Contipation: Definition
- Abnormally slow movement of feces through colon (Note: What’s normal?)
- Usually hard, dry feces in descending colon
- Infrequent or difficult evacuation
- Sense of incomplete evacuation
Constipation: LIfestyle Causes
- Put off urge
- Inactivity
- low fiber diet
- Low CHO diet
- inadequate fluid intake
- Cheese
- Post-op (fear of straining)
- Etc.
Constipation: Medication Causes
- Opioids
- Al+ and Ca++ antacids
- Anticholinergics
- Anticholinergic actions:
- Antidepressants
- Antihistamines
- Antihypertensives
- Antipsychotics
- Bismuth salts
- Diuretics
- Iron salts
- Chronic irritant laxatives
- CCB’s (calcium channel blockers)
- Sulcralfate
Note that these are used in old people
Constipation: Medical Conditions
- GI cancers
- DM (autonomic neuropathy)
- nerve damage in gut
- Age (decreased neuro. stim)
- Diverticular Dz
- pockets in gut
- Rectal stenosis, fissures, Hroids, etc.
- Stroke
- Adhesions
- Strictures
- Hernia
- Hypothyroid
- IBS (spastic colon)
- MS, PD (parkinsons)
- Pg
- E-lyte disturbances
Constipation: Symptoms
- Dull headache
- Loss of appetite
- Lack of energy
- Feeling of fatigue
- Abdominal distension
- Bloating
- Lower abdominal discomfort or pain
- Lower back pain
Constipation: The Essential Triad
- Bulk, Water, Exercise
Constipation: When to Refer
- blood in feces
- cancer
- nausea, vomiting
- obstruction
- acute abdominal pain
- fever
- 7-10 days duration
- unresponsive to adequate laxative Rx
- quadriplegia, paraplegia
- impaction risk
- Anorexia history
Constipation: Non-Drug
- Alterations in diet (fiber, bulk)
- Increased fluid
- Exercise
- Stress management
- Avoidance of constipating drugs
Constipation: Pharmacological
- Bulk Laxatives (12-72 hours)
- Metamucil, Citrucel, Fibercon
- Work by hanging onto water so that water won’t be suck out by colon
- Stool stays softer
- Safe and natural
- Not acute, more of preventative agent
- Have sugar, so be careful if diabetic
- Need enough water
- •Stimulant laxatives (6-12 hours)
- Ex-Lax, phenophaline
- Irritant causes colon to contract
- Senna, bisacodol (ducalax)
- Enteric coated, can’t be ground up
- Saline laxative (30min-3 hours)
- Sodium enema
- Magnesium citrate, milk of magnesia
- Can change electrolyte balance
- Careful for renal patients, congestive heart failure
- Lubricant laxative (24-72 hr)
- Mineral oil
- Lubricates the hard stool to slide out
- Not good for chronic use: seepage, if lay down can get into lungs, can waste fat soluble vitamins
- Surfactants (6-8 hrs)
- Docusate
- Not very effective by self (usually paired with stimulant)
- Decrease water tension, supposedly let water into stool
- 250 mg at LEAST, need quite a bit to be effect
- Turn colon into secreting organ
- Used prophylactically
- Hyperosmotic (15min-1 hour)
- Glycerin (children), lactulose (chronic-lac), sorbitol, Miralax (PEG)
- 17g mix with water
Bulk Laxatives
- Polycarbophil (Konsyl Fiber)
- Psyllium (Metamucil, others)
- Methylcellulose (Citrucel, Maltsupex)
- Good initial choice: “approximate normal”
- Nonabsorbable; expand and take up water; stimulate distension reflex and intestinal motility
- Also for IBS diarrhea
- Contraindicated: intestinal stenosis, adhesions
- Careful:
- Esophageal/intestinal obstruction (review mixing/dilution instructions)
- Diabetes: sugar
- ADR:
- Flatulance, borborygmi (rumbly tummy)
- Flatulance, borborygmi (rumbly tummy)
Stimulant Laxatives
- Not first choice (except opiod)
- cascara sagrada
- •senna, sennasides (Senokot, Ex-Lax)
- •Castor oil (Purge, Neoloid)
- •bisacodyl (Dulcolax, Correctol)
- •Phenolphthalein – tumors, genetic damage – gone
- local irritation of intestinal tract, increase peristalsis, increase fluid secretion
- Warnings:
- Casual use discouraged
- Overuse/abuse: damages physiologic neurologic colon function – “cathartic colon”
- melanosis coli: benign (stains colon)
- Urine discoloration: senna
- Bisacodyl: enteric coated (uncoated induces gastritis - don’t break, crush, etc,)
Saline Laxative
- Phillips Milk of Magnesia
- Fleet Phospho-Soda
- Magnesium Citrate
- High concentration of electrolytes - hypertonic state - osmotic gradient - draws water into colon - increased colonic pressure - stimulates movement
- Single dose or short term use
- Warnings:
- CHF, HTN (Na+)
- Renal Failure (Mg+)
Surfactant Laxatives
- “emoliants”
- Docusate (Colace, Surfak)
- Mild - increase fluid secretion, “wetting” agents; lowers surface tension, allowing water into fecal mass.
- Prevention rather than treatment
- 100 mg =placebo; use 250 mg dosage
Lubricant Laxatives
- Mineral oil
- Oil - lubricates colon, rectum, anal canal allowing easier passage of hard stool.
- Limited utility - one time use
- Warnings: seepage, fat-soluable vitamin malabsorption
- only time to use is impaction
Hyperosmotic Laxatives
- Glycerin
- Short term, episodic use; pediatrics
- Suppositories (Fleet Babylax, Sani-Supp)
- Sorbitol, lactulose
- Polyethylene glycol (PEG) +/- E-lytes
Probiotics
- “Support” for bowel health
- No restrictions on length of use
- Dietary supplement
- May support growth of beneficial microfloral in intestinal tract.
- Bifidus regularis
- Lactobacillus acidophilus
- Bifidobacterium longum
Diarrhea: Definition
- Abnormal frequency or volume of semi-liquid or fluid fecal matter.
- Classification
- Acute vs. Chronic
- Infectious vs. Noninfectious
- Physiologic
- Osmotic (ex: lactose intolerance)
- Secretory (ex: virus, bacterial)
- Exudative (ulcerative colitis)
- Motility Disorder (IBS)
Diarrhea: 3 Types
- Acute
- abrupt; < 2 weeks; abdomnal pain, malaise, flatulence, generally resolves in 3 days; causes dietary, infection, toxicity, drugs
- Chronic
- frequent passage > 4 weeks; tough to diagnose; refer – requires medical evaluation
- Traveler’s Diarrhea
- up to 10/day loose stools, w/nausea, abdominal cramps, +/- vomiting, fever; cause generally bacteria
- up to 10/day loose stools, w/nausea, abdominal cramps, +/- vomiting, fever; cause generally bacteria
Diarrhea: Refer
- Temperature > 101
- Nighttime diarrhea
- Bloody diarrhea
- Severe abdominal cramps
- Symptoms of dehydration
- Failure to subside within 3-5 days
- Pediatrics, elderly, pregnant
Diarrhea: Treatment
- Goals
- Identify and treat cause
- Prevent fluid/electrolyte loss
- Relieve symptoms
- Nondrug
- Clear liquids, then BRAT, slowly add milk/dairy
- Pharmacotherapy
- Bulk forming agents (polycarbophil); Adsorbants
- Loperamide
- Antibiotics
- C. dificil
- ORS (oral rehydration solutions)
- has more salt/sugar/bicarb than Gatorade
- Old/young: Gatorade with pretzels and bannanas
- Diet (BRAT, dairy)
- Digestive enzymes (lactase, prevention)
- Probiotics
Diarrhea: Adsorbents/Protectants
- Attapulgite and Kaolin-pectin
- Questionable efficacy – thus, GONE!
- Bismuth Subsalicylate
- Antisecretory, adsorbent, antimicrobial, antiinflammatory
- Prevention of TD
- 60 mL (4 tab) every hour times 8, or until diarrhea done
- Radiopaque
- Salicylate
- Aspirin allergy, kids
Diarrhea: Loperamide (Imodium)
- Slows intestinal motility; inhibits peristalsis; tolerance doesn’t develop
- Don’t use in presence of bloody diarrhea, body temperature > 101; with organisms that penetrate the intestinal wall (enteroinvasive E. coli, Salmonella, Shigella, pseudomembranous colitis)
- Okay if know that bug cannot get out of tube
Diarrhea: Polycarbophil, ORS
- Polycarbophil (Konsyl Fiber)
- Good for diarrhea due to IBS
- ORS
- Pedialyte, Gatorade + pretzels, crackers
- Especially important for sick, pediatrics, elderly
Gas: Etiology
- Normal
- –average – 10 passages/day
- –500-1500 mL/day)
- Affected by…
- Malabsorption (e.g., lactose intolerance)
- Gastric motility (e.g., IBS)
- Dietary composition (lactose, legumes)
- Drugs (antibiotics, acarbose)
- Changes in colonic pH
- Gas formed by
- Action of colonic bacteria on CHO’s
- hydrogen sulfide
- Anaerobic fermentation
- hydrogen
- carbon dioxide
- methane
- Swallowed
- Nitrogen
- oxygen
- Action of colonic bacteria on CHO’s
Gas: Signs/Symptoms
- “too much gas”
- Abdominal cramping
- Belching
- Bloating
- Discomfort
- Audible bowel sounds
Gas: Assesment
- more than 25 passages per day
- Diet (legumes, starch, prunes, milk, cheese)
- Meds (antibiotics, opiates, CCB’s, acarbose)
- Surgical history (abdominal surgery)
- Medical history (PUD, GERD, IBS)
- Systemic disease (DM, hypothyroid)
Gas: Treatment, Dietary
- Decrease sodas
- Avoid whipped cream, milk shakes
- Stop frequent sighing
- Relax, Slow down
- Chew thoroughly
- Avoid washing solids down with liquid
- Stop smoking
- Stop gum chewing
- Smaller meals
*
Gas: Drug Treatment
- Charcoal (Charcoal Plus DS)*
- Simethicone (Mylicon, Gas-X)*
- Lactase (Lactaid, Dairy Ease)@
- a - glactosidase (Beano)@
- Probiotics@
Key: @ is a preventer, * is a reliever
* relievers not very effective UNLESS lactose intolerant or alpha-glactosidase deficient
Hemorrhoid: Definition
- varicose condition of hemorrhoidal veins.
- pregnancy, straining at stool, constipation, prolonged sitting or standing, anal infection
- Internal vs. external
- above or below dentate line
- above: no nerves, not feel
Hemorrhoid: Symptoms
- Anal pain
- Bleeding, anemia
- Itching
- Burning
- Incontinence
- Rectal protrusion, prolapse
- Fissure, ulceration, infection
Hemorrhoid: Treatment
- Nondrug:
- Alterations in diet
- Avoidance of prolonged sitting
- Sitz bath
- Anal hygeine
- Drugs:
- Limited benefit, lots of witch craft
- Stool softeners, psyllium
- Topical anorectal preps
- Astringents, counterirritants, emollients, protectants, keratolytics, local anesthetics, wound-healing agents, vasoconstrictors, corticosteroids
Hemorrhoid: Anorectal Preps
- Astsringents (Hamamelis water i.e., witch hazel)
- good for cleaning
- Counterirritants (camphor)
- -_-
-
Emollients/protectants (mineral oil, petrolatum, zinc oxide)
- helpful <3
- Keratolytics (resourcinol)
- NO
- Local anesthetics (benzocaine, pramoxine)
- NOOOO!!!
- Wound healing (balsam Peru)
- witchcraftery
- Vasoconstrictors (ephedrine, phenylephrine)
- witchcraftery
-
Antiinflammatory - hydrocortisone
- beat the itch
- best is HC ointment
Hemorrhoid: Rx
- Hydrocortisone 1% ointment
- Two most rationale drug classes (protectant/emollient and steroid)
- Avoids other witchcraft
- Cheaper than Anusol HC or Prep H
- Caution: HPA axis
- Go to the derm aisle
Pinworms: Pathophysiology
- eggs from perianal area
- bedding/clothing
- new host’s hands
- mouth/swallowed
- eggs hatch
- larvae in small intestine
- mature female migrates to perianal area
- deposits eggs
- itch, irritation
- reinfestation
Pinworms: Symptoms
- asymptomatic
- itching
- abdominal pain
- weight loss
- appendicitis
- dermatitis
- Tape test
Pinworms: Rx
- Reverse tape on popsicle stick, squeeze cheeks, see eggs on slide
- Personal hygiene
- Launder bed clothes, bedding, etc.
- Need to identify worm, because could be hookworm
-
Pyrantel pamoate (Antiminth, Reese’s Pinworm) Pinworms only
- liquid by weight
- Mebendazole (Vermox) Pinworms and other helminths; easy dosing; tablet, off the market now