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Royal College 2023 > Constipation > Flashcards

Constipation Flashcards

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1
Q

What are 3 anatomic locations of the rectal area and what are their innervations?

A

Internal anal sphincter - L1-L2 symptoms, S2-4 PS
External anal sphincter - S2-4 (pudendal)
Puborectalis- S2-4 (pudendal, perineal)

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2
Q

Define constipation according to the Rome IV criteria?

A

Symptoms for 6+ mos and 2+ of following for >25% defecations during last 3 months:
1. Straining
2. Lumpy or hard stools
3. Sensation of incomplete evacuation
4. Sensation of anorectal obstruction/blockade
5. Manual maneuvers to facilitate defecation
6. <3 BM per week
7. Loose stools not present, insufficient criteria for IBS

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3
Q

What are 5 non GI causes of stool impaction?

A
  1. Medication side effects
  2. Neurogenic (spinal cord injury, Parkinson’s)
  3. Metabolic (hypothyroid, DM)
  4. Psychiatric
  5. Pelvic floor dysfunction
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4
Q

What is the ddx for causes of constipation?

A

Primary
- Normal transit
- Slow transit
- Dyssynergic defecation
Secondary
- Medications
- Neurologic disease
- Psychiatric disease
- Neoplastic
- Metabolic
- Diet (fibre, fluids)
- Immobility
- Mechanical obstruction

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5
Q

Outline an approach to diagnosis and management of constipation

A
  1. Hx
  2. Physical including DRE
  3. Investigations
    Blood - Ca, TSH
    Imaging - AXR
    Scope not recommended unless red flag sx (blood, weight loss, anemia, fam hx, refractory)
  4. Non pharm interventions (diet, exercise, behaviours, biofeedback)
  5. Pharm
  6. Re evaluate
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6
Q

List medications that can contribute to constipation

A

Supplements (Ca, iron)
Opioids - hydromorphone
NSAID - ibuprofen, naproxen
Antipsychotics - risperidone
TCA - amitriptyline
SSRI - paroxetine
Diuretics - furosemide
Non DHP CCB - diltiazem, verapamil

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7
Q

List disease processes that are associated with constipation (9)

A
  1. Diabetes
  2. Depression
  3. Dementia
  4. Parkinson’s
  5. MS
  6. Stroke
  7. Spinal cord injury
  8. HyperCa
  9. HypoTSH
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8
Q

What is an evidence based non pharmacologic therapy for constipation? Others maybe without evidence?

A

Biofeedback
Others:
1. Inc fluid intake
2. Inc exercise and mobility
3. Timed toileting (30 mins post)
4. Inc daily fiber 20-25 g/d
5. Stop aggravating meds

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9
Q

What are 6 steps in management of constipation per CMAJ 2013 article?

A
  1. Determine predominant symptoms (frequency, straining, incomplete)
  2. Identify possible secondary causes (meds, disease)
  3. Consider fecal impaction (AXR, DRE, manual disimpaction)
  4. Optimize behavioural factors (seated, knees above hips, toilet after AM meal, inc fluid, exercise)
  5. Trial dietary modifications for 2-4 weeks (fibre 20-30 g/d, not if immobile or bed bound)
  6. Trial previously preferred laxative 2-4 wks
  7. Trail laxative from RCTs 2-4 wks (PEG, lactulose)
  8. Trial of another laxative or combo 2-4 wks (magnesium hydroxide, docusate, bisacodyl, Senna, enema)
  9. Consider referral to geri or GI
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10
Q

What are bulk forming agents used to treat constipation?

A

Psyllium seed
Methylcellulose
Wheat dextrin

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11
Q

What are examples of osmotic laxatives?

A

PEG
Lactulose
Magnesium hydroxide
Sorbitol

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12
Q

What is this finding?

A

Fecal loading

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13
Q

What are steps in managing fecal impaction?

A

Complete obstruction
1. Manual disimpaction
2. Distal washout - docusate, sorbitol, mineral oil enema
Incomplete obstruction
1. Proximal softening - PEG
2. Distal washout

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14
Q

Management of constipation in Parkinson’s patient?

A

PEG
Probiotic/prebiotic fibre
Lubiprostone
Other: lactulose, psyllium, prucalopride, enema

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15
Q

What is the MOA of psyllium? AE? Onset?

A

Soluble fiber
Absorbs water in intestine to form viscous liquid
Promotes peristalsis and reduce transit time
AE: bloating, flatulence
Only if mobile
12-72 hours

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16
Q

What is the MOA of PEG? AE? Onset?

A

Non-absorbable, non-metabolized osmotic agent
Causes secretion of water into intestine
Improves transit and stool consistency
AE: bloating, pain, diarrhea
Onset: 1-4 days

17
Q

What is the MOA of Senna?

A

Stimulant laxative
Stimulates peristalsis which increases motility, inc secretions
AE: cramps, hypoK, pseudomelanosis coli
Efficacy unknown
Onset: 6-12 hrs

18
Q

What is the MOA of prucalopride?

A

5-HT4 receptor agonist
Selective, high affinity
Stimulates peristaltic reflex, intestinal secretions and motility
AE: pain, diarrhea, N/V, headache
Efficacy unknown
Onset: 3-12 hours

19
Q

What is the MOA of linaclotide?

A

Non-absorbed selective GC-C receptor agonist
Promotes chloride rich intestinal secretions and laxation
AE: cramps, cost, diarrhea
Onset: 12-24 hours

20
Q

What are the categories of laxatives?

A
  1. Bulking agents: psyllium, methylcellulose, polycarbophil
  2. Osmotic agents: PEG, lactulose, Mg hydroxide, sodium phosphate
  3. Stool softeners: docusate
  4. Stimulants: Senna, bisacodyl
  5. Prokinetics: prucalopride
  6. Secretagogue: linaclotide
  7. Enema/suppository: phosphate, tap water, glycerin supp
21
Q

What is the MOA of docusate? AE?

A

Anionic surfactant decreases stool surface tension = inc water penetration
AE: cramps, diarrhea
Efficacy unknown
Onset: 24-72 hours

22
Q

What is the MOA of enema/suppository? AE?

A

Distend rectum to initiate defecation reflex
Soften stool

Phosphate based can cause hyperphosphatemia and lytes

23
Q

What are red flags about constipation making you concerned for cancer?

A

Acute onset
Unresponsive to tx
Positive FOBT
Hematochezia
Anemia
Weight loss 5 kg+ in 6 months
Fam hx colon ca

24
Q

What are indications for AXR in constipation?

A

Empty rectum but suspect impaction
Persistent incontinence despite clearing impaction
Distention or pain
Persistent constipation with inc laxative use

25
Q

What are indications for colonoscopy or CT enema with constipation?

A

Systemic illness - weight loss, anemia
Hematochezia
Change in bowel habits
Prolonged pain

26
Q

What are indications for anorectal functional tests in constipation?

A

Severe or persistent symptoms of rectal outlet delay
Persistent incontinence with preserved sensations and weak sphincter

27
Q

List 4 drugs that should not be used to treat constipation in elderly?

A
  1. Docusate - lacks evidence
  2. Magnesium - avoid if cardiac or renal dysfunction
  3. Mineral oil - not oral risk aspiration
  4. Soapsuds - colonic mucosa irritation
  5. Sodium enema - dehydration, renal impairment, cardiac or lytes
  6. PEG with lytes - lytes, renal, CHF
28
Q

What are 5 types of fecal incontinence?

A
  1. Urge - aware but can’t get there in time
  2. Passive - unaware, no warning
  3. Seepage - awareness followed by normal defecation, then leak after without warning
  4. Overflow - secondary to constipation
  5. Functional - physical reason they are unable to make it to washroom in time
29
Q

What physiologic changes of aging lead to fecal incontinence?

A
  1. Dec internal sphincter tone and thickness
  2. Decrease anorectal sensory threshold and reduced rectal compliance
  3. Dec resting and squeezing pressures of external anal sphincter
  4. Increase in pudendal neuropathy
30
Q

What diagnostic tests can you use for fecal incontinence?

A

Anorectal exam
Pelvic MRI
Barum defecography
Anal sonography
Anorectal manometry
EMG
Pudendal nerve motor latency

31
Q

What are physiologic causes of fecal incontinence?

A
  1. Overflow
  2. Reduced storage capacity
  3. Weak internal anacl sphincter
  4. Weak external sphincter
  5. Weak puborectalis
  6. Dec rectal sensation
32
Q

What are risk factors for fecal incontinence?

A

Depression
Dementia
Diabetes
Functional impairment
Impaired mobility
Neurologic disease
Loose stool

33
Q

What is management for fecal incontinence?

A
  1. Adjust meds
  2. Exclude overflow - exam, AXR
  3. Education and lifestyle - avoid triggers, fibre, pads, squeeze before pressure, schedule toileting, walk to toilet, squeeze exercises
  4. Targeted therapy - medications (loperamide), pelvic floor biofeedback, anal insert devices
34
Q

What laxative is deemed potentially inappropriate according to Beer’s criteria and why?

A

Oral mineral oil
Risk of aspiration lipoid pneumonia

35
Q

What are the two best choices of laxatives for an ambulatory patient with good hydration?

A
  1. Psyllium
  2. PEG
36
Q

What are complications of fecal impaction?

A
  1. Pain
  2. Overflow incontinence/diarrhea
  3. Urinary retention/UTI
  4. Delirium
  5. Dehydration/lytes imbalance
  6. Occlusion
  7. Stercoral perforation
  8. Bacteremia/sepsis
  9. Sigmoid volvulus

Royal College 2023 (79 decks)

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