Constipation and Hemorrhoids Flashcards
Some lifestyle modifications for constipations
Increase fiber intake
Increase fluid intake
“Bowel Training”
Squatty Potty
What are types of fiber and what food contain them?
Soluble
Beans, oat bran, barley, citrus fruits, apples, carrots, etc.
Insoluble
Whole grain breads, prunes, corn, etc.
What are first line treatments for constipation?
Bulk-forming agent
Hyperosmotic agent
Bulk-forming agents MOA
promoting evacuation by dissolving or swelling to form emollient gels that facilitate passage of stools and stimulate peristalsis (bulk)
Bulk-forming agents products
Psyllium (Metamucil™) – natural source/allergy alert
Methylcellulose (Citrucel™) – synthetic so least GAS
Polycarbophil (FiberCon™) - extremely hygroscopic
Bulk-forming agents things to remember
MUST take with water to avoid obstruction
Avoid in individuals with swallowing difficulties
Most common side effect – flatulence
May interfere with the absorption of concomitant oral medications – separate by at least 2 hours
Hyperosmotic agent MOA
Large poorly absorbed ions draw water into colon or rectum to stimulate bowel movement
Hyperosmotic agent products
Polyethylene Glycol 3350 (Miralax™)
Glycerin
Miralax things to remember
Also used in bowel prep regimens for colonoscopy in addition to constipation
Odorless and tasteless and only 0.2% absorbed
No clinically significant drug interactions
Very well tolerated
Glycerin things to remember
Used for lower bowel evacuation
Quick onset (15 to 30 minutes)
Drug interactions are not clinically important
As enema, not recommended due to irritation (sodium sterate component)
Minimal side effects
Emollient agents MOA and also called?
“Stool softener”
Increase wetting efficacy of intestinal fluid and soften fecal mass
Primarily to prevent straining and painful defecation
Emollient agent product
Docusate sodium (50 or 100mg) Docusate calcium
Emollient agent things to remember
Minimal side effects
Generally well-tolerated
Will increase absorption of mineral oil so combination should be avoided
Lubricant agent MOA, products and things to know
Mineral oil
MOA: softens fecal contents by coating stool and preventing colonic absorption of fecal water
To prevent straining and painful defecation
(Safer agents (emollients) preferred)
Many safety concerns – not preferred
Saline laxative agents MOA
Ions in intestinal wall draw in water, increasing intraluminal pressure and intestinal motility
Occasional relief of constipation or when acute evacuation of bowel is required
Saline laxative agents products
Magnesium citrate
Magnesium hydroxide (MOM™)
Dibasic sodium phosphate/Monobasic sodium phosphate (Fleet™)
Magnesium sulfate (Epsom salt™)
Saline laxative agents things to remember
May cause serious electrolyte imbalances with long-term use and at higher doses!
Patients who cannot tolerate fluid loss should not use saline laxatives!
What is the recommended second line for constipation?
Stimulant agents
Stimulant agents MOA
Increase intestinal motility and secretion of water and electrolytes
Stimulant agents product
Sennosides (Senna™) - anthraquinone (8.6mg)
Bisacodyl (Dulcolax™) - diphenylmethane
How many days until pt should call PCP?
7 days
Nonpharmacologic treatment for hemorrhoids
Good perianal hygiene
Avoid prolonged toilet sitting time (~ > 10 minutes)
Avoid lifting heavy objects/sitting for long periods
Sitz bath – bid-qid for 10-20 minutes
What is sitz bath?
A sitz bath is a warm, shallow bath that cleanses the perineum, which is the space between the rectum and the vulva or scrotum.
A sitz bath can also provide relief from pain or itching in the genital area.
Local anesthetics ingredients
benzocaine, dibucaine, lidocaine, pramoxine, benzyl alcohol, dyclonine, tetracaine
Local anesthetics things to know
MOA: reversibly block transmission of nerve impulses
External use only – typically 3-6 times per day
May mask pain of more severe anorectal disorder – use with caution
Allergic reactions similar to anorectal symptoms may occur
Pharmacologic treatments for hemorrhoids
Local anesthetics
Vasoconstrictors **
Avoid in pts with diabetes, hyperthyroidism, hypertension, angina pectoris, enlarged prostate, or antidepressant meds
Protectants** (glycerin is external only)
Astringents** (witch hazel is external only)
Keratolytics
Analgesics/Anesthetics/Antipruritics
Corticosteroids
Vasocontrictors things need to know and caution
Hemorrhoids
MOA: constricts arterioles to reduce swelling and produce anesthetic effect (mechanism unknown)
External and internal use – Up to 4 times per day
Caution/avoid with diabetes, thyroid disease, HTN, angina pectoris, or enlarged prostate, and with antidepressants, antihypertensives, and cardiac medications – consult PCP
Vasoconstrictors for hemorrhoids ingredient
ephedrine, epinephrine, phenylephrine
Protectants for hemorrhoids ingredients
kaolin, ALUMINUM HYDROXYDE, COCOA BUTTER, GLYCERIN, hard fat, LANOLIN, MINERAL OIL, white pet, CALAMINE, shark liver oil, ZINC OXIDE, topical starch, cod liver oil
Protectants for hemorrhoids things need to know
MOA: prevent fecal matter from causing perianal irritation, and soften the dry anal canal by decreasing water loss
External and internal use – up to 6 times per day
Glycerin = external only
Systemic absorption minimal, ADRs uncommon
Astringents for hemorrhoids ingredients. ext? int?
Witch hazel = external only
Calamine and zinc oxide = both int. and ext.
Astringents for hemorrhoids things needs to remember
MOA: promote coagulation of skin cells to protect underlying tissue and make area drier
External and internal use –up to 6 times per day
Analgesics, Anesthetics, Antipruritics for hemorrhoids ingredients
menthol, juniper tar, camphor
Analgesics, Anesthetics, Antipruritics for hemorrhoids
MOA: temporary relief of pain, itching, burning, or discomfort by producing a local sensation to distract from these complaints
External use only – up to 6 times per day
Rectum has no nerve fibers – no internal benefits
Use sparingly and do not ingest orally
Corticosteroids for hemorrhoids
1% hydrocortisone is only corticosteroid approved for nonprescription use in anorectal preps
Act as a vasoconstrictor and antipruritic
External use only – 3 to 4 times per day
May cause skin atrophy with prolonged use and rare skin reactions
Preparation H oinment Active Ingredients:
Available in ointment, cream, gel, and suppository product forms.
The Ointment contains Petrolatum 71.9%, Mineral Oil 14%, Shark Liver Oil 3% and Phenylephrine HCl 0.25%
