (up to 24 hours in some patients) | Onset 15-60 minutes (rectal bisacodyl)
53
Stimulant Laxatives - DI
Rapid erosion of enteric coating (bisacodyl) Antacids, histamine2-receptor antagonists, proton pump inhibitors, milk Separate administration by 1 hour
54
Stimulant Laxatives - products
senna bisacodyl castor oil
55
``` Special Populations Children Advanced Age Pregnancy Lactation ```
Children Difficulty/delay in BMs 2+ weeks See previous slides < 2 years = direction of medical provider Advanced Age Avoid/use caution with mineral oil, saline and stimulant laxatives Pregnancy Bulk-forming laxatives, docusate, short-term senna or bisacodyl use Avoid castor oil, mineral oil, saline laxatives Lactation Senna, bisacodyl, PEG 3550, docusate Avoid castor oil, mineral oil
56
5 major counseling points
1. Dietary, fluid, exercise changes effective for most 2. Bulk-forming, PEG 3350 laxatives 1st line for most 3. Self-treatment limited to 7 days 4. Stop use and contact MD if rectal bleeding occurs 5. Separate most laxatives from other meds by 2 hours

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