Constipation & Diarrhoea Flashcards
(38 cards)
1
Q
What is constipation characterised by (4)
A
- Reduced frequency of bowel movements
- Unable to completely empty the bowel
- Hard small lumpy stools
- Due to slowing and water reabsorption
2
Q
What are the symptoms of constipation (8)
A
- Straining
- Feeling of incomplete emptying
- Distension
- Abdominal pain
- Pain
- Nausea & vomiting
- Discomfort
- Wind
3
Q
What are the possible causes of constipation (10)
A
- Insufficient fibre in diet
- Insufficient fluid in diet
- Lack of exercise
- Medication (E.g. opiates, TCA’s, Iron, diuretics…)
- Ignoring the urge to pass stools
- Irritable bowel syndrome (IBS)
- Pregnancy
- Old age
- Long-term laxative usage (senna pods, or laxative abuse)
- Cancer
4
Q
What are the complications of constipation (4)
A
- Faecal impaction
- Haemorrhoids
- Rectal Prolapses
- Anal Fissures
5
Q
What are the likely causes of constipation from most likely to very unlikely (4)
A
Most likely - Eating/lifestyle
Likely - Medication
Unlikely - IBS, pregnancy
Very Unlikely - Colorectal cancer
6
Q
What is faecal impaction (4)
A
- Untreated constipation
- Dried hard stools collect in rectum
- Increased pressure causes muscles in rectum to weaken
- Overflow incontinence
7
Q
What happens during faecal impaction (5)
A
- Large hard stool difficult to pass
- Large baggy rectum stretches to accommodate
- More stool comes adding to the blockage
- Watery stool works around hard stool
- Anal sphincters over time may lose tone
8
Q
What are faecal impactions treated with (3)
A
- High-dose osmotic laxative
- Bisacodyl suppository
- Sodium citrate enema
9
Q
When should constipation be referred to the GP (10)
A
- less than 10 years old
- Constipation/alternating with diarrhoea
- Blood/mucus in stools
- Major change in bowel habit - over 40y/o
- Regular medication - causative
- Duration over 14 days - adult
- Duration over 7 days - child
- Weight loss (Unintentional)
- Lethargy
- Pregnancy
10
Q
What treatment is there for constipation (8)
A
- increase fibre (soluble and insoluble)
- increase fluid
- gentle exercise
- Stimulant laxatives - Senna
- Bulk-forming laxatives - Ispaghula husk
- Osmotic Laxatives - lactulose
- Bowel Cleansing Preparations- pre-surgery - NPSA safety alert for bowel cleansing preps
- Peripheral Opioid-receptor antagonists
11
Q
What do bulk-forming laxatives do (6)
A
- Increase faecal mass
- Stimulate peristalsis (movement of food through GI tract)
- Full effect takes days
- Used if cannot increase fibre in diet (e.g. IBS)
- Need to increase fluid to avoid intestinal obstruction
- Make up with water – drink within 10 minutes
12
Q
What are examples of bulk-forming laxatives (3)
A
- ispaghula husk (Fybogel, Isogel)
- methylcellulose (Celevac)
- Sterculia (Normacol)
13
Q
What do stimulant laxatives do (8)
A
- Taken at night (ON)
- Stimulate peristalsis (movement of food through GI tract)
- Senna exact opposite of opiods
- Can cause abdominal cramp
- Avoid in intestinal obstruction
- Odd: Dantron-carcinogenic-palliative care only
- Old: Castor oil, liquid paraffin, cascara-obsolete
- Leached fat soluble vitamins from body
14
Q
What are examples of stimulant laxatives (4)
A
- Bisacodyl
- sodium picosulphate
- senna, docusate (softener and stimulant)
- Glycerol suppositories - direct rectal stimulant
15
Q
What do osmotic laxatives do (3)
A
- Increase the amount of water in the large bowel
- Drawing water from the body into the bowel retaining fluid they are administered with
- Lactulose is a semi-synthetic disaccharide - not absorbed in the GIT
16
Q
How does lactulose work (3)
A
- Discourages proliferation of ammonia-producing organisms so used hepatic encephalopathy
- Slow to work
- Can cause abdominal cramps
17
Q
What are examples of osmotic laxatives (2)
A
- Movicol - Macrogols-inert polymers of ethylene glycol
- Lactulose
18
Q
What are bowel cleansing preparations (3)
A
- Used before colonic surgery, colonoscopy, or radiological examination of the bowel to evacuate the bowel
- Not treatments for constipation
- Care-fluid and electrolytes disturbances
19
Q
What are peripheral opioid-receptor antagonists in relation to constipation (5)
A
- e.g Methylnaltrexone
- used in opioid-induced constipation in patients receiving palliative care
- subcutaneous injection
- Response to other laxatives insufficient
- Adjunct to existing laxative therapy
20
Q
How are laxatives abused and what causes (4)
A
- Method of dieting
- Regular use of laxatives can reduce effectiveness
- Electrolyte disturbances
- Also may have older customers who have got into the habit of it for no good reason
21
Q
What is diarrhoea (6)
A
- Increased passage of more watery and loose stools
- Increase in secretion of fluid into bowels
- May also be vomiting
- Losing weight
- Abdominal cramps and bloating
- Acute → chronic classification
22
Q
How is diarrhoea classified from acute to chronic (3)
A
- Acute - less than 7 days
- Persistent - more than 14 days
- Chronic - more than 28 days
23
Q
What are the infective causes of diarrhoea (5)
A
- Viral - V. unpleasant often rotavirus (Vaccine to prevent)
- Bacterial
- Travellers – enterotoxin E. coli
- C. difficile
- Protozoal
24
Q
What are non-infective causes of diarrhoea (9)
A
- Other conditions (IBS, IBD)
- Intolerance
- Laxative use/abuse
- Drug – PPI, NSAID, Dig…
- Abx → gut bacteria change
- Alcohol (excess)
- Running
- Stress
- Menstruation
25
What are the likely causes of diarrhoea from most likely to very unlikely (4)
Most likely - viral & bacterial infection
Likely - Medication-induced
Unlikely - IBS, overflow from impaction
Very Unlikely - IBD, cancer
26
When should diarrhoea be referred (8)
1. Long-term change in bowels - over 50 y/o
2. Recent travel to tropical/ subtropical climate
3. 2-3 days if unable to keep fluid in
4. Blood, mucous or fat in stools
5. Suspected faecal impaction
6. Severe abdominal pain
7. Worsening fever
8. Dehydration
27
What are the diarrhoea referral times in children (3)
1. less than 1 Y/O → over 1 day of symptoms
2. 2-3 Y/O → over 2 days of symptoms
3. over 3 Y/O → over 3 days of symptoms
28
What are the clinical features of mild diarrhoea (2)
1. anorexia
2. lightheaded
29
What are the clinical features of moderate diarrhoea (8)
1. dry mouth
2. sunken eyes
3. decreased skin turgor
4. thirsty
5. tired
6. dark strong-smelling urine
7. dizziness
8. postural hypotension
30
What are the clinical features of severe diarrhoea (9)
1. hypovolaemic shock
2. oliguria
3. anuria
4. cold extremities
5. rapid weak pulse
6. low BP
7. seizures
8. coma
9. death
31
When should diarrhoea be referred in mild, moderate and/or severe stages (3)
Mild - no referral
Moderate - referral & rehydrate immediately
Severe - referral & emergency IV fluids needed
32
What are the clinical features of diarrhoea in infants (6)
1. Sunken soft spot (fontanelle) on top of their head
2. Sunken eyes
3. Few or no tears when they cry
4. Dry and light many nappies
5. Being drowsy or irritable
6. And other diarrhoea symptoms
33
What are the treatments for diarrhoea (12)
1. Good hand hygiene essential to not infect others or reinfect
2. Alcohol gel not enough as if bacterial spores won’t be killed
3. Stay home from work or school until 48 hours until after symptoms
4. Normal feeding as much as possible
5. Often start with bland, toast etc
6. Oral rehydration sachets
7. Important to have most of your fluids as electrolyte and especially in young children
8. Drug treatment
9. Antimotility drugs (opiates) loperamide (care- can be abused)
10. co-phenotrope
11. codeine morphine (not generally recommended, holding back bacteria)
12. Adsorbents- kaolin- no longer recommended (harbours bacteria)
34
What are oral rehydration therapies (7)
1. Replace fluids and electrolytes MOST IMPORTANT THING
2. Important to make up properly
3. Typically 1 sachet + 200 mL water
4. Contains alkalising to counter acidosis
5. Hypo-osmotic so water is not drawn into the GI tract (which would make diarrhoea worse)
6. Dioralyte and electrode are common
7. WHO rehydration formula - 1L water, ½ tsp salt, 6 tsp glucose (absorption of Na is ↑by glucose)
35
How is loperamide used for diarrhoea (7)
1. Doesn’t cross BBB (blood-brain barrier) (no opiate like analgesia or addiction)
2. Uncomplicated diarrhoea
3. Not under 4 years old
4. Can be in IBS if over 18 and official diagnosis
5. Dose 4 mg stat + 2 mg after each bowel movement up to 16 mg a day
6. Morphine may be used similarly
7. Reports of serious cardiac adverse reactions with high doses or abuse/misuse
36
What are the preventative measures to diarrhoea (8)
1. Hand hygiene wash hands with warm water and soap (gel if not)
2. Drying: Disposable paper towel > newer high force air dryers > old air dryers
3. Food hygiene
4. Go from raw to cooked and not back
5. Raw at the bottom of the fridge, cooked at top (no dripping)
6. 2-8° C (ideally <5°C)
7. Clean toilet areas
8. Avoid sharing towels and cutlery etc
37
What are the causes of C. difficile (5)
1. Hospital-acquired infection (more of a colonisation)
2. When Abx used in hospital
3. broad spectrum cephalosporins and quinolones (oxacins)
4. Limits and fines on hospitals on cases
5. Limit with Abx stewardship
38
What are the treatments for C. difficile (3)
1. Review meds: Withdraw causative Abx, avoid PPI
2. Oral metronidazole or Vancomycin
3. Faecal transplant if not working
