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EXAM 1 > CONSTIPATION > Flashcards

CONSTIPATION Flashcards

1
Q

Describe stool formation?

A

Water and salts reabsorbed, resulting in drying

Bacteria
 ferment non-digestible polysaccharides, some metabolites
absorbed
 produce Vitamin K and Biotin (Vit B7), which can be absorbed Produce gases from undigested polysaccharides
 Essential for development of caecum and lymphatics Stored in rectum until urge for defecation

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2
Q

How does stool get to the rectum? And what happens once it gets to the rectum

A

Food passes from small intestine and passes along caecum, colon and into rectum by peristalsis.

Stored in rectum until urge for defecation

Stools hard when stored in rectum for longer than normal so more water absorbed

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3
Q

Definition of Constipation?

A

“The passage of hard stools (faeces) less frequently than the patient’s own normal pattern”

 Chronic constipation – generally >12 weeks in preceding 6 months

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4
Q

T/F Constipation is a disease?

A

F- Symptom

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5
Q

How do you characterise constipation?

A

 Difficulty in opening bowels
 Going <3 times per week
 Straining to open bowels more than 25% of occasions
 Hard or pellet-like stool on more than 25% occasions

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6
Q

How long does Chronic Constipation lasts for?

A

Chronic constipation – generally >12 weeks in preceding 6 months

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7
Q

Describe epidemiology of constipation?

A

Common, affects all ages
 1 in 7 adults
 1 in 5 older people
 1 in 3 children
 Late pregnancy
 Taking regular medicines

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8
Q

What Gender is Constipation common in?

A

More common in women

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9
Q

Approximately how many people in the England are written prescriptions for laxatives?

A

10 Million

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10
Q

Describe aetiology of constipation?

A

Age

Diet

Poor bowel habits
(ignoring urge to defecate)

Imaginary Constipation

Medications

Laxative abuse

IBS

Intestinal obstruction

Mechanical Ps Anus and rectum, poor thyroid function, lead poisoning, pregnancy ,travel, immobility.

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11
Q

What causes constipations when it comes to diet?

A

Diet
 Low fibre
 High animal fat
 Inadequate fluid intake
 Caffeine
 Alcohol

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12
Q

What Medicines can contribute to constipation?

A

Antacids – Al and Ca salts
 Antispasmodics
 Antidepressants – eg amitriptyline, doxepin
 Iron tablets eg ferrous sulphate
 Diuretics
 Painkillers – eg codeine, morphine
 Ca channel blockers eg diltiazem, verapamil
 ACE inhibitors eg enalapril, lisinopril
 Anticholinergic eg hyoscine, tolterodine
 Ulcer healing eg lansoprazole, omeprazole
 Antipsychotics eg haloperidol, olanzipine

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13
Q

What are the intestinal obstructions that can cause constipation?

A

Intestinal obstruction
 Scarring – from IBD, diverticulitis or post surgery Adhesions
 Intestinal cancers
 Abdominal hernia
 Gallstones wedged in intestine
 Volvolus
 Foreign bodies
 Intussusception
 Haemorrhoids
 Fissures

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14
Q

What other diseases are causing Constipation?

A

 Diabetic autonomic neuropathy
 Spinal cord injury or tumors
 Cerebrovascular accident
 Multiple sclerosis
 Parkinson’s disease
 Connective tissue disorders
 Hirschsprungs disease

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15
Q

Constipation is a symptom not a disease?

A

TRUE

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16
Q

How is Constipation diagnosed?

A

Medical history

History of symptoms
 Normal patterns of defecation
 Other symptoms
 Frequency and consistency, faecal impaction, incontinence
 How long/intense are the symptoms?
 Impact on daily life

Medications

Changes in diet and lifestyle
 Change jobs
 Holidays
 Diet

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17
Q

What is the prevalence and aetiology of constipation in Children?

A

Prevalent in 5-30% children

Aetiology often unknown

18
Q

Describe symptoms of constipation in children?

A

Symptoms:
 Infrequent bowel activity
 Foul smelling wind and stools
 Excessive flatulence
 Irregular stool texture
 Abdominal pain, distension or discomfort
 Soiling/overflow

19
Q

Describe specific causes of constipation in older people?

A

Main causes:
 Age-related decline in GI motility
 Decreased mobility
 Poor diet – low solid and liquid intake
 Wasting of pelvic floor muscles
 Side effects of medicines

Faecal impaction may occur

20
Q

When Constipation has been confirmed what appropriate steps need to be taken to manage the problem?

A

o Lifestyle and dietary changes

o Short course of laxatives

21
Q

What are the goals of constipation management?

A
  1. Achieve an individual’s normal frequency of defecation
  2. Establishing regular, comfortable defecation
  3. Preventing laxative dependence
  4. Relieving discomfort
22
Q

What are the 4 classes of drugs that are used to treat constipation?

A
  1. Bulking agents
  2. Stimulant Laxatives
  3. Faecal Softeners
  4. Osmotic Laxatives
23
Q

What are examples of Bulking agents?

A
  1. Ispaghula husk: -Cannot take before bed, ensure good fluid intake and it remains effective despite long-term use.
  2. Methylcellulose: 500mg tablets . 3-6 tablets BD with at least 300ml of water
    - Break tablets in the mouth before swallowing
    - Cannot take before bed
    -Ensure good fluid intake
    -2-3 days for effect
24
Q

What are examples of Faecal softeners?

A

Docusate (oral and rectal)
Glycerol (suppository)
Arachis oil (enema)

25
Q

What are the examples of Osmotic laxatives?

A

Lactulose
Macrogols (inert polymers of ethylene glycol)
Magnesium hydroxide and Magnesium sulphate
Phosphate (suppository and enema)
Sodium citrate (microenema)

26
Q

What is the mechanism of action of bulking agents?

A

◦ Typically, polysaccharides increase osmolality in gut when broken down, causing water retention
◦ Retention of water in the GIT, so expanding and softening the stool
◦ Bulkier stools distend the colon
◦ Promotion of peristalsis via stimulating colonic mucosal receptors/stretch receptors
◦ This leads to acetylcholine release ( parasympathetic drive)
◦ ACh activates muscarinic acetylcholine receptors (mostly M2 and M3 subtypes)
◦ Increased peristalsis
◦ Also creates mucus layer in intestinal lining, facilitating defecation

27
Q

What are examples of Stimulant laxatives? ( Short-Term USE)

A

Bisacodyl (oral and rectal): 5-10mg OD, onset of action 10-14 hrs
-SUPPOSITORIES- Act in 20-60 mins and they cause local inflammation

Senna: 7.5-15mg, onset of action 8-12 hrs.

Dantron- onset of action- 6-12hrs, colours urine, ONLY in terminally ill patients

Sodium Picosulphate- 5-10mg OD, tabs/syrups, Onset of action 10-14 hrs.

28
Q

What drugs are used in patient groups with constipation who are on Opioids?

A

AVOID BULK FORMING LAXATIVES.

1) Osmotic laxative (or Docusate) OR Stimulant Laxative

2) Naloxegol
◦ Peripherally acting mu-opioid receptor antagonist (PAMORA)
◦ Oral
◦ If not adequately responded to laxatives
◦ PAMORAs don’t antagonise the important central
opioid receptors

3) Methylnaltrexone
◦ PAMORA
◦ Subcutaneous
◦ No evidence submitted to NICE

4) Naldemedine (NICE TA651) Sept 2020
◦ PAMORA
◦ Oral
◦ A new option

29
Q

What Lifestyle Advice should be given to patients with Constipation?

A

High fibre diet
◦ 30g fibre/day with sufficient fluid (most only get 18g)
◦ Caution: obstructive symptoms or fecal impaction
◦ Ineffective in slow-transit constipation or defecatory disorders
◦ Switch from ‘white’ to ‘wholemeal’

Limited evidence but also recommend…
◦ Increased physical activity
◦ Adequate fluid intake
◦ 2L water per day

30
Q

What drugs are used in Patient Groups with Constipation who are Pregnant AND Breastfeeding?

A

Pregnancy
◦ Offer a bulk-forming laxative
◦ Add or switch to an osmotic laxative
◦ Can consider a short course of a stimulant such as Senna (NEVER close to term, only prescribed, NOT
OTC)
◦ Glycerol suppository
◦ Laxatives in Pregnancy

Breastfeeding
◦ Offer a bulk-forming laxative
◦ Add or switch to an osmotic laxative
◦ Can consider a short course of a stimulant laxative such as Bisacodyl or Senna.
◦ Glycerol suppository
◦ Laxatives in Breastfeeding

31
Q

What does the Guideline say about Faecal loading and/ or Impaction of Soft stools?

A

-Stimulant

Response inadequate or slow:
-Docusate or sodium citrate mini enema

Response still inadequate:
-Sodium phosphate or Arachis oil retention enema

Consider need for regular laxative to maintain
bowel movements.

32
Q

What drugs are used in Patient Groups with Constipation who are Children?

A

1st line – Macrogols AND negotiated and nonpunitive behavioural interventions suited to persons stage of development

2nd line – add stimulant laxative
(or 1st line not tolerated) – change to stimulant laxative

3rd line – add lactulose (or other softening laxative) if macrogol not tolerated

Continue at maintenance dose (which may be for several months)

Some paediatric Macrogol = NOT licenced for children under 2 (such as Cosmocol paediatric) = Informed and documented verbal consent recommended for prescriber).

Suppositories and Enemas not recommended for routine use in primary care.
Laxatives may be needed for several months (to overcome the learned behaviour).

33
Q

List everything you know about Prucalopride?- Resolor

A
  • A selective serotonin 5HT4 -receptor agonist with prokinetic properties
  • Should only be prescribed by clinicians experienced in treating chronic constipation after careful review
  • 2 mg tablets once daily, review treatment if no response after 4 weeks. (Reduced dose in elderly)
  • Side effects: headache and GI disturbances
  • Increased doses will not improve response
  • 1-2 weeks for effect

Linaclotide = USE IN IBS!!

34
Q

What is the Mechanism of Action of Prucalopride?

A

Prucalopride is a 5HT4 -receptor agonist
5HT4 receptors are present in GI tract, especially myenteric plexus

5HT4 activation leads to increased release of ACh

  rest and digest/parasympathetic drive
This increases peristalsis and propulsion

35
Q

What is the mechanism of action of Osmotic Laxatives?

A

Poorly absorbed so act as osmotic agents and increase water retention in the gut lumen

As hyperosmolar agents, they are absorbed into stool by osmosis, making it softer

Softer stools are easier to pass!

Many osmotic laxatives also contain Mg2 (Magnesium)

Mg2+ triggers release of cholecystokinin (CCK)

CCK increases intestinal secretions and colonic motility

Decreases transit time through gut

36
Q

What is the mechanism of action of Stimulant Laxative?

A

Stimulate local reflexes of myenteric nerve plexus of the gut

Irritate nerve endings in wall of intestine

Motor effect on gut wall-increases propulsion

Increase secretion of water into the bowel

Increases gut motility and decreased transit time

37
Q

How does the Stimulant Laxative SENNA work?

A

Anthraquinone laxative
Combine with sugars to form glycosides
◦ Glycosides are molecules where the sugar is attached to a functional group via a glycosidic bond.

◦ Glycoside bond hydrolysed by colonic bacteria to release irritant anthracene glycoside derivatives, specifically sennosides A and B

◦ Absorbed and have direct action on myenteric nerve plexus, increasing smooth muscle activity
◦ Also postulated to increase PGE2 secretion (which increases gut motility).

◦ Also reduce colonic water absorption

38
Q

How does Stool Softeners Work?

A

 Known as emollient laxatives
Some work as S wetting agents/surfactants (e.g. Docusate)
Reduced ST allows water/fats to penetrate stool

This softens the stool, making it easier to pass
Docusate also has some Stimulant Activity

Arachis oil and Paraffin creates a barrier between stool and intestinal wall

This eases the passage of stool through intestine
Paraffin no longer popular due to concerns over Carcinogenicity

39
Q

What do PAMORAs do?

A

PAMORAs are competitive antagonist at intestinal mu-opioid receptors
*Prevent opioid activation of intestinal mu-opioid receptors
*Targeting underlying opioid induced side effects ie reduced GI motility, hypertonicity, increased fluid absorption
*This results in normal propulsion and peristalsis

40
Q

What should be done for Children who have Constipation in terms of responding to Symptoms?

A

Children – although there are laxatives licensed for children OTC, they require initial referral to a GP to have a physical examination

  • Remember: MACROGOL is 1st line
  • PAEDIATRIC DOSE Macrogol is a POM (people will ask to purchase it as ADULT Macrogol products are P).
41
Q

What are the Reg flags Of Constipation?

A
  • Pain on defecation – causing suppression of reflex
  • Patient over 40 years with sudden change in bowel habits (no obvious cause)
  • Greater than 14 days’ duration (no obvious cause)
  • Associated fatigue
  • Presence of blood
  • Repeated failure of laxatives
  • Suspected laxative abuse

EXAM 1 (14 decks)

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