66: Constipation Flashcards by Brooke Thornburg

Constipation

-dec freq
-disorder of motility and rectal function
-cramping, bloating
-hard dry stools
-straining, blockage

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Gi transit time

-mouth to anus
-30-40 hours
-upto 72 hours can still be normal tho

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movement of water in and out of stool

-more time for colon to absorb water from waste
-results in stool becoming hard and difficult to push out

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Acute constipation

-noticeable change in normal bowel movement pattern
-less than 3/week
-dry, hard stools
-painful movements
-hard to pass stool
-brought on by change in condition or drug

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Chronic constipation

-more than 6 weeks
-may respond to lax but it comes back
-does not respond to diet

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Common causes of chronic constipation

-dietary (poor fluid/calorie intake)
-failure to heed defecation reflex
-impaired physical mobility
-lack of privacy
-inc distress

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Disease states that slow GI motility

-diabetes
-parkinsons
-CNS probs
-MS

-constipation

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Common drug causes of constipation

-opioids
-NSAIDs
-Antacids
-strong anticholinergics
-iron
-vearpamil, clonidine, Ca channel blockers
-diuretics
-chronic use of stimulant lax

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Refer constipated pt if

-symptoms >2weeks
-black/tarry stool
-ab bain or discomfort
-fever
-severe N/V
-family history of IBD or colon cancer
-drastic change in symptoms

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Measures to promote bowel movements

-ample fluids and fiber (add slowly)
-6-8 glasses of water per day
-prunes, kiwi, psyllium
-do not ignore urge to defecate
-poop first thing in the AM and within 30 min after meals

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Dietary fiber

-add slowly over 7-10days to minimize gas
-20-30g/day
-veggies, fruits, beans, whole grains

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Prunes

-sorbitol
-12g fiber
-dihydrophenylsatin (natural lax)

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Bulk lax products

-psyllium (Metamucil)
-Methylcellulose (citrucel)
-Calcium polycarbophil (Fibercon)

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Bulk lax moa

-forms emmolient gels that retain water
-swells and stimulates BM

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Bulk lax pros

-soften stool better than DOCUSATE
-few side effects

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bulk lax disadvantages

-taste
-must drink enough fluids
-gas
-impact on drug absorption
-not ideal if beddridden

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Bulk lax admin

-mix citrucel w at least 8 oz cold water
-drink immediately
-produce less gas

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Surfactant / Emoillient product

-Docusate (DOSS) 100mg qd or bid

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Docusate

-surfactant/emmolient lax
-100mg qd or bid
-helps prevent hard stools (hemorrhoids)
-NOT effective for active constipation

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Lubricant product for constipation

-Mineral Oil

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Mineral oil

-lubricant for constipation
-30-60mL qd
-lubricates lumen and softens stool

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mineral oil disadvantages

-oily
-only effective in PREVENTION of constipation
-may dec absorption of fat-soluble vitamins

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Saline laxative products

-MOM
-Mg Citrate
-Saline Enema (rapid onset)

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Saline laxatives moa

-draws fluid into colon which inc motility
-quick onset (good for acute)
-most economical

avoid saline laxatives in

renal patients (Na Mg)

Hyperosmotic agents for constipation

-Sorbitol 30-60mL/qd -Lactulose 30-60mL/gd -PEG 17g in H2O qd -Glycerin suppositories (quick onset)

Hyperosmotic agents MOA

-draws fluid into colon due to high concentration of sugar, PEG, or glycerin -softens stool while stimulating BM -great for chronic

Hyperosmotic agents cons

-1-3 day onset -sweet taste -minor nausea, cramping

PEG (miralax)

-hyperosmotic for constipation -17g PO qd -mix w 4-8oz liquid -onset in 1-3 days -well tolerates

Stimulant lax products

-Senna 2 tabs qd or bid -bisacodyl (enteric coated) 1-2 tab qd

Stimulant lax MOA

-locally stimulates enteric nerves =contraction and mobility =inc fluid and Na secretion into lumen

Stimulant lax pros

-6-12 h onset -works in pt w motility disorders -DOC for OIC

stimulant lax cons

-risk of nausea and cramping -avoid long-term use in pts w normal GI motility

Bisacodyl suppositories

-stimulant lax -10mg PR -quick onset

Newer lax

-Lubiprostone -Linaclotide -Plecanatide -Lactitol

Lubiprostone

-24mcg BID wf + water -activates chloride channels -N/D, HA -$$$

Linaclotide

-145mcg qd 30 min before first meal -inc chloride and bicarbonate secretions -diarrhea -$$$

Plecanatide

-3mg qd -inc chloride and bicarbonate secretions -diarrhea -$$$

Lactitol

-20g qd -osmotic -do NOT admin w other meds

Chloride channels

-allow water to pass into lumen

Options to relieve acute constipation within 1 hour

-Enema -Bisacodyl or Glycerin suppository -fleets is RAPID

Options to relieve acute constipation within 3-6 hours

-citrate of magnesia -larger doses of PEG -also used for GI prep

Options to relieve acute constipation within 24 hours

-bisacodyl or Senna tablets (stimulant)

Options to relieve acute constipation within 48 hours

-Milk of Magnesia -PEG -hyperosmotic

Chronic constipation step therapy

1. relieve acute (dietary mods) 2. Bulk lax and fluids 3. PEG, lactulose or sorbitol 4. Short-term stimulant then maintence agent 5. Lubiprostone, linaclotide, prucalopride, plecanatide (CIO)

Follow up constipation

-1-2 days for acute -1-2 weeks chronic -stool freq -episodes of diarrhea -deitary changes -any SE from meds

Tx of constipation in spinal cord injury

-routine use of bowel stimulants -usually suppositories

Tx of constipation in pregnancy

-diet, fiber, docusate -senna in more severe cases

Tx of constipation in diabetics

-prokinetic agents (metoclopramide, prucalopride) -stimulants

Tx of constipation in pts on opioids

-stimulants -then add docusate, lactulose, or PEG prn -AVOID bulk lax -opioid antagonists if those dont work

Opioid antagonists for constipation in pt on opioids

-Methylnaltrexone -Naloxegol

Methylnaltrexone (Relistor)

-mu opioid antagonist -dose based on weight -8-12mg SC every other day -BM within 30 min -$$$

Naloxegol (Movantik)

-opioid receptor antagonist -25mg PO qd, half if CrCl <60ml/min -1 hr prior to 1st meal or 2 hrs after meal (empty tummy, high-fat meal increases rate and extent of aabsorption) -tablet can be crushed -$$$

Preps for GI procedures

-hyperosmotics -saline lax -clear liquid diet -drink lots of fluids -day before

Oral prep agents

-PEG -SAS prep -OsmoPrep, Visicol -Suprep -Suclear -Prepopik

PEG for GI procedure prep

-Nulytely, Golytely, HalfLytely, Colyte -2-4L -8 oz q10min -fridge -add crystal lite for flava

SAS Prep

-day before procedure -clear liquids all day -1 bottle miralax into 2 bottles gatorade -fridge 0drink extra 8 oz clear fluid every hour -4 5mg bisacodyl at noon -at 2pm drink miralax 8oz every 10-20min over 1 hour -wait 30 min then drink second bottle at same rate

Other commercial prep agents

-not used bc risk of CVD, renal and electrolyte abnormalities -osmoprep, suprep, suclear, prepopik