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PHAR154 > Constipation > Flashcards

Constipation Flashcards

1
Q

True or false: the poor quality of life that is experienced from constipation is comparable to osteoarthritis and diabetes

A

true

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2
Q

Describe the physiology of the gut.

A

interplay of intestinal smooth muscle
-parasympathetic stimulates motility
-sympathetic inhibits motility
-GI hormones
-serotonin (90% of serotonin is in the gut)
-CNS (ex: emotions)
gastro-colic reflex

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3
Q

What is the gastrocolic reflex?

A

physiological reflex that controls the motility of the lower GI tract following a meal
as a result, the colon has increased motility in response to the stretch of the stomach with the ingestion of food

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4
Q

What is “normal” BM activity?

A

wide range: 2x per week to 3x per day

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5
Q

What is the normal flora of the gut?

A

lactobacillus
bifidobacterium
saccharomyces

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6
Q

Describe fluid recovery in the gut.

A

9L of fluid enters duodenum per day
-2L from diet and 7L from intestinal secretions
approx 8L absorbed by small intestine
large intestines absorbs about 850ml
about 150ml excreted in stool/day

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7
Q

What is the etiology of constipation?

A

not a normal part of aging but aging comes with:
-disease states
-drug causes
-immobility
-fluids (maybe)

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8
Q

True or false: constipation only means passing infrequent stools

A

false
could also mean hard stools or sense of incomplete emptying after a bowel movement

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9
Q

What is a good question to always ask in a constipation counsel?

A

whats normal for you?

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10
Q

What are some complications of constipation?

A

hard stools
anal fissures
rectal bleeding
hemorrhoids

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11
Q

What is the most common pattern of bowel movement?

A

one bowel movement per day
this pattern is seen in less than 50% of people

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12
Q

True or false: in the majority of cases, constipation is harmless

A

true

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13
Q

Is pain a characteristic symptom of constipation?

A

not really
if pain consistently enters the equation, start thinking another cause such as IBS

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14
Q

What should be kept in mind for differential diagnosis when you are doing counsel surrounded around bowel movements?

A

medication-induced constipation
diabetes
colon cancer
IBS
depression

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15
Q

How many days without a bowel movement is concerning for us?

A

3 days or more

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16
Q

What are the red flags for constipation?

A

changes in stool texture
blood in stool
hemorrhoids
weight loss
decreased appetite
nausea and vomiting
frequent pain
narrower stools
unresponsive to treatments

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17
Q

For someone who has been experiencing lingering constipation, what is the time frame at which they should seek an MD?

A

three weeks or more
the context is constipation, not the lack of BM for 3 weeks

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18
Q

What is the answer to how long is too long for constipation?

A

depends on how often they poop in the first place
add more clinical symptoms=refer faster

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19
Q

What is a large bowel obstruction?

A

part or all of the large intestine is blocked
waste cant move through the bowel properly and out of the body

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20
Q

What is the most common cause of a large bowel obstruction?

A

a growth or tumor that blocks the intestine such as cancer

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21
Q

What are the symptoms of large bowel obstruction?

A

cramping and pain
swelling and bloating
unable to pass gas
constipation
vomiting
more than normally seen with simple constipation or IBS-C

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22
Q

How much fiber does a woman need per day? What about men?

A

women: 25g
men: 38g

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23
Q

At what speed should fiber be added to someone’s diet?

A

add it slowly

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24
Q

Which fiber is given credit for better effect on BM?

A

insoluble fiber

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25
Q

True or false: the majority of Canadians consume the recommended amounts of fiber

A

false

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26
Q

What should someone expect as a side effect when they start adding more fiber to their diet? How much should fiber be added when increasing your intake?

A

gas
go slow, increase by up to 5g/day

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27
Q

How much fiber is in the following: granola bars, cashews, apple, bran flakes, bran muffin

A

granola bars: 1g
apple: 3g
cashes (1/4 cup): 1g
bran flakes (3/4 cup): 5g
bran muffin: 4g

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28
Q

What is bowel re-training?

A

re-establishing the gastrocolic reflex
-defecation stimulation post meal
finding the best time for BM
more applicable to the nursing home world

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29
Q

Are prunes a natural laxative?

A

prunes contain sorbitol which has a laxative effect
prunes contain insoluble and soluble fiber
if it worked quickly, it was due to the sorbitol

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30
Q

How many prunes should be given to adults if they are considering it for constipation?

A

prunes: start with 4
prune juice: start with 1/2 cup

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31
Q

What are the agents of choice for prevention of constipation?

A

bulk-forming agents

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32
Q

True or false: bulk-forming agents are insoluble fiber

A

false
soluble fiber

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33
Q

What are the bulk-forming agents?

A

psyllium
polycarbophil
guar gum
wheat dextran
inulin
methylcellulose
bran

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34
Q

What is the MOA of bulk-forming agents?

A

swell in intestinal fluid–>creates gel–>facilitate passage

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35
Q

What are the expectations to provide with bulk-forming agents?

A

usually takes a few days (2-3)
patient preference for taste
needs fluids (240ml water)
not easy to swallow sometimes (not ideal if strong gag reflex)

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36
Q

How should psyllium be taken when first starting?

A

1 serving each day, as you adjust you can increase to 3 servings per day
- >12yrs:one tsp (7g) in 240ml water
- 6-12yrs: 1/2 tsp (3.5g) in 240ml water
- <6yrs: do not use
start with BID

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37
Q

Who shouldnt take the flavoured versions of psyllium?

A

diabetics
the flavoured versions have sugar

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38
Q

True or false: psyllium-induced obstruction is fairly common

A

false
extremely rare

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39
Q

What are the symptoms of psyllium-induced obstruction?

A

pain/cramps/nauseous
can maybe feel a mass
no fecal output
diarrhea (there can be some leakage)

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40
Q

True or false: inulin is more effective than psyllium

A

false
psyllium is more effective

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41
Q

Differentiate between psyllium and inulin.

A

psyllium:
-more effective
-thickens
-OD to TID
-mix with H20
-lowers cholesterol (5%)
inulin:
-much more palatable
-non-thickening
-OD to TID
-can add to fluid or food
-less cholesterol effect

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42
Q

True or false: psyllium capsules are not a good choice as you must take lots of capsules each day (6-8)

A

true

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43
Q

How long should someone use psyllium for?

A

try for a month and then re-assess
can use it forever

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44
Q

What is an example of a stool softener?

A

docusate

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45
Q

How does docusate work?

A

anionic surfactant
=better mixing of aqueous and fatty compounds to soften the fecal mass

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46
Q

In what manner is docusate commonly used?

A

prevention
common on maternity wards and with palliative care
added to other laxatives (for the “gentle touch” marketing)

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47
Q

What does the efficacy of docusate benefit from?

A

efficacy benefits from increase in water

48
Q

How long does it take for docusate to work?

A

1-2 days (up to 3-5 days in some)

49
Q

What is the adult dose of Colace (docusate)?

A

1-2 caps per day
4 caps per day in nursing homes
up to 8 caps in palliative care

50
Q

What is the reputation of docusate?

A

not a strong agent or maybe not even effective at all
probably because of underdosing

51
Q

What is a contraindication of docusate?

A

use with mineral oil

52
Q

What is a lubricant used for constipation?

A

mineral oil

53
Q

How does mineral oil work for constipation?

A

softens fecal matter by “coating it”

54
Q

What are the main problems of mineral oil for constipation?

A

anal seepage
lipid pneumonia (esp when lying down so avoid HS dosing)

55
Q

Does mineral oil decrease the absorption of fat soluble vitamins?

A

no
would have to be taken at the same time as food for this to occur but we eat multiple times a day so its not an issue

56
Q

What should the patients expect with mineral oil for constipation?

A

orally takes about 6-8 hours
mineral oil enema (Fleet) works very quick

57
Q

What are some products that have attempted to make mineral oil taste better?

A

Agarol (agar + MO)
Magnolax (MgOH + MO)
Lanosyl (MO jelly)

58
Q

What is the difference between heavy vs light mineral oil?

A

heavy has less chance of sticking to throat and better at sticking around GIT

59
Q

What are saline (osmotic) laxatives?

A

non-absorbale ions (ex: Mg citrate, MgOH)
remains in the gut–>highly osmotic–>draws water in

60
Q

What are the indications for osmotic laxatives?

A

bowel evac for exams (Citro-Mag, PicoSalex)
bowel evac for acute constipation (Fleet enema)
general use (ex: overnight relief)

61
Q

In which patients should osmotic laxatives be used carefully?

A

patients with congestive heart failure and chronic renal insufficiency

62
Q

How fast do osmotic laxatives work?

A

Philips: overnight treatment
Fleet enema: 2-5 minutes

63
Q

What is the youngest age we are comfortable giving an enema to?

A

2yrs is the youngest for an enema

64
Q

How do glycerin suppositories work?

A

osmotic effect and a local irritant effect
in infants, just the mass can lead to defecation

65
Q

What is the agent of choice for constipation for very young kids?

A

glycerin suppositories

66
Q

How fast do glycerin suppositories work?

A

bowel evac within 30 min

67
Q

True or false: oral lactulose reaches the colon virtually unchanged

A

true

68
Q

How does lactulose work?

A

in the colon–>bacteria–>lactic acid–>osmotic pressure–>increase stool volume

69
Q

What is the dosing for lactulose?

A

15-60ml OD
works in 1-2 days

70
Q

What is the main side of lactulose?

A

gas/bloating

71
Q

Is lactulose safe in diabetics?

A

yes

72
Q

What is the use of PEG 3350?

A

prevention therapy

73
Q

How long does PEG 3350 take to work?

A

a few days

74
Q

What is the dosing of PEG 3350?

A

start with one capful (17g), then titrate q2-3 days by 25% to achieve mushy stool consistency
dissolves completely in fluid

75
Q

How many days should PEG 3350 be used for?

A

label states use <7d unless MD

76
Q

What is the age use for PEG 3350?

A

not for kids <18 unless MD

77
Q

What are all the non-saline osmotic laxatives?

A

glycerin supp
lactulose syrup
PEG 3350

78
Q

What is the MOA of stimulant laxatives?

A

irritant to gut lining

79
Q

What is the onset of action of stimulant laxatives?

A

6-12 hours (overnight)

80
Q

What are the side effects of stimulant laxatives?

A

diarrhea and cramps if too much is given
-an effective dose for one person could see cramps for another
bisacodyl and senna are minimally absorbed

81
Q

What is the name of the historical stimulant laxative?

A

phenolphthalein

82
Q

What is the old thinking regarding stimulant laxative overuse?

A

cathartic colon occurs with chronic use of stimulant laxatives (>3 times per week for at least 1 year)–>atonic colon
when the drug is dc, changes in the colon may partially return to normal because of drug-induced damage to the colon
the new thinking suggests this is not true

83
Q

What is the dosing for senna?

A

8.6mg: 2-4 tabs OD-BID HS
-HS not needed, go for 8am and 7pm
17.2mg: 1-2 tabs OD-BID HS
-same comment as above

84
Q

What is the dosing for bisacodyl?

A

suppository: one supp per day
-onset in 15-60min
tabs: 1-2 tabs daily
-onset: 6-12 hours

85
Q

How should we start the average patient on senna?

A

start around 8mg
make adjustments each night thereafter

86
Q

How is senna used for a patient on T3s?

A

if T3 started late in day–>8mg first night
if T3 started early in day–>16mg first night
can make adjustments each night thereafter

87
Q

True or false: use senna if its been 3 days with no BM when using preventive agents

A

true

88
Q

Does it make sense to use Senokot S as prn use?

A

no
the docusate will just be going along for the ride because its underdosed

89
Q

Why was castor oil put behind the counter?

A

was being used as an abortifacient
could spark contractions and premature labour

90
Q

What are microlax enemas?

A

physical + chemical rx with fecal matter
5ml dose–>evacuation in 5-20 min
nursing home use is common

91
Q

Describe Colyte (PEG).

A

used for pre-colonoscopy
has added electrolytes
drink 240ml q10min–>4L
expect 1 BM within first hour

92
Q

What is lubiprostone used for?

A

management of chronic idiopathic constipation
predominantly IBS associated constipation in women and opioid-induced constipation

93
Q

What is the role of probiotics in constipation?

A

nobody really knows
would be more so for prevention, not acute needs

94
Q

What are the non-pharm measures to try prevent constipation in the elderly?

A

dietary efforts preferred over meds
-bran for prevention, prunes for acute needs
exercise (iffy value esp for seniors)
fluid intake (iffy value)

95
Q

What are the red flags for elderly and constipation?

A

unexplained new onset/worsening
-a new med could be considered an “explained” onset
blood in stools
weight loss, anorexia
fever
nausea and vomiting
family history of colorectal cancer

96
Q

What is normal BM for infants?

A

1 BM per each feed to 1 per week
breast feed ~3 a day
formula ~2 a day

97
Q

What are the common causes of constipation in paeds?

A

starting solid foods
enough fluids
medical causes are rare

98
Q

What is our process for constipation with infants?

A

always have MD referral in mind
rectal stim (Q tip with vaseline)
-1/4 inch and run it around ring of the rectum in a circular motion for up to 5 min
glycerin suppository

99
Q

What are the reasons for constipation in children?

A

too busy to poop
dietary issues
toilet training issues
-stool lifts can help with propulsion
with-holding behaviour
-family conflict, anal fissures, bathrooms in strange places

100
Q

What is the formula for fiber amount for kids?

A

age + 5=g amount

101
Q

True or false: there are many suppositories that are contraindicated in kids

A

false
almost all are fine

102
Q

Which laxative is a great choice for prevention of constipation in kids?

A

PEG 3350
start with 1/2 capful, then titrate

103
Q

What is the main goal with treating constipation in kids?

A

soft stool each day
a child may need to take this medication for a long period of time (often up to 4-6 months)
dont make too many changes based on a single stool

104
Q

How much do we decrease the dose of a laxative if the child is having regular loose stools or diarrhea?

A

25%

105
Q

What percentage of pregnant women experience constipation?

A

~50%

106
Q

If a woman is experiencing constipation during pregnancy and believes that her iron is to blame, is it our call to stop the iron?

A

no

107
Q

Why are laxatives safe in pregnancy?

A

they have minimal systemic absorption
therefore they are not expected to be associated with an increased risk of congenital abnormalities

108
Q

Which laxative is very common in pregnancy?

A

docusate

109
Q

Do MoM, senna, or bisacodyl pose a birth defect concern?

A

no
uterine contraction concern? yes

110
Q

True or false: diabetics would have less constipation than non-diabetics

A

false

111
Q

What is the most common adverse effect with chronic opioid use?

A

opioid-induced constipation
-41 to 90% of users

112
Q

True or false: lowering the dose of an opioid will improve constipation

A

false

113
Q

Does tolerance develop to opioid-induced constipation?

A

no

114
Q

What is a good move for ambulatory patients on T3s?

A

starting senna blindly

115
Q

What are the laxatives recommended for opiate-induced constipation?

A

osmotic laxatives (lactulose, PEG 3350)
stimulants

116
Q

What are some drugs that can induce constipation?

A

opioids
first gen antihistamine
TCA

PHAR154 (18 decks)

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