Ex. 6 - Constipation (66-67) Flashcards
How do you define constipation
Usually involved both decreased frequency plus signs and symptoms (>25% of the time)
-Cramping
-Bloating
-Lumpy/hard dry stools
-Straining
-Sensation of incomplete evacuation or blockage
Constipation stats
Over 4M in US are frequently constipated
At least 2.5 M/yr see their MD for constipation
More common in women, non-white and elderly
Most patients treat themselves
$500m to $800m yearly spent on tx
30-50% of elderly frequently use laxatives
-Higher in LTCF
Disorder of colonic motility or anorectal function
ABCs of defectaion
Muscles of mechanical barrier
Puborectalis
EAS
IAS
-Normally, the muscles tend to relax, go normally
Dyssynergic defecation
-Neurologic system plays a role
GI transit time
Mouth to anus time: Normally 30-40 hrs
Can be up to 72 hrs
-Anything speeds up: watery stools
Anything slows down: hard, dry stools - constipation
Food move too slowly through GI tract
Movement of water in and out of stool
-Slow transit results in more time for colon to absorb water from waste
-Resulting in stool, becoming hard and difficult to push out
Acute constpation
A noticeable change in normal bowel movement pattern
-Less than 3 bowel movements/week
Other key features
-Stools dry and hard
-BMs is painful and stools difficult to pass
-Feeling that bowels have not been fully emptied
Usually brought on by change in condition or drug
Chronic constipation
Primary causes
-Normal transit “Functional” symptomatic - (most common)
Slow transit
Evacuation disorder
Secondary causes
-Medications
-Obstruction (cancer, stricture)
-Metabolize (e.g. hypothyroid, hyprecalcemia)
-Neurological (eg. parkisnonism, MS)
Systemic (eg. sclerdoerma, amyloidosis)
-Psychiatric (depression, eating disorders)
Chronic constipation criteria
-Straining
-Lumpy or hard stools
-Sensation of incomplete evacuation
-Sensation of anorectal obstruction/blockage
-Manual maneuvers to facilitate defecations
-<3 defecations per week
Chronic constipation cont.
Symptoms lasting>6 weeks
-May respond to laxative tx but returns when laxatives d/c
-Does not respond to dietary changes alone
Chronic Idiopathic Constipation
-No identified cause
Constipation: Common causes
Especially if elderly
Dietary
-poor fluid intake
-decreased calorie intake
Failure to heed defecation reflex
Impaired physical mobility
Lack of privacy (LTCF)
Increased psychological distress
Disease states that slow down GI motility
-Diabetes
-Parkinson’s
-CNS injury or disease
-MS
Common drug causes of constipation
Analgesics/Opioids
-Mu receptor agonist in GI tract
Leading cause
Analgesics/NSAIDS
-NSAIDs to a much less extent than opioids
-Inhibition of PGs
-Prostaglandin E series play a significant role in GI physiology
-intestinal motility
-intestinal fluid movement
Antacids
-Aluminum, Calcium
Agents w/strong anticholinergic properties
-Antihistamines, antimuscarinics, amitriptyline
-Verapamil, Clonidine, Ca channel blockers
-Iron preparations
-Diuretics
-Chronic use of stimulant laxatives ???
-unlikely if normal doses are utilized
When to refer
Refer pt to PCP if:
-Symptoms have persisted (with appropriate interventions) for greater than two weeks w/o significant relief
-Who has black or tarry stools
-who has marked abd pain or discomfort
-who has a fever
-Also has severe nausea/vomiting
-Has a family history of IBD or colon cancer
-has drastic change in severity or nature of symptoms
Questions to ask patients complaining of constipation
How long have you been constipated? Why?
How often do you normally have a bowel movement?
-Why?
What is the size and color of your stools
-Why?
-Black stools indicate blood!!
Have you noticed periods of constipation mixed w/diarrhea?
-why?
Have you noticed a change in the caliber of the stool?
-Why?
Do you have much gas?
Why?
-gas shows GI tract is working
Has your appetite or weight changed?
-Why
What have you tried so far?
-Why
Bristol stool scale
Slow Transit
Type 1:
-Separate, hard lumps like nuts
Type 2:
-Sausage-like but lumpy
Type 3:
Like a sausage but with cracks in the surface
Type 4:
Like a sausage or snake, smooth and soft
Type 5:
Soft blobs with clear cut edges
Type 6:
Fluffy pieces with ragged edges, a mushy stool
Type 7: Watery no solid pieces
Fast transit
Measures to help promote regular bowel habits: water
Include ample fluids and fiber in diet
-6-8 glasses of water per day
Measures to help promote regular bowel habits: High fiber
Add high fiber foods to diet slowly
-20-30 g of fiber per day
-increase fiber over 7-10 days
-Minimize gas
-Natural fiber is degraded by bacteria
-Vegetables, fruits, beans, whole grains
