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Pharmacy 301 > 301 Diarrhoea & Constipation > Flashcards

301 Diarrhoea & Constipation Flashcards

1
Q

What is constipation?

A

Small, infrequent and difficult passage of stools

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2
Q

How many times a week is constipation classified as? And what types on the Bristol scale?

A

<2-3 per week
Type 1 or 2

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3
Q

Possible causes of constipation

A
  1. Diet and lifestyle (fibre, fluid, food intake, exercise)
  2. Improper bowel habits - not responding to gastrocolic reflex - urger to defaecate
  3. Physiological changes (pregnancy, old age)
  4. Medication
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4
Q

What medication commonly causes constipation?

A
  1. Supplements - iron, calcium
  2. Opioid analgesics (codeine, morphine)
  3. Antitussives (pholcodine, codeine)
  4. Verapamil
  5. Antidiarrhoeal drugs (imprudent use)
  6. Aluminium (in antacids)
  7. Anticholinergics
  8. Drugs with intrinsic anticholinergic effects (TCAs, phenothiazines, sedating antihistamines)
  9. Diuretics (if dehydration occurs)
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5
Q

Concurrent disorders that can cause constipation: endocrine disorders

A

Hypothyroidism, diabetes, chronic kidney disease

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6
Q

Concurrent disorders that can cause constipation: neurological conditions

A

Parkinson’s disease, spinal cord injury, stroke or multiple sclerosis

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7
Q

Concurrent disorders that can cause constipation: recent surgery

A

Scar tissue (adhesions) from past surgery can compress, squeeze or narrow intestine & rectum causing constipation

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8
Q

Concurrent disorders that can cause constipation: pregnancy

A

Hormonal changes or enlarged uterus pushes on intestine

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9
Q

Concurrent disorders that can cause constipation: other

A

Diverticulitis (bowel condition causing abdominal pain)
Bowel cancer

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10
Q

Counselling points with constipation in the elderly

A

NOT due to reduced bowel motility/tone
May be due to lifestyle changes & chronic illness
Most have normal frequency but strain at stool
May reflect dehydration state
Bowel cancer risk increases 50+
May use laxatives to treat & prevent

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11
Q

How do we assess constipation symptoms?

A

Assess symptoms, onset, frequency, accompanying symptoms & duration (acute or chronic)

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12
Q

What criteria should be present in constipation diagnosis?

A

2 criteria:
1. Change in bowel frequency for patient
2. Hard stools passed, often with difficulty & straining

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13
Q

What are accompanying symptoms of constipation?

A

Abdominal discomfort or bloating, nausea, blood or mucus in stool (refer!)

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14
Q

Acute vs chronic diarrhoea

A

A: >4 days
C: >3 months

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15
Q

When to refer constipation

A
  1. Blood/mucus in stools (tarry, red/black)
  2. Persistent abdominal pain, pain on defecation
  3. Unintentional weight loss (50+)
  4. Sudden unexplained bowel habit changes lasting 2+ weeks
  5. Constipation >1 week after laxative use or 2 weeks of dietary intervention
  6. Suspected laxative misuse
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16
Q

Lifestyle management of constipation

A
  1. Increase dietary intake of fibre (fruit and veg, wholegrains)
  2. Increase fluid intake
  3. Reduce refined carbs intake
  4. Regular exercise
  5. Respond to urge to defecate - gastro-colic reflex greatest after meals
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17
Q

Types of pharmacological management of constipation

A
  1. Bulk-forming laxatives
  2. Stimulant laxatives
  3. Osmotic laxatives
  4. Stool softeners
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18
Q

Types of laxatives with examples: bulk-forming

A

Soluble fiber forms bulkier stools, stimulating colon to contract push stool out (fybogel, methylcellulose)

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19
Q

Types of laxatives with examples: stimulant

A

Activate nerves control muscles in colon (Bisacodyl, Senna)

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20
Q

Types of laxatives with examples: osmotic

A

Pulls water from body parts into colon, to softens stool so it is easier to pass, they contain salt that holds water in colon (lactulose, magnesium hydroxide solution Dulcolax)

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21
Q

Types of laxatives with examples: stool softeners

A

Increase water and fat in stool to soften it (Docusate)

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22
Q

How do bulk-forming laxatives act?
How long for maximal effect?
Safe in pregnancy?
Useful when?
1st choice in what?
Options?

A
  1. Increase stool mass, traps water in stool, larger stool stimulates peristalsis & bowel movement
  2. Take several days for maximum effect
  3. Yes
  4. Prophylaxis & treatment in young & elderly
  5. Chronic constipation but requires adequate fluid intake & mobility (especially elderly)
  6. Ispaghula husk (fybogel), sterculia
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23
Q

Side effects of bulk-forming laxatives

A

Flatulence
Bloating
Abdominal discomfort

24
Q

Precautions with bulk-forming laxatives

A

In moderate-severe renal impairment consider K+ content and fluid volume required
May not be acceptable

25
Q

How do stimulant laxatives act?
Onset time?
Used in combo with bulk-forming when?
Can be used long term for?

A
  1. Stimulate nerve endings in plexus of bowel wall, increased peristalsis
  2. Oral 6-12 hours and rectal 15-60 mins
  3. Used when bulk-forming or osmotic laxatives are ineffective or inappropriate
  4. IBS & diverticulitis under medical supervision
  5. Spinal damage, prevention of opioid-induced constipation
26
Q

Side effects of stimulant laxatives (includes Senna)

A

Abdominal discomfort, cramps, nausea
Fluid & electrolyte imbalance (prolonged/excessive doses)
Senna may cause red-brown discolouration of urine

27
Q

Precautions of stimulant laxatives

A

Short term use preferred - risk of dehydration if diarrhoea occurs
Pregnancy - Senna used in pregnancy but best avoided or used occasionally - care in late weeks

28
Q

How do osmotic laxatives act?
Types?
Onset time?
Used for?

A
  1. Retain fluid within bowel (osmotic effect) to stimulate peristalsis & formation of soft stool
  2. Saline or non-saline
  3. 2-4 days for effect
  4. Chronic constipation
29
Q

Types of non-saline osmotic laxatives

A
  1. Sorbitol (Sorbilax liquid)
  2. Lactulose (Actilax, Duphalac or Lac-dol syrup)
  3. Macrogol (PEG) (Osmolax oral powder)
30
Q

Types of saline osmotic laxatives

A
  1. Magnesium sulphate (Epsom salts oral)
  2. Sodium phosphate (Fleet ready-to-use enema)
  3. Sodium citrate/sorbitol (Microlax small volume enema (stimulant + osmotic))
  4. Sodium picosulphate/Mg (Picolax, Picoprep, stimulant + osmotic oral)
31
Q

What are osmotic laxatives with electrolytes?
Why are they used?
Examples

A
  1. Contain macrogol (PEG) + electrolytes
  2. Reduced risk of electrolyte problems
  3. Colonlytely, Glycoprep, Movicol
32
Q

What are larger doses of osmotic laxatives used for?

A
  1. Severe constipation
  2. Bowel prep prior to colonoscopy
  3. Faecal impaction
33
Q

Side effects of osmotic laxatives

A

Rectal irritation, nausea, bloating
Cramps, fluid + electrolyte imbalance (reduced K+) - especially saline laxatives

34
Q

Precautions with saline osmotic laxatives and why and when not to use

A
  1. (Especially sodium phosphate) - elderly, renal impairment, CV disease
  2. Increased risk of fluid/electrolyte problems - renal failure
  3. Intestinal obstruction, acute abdominal conditions (appendicitis), inflammatory bowel conditions
35
Q

What are glycerol osmotic laxatives?
Used as?
Used for?
Onset time

A
  1. (Glycerin - glycerol suppositories), osmotic + lubricant + local stimulant
  2. Suppositories only - adult, child, infant
  3. Acute constipation when stools are present in lower rectum
  4. 1-2hrs for effect
36
Q

What are stool softeners?
Onset time?
Useful when?
Valuable for?
Used in combo with?

A
  1. Lubricating or detergent action
  2. 1-3 days
  3. Patients with haemorrhoids, anal fissure, prevention of post-op straining
  4. Elderly & for opioid-induced constipation
  5. Other laxatives (coloxyl with senna)
37
Q

Examples of stool softeners

A
  1. Docusate coloxyl tabs, supp, enema
  2. Poloxamer coloxyl drops for young children
  3. Liquid paraffin agarol
  4. Parachoc oral liquid
    (1 & 2 have detergent action, 3 as a lubricant (aspiration risk))
38
Q

What is detergent action in stool softeners?

A

Reduce surface tension of hard faeces - allows water to penetrate

39
Q

Indications of suppositories/enemas
Onset time?
Used when?
Avoid when?
Types of enema?

A
  1. When oral laxatives are not effective
  2. For rapid relief (faeces in lower rectum) - onset of actions 30mins to 3hrs
  3. For occasional use only
  4. Avoid in patients with haemorrhoids or anal fissure
    2 types of enemas: small and large volume enemas
40
Q

How to use a small volume enema?

A
  1. Remove seal
  2. Squeeze tube slightly until a drop of liquid smears the tip of the enema (for easier insertion)
  3. Insert tube fully into rectum (half-length in children under 3 yrs)
  4. Squeeze shoulder of tube until empty
  5. Keeping tube squeezed tightly, withdraw nozzle
41
Q

How to use suppositories

A
  1. Wash hands
  2. Lie on one side with your knees pulled up towards the chest
  3. Gently push suppository, pointed end first, into your back passage with your finger
  4. Push the suppository in as far as possible
  5. Lower your legs, roll over onto your stomach & remain still for a few minutes
  6. If you feel your body trying to expel the suppository, try to resist this
  7. Lie still & press your buttocks together
  8. Wash your hands
42
Q

What is diarrhoea?

A

An increase in frequency of passage of soft or watery stools relative to persons usual bowel habit
Not a disease - symptom of underlying condition
Infection or GI disorder

43
Q

What are the diarrhoea classes?

A
  1. Acute <7 days
  2. Persistent >14 days
  3. Chronic >1 month
44
Q

Clinical features of diarrhoea

A
  1. N + V may be present prior to bout of acute diarrhoea
  2. Cramping, flatulence & tenderness may present
  3. Acute infective diarrhoea often watery in nature with no blood present
  4. Often resolved after 2-4 days
45
Q

Possible causes of diarrhoea: in community pharmacy

A
  1. Viral and bacterial (most likely)
  2. Medication (likely)
  3. IBS, giardiasis, faecal impaction (less likely)
  4. UC & Crohn’s disease, colorectal cancer, malabsorption syndromes (least likely)
46
Q

Possible causes of diarrhoea: medications

A
  1. Alpha blockers
  2. ACEIs
  3. Antacids (Mg salts)
  4. Antibiotics
  5. Metformin, acarbose
  6. SSRIs and SNRIs
  7. Beta blockers
  8. Dopaminergics
  9. NSAIDs
  10. PPIs
47
Q

Conditions to rule out in diarrhoea

A
  1. Medicine-induced diarrhoea
  2. IBS
  3. Giardiasis
  4. Faecal impaction
  5. UC & Crohn’s disease
48
Q

Questions to ask with diarrhoea symptoms

A

How frequent are bowel motions?
How severe is diarrhoea i.e. how loose are the stools? - loose or watery?
Colour of stool?

49
Q

Questions to ask about onset and duration of diarrhoea

A

How long have they had symptoms?
Was it related to anything ingested? (check last few days)
Any recent dietary changes?
Recent overseas travel?

50
Q

Factors to consider with diarrhoea

A
  1. Age: caution - children & elderly
  2. Any signs of dehydration? - dry mucous membranes, thirst, sunken eyes, decreased urine output, loss of skin elasticity
51
Q

Management options in diarrhoea: oral rehydration (ORS)

A
  1. (Glucose 75mmol/L, Na 75mmol/L, K 20mmol/L, Chloride 65mmol/L & citrate 10mmol/L)
  2. Can be given to all patients groups
  3. Replace the fluid that is lost, especially important in young children & elderly
  4. Small amounts (50mls) best sipped every 5-10 mins
  5. Dose: Infants (50-100ml per kg for 1st 4 hours then by 5-7ml/kg per hour), Adults (2L in the 1st 24 hours then unrestricted normal fluids & 200-400ml ORS per loose stool or vomit)
52
Q

Management options in diarrhoea: rice-based ORS

A

Often used in some developing countries where glucose may not be available
Diabetics

53
Q

Management options in diarrhoea: loperamide

A
  1. Synthetic opioid analogue - exerts action via opioid receptors, slows GI tract time & increases capacity of gut
  2. 2 caps followed by 1 cap after each diarrhoeal bout, max dose 16mg (8 caps) per day
  3. Well tolerated but cramps, N + V, tiredness, dry mouth reported
54
Q

Management options in diarrhoea: diphenoxylate

A
  1. Similar action to loperamide, however side effects are more common (drowsiness etc.)
  2. 2 tabs (5mg) four times a day, max 20mg (8 tabs) per day
55
Q

Management options in diarrhoea: others

A
  1. Adsorbants (kaolin and pectin)
  2. Codeine

Pharmacy 301 (23 decks)

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