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Pharm 154* > Constipation > Flashcards

Constipation Flashcards

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
Q

How do prunes/dried plums help with constipation?

A

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

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26
Q

What are bulk-forming agents?

A

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)

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27
Q

How do bulk-forming agents work?

A

They swell in intestinal fluids—>creates gel—> facilitate passage

Can usually take a few days to see effects

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28
Q

How much Metamucil (psyllium) should be started initially?

A

7g TID, and dose can be adjusted to ideal stool softness

Normal hydration is fine, but avoid dehydration

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29
Q

What is the incidence of psyllium-induced obstructions?

A

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)

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30
Q

What are some symptoms associated with psyllium-induced obstruction?

A

Pain

Cramps

Nauseous

Can feel a mass

No fecal output

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31
Q

Is psyllium more effective vs. inulin for clearing constipation?

A

Yes, but inulin is more palatable

Psyllium thickens fluid (less palatable)

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32
Q

Are psyllium capsules recommended by pharmacists?

A

No, because the dosing frequency is high, go for powder instead (plus powder is cheaper)

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33
Q

What are stool softeners?

A

Effectively detergents /anionic surfactant (allow oily fecal matter and water to mix)

Ex. Docusate

34
Q

How long do stool softers take to clear constipation?

A

Takes 1-2 days (3-5 days in some patients)

35
Q

What is a contraindications with docusate (stool softener)?

A

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
Q

What are the different types of docusate (stool softeners)?

A

The following have equivalent stool softening abilities (equipotent):

Docusate Na+: 100mg

Docusate Ca2+: 240mg

37
Q

What is the role of lubricants in treating constipation?

A

Mineral oil is often ingested to soften fecal matter. Physicians do not like this agent

Can resolve constipation in about 6-8 hours

38
Q

What are some problems with mineral oil use in constipation?

A

Anal seepage

Lipid pneumonia (drops from mouth can fall into the airways)

Possible decrease in absorption of fat soluble vitamins (unlikely)

39
Q

What is the difference between heavy mineral oil and normal mineral oil?

A

The heavy mineral oil is less likely to stick on the throat. It will stay in the GI tract

40
Q

What is the efficacy of mineral oil enemas?

A

They work very fast to clear constipation(within 30 min)

41
Q

How do saline (osmotic) agents work in treating constipation?

A

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
Q

How much magnesium is needed to experience diarrhea (reverse constipation)?

A

Above 800mg of Mg has laxative effects

43
Q

What makes milk of magnesia (osmotic) unpopular for constipation treatment?

A

Very chalky flavour

44
Q

What is the earliest age at which an enema can be given?

A

2 years old, any patient younger should use a suppository

Why does a child under 2 have constipation?

45
Q

What is the effect of Glycerin suppositories?

A

It has osmotic effect and a local irritant effect

Especially useful in very young children

Bowel evacuation within 30 min

46
Q

What is the efficacy of lactulose syrup (osmotic)?

A

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
Q

How is PEG 3350 used for constipation treatment?

A

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
Q

What is the DOC for constipation prevention?

A

PEG 3350, especially in older adults

49
Q

What are some common stimulants used in constipation treatment?

A

Bisacodyl and Senna

50
Q

What is the mechanism of action for stimulants in constipation therapy?

A

They are irritating to gut lining, promote GI motility

51
Q

What are some side effects seen in stimulant use in constipation treatment?

A

They are minimally absorbed (no systemic symptoms)

Can experience diarrhea/cramps

52
Q

What is the reason for the intentional overuse of stimulants in constipation treatment?

A

Patients with anorexia may use these agents to move food out of their system

53
Q

What are some warnings for stimulant overuse?

A

Chronic use may produce hypokalemia or dehydration

Laxative dependence

Chronic constipation

54
Q

Does chronic use of stimulants disrupt normal bowel function after going cold turkey?

A

No, new evidence suggests this does not happen

55
Q

How should senna be dosed?

A

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
Q

Can patients use Tylenol #3 (T3) and senna together to prevent opiate-associated constipation?

A

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
Q

Review Slide 76 for agents for constipation treatment

A
58
Q

What are the most common rescue constipation treatments?

A

Senna
Bisacodyl
Milk of Magnesia

Likely not mineral oil

59
Q

What are some common prevention agents for constipation?

A

PEG 3350

Docusate

60
Q

What is Colyte?

A

It has added electrolytes and it contains PEG 3350

Expect bowel movement within an hour

61
Q

What is the efficacy of probiotics in constipation?

A

No definitive product that has shown evidence for helping prevent constipation, no role in overnight treatment

62
Q

What are some patient groups of interest when it comes to constipation?

A

Ambulatory elderly

Paediatrics

Pregnancy

Palliative Care

63
Q

Who is an ambulatory elderly patient?

A

They usually have multiple disease states/medications

If the are old, they may also have a suppressed bowel reflex

64
Q

What do pharmacists recommend to elderly patients for constipation?

A

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
Q

What are some natural options for elderly patients with constipation?

A

Prevention (increase fiber)

Acute relief (prune or dried plums)

66
Q

What are the most common constipation therapies used in the elderly?

A

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
Q

Review slide 95 for a treatment algorithm for constipation treatment in the elderly

A
68
Q

When should pharmacists be worried about elderly patients with constipation?

A

Unexplained new onset/worsening

Blood in stools

Weight loss, anorexia

Fever

Nausea and vomiting

Family history of colorectal cancer

69
Q

What is a normal bowel movement schedule for infants?

A

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
Q

How to tell if a baby is constipated?

A

The baby is likely to be constipated if the baby cries

71
Q

What are some paediatric (infants) treatments for constipation?

A

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
Q

What causes constipation in toddlers?

A

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
Q

Can any of the adult constipation products be used in paediatrics?

A

Yes, none of them are contraindicated in paediatrics

74
Q

What is the dosing for PEG 3350 in paediatrics?

A

Start with 1/2 capful and titrate up

PEG3350 can take a few days to work (prevention agent)

75
Q

How many women are constipated during pregnancy?

A

50% of women

76
Q

Are iron supplements the main cause of constipation in pregancy?

A

Probably not, it is likely due to all of the changes associated with pregnancy

77
Q

What are some good agents for constipation therapy in pregnant women?

A

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
Q

How many patients on opiates have constipation?

A

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
Q

Should senna and opioids be combined to prevent constipation?

A

Yes, because it is easier to prevent than treat

80
Q

What are some medications that cause constipatioon?

A

Opioid pain relievers

Antihistamines

TCAs

Pharm 154* (18 decks)

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