Exam 4 - Constipation Flashcards
(181 cards)
1
Q
Parts of the small intestine
A
Duodenum
Jejunum
Ileum
2
Q
What does the small intestine do?
A
Breaks down food
Absorbs nutrients
Extracts water
Moves food along GI tract
3
Q
Duodenum
A
First part of the small intestine
4
Q
What feeds into the duodenum?
A
Stomach
Liver
Gallbladder
Pancreas
(Silly Little Gay People)
5
Q
Chemical digestion
A
Occurs due to liver, gallbladder, and pancreas sending digestive juices into the duodenum
6
Q
Jejunum
A
Middle (second) part of the small intestine
7
Q
What is the jejunum made up of?
A
Many coils that contain many blood vessels
8
Q
What happens in the jejunum?
A
Muscles churn food back and forth so it mixes with digestive juices
(This just sounds like it would happen in the middle)
9
Q
Peristalsis
A
Keeps the food moving forward in the jejunum
10
Q
Ileum
A
- Last and longest section of the SI
- Walls start to thin and become more narrow
- Reduced blood flow
11
Q
Where does food spend a majority of digestive time?
A
In the ileum
12
Q
Where is the most water and nutrients absorbed?
A
In the ileum
12
Q
How long does ingested food stay in the stomach?
A
For about 3 hours
13
Q
After being in the stomach, where does the ingested food go?
A
It moves to the SI for about 3 hrs
14
Q
Peristaltic waves
A
Moves the partially digested food from the SI toward the duodenum
15
Q
Partially digested food is moved by contractions from the small intestine to the _____
A
Large intestine
16
Q
What is defecation controlled by?
A
Both voluntary and involuntary reflexes
16
Q
Where is fecal matter stored
A
In the sigmoid colon until defecation
17
Q
What can constipation stem from
A
Primary or secondary mechanisms
18
Q
Secondary constipation
A
Systemic, neurologic, and psychological disorders and/or structural abnormalities
19
Q
Primary constipation
A
Slower than normal GI transit time or a defamatory disorder (ie pelvic floor disorder)
20
Q
What factors can contribute to constipation?
A
Inadequate dietary fiber and fluid intake
21
Q
Dietary fiber
A
Dissolves or swells in intestinal fluid causing an increase in fecal bulk to lan in stimulating peristalsis and elimination of stool
22
Q
Diets low in ______ may be associated w/ decreased bowel movements/constipation
A
Calories, carbs, or fiber
23
What does inadequate intake of fluids lead to?
Developing dehydration w/ consequential constipation
24
How many visits to the hospital are because of constipation?
2.5 million visits per year
24
Common causes of constipation
Structural issues
Lack of physical exercise
Inadequate fluid intake
Psychological
Some medications
Inadequate fiber intake
Systemic
(SLIPS In Shit)
25
Clinical descriptions of constipation
- Feeling as though not a complete evacuation
- Passing hard, dry stool
- Straining
- Decreased frequency
- Passing small stools
(Feeling Pretty Shitty, Don’t Push)
26
Constipation definition
Usually defined as having fewer than 3 bowel movements per week and involves straining/difficult passage of hard, dry stools
*not a set definition because it can look very different for different people
27
Medications that can cause constipation
Antacids
Anticholinergics
Antihistamines
Calcium supplements
Opioids
(3 antis)
28
What antacids most commonly cause constipation?
Calcium and aluminum compounds
Bismuth subsalicylate
29
What anticholinergics most commonly cause constipation?
Bentropine and glycopyrrolate
30
What antihistamines commonly cause constipation?
Diphenhydramine
Loratadine
31
Calcium supplements that commonly cause constipation
Calcium carbonate
32
What can happen if constipation is left untreated?
Hemorrhoids
Rectal prolapse
Anal fissures
Fecal impaction
(Having Rough Ass Fucks)
33
Psychological issues that cause constipation
Stress
Depression
Eating disorder
33
Structural issues that cause constipation
Colorectal injury/inflammation
Other structural abnormalities
Pelvic floor disorders
(COP)
34
Systematic causes of constipation
Parkinsonism
Diabetes
MS
Menopause
Dementia
Dehydration
IBS
Thyroid disorders
Dietary fiber
(Please Don’t Make Me Do Drugs In The Dark)
35
In addition to the typical clinical descriptions, what can be seen in patients who are constipated?
Bloating
Flatulence
Lower back pain
Anorexia
Abdominal discomfort
Lethargy
Dull headache
(Been Feeling Like Ass A Lot [of] Days)
36
When can constipation be treated w/ self care measures?
When it is occasional and temporary
**continuous constipation lasting over several weeks-months or if it is complicated by other conditions requires sustained and aggressive treatment
36
Exclusions to self care for constipation
- Blood in stool or dark, tarry stool
- Daily laxative use
- Anorexia
- Chronic medical condition that may preclude
- Recurring bowel symptoms after dietary/lifestyle changes
- Age less than 2
- Nausea/vomiting
- IBS
- Unexplained flatulence
- Marked abdominal pain/dissension/cramping
- Symptoms lasting longer than 2 weeks or recur over 3 months
- Fever
- Unexplained changes in stool
(Big Dumb Ass CRANIUMS Fuck Up)
37
Different treatment approaches to treat constipation
Lifestyle changes
Pharmacologic interventions
38
American Dietetic Association fiber recommendations
Adult women: 25 g daily
Adult men: 38 g daily
39
Fruits and vegetables
Increase stool mass and normalize bowel movements
40
How long does it take for a high fiber diet to start having an effect?
3-5 days
41
What can increasing dietary fiber intake cause?
Erratic frequency
Flatulence
Abdominal discomfort
42
Recommendations for increasing dietary fiber intake
As fiber increases, so should fluid intake
- Eight 8 oz glasses a day
- Pregnant/lactating women need more
42
How should you go about increasing your dietary fiber intake?
Gradually increasing over a few weeks
43
Bulk forming fiber laxatives
Methylcellulose (citrucel)
Calcium polycarbophi (fibercon)
Psyllium (metamucil)
43
What foods are high in fiber?
Oats
Potatoes
Almonds
Weet bix
Peas
Apples
Wholemeal bread
Bananas
Oranges
Broccoli
Corn
Spinach
Strawberries
Quinoa
Lentils
Chickpeas
(Old PAWPAW BOB Can’t See Shit, Quit Looking Close)
43
Contraindications to dietary fiber
Intestinal obstruction
Abdominal pain
Inadequate fluid intake
44
Dietary fiber supplements
Inulin (FiberChoice, Metamucil Clear & Natural)
Partially hydrolyzed guar gum (Sunfiber)
Powdered cellulose (Unifiber)
Wheat dextrin (Benefiber)
45
Systematic adverse drug reactions in bulk forming agents
Abdominal cramping
Flatulence
45
Dosage forms of bulk forming agents
Powders
Capsules
Gummies
Tablets
Wafers
Chews
(Painful Constipation? Get The Water Can)
45
Types of pharmacologic interventions for constipation
Bulk forming laxatives
Lubricant laxatives
Emollient laxatives (stool softeners)
Saline laxatives
Stimulant laxatives
Hyperosmotic laxatives
(BLESS Him)
45
What is the treatment of choice for constipation in most cases?
Bulk forming agents such as Metamucil, FiberCon, and Citrucel
This is because they closely mimic the body’s natural processes
46
Onset of bulk forming agents
12-24 hours but may take up to 72 hours
46
What do laxative recommendations depend on?
The underlying cause of constipation and patient preferences
47
Counseling on bulk forming agents
Must take w/ adequate liquid
Useful in short term constipation relief
Sugar content may be an issue for those w/ diabetes or restricted caloric intake
47
MOA of bulk forming agents
Absorb water and form emollient gels that stimulate peristalsis
48
Hyperosmotic agent age restrictions
Only use in 17+
49
Who can use glycerin
Adults and children
50
Onset of hyperosmotic agents
12-72 hours but could take up to 96 hours
51
ADRs for hyperosmotic agents
Bloating
Flatulence
Abdominal discomfort
Cramping
Electrolyte/fluid imbalance
(B FACE)
52
Exclusions for the use of hyperosmotic agents
Patients w/ renal disease or IBS should be referred
53
Directions of use for hyperosmotic agents
Take po qd prn
53
Administration of hyperosmotic agents
17g (one capful/packet) mixed w/ 4-8 oz of water
54
What is the hyperosmotic agent glycerin used for
Lower bowel evacuation
55
Dosage forms of glycerin
Solid and liquid suppositories
55
Onset of glycerin
15-30 min
56
Dosing of glycerin
One suppository used once or as directed by PCP
57
Who should avoid using glycerin?
Patients w/ preexisting rectal irritation
57
What do emollients (stool softeners) do?
Soften fecal mass by increasing the wetting efficiency of intestinal fluid to help the mixing of aqueous and fatty substances
57
ADRs of glycerin
Rectal irritation (more likely w/ overuse)
57
Why are emollients used?
To prevent straining and painful defecations due to recent abdominal or rectal surgery, pregnancy, and postpartum
58
Dosing of docusate sodium and docusate calcium (stool softeners)
50-300 mg daily either in single or divided doses
59
Docusate sodium usual doses
50 mg or 100 mg
60
Docusate calcium usual doses
240 mg capsules
61
Onset of emollients (stool softeners)
12-72 hours; may take up to 3-5 days to see full effects
62
What may happen if you take a larger than recommended dose of stool softeners?
Adverse effects such as:
- weakness
- sweating
- muscle cramping
- irregular heartbeat
63
What are stool softeners often used w/ in constipation
Stimulant laxatives
Mainly for opioid induced constipation
64
What is the only available OTC lubricant product
Mineral oil (liquid petroleum)
65
MOA of lubricants
Softens fecal contents by coating the stool and preventing reabsorption of water by the colon
66
Onset of lubricants
PO: 6-8 hrs
Rectal: 5-15 hrs
67
What are important counseling points for mineral oil?
Patients must remain upright after taking po dosing
Do not use in patients at risk for aspiration
Larger than recommended dosing may lead to oil leakage via anal sphincter or anal pruritis
68
Interactions w/ mineral oil
May impair absorption of fat soluble vitamins
Do NOT use w/ docusate because it can cause increased mineral oil absorption
69
Who should NOT use mineral oil
Patients younger than 6 yrs
Pregnant women
Bedridden/older adults
Patients w/ difficulties swallowing
70
What are the types of saline laxatives
- Magnesium citrate
- Magnesium hydroxide (milk of magnesia)
- Dibasic and monobasic sodium phosphate
- Magnesium sulfate
71
MOA of saline laxatives
Draws water into the SI and LI (oral products) or into the colon (rectal) through osmosis
Promotes GI mortality
72
Dosage forms of saline laxatives
Liquid/solid oral ingestions
Liquid for rectal insertion
73
Indications for saline laxatives
Constipation
Acute bowel evacuation (colonoscopy prep)
74
When is it okay to use magnesium hydroxide (milk of magnesia)
Occasional use in otherwise healthy patients
75
Onset of magnesium hydroxide (milk of magnesia)
30 min to 6 hrs after admin
76
Dosing for magnesium hydroxide (milk of magnesia)
400 mg/5 mL product
2-4 tablets or 30-60 mL daily as single or divided doses
77
Magnesium citrate is commonly used for
Colonoscopy
78
Onset of magnesium citrate
PO: 30 min - 1 hr
Rectal: 2-15 min
79
How should you administer magnesium salts
W/ 8 oz of water to prevent dehydration
80
What can occur w/ long term use of magnesium salts
Electrolyte imbalances (ie. Hypermagnesemia)
81
Who should avoid using magnesium salts?
Patients on sodium, phosphate, or magnesium reduced diets
Patients at increased risk of magnesium toxicity (newborns, older adults, renal impaired)
82
ADRs in magnesium salts
Dehydration
Abdominal cramping
Nausea/vomiting
(DAN)
83
What can sodium phosphate cause
Hyperphosphatemia
Hypocalcemia
Hypernatremia
84
Who should use caution w/ sodium phosphate
- Patient who are renally impaired
- Patients on sodium restricted diets
- Patients on meds that may affect serum electrolyte levels (ie diuretics)
85
In what patient group is sodium phosphate contraindicated in?
Patients who have experienced congestive heart failure (CHF)
86
What patients should NOT use rectal admin of sodium phosphate
Patients with:
- megacolon
- GI obstruction
- colostomy
- imperforate anus
87
What is the ONLY OTC use of sodium phosphates
Constipation ONLY - NOT bowel prep
Recommended not to exceed 1 dose in 24 hours
88
How are stimulant agents classified?
By chemical structures and pharmacologic activity
89
Types of stimulant agents
Anthraquinones (senna)
Diphenylmethanes (bisacodyl)
90
Dosing for senna
17.2 mg once daily
91
Dosing of bisacodyl
1-3 tablets once daily
92
Adverse effects of stimulant agents
Cramping
Nausea/vomiting
Dehydration
93
Where is the primary site of action of stimulating agents?
Colon
94
MOA for stimulating agents
Increases intestinal peristalsis through mucosal irritation or stimulation (which increases gut motility)
Increases secretion of water and electrolytes in the intestine
95
Onset of action for stimulating agents
PO: 6-10 hours after admin, may take up to 24 hours
Rectal: 15-20 min after admin
96
Major concerns of stimulating agents
- Severe cramping
- Electrolyte and fluid deficiencies
- Enteric loss of protein
- Malabsorption due to hypermotility and catharsis
- Hypokalemia
97
Stimulating agent overdose symptoms
Sudden vomiting
Nausea
Diarrhea
Severe abdominal cramping
98
What is often used to treat opioid induced constipation
Stimulating agents and docusate
99
What happens w/ prolonged use of senna
Possible harmless, reversible melanotic pigmentation of colonic mucosa
Can be seen on sigmoidoscopy, colonoscopy, or rectal biopsy
100
What is counseling point of using senna
Can color urine pinkish red, shades of violet, or reddish brown
101
What testing result can be inaccurate due to the use of senna
Presence can affect interpretation of phenolsulfonphthalein test (test to diagnose kidney stones)
102
Bisacodyl coating
Enteric coating on tabs to prevent irritation of gastric mucosa
103
Counseling point of using bisacodyl
Do not break, crush, chew, or give w/ agents that increase gastric pH
104
What can you NOT consume when taking bisacodyl? Why?
Antacids
H2RAs
PPIs
Milk (within 1 hr)
Causes rapid erosion of enteric coating, leading to gastric or duodenal irritation
105
Cascara sagrada, casanthranol, and phenolphthalein
Deemed not safe and not effective
Still marketed as dietary supplements
106
Aloe and rhubarb
Should NOT recommend
Not included in FDA guidelines
107
What is the 1st line treatment for constipation
Bulk forming agents
Ex. Citrucel, fibercon, metamucil
108
What should be used if faster onset is needed than the first line treatment can provide?
PEG
109
What should be the last option for constipation?
Stimulants
Ex. Senna and bisacodyl
110
What is considered a complementary therapy for constipation?
Castor oil
111
Castor oil was historically viewed as what?
A stimulant laxative BUT actual mechanism is unknown
112
How fast does castor oil work?
Acts quickly and has significant laxative effects
113
What can prolonged use of castor oil lead to?
Excessive loss of fluid, electrolytes, and nutrients
114
Patient preferences
Palatability and convenience
Liquid formulations and emollients may be more palatable if mixed w/ juice
Mixing gritty, bulk forming laxative powders (like psyllium) w/ orange juice instead of water may increase palatability
Patient may prefer water or “single serving” packets of bulk forming laxatives for convenience and ease of use
115
When should you seek medical attention for constipation
All treatment options should have visible effects in 2-5 days
If symptoms worsen
If symptoms are not resolved within 7 days of initiating self care measures
Patient meets any exclusions to self care
116
How is constipation defined in kids?
Based on age
Typically a delay of difficulty over a period of 2 days
117
How many kids are affected by constipation?
Up to 37% of children
118
What is the most common cause of abdominal pain in children?
Constipation
119
Factors affecting bowel habits in children
Dietary changes (human to cow milk)
Fear of defecation (after it hurts once, child may withhold defection, exacerbating the issue)
Chronic medical conditions
Toilet facilities
Emotional distress (family conflicts)
Change in routine/environment (going to school for the first time)
(Don’t Force Children To Empty Colon)
120
Signs/symptoms of fecal impaction
- Constipation accompanied by watery diarrhea
- Abdominal cramping
- Fecal soiling
- Rectal bleeding
- Small, semi-formed stools
(Cause Ass Feels Really Stuffed)
121
How can mild constipation be relieved in children?
By dietary or behavioral changes
- increase WATER intake
- drinking fruit juices containing sorbitol (prune, apple, pear)
- eating high fiber cereals, grains, vegetables, and fruits
122
What is the recommended dietary fiber intake for children?
Age + 5 g a day
123
Nonpharmacologic recommendations for parents/caregivers
Establish a regular stooling time for toilet training children (after morning meals)
Develop a reward/support system (positive talk; charts/stickers)
Encourage kids to go as soon as they feel the urge
124
Oral laxatives approved for self care in children 2-6 years of age
Docusate
Magnesium hydroxide
Senna
125
Rectal laxatives approved for self care in children 2-6 years of age
Use of glycerin
Mineral oil
Sodium phosphate
126
Oral laxatives approved for self care in children 6-12 years of age
5 Ms:
- Methylcellulose
- Mineral oil
- Magnesium citrate
- Magnesium hydroxide
- Magnesium sulfate
Calcium polycarbophil
Docusate sodium
Senna
Bisacodyl
Castor oil
127
Rectal laxatives approved for self care in children 6-12 years of age
Glycerin
Mineral oil
Sodium phosphate
Bisacodyl suppositories
128
First line treatment in children 2-6 for constipation
Oral docusate sodium and/or magnesium hydroxide
129
If faster relief is needed in children 2-6 for constipation
Use pediatric glycerin suppositories
130
If all other treatments fail in children 2-6 for constipation
Oral senna
Oral magnesium citrate
Rectal mineral oil
Sodium phosphate enema
131
First line treatment in children 6-12 for constipation
Bulk forming agents
Oral docusate sodium
Oral magnesium hydroxide
132
Use if faster relief is needed in children 6-12 for constipation
Glycerin or bisacodyl suppositories
LAST RESORT: mineral oil or sodium phosphate enema
133
Use if other treatments have failed in children 6-12
Oral stimulants
134
How many elderly patients in community based settings experience constipation
Up to 20%
135
How many elderly patients in nursing homes experience constipation?
Up to 50%
136
Risk factors in advanced age patients
- Dietary changes (fluid restrictions, reduced calorie)
- Physiologic changes
- Decreased physical activity
- Increased use of constipating medications
- Comorbid conditions
(Decrepit Patients Die In Constipation)
137
What are generally considered safe in patients of advanced age?
Rectal therapy w/ suppositories or enemas
138
First line treatment in advanced age patients
Lifestyle modifications
*Consider fluid restrictions due to comorbidities
139
Second line of treatment in advanced age patients
Bulk forming laxatives > PEG 3350
Stool softeners IN ADDITION TO other pharm and nonpharm recommendations
140
Which stool softener is best in patient w/ anal fissures and/or hemorrhoids
Docusate
141
Medications to avoid/use with caution in patients of advanced age
Mineral oil
Saline laxatives
Sodium phosphate products
142
Why should patients of advanced age avoid using mineral oil?
Aspiration risks
143
Why should patients of advanced age avoid using saline laxatives?
Fluid
Electrolyte depletion
Magnesium toxicity
Drug interactions
144
How many pregnant patients experience constipation during pregnancy/postpartum
1/3 women
145
What meds should be avoided for pregnant women?
Castor oil
Mineral oil
High doses/long term saline laxative use
146
Why should castor oil NOT be used in pregnant women
Uterine contractions and rupture
147
Why should mineral oil NOT be used in pregnant women?
Impairment of fat-soluble vitamin absorption
148
Why should high doses/long term saline laxative use NOT be used in pregnant women?
Electrolyte imbalance
149
First line treatment of constipation in pregnant patients
Dietary measures
150
Second line treatment in pregnant patients
Bulk forming laxatives and docusate for dry/hard stools
151
What medications are considered LOW risk in pregnancy
Senna
Bisacodyl
152
What medications are compatible w/ breastfeeding? Why?
Senna
Bisacodyl
PEG
Docusate
Minimal absorption
Don’t accumulate in significant amounts in breastmilk
153
What meds should you AVOID during lactation?
Castor oil
Mineral oil
154
What percentage of patients experience constipation while taking opioids?
40%
155
Why do opioids cause constipation?
Opioids bind to bowel and CNS receptors to decrease GI motility and intestinal secretions
This causes longer retention time of fecal matter and consequent drying of the stool
156
Does opioid formulation matter when it comes to constipation?
Oral agents are generally more constipating that parenteral agents
Transdermal fentanyl patches are less constipating than oral agents
157
Medications for acute opioid induced constipation
Saline laxative or rectally administered
158
What may be needed for acute opioid induced constipation?
Preparations may be needed for acute evacuation
159
What is most commonly recommended in chronic constipation?
Stimulants
160
What is typically NOT effective in chronic constipation?
Stool softeners alone
161
Combination treatment for chronic constipation
Emollient (stool softeners) and a stimulant
162
What can excessive use of laxatives cause?
Acute diarrhea/vomiting
Fluid/electrolyte loss (hypokalemia)
Dehydration
163
Risk factors for laxative overuse
Patients without symptoms of constipation but take laxatives for regular (daily) BMs or those wanting softer stool
People using laxatives to “detox the system”
Patients w/ eating disorders (anorexia, bulimia)
Elderly patients
Patients w/ misconceptions about normal frequency
Patients w/ fear of constipation
