Constipation Flashcards
Constipation is defined as infrequent defecation, < __ / week, along with other symptoms:______, _______, ______ etc
<3 times per week
straining or painful
hard, lumpy stools
incomplete evacuation
bloating and abdominal discomfort
sense of rectal blockage
Primary constipation is classified as the following:
1)
2)
3)
1) Normal Transit (Normal frequency but stool is hard and or difficult to pass)
2) Slow transit (Infrequent BM)
3) Pelvic floor dysfunction (Neurological)
Secondary constipation is due to ______, _______ or conditions
medications, diseases
Some medical conditions that can lead to constipation:
1)
2)
3)
1) CV disease ( stroke )
2) GI (IBS)
3) Neurological (Parkinsons, spinal cord injury)
Diabetes, thyroid disorders, psychiatric (depression, anxiety)
Common risk factors:
1)
2)
3)
1) Female Sex
2) Pregnancy
3) >65
Changes in diet, low socioeconomic status, low fluid or caloric intake, living conditions, sedentary lifestyle, ignoring urge to defecate
Some examples of medication causes:
Anticholinergics, Antihistamines, Antidiarrheal drugs, Iron, Opioids, NSAIDs, antidepressants etc
RED FLAGS
1)
2)
3)
1) CHILDREN <2
2) CONSTIPATED > 2 WEEKS
3) NO BM 7 DAYS
Blood or mucus in stool, systemic symptoms, symptoms of anemia, family hx of colon cancer, constipation and diarrhea (suggestive of IBS), persistent abdominal pain, severe pain during defacation, recent abdominal surgery, weight loss >5%, abdominal or rectal mass, impaction
Examples of non-pharm include:
increase fibre intake (25-38g)
increase fluids (2.2-3L)
encourage regular daily bowel routine
avoid straining
increase physical activity
First line non-prescription agents are:
1) Bulk forming (psyllium)
2) Osmotic (PEG3350)
Psyllium works by _______ stool fluid content
increasing
Psyllium onset is __ - __ days
1-3 days
Psyllium is contraindicated in _________
fecal impaction
Psyllium must be taken with ____ of ____ to prevent fecal impaction
250 ml of water, avoid esophageal obstruction
Main side effect of psyllium =
bloating, space by 2 hr from other meds
Osmotic laxatives work by drawing fluid into _______ and stimulate peristalsis
the lumen
These two non prescription agents are safe for long term use
1)
2)
Psyllium
PEG
The onset of PEG is __ - __ days
2-4
_____ is more effective and causes less side effects than lactulose
PEG3350
These two osmotic are effective in opioid induced constipation:
1)
2)
PEG
Lactulose
The onset of lactulose is __ - __ days
1-2 days
Common side effects of lactulose include:
Flatulence, cramps, diarrhea, bloating, nausea
Main concern with sorbitol 70% solution is:
bowel necrosis
The osmotic laxative with the fastest onset of 15 min to 1 hour is
glycerin suppositories
Main concern with osmotic saline laxatives like magnesium citrate, magnesium hydroxide, magnesium sulphate, sodium phosphate enema is that they can cause ________
electrolyte imbalances
Avoid osmotic saline laxatives (ex magnesium hydroxide) in patients with _____ / _____
renal failure / cardiac disease
Stimulant laxatives have an onset of ___ - ___ hours
6-12 hours
Drawback to stimulant laxatives is that they have the potential for _____
dependence
Stimulant laxatives, like PEG and lactulose, are effective in ________ constipation
opioid-induced
Stimulant laxatives are an option if ______ laxatives are not tolerated/fail
osmotic
Of the stimulant laxatives (Senna, bisacodyl, cascara sagrada), ______ has less abdominal discomfort
senna
Stool softeners/emollients are generally _______
NOT RECOMMENDED
Mineral oil should be avoided due to the risk of ______
aspiration
These 3 are examples of prescription agents used in constipation:
1)
2)
3)
1) Prucalopride
2) Methylnatrexone/naloxegol
3) Linaclotide
Prucaprolide is used in _____ with chronic idiopathic constipation
WOMEN
Methylnaltrexone and naloxegol are used in _________ constipation
opioid-induced, reserved for refractory cases and they are $$$
Linaclotide is used for _______ ________ constipation in adults when traditional therapies are ineffective
chronic idiopathic
First line treatment in pregnancy and breastfeeding:
Non-pharm therapy
If non-pharm treatment does not work in pregnancy or breastfeeding the following class of medication can be used:
bulk-forming agents (psyllium) (not systemically absorbed)
The following are contraindicated in pregnancy
1.
2.
3.
4.
5.
mineral oil
castor oil
docusate (breast feeding CI)
linaclotide (breast feeding CI)
prucalopride (breast feeding CI)
Over use of stimulants can lead to ______ colon
cathartic
Second line for breastfeeding
Magnesium hydroxide (Saline laxative)
First line treatment in children with constipation:
PEG3350, Lactulose is 2nd because less effective and causes more bloating and abdominal pain
____ and ____ can be used in children when other therapies have failed
Senna and bisacodyl (contraindicated in infants)
This treatment is safe and effective, and a good option if PO route is refused/immediate relief is needed in children
glycerin suppository
