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Flashcards in PooPoo Deck (25)
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1

Functional Constipation
-Cause
-criteria for irritable bowel syndrome not sufficiently met*

associated with difficult or delayed evacuation, hard stools, abdominal bloating or discomfort

≥ 2 of the following:

-straining during ≥ 25% of defecations
-lumpy or hard stools during ≥ 25% of defecations
-feeling of incomplete evacuation during ≥ 25% of defecations
-feeling of anorectal obstruction or blockage during ≥ 25% of defecations
-manually facilitating defecation during ≥ 25% of defecations
- < 3 unassisted bowel movements/week

2

Slow Transit Constipation
-cause
-treatment

-associated with prolonged time between bowel movements, lack of urge to defecate, abdominal distention, bloating, and discomfort

1st- Hyperosmotic laxatives [miralax, lactulose]
Senna, bisacodyl and other stimulants are SECOND line

3

outlet dysfunction (or defecatory disorder)

associated with excessive straining and feeling of incomplete evacuation due to mechanical causes such as Hirschsprung disease, anal stricture, cancer, prolapse, rectoceles, or pelvic floor dysfunction

4

Secondary Constipation

due to diet, lifestyle, pregnancy, advanced age, medications or underlying medical conditions

5

Constipation Alarm Signs

acute onset (especially in elderly)
fever
nausea and/or vomiting
unintentional weight loss > 10 lbs (4.5 kg)
anemia
hematochezia
melena
positive fecal occult blood test
change in bowel habits
symptoms refractory to conventional therapy (regardless of age)
family history of colon cancer or inflammatory bowel disease

6

emollient (stool softener)

mechanism - decreases surface tension allowing water to enter stool more easily; Facilitate mixing of aqueous and fatty materials in the intestinal tract

agents - dioctyl sodium sulfosuccinate (docusate sodium, Colace) 100 mg orally twice daily, Peri-Colace

usually well tolerated
may be useful in bed bound patients at risk of fecal impaction

*****Used for prevention, NOT treatment.

Commonly prescribed with medications that may cause constipation (chronic opiate use, iron supplementation)

**Safe in pregnancy

7

Bulk Laxative

mechanism - hydrophilic, colonic bacteria produce osmotically potent metabolites

agents - Fibercon 2 tablets orally 1-4 times/day with 8 ounces water after each dose, Citrucel or Metamucil 1 Tablespoon orally 1-3 times/day with 8 ounces water after each dose

usually well-tolerated, may cause flatulence and bloating
contraindicated if partial mechanical obstruction

Administer 240 mL of water with each dose to prevent esophageal / GI obstruction and worsening symptom

**Physical binding of other substances including medications

*Safe in pregnancy

8

saline laxative

mechanism - increase colonic motility via release of cholecystokinin; Osmotic effects to retain fluid in GI tract (hyperosmolar)

agents - milk of magnesia 30 mL/day, magnesium citrate 30 mL/day, Fleet enema 1 enema (118 mL) rectally

-magnesium-containing laxatives risk hypermagnesemia with chronic use in renal insufficiency
-phosphate-containing laxatives risk hypocalcemia with high doses

enemas risk traumatic and toxic damage to rectum

**May be used occasionally to treat constipation in otherwise healthy adult

******ADRs: fluid and electrolyte disturbances: Mg (renal dysfunction) or Na (CHF) accumulation

9

hyperosmolar laxative

mechanism - metabolized by colonic bacteria to hydrogen and organic acids, causing osmotic effect

agents - lactulose 1-2 Tablespoons orally 1-2 times/day; PEG; glycercin; Sorbitol

usually well-tolerated, may cause transient bloating, may alter electrolyte transport and colonic motility

10

stimulant laxative

mechanism - direct stimulation of myenteric plexus of colon; induce fluid and electrolyte secretion or induce peristalsis

agents - castor oil 30-60 mL/day, bisacodyl (Dulcolax) 5-15 mg/day, phenolphthalein 1-2 tablets/day

may affect electrolyte balance, may precipitate hypokalemia, fluid and salt overload, diarrhea; other adverse effects specific to stimulant used
-SHORT TERM

11

PEG

Hyperosmolar

not absorbed and lacks electrolytes, good option for patients with renal or cardiac dysfunction

Safe in pregnancy

12

Lubricant Laxative

Coats stool to allow easy passage / Prevents colonic water absorption

Systemic absorption – can generate immune response

Aspiration – may lead to lipoid pneumonia

Decreases absorption of fat-soluble vitamins
***DO NOT use in pregnancy

13

meds that CAUSE blocked poopie

Opiates
Anticholinergics (eg. tricyclic antidepressant (amitryptiline), diphenhydramine, benztropine, etc)
NDHP-CCB (eg verapamil)
Oral iron preparations
Calcium or aluminum antacids
NSAIDs
Clonidine
Diuretics

14

those who need to avoid straining (eg hemorrhoids, hernia, MI)

Stool softeners or PEG

15

Children Tx for Constipation

1) Diet, fluid exercise
2) Avoid under 6 years without evaluation
3) Glycerin suppository, docusate

16

Diarrhea Treatment (Self vs Not-self)

self treat
---- <3-9% body weight; <5 poopies; minimal s/e
NOT self-treat
---- > 9% body weight loss; +6 poopies; fever, low BP, dizzy, severe abd pain

17

Diarrhea Treatment Goals

Goal of treatment: Identify and Treat primary cause, Manage secondary causes, prevent electrolyte & acid/base disturbances & dehydration , provide symptomatic relief

Note the primary goal is NOT ALWAYS to stop diarrhea (see below, Infectious diarrhea)!

--Non-pharmacological
----- Rehydration , oral preferred
----------Avoid Soda products, Gatorade*, broth, Tea
-----Diet
----------Resume age-appropriate diet once rehydrated
------Secondary causes can include medications. An evaluation of medications an possible substitution of offending medications should be considered (if possible)
----------Magnesium containing antacids, metformin (1/3 of patients), antibiotics (25% incidence), anti-inflammatory / anti-gout agents (eg. colchicine), etc

18

Opiates and derivatives; AKA Antimotility / Antiperistaltic agents

- Acts on peripheral (eg loperamide (Immodium*)) and central (eg diphenoxylate/atropine (Lomotil*)) opioid receptors depending on the agent.
***[ atropine avoided to avoid abuse]
***Those that act on central mu receptors are control substances and prescription only
-Noninfectious diarrhea (acute & chronic)
--Adverse effects: constipation, fatigue, dizziness

19

Adsorbents

APolycarbophil calcium

Works through non-selective adsorption, providing bulk in digestive tract

-Not systemically absorbed

-Binds 60 times its weight in water
---Also used for constipation (absorbs water / fluids)
-Can also bind drugs leading to altered drug bioavailability

20

Antisecretory agents (2)

Bismuth subsalicylate
-for acute diarrhea

Contraindications
-ASA allergy
-Nursing or pregnant women
-GI bleeding
-Immunocompromised patients

Drug interactions
-Decrease protein binding of warfarin
-Decrease absorption of TCN, quinolones

Octreotide
-severe secretory diarrhea assc with chemo, HIV, DM, GI tumor etc.
- SQ or IV 50 mcg TID
S/E: nausea, bloating, gallstones

21

Crofelemer

FDA approved for symptomatic relief of non-infectious diarrhea in patients with HIV/AIDS on anti-retroviral therapy

22

Probiotics (diarrhea)

- Help maintain normal GI flora, reduce colonization of disease-causing bacteria

Evidence - Vary based on intended use (acute treatment, prevention, antibiotic associated, adults, children), strain of bacterium and timing of administration

23

Digestive enzymes

Lactaid

Use in patients with lactase deficiency who are lactose intolerant

24

Clostridium difficile (3)

-cessation of the inciting antibiotic as soon as possible
-NONsevere tx:
---oral metronidazole
--s/e-> dose-dependent peripheral neuropathy; nausea and metallic taste.

------->> oral vancomycin for pregnant, breast feeding,
flagyl allergy

Rifaximin— Small case series have suggested that sequential therapy with vancomycin followed by Rifaximin may be effective for the treatment of recurrent CDI

25

Traveler's diarrhea and tx

Mild / severe

Escherichia coli
--self-limited with symptoms lasting for approximately one to five days

For mild to moderate disease, anti-motility drugs(eg. loperamide) may be used as monotherapy

***Antibiotics are warranted to treat diarrhea in those who develop severe diarrhea, characterized by
*******- more than four unformed stools daily, fever, or blood, pus, or mucus in the stool.
-----In addition, some travelers desire antibiotic treatment for milder disease if the illness is a large burden on a business trip or vacation.

For sever disease, anti-motility drugs(eg. loperamide) may be used cautiously as adjunctive therapy
use in combination with simethicone may provide faster relief of symptoms