Constipation Flashcards
Constipation is defaecation that is unsatisfactory because of _____________ stools, difficult ________________, or seemingly ______________ defaecation
Infrequent
stool passage
incomplete
Constipation can occur at any age and is commonly seen in _____________, the _____________, and during ______________.
women
elderly
pregnancy
It is important for those who complain of constipation to understand that bowel habit can vary considerably in frequency without ______________
doing harm
*Some people erroneously consider themselves constipated if they do not have a bowel movement each day.
What are the red flags of constipation? (6)
- New onset
- Age > 50 years
- Accompanying anaemia or…
- Abdominal pain
- Weight loss
- Overt or occult blood in the stool
*these should provoke urgent investigation because of the risk of malignancy or other serious bowel disorders
In those patients with secondary constipation caused by a drug, the drug should be ___________.
reviewed
What is the lifestyle advice given to patients with constipation? (3)
Increase dietary fiber (gradually to minimize flatulence and bloating)
Adequate fluid intake
Exercise
If fiber is increased rapidly, it may lead to what symptoms? (2)
Flatulence
Bloating
The effects of a high-fibre diet may be seen in ___________ although it can take as long as ____________
a few days
4 weeks
Fruits high in ___________ and ___________, and fruit juices high in ___________, can help prevent and treat constipation
fibre
sorbitol
sorbitol
Misconceptions about bowel habits have led to excessive laxative use. Laxative abuse may lead to ______________
hypokalaemia
Before prescribing laxatives it is important to be sure that ____________________ and that __________________.
the patient is constipated
the constipation is not secondary to an underlying undiagnosed complaint
What are the different types of laxatives? (4)
- Bulk-forming
- Stimulant
- Stool softeners
- Osmotic
Bulk forming laxatives include…? (3)
- Ispaghula husk
- Methylcellulose (also acts as a stool softener)
- Sterculia
What must be maintained when taking laxatives to prevent bowel obstruction?
Adequate fluid intake
Bulk-forming laxatives are ideal in which patients?
Adults with small hard stools if fiber cannot be increased in the diet
Onset of action of bulk-forming laxatives is up to _____________
72 hours
_____________, ____________, and _____________ may be exacerbated by bulk-forming laxatives
Flatulence
Bloating
Cramping
Which drugs are offered as stimulant laxatives? (5)
- Bisacodyl
- Sodium pico sulfate
- Anthraquinones (senna, co-danthramer, co-danthrusate)
- Docusate sodium (stimulant and stool softener)\
- Glycerol suppositories (also softening effects)
What is the mechanism of action of stimulant laxatives?
Increase intestinal motility
What is the major side effect of stimulant laxatives?
Abdominal cramping
Stimulant laxatives should be avoided in cases of _________________
Intestinal obstruction
The use of co-danthramer and co-danthrusate is limited to constipation in ______________ patients because of potential carcinogenicity (based on animal studies) and evidence of genotoxicity.
terminally ill
The use of co-danthramer and co-danthrusate is limited to constipation in terminally ill patients because of potential _______________ (based on animal studies) and evidence of _____________.
carcinogenicity
genotoxicity
Docusate sodium is believed to act as both a ____________ laxative and as a ______________
stimulant
faecal softener
Glycerol suppositories act as a ___________ and as a rectal _______________ by virtue of the mildly irritant action of glycerol.
lubricant
stimulant
______________ suppositories act as a lubricant and as a rectal stimulant by virtue of the mildly irritant action of ______________.
Glycerol
glycerol
What is the mechanism of action of stool softeners?
Decrease surface tension and increase penetration of intestinal fluid into the fecal mass
Faecal softeners are claimed to act by decreasing ________________ and increasing ______________ into the faecal mass.
surface tension
penetration of intestinal fluid
What are the different stool softeners? (4)
- Docusate sodium (also stimulant)
- Glycerol suppositories (also stimulant)
- Arachis oil enemas
- Liquid paraffin
Why is liquid paraffin used with caution as a stool softener?
Because of its adverse effects, which include:
- anal seepage
- risks of granulomatous disease of the gastro-intestinal tract
- lipoid pneumonia on aspiration
What is the mechanism of action of osmotic laxatives?
Increase water content of large bowel either by drawing fluid from the body into the bowel OR by retaining the water they were administered with
What are the different osmotic laxatives? (2)
- Lactulose
2. Macrogols (inert polymers of ethylene glycol)
Lactulose is a semi-synthetic disaccharide which is not absorbed from the gastro-intestinal tract. It produces an ______________ diarrhoea of ________ faecal pH, and discourages the proliferation of _______________. It is therefore useful in the treatment of hepatic encephalopathy
osmotic
low
ammonia-producing organisms
Lactulose is a semi-synthetic disaccharide which is not absorbed from the gastro-intestinal tract. It produces an osmotic diarrhoea of low faecal pH, and discourages the proliferation of ammonia-producing organisms. It is therefore useful in the treatment of _______________
hepatic encephalopathy
_________________ are inert polymers of ethylene glycol which sequester fluid in the bowel; giving fluid with them may reduce the dehydrating effect sometimes seen with osmotic laxatives.
Macrogols
Giving ______________ with macrogols may reduce the dehydrating effect sometimes seen with osmotic laxatives.
fluid
Giving fluid with macrogols may reduce the ______________ effect sometimes seen with osmotic laxatives.
dehydrating
______________ is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate to severe irritable bowel syndrome associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain
Linaclotide
________________ is a selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of chronic constipation in adults, when other laxatives have failed to provide an adequate response
Prucalopride
Linaclotide is a guanylate cyclase-C receptor agonist that is licensed for the treatment of moderate to severe ________________ associated with constipation. It increases intestinal fluid secretion and transit, and decreases visceral pain
irritable bowel syndrome
Prucalopride is a selective serotonin 5HT4-receptor agonist with prokinetic properties. It is licensed for the treatment of _____________ in adults, when other laxatives have failed to provide an adequate response
chronic constipation
Bowel cleansing preparations are used before ______________, _______________, or ______________ to ensure the bowel is free of solid contents
colonic surgery
colonoscopy
radiological examination
What are the main bowel cleansing preparations? (4)
- Macrogol (also used as an osmotic laxative)
- Citric acid with magnesium carbonate
- Magnesium citrate with sodium picosulfate
- Sodium acid phosphate with sodium phosphate
Can bowel cleansing treatments be used as treatments for constipation?
No, these are not treatments for constipation
What is the treatment of choice for short-duration constipation not responding to dietary measures?
First line:
- Bulk-forming laxatives, ensuring adequate fluid intake
Second-line:
- add or switch to an osmotic laxative IF stools remain hard
- if stools are soft but difficult to pass or the person complains of inadequate emptying, a stimulant laxative should be added
A patient is complaining of short-duration constipation that is has not responded to lifestyle modification or bulk-forming laxatives. Their stools remain hard and difficult to pass. What medication should be recommended?
Add or switch to an osmotic laxative
A patient is complaining of short-duration constipation that is has not responded to lifestyle modification or bulk-forming laxatives. Their stools are soft but difficult to pass and they have the feeling of inadequate emtying. What medication should be recommended?
Add a stimulant laxative
What is the laxative of choice in patients with opioid-induced constipation?
Osmotic laxative and a stimulant laxative
Eg docusate sodium
Which laxatives should be avoided in opioid-induced constipation?
Bulk-forming laxatives
_______________ is recommended for the treatment of opioid-induced constipation when response to other laxatives is inadequate
Naloxegol
_______________ is also licensed for the treatment of opioid-induced constipation when response to other laxatives is inadequate but should only be used as an adjunct to existing therapy in patients receiving palliative care
Methylnaltrexone bromide
The treatment of faecal impaction depends on the __________________.
In patients with hard stools, a high dose of an oral _________________ may be considered. In those with soft stools, or with hard stools after a few days treatment with a macrogol, an _________________ should be started or added to the previous treatment.
stool consistency
macrogol
oral stimulant laxative
In cases of fecal impaction, if oral laxatives are inadequate, for soft stools consider __________________ and for hard stools ___________________. Alternatively, a __________________ may be tried
Rectal bisacodyl
Rectal glycerol OR glycerol plus bisacodyl
Docusate sodium or sodium citrate enema
If oral and rectal laxatives are insufficient in treating fecal impaction, a _________________ may be necessary
Retention enema (sodium acid phosphate or arachis oil)
In the management of chronic constipation, treatment should be started with a(n) ____________ laxative, whilst ensuring good hydration. If stools remain hard, add or change to a(n) _____________ laxative such as a(n) _____________.
bulk-forming
osmotic
macrogol
*lactulose is an alternative if macrogols are not effective or not tolerated); if the response is inadequate, a stimulant laxative can be added
In the treatment of chronic constipation, the dose of laxative should be adjusted gradually to produce ____________ stools per ________________
one or two soft, formed
day
If at least ___________ laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least ____________, the use of prucalopride (in women only) should be considered.
two
6 months
If at least two laxatives (from different classes) have been tried at the highest tolerated recommended doses for at least 6 months, the use of _______________ (in women only) should be considered.
prucalopride
If treatment with prucalopride is not effective after ______________, the patient should be re-examined and the benefit of continuing treatment reconsidered
4 weeks
What is the mechanism of action of prucalopride?
Promotion of ACh release via activation of 5-HT receptors leading to contraction of colonic longitudinal smooth muscles
When and how should laxatives be withdrawn?
Slowly, when regular bowel movements occur without difficulty
If a combination of laxatives has been used, ___________________; if possible, the _____________ laxative should be reduced first.
reduce and stop one laxative at a time
stimulant
If dietary and lifestyle changes fail to control constipation in pregnancy, _______________ are likely to help women experiencing constipation in pregnancy, and raise no serious concerns about side-effects to the mother or fetus
fibre supplements in the form of bran or wheat
A(n) _______________ laxative is the first choice during pregnancy if fibre supplements fail.
bulk-forming
*An osmotic laxative, such as lactulose, can also be used. Bisacodyl or senna may be suitable if a stimulant effect is necessary but use of senna should be avoided near term or if there is a history of unstable pregnancy
Bisacodyl or senna may be suitable if a stimulant effect is necessary but use of ______________ should be avoided near term or if there is a history of unstable pregnancy
senna
______________ laxatives are more effective than ______________ laxatives but are more likely to cause side-effects (diarrhoea and abdominal discomfort), reducing their acceptability to patients
Stimulant
bulk-forming
A(n) _____________ laxative is the first choice during breast-feeding, if dietary measures fail
bulk-forming
Lactulose or a macrogol may be used if stools remain hard. As an alternative, a short course of a stimulant laxative such as bisacodyl or senna can be considered
Without early diagnosis and treatment of constipation in children, an acute episode of constipation can lead to ______________ and become ___________
anal fissure
chronic
What is the first-line treatment for constipation in children?
Laxatives in combination with dietary modification or behavioral intervention
*dietary modifications alone should NOT be recommended as first-line in children
______________ alone is not recommended as first-line treatment for constipation in children
Diet modification
______________ (which may cause bloating and flatulence and reduces the absorption of micronutrients) is not recommended for treatment of constipation in children
Unprocessed bran
What is the first-line laxative for managing constipation in children without fecal impaction?
Macrogol
Second line:
- add or change to a stimulant
Third line:
- lactulose or another softening agent
In children with chronic constipation, laxatives should be continued _______________ a regular pattern of bowel movements or toilet training is established.
for several weeks after
In children who have been treated for chronic constipation, the dose of laxatives should be tapered gradually, over a period of ___________, according to response. Some children may require laxative therapy for ____________
months
several years
What time of day should laxatives be administered in children?
A time that produces an effect that is likely to fit in with the child’s toilet routine
Treatment of faecal impaction in children may initially increase symptoms of ____________ and ___________
soiling
abdominal pain
In children over 1 year of age with faecal impaction, an oral preparation containing a ___________________ is used to clear faecal mass and to establish and maintain soft well-formed stools, using an escalating dose regimen depending on symptoms and response.
macrogol (such as macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride)
In children with fecal impaction, if disimpaction does not occur after 2 weeks of oral macrogols, a ______________ laxative can be added or if stools are hard, used in combination with an osmotic laxative such as ______________
stimulant
lactulose
Regarding fecal impaction in children, _______________ use of laxatives is essential to maintain well-formed stools and prevent recurrence of faecal impaction; ______________ use may provoke relapses
Long-term regular
intermittent
Macrogol (osmotic laxative) is not licensed for treatment of chronic constipation or prevention of fecal impaction in children under ___________; it is not licensed for treatment of fetal impaction in children under __________
2 yo
5 yo
