Constipation & Diarrhoea Flashcards
What is constipation characterised by (4)
- Reduced frequency of bowel movements
- Unable to completely empty the bowel
- Hard small lumpy stools
- Due to slowing and water reabsorption
What are the symptoms of constipation (8)
- Straining
- Feeling of incomplete emptying
- Distension
- Abdominal pain
- Pain
- Nausea & vomiting
- Discomfort
- Wind
What are the possible causes of constipation (10)
- Insufficient fibre in diet
- Insufficient fluid in diet
- Lack of exercise
- Medication (E.g. opiates, TCA’s, Iron, diuretics…)
- Ignoring the urge to pass stools
- Irritable bowel syndrome (IBS)
- Pregnancy
- Old age
- Long-term laxative usage (senna pods, or laxative abuse)
- Cancer
What are the complications of constipation (4)
- Faecal impaction
- Haemorrhoids
- Rectal Prolapses
- Anal Fissures
What are the likely causes of constipation from most likely to very unlikely (4)
Most likely - Eating/lifestyle
Likely - Medication
Unlikely - IBS, pregnancy
Very Unlikely - Colorectal cancer
What is faecal impaction (4)
- Untreated constipation
- Dried hard stools collect in rectum
- Increased pressure causes muscles in rectum to weaken
- Overflow incontinence
What happens during faecal impaction (5)
- Large hard stool difficult to pass
- Large baggy rectum stretches to accommodate
- More stool comes adding to the blockage
- Watery stool works around hard stool
- Anal sphincters over time may lose tone
What are faecal impactions treated with (3)
- High-dose osmotic laxative
- Bisacodyl suppository
- Sodium citrate enema
When should constipation be referred to the GP (10)
- less than 10 years old
- Constipation/alternating with diarrhoea
- Blood/mucus in stools
- Major change in bowel habit - over 40y/o
- Regular medication - causative
- Duration over 14 days - adult
- Duration over 7 days - child
- Weight loss (Unintentional)
- Lethargy
- Pregnancy
What treatment is there for constipation (8)
- increase fibre (soluble and insoluble)
- increase fluid
- gentle exercise
- Stimulant laxatives - Senna
- Bulk-forming laxatives - Ispaghula husk
- Osmotic Laxatives - lactulose
- Bowel Cleansing Preparations- pre-surgery - NPSA safety alert for bowel cleansing preps
- Peripheral Opioid-receptor antagonists
What do bulk-forming laxatives do (6)
- Increase faecal mass
- Stimulate peristalsis (movement of food through GI tract)
- Full effect takes days
- Used if cannot increase fibre in diet (e.g. IBS)
- Need to increase fluid to avoid intestinal obstruction
- Make up with water – drink within 10 minutes
What are examples of bulk-forming laxatives (3)
- ispaghula husk (Fybogel, Isogel)
- methylcellulose (Celevac)
- Sterculia (Normacol)
What do stimulant laxatives do (8)
- Taken at night (ON)
- Stimulate peristalsis (movement of food through GI tract)
- Senna exact opposite of opiods
- Can cause abdominal cramp
- Avoid in intestinal obstruction
- Odd: Dantron-carcinogenic-palliative care only
- Old: Castor oil, liquid paraffin, cascara-obsolete
- Leached fat soluble vitamins from body
What are examples of stimulant laxatives (4)
- Bisacodyl
- sodium picosulphate
- senna, docusate (softener and stimulant)
- Glycerol suppositories - direct rectal stimulant
What do osmotic laxatives do (3)
- Increase the amount of water in the large bowel
- Drawing water from the body into the bowel retaining fluid they are administered with
- Lactulose is a semi-synthetic disaccharide - not absorbed in the GIT
How does lactulose work (3)
- Discourages proliferation of ammonia-producing organisms so used hepatic encephalopathy
- Slow to work
- Can cause abdominal cramps
What are examples of osmotic laxatives (2)
- Movicol - Macrogols-inert polymers of ethylene glycol
- Lactulose
What are bowel cleansing preparations (3)
- Used before colonic surgery, colonoscopy, or radiological examination of the bowel to evacuate the bowel
- Not treatments for constipation
- Care-fluid and electrolytes disturbances
What are peripheral opioid-receptor antagonists in relation to constipation (5)
- e.g Methylnaltrexone
- used in opioid-induced constipation in patients receiving palliative care
- subcutaneous injection
- Response to other laxatives insufficient
- Adjunct to existing laxative therapy
How are laxatives abused and what causes (4)
- Method of dieting
- Regular use of laxatives can reduce effectiveness
- Electrolyte disturbances
- Also may have older customers who have got into the habit of it for no good reason
What is diarrhoea (6)
- Increased passage of more watery and loose stools
- Increase in secretion of fluid into bowels
- May also be vomiting
- Losing weight
- Abdominal cramps and bloating
- Acute → chronic classification
How is diarrhoea classified from acute to chronic (3)
- Acute - less than 7 days
- Persistent - more than 14 days
- Chronic - more than 28 days
What are the infective causes of diarrhoea (5)
- Viral - V. unpleasant often rotavirus (Vaccine to prevent)
- Bacterial
- Travellers – enterotoxin E. coli
- C. difficile
- Protozoal
What are non-infective causes of diarrhoea (9)
- Other conditions (IBS, IBD)
- Intolerance
- Laxative use/abuse
- Drug – PPI, NSAID, Dig…
- Abx → gut bacteria change
- Alcohol (excess)
- Running
- Stress
- Menstruation
What are the likely causes of diarrhoea from most likely to very unlikely (4)
Most likely - viral & bacterial infection
Likely - Medication-induced
Unlikely - IBS, overflow from impaction
Very Unlikely - IBD, cancer
When should diarrhoea be referred (8)
- Long-term change in bowels - over 50 y/o
- Recent travel to tropical/ subtropical climate
- 2-3 days if unable to keep fluid in
- Blood, mucous or fat in stools
- Suspected faecal impaction
- Severe abdominal pain
- Worsening fever
- Dehydration
What are the diarrhoea referral times in children (3)
- less than 1 Y/O → over 1 day of symptoms
- 2-3 Y/O → over 2 days of symptoms
- over 3 Y/O → over 3 days of symptoms
What are the clinical features of mild diarrhoea (2)
- anorexia
- lightheaded
What are the clinical features of moderate diarrhoea (8)
- dry mouth
- sunken eyes
- decreased skin turgor
- thirsty
- tired
- dark strong-smelling urine
- dizziness
- postural hypotension
What are the clinical features of severe diarrhoea (9)
- hypovolaemic shock
- oliguria
- anuria
- cold extremities
- rapid weak pulse
- low BP
- seizures
- coma
- death
When should diarrhoea be referred in mild, moderate and/or severe stages (3)
Mild - no referral
Moderate - referral & rehydrate immediately
Severe - referral & emergency IV fluids needed
What are the clinical features of diarrhoea in infants (6)
- Sunken soft spot (fontanelle) on top of their head
- Sunken eyes
- Few or no tears when they cry
- Dry and light many nappies
- Being drowsy or irritable
- And other diarrhoea symptoms
What are the treatments for diarrhoea (12)
- Good hand hygiene essential to not infect others or reinfect
- Alcohol gel not enough as if bacterial spores won’t be killed
- Stay home from work or school until 48 hours until after symptoms
- Normal feeding as much as possible
- Often start with bland, toast etc
- Oral rehydration sachets
- Important to have most of your fluids as electrolyte and especially in young children
- Drug treatment
- Antimotility drugs (opiates) loperamide (care- can be abused)
- co-phenotrope
- codeine morphine (not generally recommended, holding back bacteria)
- Adsorbents- kaolin- no longer recommended (harbours bacteria)
What are oral rehydration therapies (7)
- Replace fluids and electrolytes MOST IMPORTANT THING
- Important to make up properly
- Typically 1 sachet + 200 mL water
- Contains alkalising to counter acidosis
- Hypo-osmotic so water is not drawn into the GI tract (which would make diarrhoea worse)
- Dioralyte and electrode are common
- WHO rehydration formula - 1L water, ½ tsp salt, 6 tsp glucose (absorption of Na is ↑by glucose)
How is loperamide used for diarrhoea (7)
- Doesn’t cross BBB (blood-brain barrier) (no opiate like analgesia or addiction)
- Uncomplicated diarrhoea
- Not under 4 years old
- Can be in IBS if over 18 and official diagnosis
- Dose 4 mg stat + 2 mg after each bowel movement up to 16 mg a day
- Morphine may be used similarly
- Reports of serious cardiac adverse reactions with high doses or abuse/misuse
What are the preventative measures to diarrhoea (8)
- Hand hygiene wash hands with warm water and soap (gel if not)
- Drying: Disposable paper towel > newer high force air dryers > old air dryers
- Food hygiene
- Go from raw to cooked and not back
- Raw at the bottom of the fridge, cooked at top (no dripping)
- 2-8° C (ideally <5°C)
- Clean toilet areas
- Avoid sharing towels and cutlery etc
What are the causes of C. difficile (5)
- Hospital-acquired infection (more of a colonisation)
- When Abx used in hospital
- broad spectrum cephalosporins and quinolones (oxacins)
- Limits and fines on hospitals on cases
- Limit with Abx stewardship
What are the treatments for C. difficile (3)
- Review meds: Withdraw causative Abx, avoid PPI
- Oral metronidazole or Vancomycin
- Faecal transplant if not working
