Constipation and Hemorrhoids

Question 1

Some lifestyle modifications for constipations

Answer 1

Increase fiber intake
Increase fluid intake
“Bowel Training”
Squatty Potty

Question 2

What are types of fiber and what food contain them?

Answer 2

Soluble
Beans, oat bran, barley, citrus fruits, apples, carrots, etc.

Insoluble
Whole grain breads, prunes, corn, etc.

Question 3

What are first line treatments for constipation?

Answer 3

Bulk-forming agent

Hyperosmotic agent

Question 4

Bulk-forming agents MOA

Answer 4

promoting evacuation by dissolving or swelling to form emollient gels that facilitate passage of stools and stimulate peristalsis (bulk)

Question 5

Bulk-forming agents products

Answer 5

Psyllium (Metamucil™) – natural source/allergy alert

Methylcellulose (Citrucel™) – synthetic so least GAS

Polycarbophil (FiberCon™) - extremely hygroscopic

Question 6

Bulk-forming agents things to remember

Answer 6

MUST take with water to avoid obstruction

Avoid in individuals with swallowing difficulties

Most common side effect – flatulence

May interfere with the absorption of concomitant oral medications – separate by at least 2 hours

Question 7

Hyperosmotic agent MOA

Answer 7

Large poorly absorbed ions draw water into colon or rectum to stimulate bowel movement

Question 8

Hyperosmotic agent products

Answer 8

Polyethylene Glycol 3350 (Miralax™)

Glycerin

Question 9

Miralax things to remember

Answer 9

Also used in bowel prep regimens for colonoscopy in addition to constipation

Odorless and tasteless and only 0.2% absorbed

No clinically significant drug interactions

Very well tolerated

Question 10

Glycerin things to remember

Answer 10

Used for lower bowel evacuation

Quick onset (15 to 30 minutes)

Drug interactions are not clinically important

As enema, not recommended due to irritation (sodium sterate component)

Minimal side effects

Question 11

Emollient agents MOA and also called?

Answer 11

“Stool softener”

Increase wetting efficacy of intestinal fluid and soften fecal mass

Primarily to prevent straining and painful defecation

Question 12

Emollient agent product

Answer 12

Docusate sodium (50 or 100mg)
Docusate calcium

Question 13

Emollient agent things to remember

Answer 13

Minimal side effects

Generally well-tolerated

Will increase absorption of mineral oil so combination should be avoided

Question 14

Lubricant agent MOA, products and things to know

Answer 14

Mineral oil

MOA: softens fecal contents by coating stool and preventing colonic absorption of fecal water

To prevent straining and painful defecation
(Safer agents (emollients) preferred)

Many safety concerns – not preferred

Question 15

Saline laxative agents MOA

Answer 15

Ions in intestinal wall draw in water, increasing intraluminal pressure and intestinal motility

Occasional relief of constipation or when acute evacuation of bowel is required

Question 16

Saline laxative agents products

Answer 16

Magnesium citrate

Magnesium hydroxide (MOM™)

Dibasic sodium phosphate/Monobasic sodium phosphate (Fleet™)

Magnesium sulfate (Epsom salt™)

Question 17

Saline laxative agents things to remember

Answer 17

May cause serious electrolyte imbalances with long-term use and at higher doses!

Patients who cannot tolerate fluid loss should not use saline laxatives!

Question 18

What is the recommended second line for constipation?

Answer 18

Stimulant agents

Question 19

Stimulant agents MOA

Answer 19

Increase intestinal motility and secretion of water and electrolytes

Question 20

Stimulant agents product

Answer 20

Sennosides (Senna™) - anthraquinone (8.6mg)

Bisacodyl (Dulcolax™) - diphenylmethane

Question 21

How many days until pt should call PCP?

Answer 21

7 days

Question 22

Nonpharmacologic treatment for hemorrhoids

Answer 22

Good perianal hygiene

Avoid prolonged toilet sitting time (~ > 10 minutes)

Avoid lifting heavy objects/sitting for long periods

Sitz bath – bid-qid for 10-20 minutes

Question 23

What is sitz bath?

Answer 23

A sitz bath is a warm, shallow bath that cleanses the perineum, which is the space between the rectum and the vulva or scrotum.

A sitz bath can also provide relief from pain or itching in the genital area.

Question 24

Local anesthetics ingredients

Answer 24

benzocaine, dibucaine, lidocaine, pramoxine, benzyl alcohol, dyclonine, tetracaine

Question 25

Local anesthetics things to know

Answer 25

MOA: reversibly block transmission of nerve impulses External use only – typically 3-6 times per day May mask pain of more severe anorectal disorder – use with caution Allergic reactions similar to anorectal symptoms may occur

Question 26

Pharmacologic treatments for hemorrhoids

Answer 26

Local anesthetics Vasoconstrictors ** Avoid in pts with diabetes, hyperthyroidism, hypertension, angina pectoris, enlarged prostate, or antidepressant meds Protectants** (glycerin is external only) Astringents** (witch hazel is external only) Keratolytics Analgesics/Anesthetics/Antipruritics Corticosteroids

Question 27

Vasocontrictors things need to know and caution | Hemorrhoids

Answer 27

MOA: constricts arterioles to reduce swelling and produce anesthetic effect (mechanism unknown) External and internal use – Up to 4 times per day Caution/avoid with diabetes, thyroid disease, HTN, angina pectoris, or enlarged prostate, and with antidepressants, antihypertensives, and cardiac medications – consult PCP

Question 28

Vasoconstrictors for hemorrhoids ingredient

Answer 28

ephedrine, epinephrine, phenylephrine

Question 29

Protectants for hemorrhoids ingredients

Answer 29

kaolin, ALUMINUM HYDROXYDE, COCOA BUTTER, GLYCERIN, hard fat, LANOLIN, MINERAL OIL, white pet, CALAMINE, shark liver oil, ZINC OXIDE, topical starch, cod liver oil

Question 30

Protectants for hemorrhoids things need to know

Answer 30

MOA: prevent fecal matter from causing perianal irritation, and soften the dry anal canal by decreasing water loss External and internal use – up to 6 times per day Glycerin = external only Systemic absorption minimal, ADRs uncommon

Question 31

Astringents for hemorrhoids ingredients. ext? int?

Answer 31

Witch hazel = external only Calamine and zinc oxide = both int. and ext.

Question 32

Astringents for hemorrhoids things needs to remember

Answer 32

MOA: promote coagulation of skin cells to protect underlying tissue and make area drier External and internal use –up to 6 times per day

Question 33

Analgesics, Anesthetics, Antipruritics for hemorrhoids ingredients

Answer 33

menthol, juniper tar, camphor

Question 34

Analgesics, Anesthetics, Antipruritics for hemorrhoids

Answer 34

MOA: temporary relief of pain, itching, burning, or discomfort by producing a local sensation to distract from these complaints External use only – up to 6 times per day Rectum has no nerve fibers – no internal benefits Use sparingly and do not ingest orally

Question 35

Corticosteroids for hemorrhoids

Answer 35

1% hydrocortisone is only corticosteroid approved for nonprescription use in anorectal preps Act as a vasoconstrictor and antipruritic External use only – 3 to 4 times per day May cause skin atrophy with prolonged use and rare skin reactions

Question 36

Preparation H oinment Active Ingredients:

Answer 36

Available in ointment, cream, gel, and suppository product forms. The Ointment contains Petrolatum 71.9%, Mineral Oil 14%, Shark Liver Oil 3% and Phenylephrine HCl 0.25%