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Pharm 154* > Constipation > Flashcards

Constipation Flashcards

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1
Q

What is the effect of constipation to quality of life?

A

If it is everyday, constipation can reduce quality of life similar to having osteoporosis or diabetes

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2
Q

How do the nervous system and hormones impact the GI tract?

A

PNS (stimulate motility)
SNS (inhibit motility)
GI hormones
Serotonin
CNS (emotions)

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3
Q

What is gastro-colic reflex?

A

30 min after a morning meal, humans will naturally excrete feces (this can be suppressed by holding feces in)

Patients can make their gastric-colic reflex stronger

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4
Q

What is the range of normal bowel movements?

A

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

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5
Q

Are regular enemas useful in removing normal poop during good health?

A

No, your body has the mechanisms to take care of it

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6
Q

How much water flows through the duodenum?

A

9L enters the duodenum/day

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7
Q

How much of the water that flows through the duodenum comes from the diet?

A

2L from diet (includes food and water)

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8
Q

How many litres of water that flow through the duodenum come form intestinal secretions?

A

7L

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9
Q

How much water is absorbed by the Gi tract per day?

A

Out of the 9L that enters via the duodenum, 8L are absorbed

From the remaining 1L, 850mL are absorbed by the large intestine

This effectively leaves 150mL of water/day released via feces

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10
Q

Is constipation a normal part of aging?

A

No, constipation is seen in many older adults, but it is not normal

It can be caused by the following reasons:
Disease states
Drug adverse effects
Immobility
Fluid intake (maybe?)

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11
Q

Is there a normal bowel movement schedule?

A

Not really, each person has their own normal

Less than 50% of people have one bowel movement/day. Most people have an irregular schedule (do not have a bowel movement everyday)

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12
Q

What are are some complications of constipation?

A

Hard stools

Anal fissures

Anal tears

Rectal bleeding

Hemorrhoids

Abdominal discomfort and swelling

Abdominal pain

Bloating

Aggravation of hernias

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13
Q

Are most cases of constipation severe?

A

No, but we still have to be cautious

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14
Q

What are some GI conditions pharmacists should know how to differentials diagnose?

A

Anal fissure (seen in kids who hold poop, withholding behaviour)

Medication-induced constipation

Diabetes mellitus (lower nerve control)

Colon cancer

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15
Q

When should we get worried about the last time they had a bowel movement?

A

Longer than 3 or more days without one

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16
Q

What are some red flags that warrant MD referral in constipation?

A

Changes in stool texture

Blood in stool

Hemorrhoids

Weight loss

Decreased appetite

Nausea

Vomiting

Constipation that lingers for three weeks

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17
Q

What is a large bowel obstruction?

A

It occurs when part or all of the large intestine is blocked

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18
Q

What can cause a large bowel obstruction?

A

Large bowel obstruction can occur due to the following reasons:
Growth or tumour that blocks intestine

Twisting of the bowel (volvulus)

A narrowing (stricture) of the bowel, caused by scar tissue from conditions such as diverticulitis and Crohn’s disease

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19
Q

What are the symptoms of a large bowel obstruction?

A

These symptoms are more than what is seen in normal constipation

Belly cramping and pain

Belly swelling and bloating

Unable to pass gas

Unable to pass stool (constipation)

Vomiting

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20
Q

What are some non-pharmacological treatments for constipation?

A

Fluids
Exercise
FIber

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21
Q

When fluid is reccomended, does it mean well hydrated patients should drink even more water?

A

No, maintain normal hydration

Add fluid only if patient is chronically dehydrated

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22
Q

What diet modification can help reduce constipation?

A

Increasing fiber in the diet will improve constipation

Men need 38 g of fiber, women need 25g

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23
Q

Is soluble fiber better for constipation vs. insoluble fiber?

A

No, insoluble fibre is given credit for better impact

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24
Q

What is bowel re-training?

A

This is not done my pharmacists (usually nurses)

They attempt to strengthen the gastric-colic reflex that naturally occurs about 30 min following morning meal

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25
How do prunes/dried plums help with constipation?
If constipation is cleared quickly, attribute it to the sorbital in prunes If constipation took up to 3 days to resolve, give credit to the fibre content of prunes Start with 4 prunes or 1/2 cup juice
26
What are bulk-forming agents?
These are used after patient has tried o introduce fiber into their diet without success They are the DOC for prevention (PEG 3350), not for acute treatment Bulk-forming agents are soluble fibres (ex. Psyllium, Inulin, methyl cellulose, bran)
27
How do bulk-forming agents work?
They swell in intestinal fluids—>creates gel—> facilitate passage Can usually take a few days to see effects
28
How much Metamucil (psyllium) should be started initially?
7g TID, and dose can be adjusted to ideal stool softness Normal hydration is fine, but avoid dehydration
29
What is the incidence of psyllium-induced obstructions?
Very rare, likely due to inappropriate use (Swallowing Metamucil pellets(now discontinued) without water. The pellets got stuck to the tissue due to it pulling water)
30
What are some symptoms associated with psyllium-induced obstruction?
Pain Cramps Nauseous Can feel a mass No fecal output
31
Is psyllium more effective vs. inulin for clearing constipation?
Yes, but inulin is more palatable Psyllium thickens fluid (less palatable)
32
Are psyllium capsules recommended by pharmacists?
No, because the dosing frequency is high, go for powder instead (plus powder is cheaper)
33
What are stool softeners?
Effectively detergents /anionic surfactant (allow oily fecal matter and water to mix) Ex. Docusate
34
How long do stool softers take to clear constipation?
Takes 1-2 days (3-5 days in some patients)
35
What is a contraindications with docusate (stool softener)?
Do not take docusate with mineral oil. The docusate can breakup the mineral oil and it can improve mineral oil absorption = enters the blood
36
What are the different types of docusate (stool softeners)?
The following have equivalent stool softening abilities (equipotent): Docusate Na+: 100mg Docusate Ca2+: 240mg
37
What is the role of lubricants in treating constipation?
Mineral oil is often ingested to soften fecal matter. Physicians do not like this agent Can resolve constipation in about 6-8 hours
38
What are some problems with mineral oil use in constipation?
Anal seepage Lipid pneumonia (drops from mouth can fall into the airways) Possible decrease in absorption of fat soluble vitamins (unlikely)
39
What is the difference between heavy mineral oil and normal mineral oil?
The heavy mineral oil is less likely to stick on the throat. It will stay in the GI tract
40
What is the efficacy of mineral oil enemas?
They work very fast to clear constipation(within 30 min)
41
How do saline (osmotic) agents work in treating constipation?
Contains non-absorbable ions (Mg citrate, MgOH) They remain in the gut, and water is drawn in due to osmostic pressure Usually used as bowel evacuation
42
How much magnesium is needed to experience diarrhea (reverse constipation)?
Above 800mg of Mg has laxative effects
43
What makes milk of magnesia (osmotic) unpopular for constipation treatment?
Very chalky flavour
44
What is the earliest age at which an enema can be given?
2 years old, any patient younger should use a suppository Why does a child under 2 have constipation?
45
What is the effect of Glycerin suppositories?
It has osmotic effect and a local irritant effect Especially useful in very young children Bowel evacuation within 30 min
46
What is the efficacy of lactulose syrup (osmotic)?
Can take 1-2 days to clear constipation Even though it is made from sugar, most of it passes through the GI tract without absorption. Safe for diabetics
47
How is PEG 3350 used for constipation treatment?
It is useful in prevention therapy, and can take a few days to work Start at 17g and titrate up as needed (adjust dose experimentally) Use for 7 days unless MD instructs otherwise Do not use in kids under 18 unless MD instructs otherwise
48
What is the DOC for constipation prevention?
PEG 3350, especially in older adults
49
What are some common stimulants used in constipation treatment?
Bisacodyl and Senna
50
What is the mechanism of action for stimulants in constipation therapy?
They are irritating to gut lining, promote GI motility
51
What are some side effects seen in stimulant use in constipation treatment?
They are minimally absorbed (no systemic symptoms) Can experience diarrhea/cramps
52
What is the reason for the intentional overuse of stimulants in constipation treatment?
Patients with anorexia may use these agents to move food out of their system
53
What are some warnings for stimulant overuse?
Chronic use may produce hypokalemia or dehydration Laxative dependence Chronic constipation
54
Does chronic use of stimulants disrupt normal bowel function after going cold turkey?
No, new evidence suggests this does not happen
55
How should senna be dosed?
Initial dose: 8mg on first night Increase by 1 tab every night until you are using 3 tabs/night If patient still has constipation after 3 days of senna use, probe for cause
56
Can patients use Tylenol #3 (T3) and senna together to prevent opiate-associated constipation?
We can use them together to prevent onset of constipation, treatment is harder and needs higher doses of senna Take 2 tabs/day until they come off T3s
57
Review Slide 76 for agents for constipation treatment
58
What are the most common rescue constipation treatments?
Senna Bisacodyl Milk of Magnesia Likely not mineral oil
59
What are some common prevention agents for constipation?
PEG 3350 Docusate
60
What is Colyte?
It has added electrolytes and it contains PEG 3350 Expect bowel movement within an hour
61
What is the efficacy of probiotics in constipation?
No definitive product that has shown evidence for helping prevent constipation, no role in overnight treatment
62
What are some patient groups of interest when it comes to constipation?
Ambulatory elderly Paediatrics Pregnancy Palliative Care
63
Who is an ambulatory elderly patient?
They usually have multiple disease states/medications If the are old, they may also have a suppressed bowel reflex
64
What do pharmacists recommend to elderly patients for constipation?
Dietary measures (increase fiber) Water’s value is iffy PEG 3350 (Patient needs education on adjusting doses. The side effects for laxatives are overblown)
65
What are some natural options for elderly patients with constipation?
Prevention (increase fiber) Acute relief (prune or dried plums)
66
What are the most common constipation therapies used in the elderly?
Any of the following can be used together as long as their respective dosing instructions are followed Prevention: Bulk-forming agents Docusate PEG 3350 Acute relief: Senna
67
Review slide 95 for a treatment algorithm for constipation treatment in the elderly
68
When should pharmacists be worried about elderly patients with constipation?
Unexplained new onset/worsening Blood in stools Weight loss, anorexia Fever Nausea and vomiting Family history of colorectal cancer
69
What is a normal bowel movement schedule for infants?
1 bowel movement per each feed to once per week Bowel movement rate usually picks up after starting solid foods and start getting enough fluids
70
How to tell if a baby is constipated?
The baby is likely to be constipated if the baby cries
71
What are some paediatric (infants) treatments for constipation?
Always have MD referral in mind (less likely to recommend a product) Rectal stimulation via applying Vaseline on anus with q-tip Glycerin suppository
72
What causes constipation in toddlers?
Too busy to poop (leads to withholding behaviour due to large and hard poop) Dietary issues Toilet training issues (placed legs on a stool, will help feces leave the body)
73
Can any of the adult constipation products be used in paediatrics?
Yes, none of them are contraindicated in paediatrics
74
What is the dosing for PEG 3350 in paediatrics?
Start with 1/2 capful and titrate up PEG3350 can take a few days to work (prevention agent)
75
How many women are constipated during pregnancy?
50% of women
76
Are iron supplements the main cause of constipation in pregancy?
Probably not, it is likely due to all of the changes associated with pregnancy
77
What are some good agents for constipation therapy in pregnant women?
Docusate is very common (should unload a few days before) PEG 3350 Psyllium *senna and bisacodyl are not recommended because the could cause uterine contraction concerns
78
How many patients on opiates have constipation?
40-90%, and these patients will not see a decrease in the severity of constipation They start to reduce opioid dose to help reduce constipation. They are in pain because their constipation is too overbearing
79
Should senna and opioids be combined to prevent constipation?
Yes, because it is easier to prevent than treat
80
What are some medications that cause constipatioon?
Opioid pain relievers Antihistamines TCAs

Pharm 154* (18 decks)

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