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OTC > Exam 4 - Constipation > Flashcards

Exam 4 - Constipation Flashcards

1
Q

Parts of the small intestine

A

Duodenum
Jejunum
Ileum

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2
Q

What does the small intestine do?

A

Breaks down food
Absorbs nutrients
Extracts water
Moves food along GI tract

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3
Q

Duodenum

A

First part of the small intestine

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4
Q

What feeds into the duodenum?

A

Stomach
Liver
Gallbladder
Pancreas

(Silly Little Gay People)

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5
Q

Chemical digestion

A

Occurs due to liver, gallbladder, and pancreas sending digestive juices into the duodenum

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6
Q

Jejunum

A

Middle (second) part of the small intestine

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7
Q

What is the jejunum made up of?

A

Many coils that contain many blood vessels

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8
Q

What happens in the jejunum?

A

Muscles churn food back and forth so it mixes with digestive juices

(This just sounds like it would happen in the middle)

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9
Q

Peristalsis

A

Keeps the food moving forward in the jejunum

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10
Q

Ileum

A
  • Last and longest section of the SI
  • Walls start to thin and become more narrow
  • Reduced blood flow
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11
Q

Where does food spend a majority of digestive time?

A

In the ileum

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12
Q

Where is the most water and nutrients absorbed?

A

In the ileum

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12
Q

How long does ingested food stay in the stomach?

A

For about 3 hours

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13
Q

After being in the stomach, where does the ingested food go?

A

It moves to the SI for about 3 hrs

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14
Q

Peristaltic waves

A

Moves the partially digested food from the SI toward the duodenum

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15
Q

Partially digested food is moved by contractions from the small intestine to the _____

A

Large intestine

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16
Q

What is defecation controlled by?

A

Both voluntary and involuntary reflexes

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16
Q

Where is fecal matter stored

A

In the sigmoid colon until defecation

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17
Q

What can constipation stem from

A

Primary or secondary mechanisms

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18
Q

Secondary constipation

A

Systemic, neurologic, and psychological disorders and/or structural abnormalities

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19
Q

Primary constipation

A

Slower than normal GI transit time or a defamatory disorder (ie pelvic floor disorder)

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20
Q

What factors can contribute to constipation?

A

Inadequate dietary fiber and fluid intake

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21
Q

Dietary fiber

A

Dissolves or swells in intestinal fluid causing an increase in fecal bulk to lan in stimulating peristalsis and elimination of stool

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22
Q

Diets low in ______ may be associated w/ decreased bowel movements/constipation

A

Calories, carbs, or fiber

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23
Q

What does inadequate intake of fluids lead to?

A

Developing dehydration w/ consequential constipation

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24
Q

How many visits to the hospital are because of constipation?

A

2.5 million visits per year

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24
Q

Common causes of constipation

A

Structural issues
Lack of physical exercise
Inadequate fluid intake
Psychological
Some medications

Inadequate fiber intake

Systemic

(SLIPS In Shit)

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25
Q

Clinical descriptions of constipation

A
  • Feeling as though not a complete evacuation
  • Passing hard, dry stool
  • Straining
  • Decreased frequency
  • Passing small stools

(Feeling Pretty Shitty, Don’t Push)

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26
Q

Constipation definition

A

Usually defined as having fewer than 3 bowel movements per week and involves straining/difficult passage of hard, dry stools

*not a set definition because it can look very different for different people

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27
Q

Medications that can cause constipation

A

Antacids
Anticholinergics
Antihistamines
Calcium supplements
Opioids

(3 antis)

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28
Q

What antacids most commonly cause constipation?

A

Calcium and aluminum compounds
Bismuth subsalicylate

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29
Q

What anticholinergics most commonly cause constipation?

A

Bentropine and glycopyrrolate

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30
Q

What antihistamines commonly cause constipation?

A

Diphenhydramine
Loratadine

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31
Q

Calcium supplements that commonly cause constipation

A

Calcium carbonate

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32
Q

What can happen if constipation is left untreated?

A

Hemorrhoids
Rectal prolapse
Anal fissures
Fecal impaction

(Having Rough Ass Fucks)

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33
Q

Psychological issues that cause constipation

A

Stress
Depression
Eating disorder

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33
Q

Structural issues that cause constipation

A

Colorectal injury/inflammation
Other structural abnormalities
Pelvic floor disorders

(COP)

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34
Q

Systematic causes of constipation

A

Parkinsonism
Diabetes
MS
Menopause
Dementia
Dehydration
IBS
Thyroid disorders
Dietary fiber

(Please Don’t Make Me Do Drugs In The Dark)

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35
Q

In addition to the typical clinical descriptions, what can be seen in patients who are constipated?

A

Bloating
Flatulence
Lower back pain
Anorexia
Abdominal discomfort
Lethargy
Dull headache

(Been Feeling Like Ass A Lot [of] Days)

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36
Q

When can constipation be treated w/ self care measures?

A

When it is occasional and temporary

**continuous constipation lasting over several weeks-months or if it is complicated by other conditions requires sustained and aggressive treatment

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36
Q

Exclusions to self care for constipation

A
  • Blood in stool or dark, tarry stool
  • Daily laxative use
  • Anorexia
  • Chronic medical condition that may preclude
  • Recurring bowel symptoms after dietary/lifestyle changes
  • Age less than 2
  • Nausea/vomiting
  • IBS
  • Unexplained flatulence
  • Marked abdominal pain/dissension/cramping
  • Symptoms lasting longer than 2 weeks or recur over 3 months
  • Fever
  • Unexplained changes in stool

(Big Dumb Ass CRANIUMS Fuck Up)

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37
Q

Different treatment approaches to treat constipation

A

Lifestyle changes
Pharmacologic interventions

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38
Q

American Dietetic Association fiber recommendations

A

Adult women: 25 g daily
Adult men: 38 g daily

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39
Q

Fruits and vegetables

A

Increase stool mass and normalize bowel movements

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40
Q

How long does it take for a high fiber diet to start having an effect?

A

3-5 days

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41
Q

What can increasing dietary fiber intake cause?

A

Erratic frequency
Flatulence
Abdominal discomfort

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42
Q

Recommendations for increasing dietary fiber intake

A

As fiber increases, so should fluid intake

  • Eight 8 oz glasses a day
  • Pregnant/lactating women need more
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42
Q

How should you go about increasing your dietary fiber intake?

A

Gradually increasing over a few weeks

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43
Q

Bulk forming fiber laxatives

A

Methylcellulose (citrucel)
Calcium polycarbophi (fibercon)
Psyllium (metamucil)

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43
Q

What foods are high in fiber?

A

Oats

Potatoes
Almonds
Weet bix
Peas
Apples
Wholemeal bread

Bananas
Oranges
Broccoli

Corn
Spinach
Strawberries

Quinoa
Lentils
Chickpeas

(Old PAWPAW BOB Can’t See Shit, Quit Looking Close)

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43
Q

Contraindications to dietary fiber

A

Intestinal obstruction
Abdominal pain
Inadequate fluid intake

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44
Q

Dietary fiber supplements

A

Inulin (FiberChoice, Metamucil Clear & Natural)

Partially hydrolyzed guar gum (Sunfiber)

Powdered cellulose (Unifiber)

Wheat dextrin (Benefiber)

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45
Q

Systematic adverse drug reactions in bulk forming agents

A

Abdominal cramping
Flatulence

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45
Q

Dosage forms of bulk forming agents

A

Powders
Capsules
Gummies
Tablets
Wafers
Chews

(Painful Constipation? Get The Water Can)

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45
Q

Types of pharmacologic interventions for constipation

A

Bulk forming laxatives
Lubricant laxatives
Emollient laxatives (stool softeners)
Saline laxatives
Stimulant laxatives
Hyperosmotic laxatives

(BLESS Him)

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45
Q

What is the treatment of choice for constipation in most cases?

A

Bulk forming agents such as Metamucil, FiberCon, and Citrucel

This is because they closely mimic the body’s natural processes

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46
Q

Onset of bulk forming agents

A

12-24 hours but may take up to 72 hours

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46
Q

What do laxative recommendations depend on?

A

The underlying cause of constipation and patient preferences

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47
Q

Counseling on bulk forming agents

A

Must take w/ adequate liquid

Useful in short term constipation relief

Sugar content may be an issue for those w/ diabetes or restricted caloric intake

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47
Q

MOA of bulk forming agents

A

Absorb water and form emollient gels that stimulate peristalsis

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48
Q

Hyperosmotic agent age restrictions

A

Only use in 17+

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49
Q

Who can use glycerin

A

Adults and children

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50
Q

Onset of hyperosmotic agents

A

12-72 hours but could take up to 96 hours

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51
Q

ADRs for hyperosmotic agents

A

Bloating
Flatulence
Abdominal discomfort
Cramping
Electrolyte/fluid imbalance

(B FACE)

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52
Q

Exclusions for the use of hyperosmotic agents

A

Patients w/ renal disease or IBS should be referred

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53
Q

Directions of use for hyperosmotic agents

A

Take po qd prn

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53
Q

Administration of hyperosmotic agents

A

17g (one capful/packet) mixed w/ 4-8 oz of water

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54
Q

What is the hyperosmotic agent glycerin used for

A

Lower bowel evacuation

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55
Q

Dosage forms of glycerin

A

Solid and liquid suppositories

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55
Q

Onset of glycerin

A

15-30 min

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56
Q

Dosing of glycerin

A

One suppository used once or as directed by PCP

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57
Q

Who should avoid using glycerin?

A

Patients w/ preexisting rectal irritation

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57
Q

What do emollients (stool softeners) do?

A

Soften fecal mass by increasing the wetting efficiency of intestinal fluid to help the mixing of aqueous and fatty substances

57
Q

ADRs of glycerin

A

Rectal irritation (more likely w/ overuse)

57
Q

Why are emollients used?

A

To prevent straining and painful defecations due to recent abdominal or rectal surgery, pregnancy, and postpartum

58
Q

Dosing of docusate sodium and docusate calcium (stool softeners)

A

50-300 mg daily either in single or divided doses

59
Q

Docusate sodium usual doses

A

50 mg or 100 mg

60
Q

Docusate calcium usual doses

A

240 mg capsules

61
Q

Onset of emollients (stool softeners)

A

12-72 hours; may take up to 3-5 days to see full effects

62
Q

What may happen if you take a larger than recommended dose of stool softeners?

A

Adverse effects such as:
- weakness
- sweating
- muscle cramping
- irregular heartbeat

63
Q

What are stool softeners often used w/ in constipation

A

Stimulant laxatives

Mainly for opioid induced constipation

64
Q

What is the only available OTC lubricant product

A

Mineral oil (liquid petroleum)

65
Q

MOA of lubricants

A

Softens fecal contents by coating the stool and preventing reabsorption of water by the colon

66
Q

Onset of lubricants

A

PO: 6-8 hrs
Rectal: 5-15 hrs

67
Q

What are important counseling points for mineral oil?

A

Patients must remain upright after taking po dosing

Do not use in patients at risk for aspiration

Larger than recommended dosing may lead to oil leakage via anal sphincter or anal pruritis

68
Q

Interactions w/ mineral oil

A

May impair absorption of fat soluble vitamins

Do NOT use w/ docusate because it can cause increased mineral oil absorption

69
Q

Who should NOT use mineral oil

A

Patients younger than 6 yrs
Pregnant women
Bedridden/older adults
Patients w/ difficulties swallowing

70
Q

What are the types of saline laxatives

A
  • Magnesium citrate
  • Magnesium hydroxide (milk of magnesia)
  • Dibasic and monobasic sodium phosphate
  • Magnesium sulfate
71
Q

MOA of saline laxatives

A

Draws water into the SI and LI (oral products) or into the colon (rectal) through osmosis

Promotes GI mortality

72
Q

Dosage forms of saline laxatives

A

Liquid/solid oral ingestions
Liquid for rectal insertion

73
Q

Indications for saline laxatives

A

Constipation

Acute bowel evacuation (colonoscopy prep)

74
Q

When is it okay to use magnesium hydroxide (milk of magnesia)

A

Occasional use in otherwise healthy patients

75
Q

Onset of magnesium hydroxide (milk of magnesia)

A

30 min to 6 hrs after admin

76
Q

Dosing for magnesium hydroxide (milk of magnesia)

A

400 mg/5 mL product

2-4 tablets or 30-60 mL daily as single or divided doses

77
Q

Magnesium citrate is commonly used for

A

Colonoscopy

78
Q

Onset of magnesium citrate

A

PO: 30 min - 1 hr
Rectal: 2-15 min

79
Q

How should you administer magnesium salts

A

W/ 8 oz of water to prevent dehydration

80
Q

What can occur w/ long term use of magnesium salts

A

Electrolyte imbalances (ie. Hypermagnesemia)

81
Q

Who should avoid using magnesium salts?

A

Patients on sodium, phosphate, or magnesium reduced diets

Patients at increased risk of magnesium toxicity (newborns, older adults, renal impaired)

82
Q

ADRs in magnesium salts

A

Dehydration
Abdominal cramping
Nausea/vomiting

(DAN)

83
Q

What can sodium phosphate cause

A

Hyperphosphatemia
Hypocalcemia
Hypernatremia

84
Q

Who should use caution w/ sodium phosphate

A
  • Patient who are renally impaired
  • Patients on sodium restricted diets
  • Patients on meds that may affect serum electrolyte levels (ie diuretics)
85
Q

In what patient group is sodium phosphate contraindicated in?

A

Patients who have experienced congestive heart failure (CHF)

86
Q

What patients should NOT use rectal admin of sodium phosphate

A

Patients with:
- megacolon
- GI obstruction
- colostomy
- imperforate anus

87
Q

What is the ONLY OTC use of sodium phosphates

A

Constipation ONLY - NOT bowel prep

Recommended not to exceed 1 dose in 24 hours

88
Q

How are stimulant agents classified?

A

By chemical structures and pharmacologic activity

89
Q

Types of stimulant agents

A

Anthraquinones (senna)
Diphenylmethanes (bisacodyl)

90
Q

Dosing for senna

A

17.2 mg once daily

91
Q

Dosing of bisacodyl

A

1-3 tablets once daily

92
Q

Adverse effects of stimulant agents

A

Cramping
Nausea/vomiting
Dehydration

93
Q

Where is the primary site of action of stimulating agents?

A

Colon

94
Q

MOA for stimulating agents

A

Increases intestinal peristalsis through mucosal irritation or stimulation (which increases gut motility)

Increases secretion of water and electrolytes in the intestine

95
Q

Onset of action for stimulating agents

A

PO: 6-10 hours after admin, may take up to 24 hours

Rectal: 15-20 min after admin

96
Q

Major concerns of stimulating agents

A
  • Severe cramping
  • Electrolyte and fluid deficiencies
  • Enteric loss of protein
  • Malabsorption due to hypermotility and catharsis
  • Hypokalemia
97
Q

Stimulating agent overdose symptoms

A

Sudden vomiting
Nausea
Diarrhea
Severe abdominal cramping

98
Q

What is often used to treat opioid induced constipation

A

Stimulating agents and docusate

99
Q

What happens w/ prolonged use of senna

A

Possible harmless, reversible melanotic pigmentation of colonic mucosa

Can be seen on sigmoidoscopy, colonoscopy, or rectal biopsy

100
Q

What is counseling point of using senna

A

Can color urine pinkish red, shades of violet, or reddish brown

101
Q

What testing result can be inaccurate due to the use of senna

A

Presence can affect interpretation of phenolsulfonphthalein test (test to diagnose kidney stones)

102
Q

Bisacodyl coating

A

Enteric coating on tabs to prevent irritation of gastric mucosa

103
Q

Counseling point of using bisacodyl

A

Do not break, crush, chew, or give w/ agents that increase gastric pH

104
Q

What can you NOT consume when taking bisacodyl? Why?

A

Antacids
H2RAs
PPIs
Milk (within 1 hr)

Causes rapid erosion of enteric coating, leading to gastric or duodenal irritation

105
Q

Cascara sagrada, casanthranol, and phenolphthalein

A

Deemed not safe and not effective

Still marketed as dietary supplements

106
Q

Aloe and rhubarb

A

Should NOT recommend
Not included in FDA guidelines

107
Q

What is the 1st line treatment for constipation

A

Bulk forming agents

Ex. Citrucel, fibercon, metamucil

108
Q

What should be used if faster onset is needed than the first line treatment can provide?

A

PEG

109
Q

What should be the last option for constipation?

A

Stimulants

Ex. Senna and bisacodyl

110
Q

What is considered a complementary therapy for constipation?

A

Castor oil

111
Q

Castor oil was historically viewed as what?

A

A stimulant laxative BUT actual mechanism is unknown

112
Q

How fast does castor oil work?

A

Acts quickly and has significant laxative effects

113
Q

What can prolonged use of castor oil lead to?

A

Excessive loss of fluid, electrolytes, and nutrients

114
Q

Patient preferences

A

Palatability and convenience

Liquid formulations and emollients may be more palatable if mixed w/ juice

Mixing gritty, bulk forming laxative powders (like psyllium) w/ orange juice instead of water may increase palatability

Patient may prefer water or “single serving” packets of bulk forming laxatives for convenience and ease of use

115
Q

When should you seek medical attention for constipation

A

All treatment options should have visible effects in 2-5 days

If symptoms worsen

If symptoms are not resolved within 7 days of initiating self care measures

Patient meets any exclusions to self care

116
Q

How is constipation defined in kids?

A

Based on age

Typically a delay of difficulty over a period of 2 days

117
Q

How many kids are affected by constipation?

A

Up to 37% of children

118
Q

What is the most common cause of abdominal pain in children?

A

Constipation

119
Q

Factors affecting bowel habits in children

A

Dietary changes (human to cow milk)

Fear of defecation (after it hurts once, child may withhold defection, exacerbating the issue)

Chronic medical conditions

Toilet facilities

Emotional distress (family conflicts)

Change in routine/environment (going to school for the first time)

(Don’t Force Children To Empty Colon)

120
Q

Signs/symptoms of fecal impaction

A
  • Constipation accompanied by watery diarrhea
  • Abdominal cramping
  • Fecal soiling
  • Rectal bleeding
  • Small, semi-formed stools

(Cause Ass Feels Really Stuffed)

121
Q

How can mild constipation be relieved in children?

A

By dietary or behavioral changes

  • increase WATER intake
  • drinking fruit juices containing sorbitol (prune, apple, pear)
  • eating high fiber cereals, grains, vegetables, and fruits
122
Q

What is the recommended dietary fiber intake for children?

A

Age + 5 g a day

123
Q

Nonpharmacologic recommendations for parents/caregivers

A

Establish a regular stooling time for toilet training children (after morning meals)

Develop a reward/support system (positive talk; charts/stickers)

Encourage kids to go as soon as they feel the urge

124
Q

Oral laxatives approved for self care in children 2-6 years of age

A

Docusate
Magnesium hydroxide
Senna

125
Q

Rectal laxatives approved for self care in children 2-6 years of age

A

Use of glycerin
Mineral oil
Sodium phosphate

126
Q

Oral laxatives approved for self care in children 6-12 years of age

A

5 Ms:
- Methylcellulose
- Mineral oil
- Magnesium citrate
- Magnesium hydroxide
- Magnesium sulfate

Calcium polycarbophil
Docusate sodium
Senna
Bisacodyl
Castor oil

127
Q

Rectal laxatives approved for self care in children 6-12 years of age

A

Glycerin
Mineral oil
Sodium phosphate
Bisacodyl suppositories

128
Q

First line treatment in children 2-6 for constipation

A

Oral docusate sodium and/or magnesium hydroxide

129
Q

If faster relief is needed in children 2-6 for constipation

A

Use pediatric glycerin suppositories

130
Q

If all other treatments fail in children 2-6 for constipation

A

Oral senna
Oral magnesium citrate
Rectal mineral oil
Sodium phosphate enema

131
Q

First line treatment in children 6-12 for constipation

A

Bulk forming agents
Oral docusate sodium
Oral magnesium hydroxide

132
Q

Use if faster relief is needed in children 6-12 for constipation

A

Glycerin or bisacodyl suppositories

LAST RESORT: mineral oil or sodium phosphate enema

133
Q

Use if other treatments have failed in children 6-12

A

Oral stimulants

134
Q

How many elderly patients in community based settings experience constipation

A

Up to 20%

135
Q

How many elderly patients in nursing homes experience constipation?

A

Up to 50%

136
Q

Risk factors in advanced age patients

A
  • Dietary changes (fluid restrictions, reduced calorie)
  • Physiologic changes
  • Decreased physical activity
  • Increased use of constipating medications
  • Comorbid conditions

(Decrepit Patients Die In Constipation)

137
Q

What are generally considered safe in patients of advanced age?

A

Rectal therapy w/ suppositories or enemas

138
Q

First line treatment in advanced age patients

A

Lifestyle modifications

*Consider fluid restrictions due to comorbidities

139
Q

Second line of treatment in advanced age patients

A

Bulk forming laxatives > PEG 3350

Stool softeners IN ADDITION TO other pharm and nonpharm recommendations

140
Q

Which stool softener is best in patient w/ anal fissures and/or hemorrhoids

A

Docusate

141
Q

Medications to avoid/use with caution in patients of advanced age

A

Mineral oil
Saline laxatives
Sodium phosphate products

142
Q

Why should patients of advanced age avoid using mineral oil?

A

Aspiration risks

143
Q

Why should patients of advanced age avoid using saline laxatives?

A

Fluid
Electrolyte depletion
Magnesium toxicity
Drug interactions

144
Q

How many pregnant patients experience constipation during pregnancy/postpartum

A

1/3 women

145
Q

What meds should be avoided for pregnant women?

A

Castor oil
Mineral oil
High doses/long term saline laxative use

146
Q

Why should castor oil NOT be used in pregnant women

A

Uterine contractions and rupture

147
Q

Why should mineral oil NOT be used in pregnant women?

A

Impairment of fat-soluble vitamin absorption

148
Q

Why should high doses/long term saline laxative use NOT be used in pregnant women?

A

Electrolyte imbalance

149
Q

First line treatment of constipation in pregnant patients

A

Dietary measures

150
Q

Second line treatment in pregnant patients

A

Bulk forming laxatives and docusate for dry/hard stools

151
Q

What medications are considered LOW risk in pregnancy

A

Senna
Bisacodyl

152
Q

What medications are compatible w/ breastfeeding? Why?

A

Senna
Bisacodyl
PEG
Docusate

Minimal absorption
Don’t accumulate in significant amounts in breastmilk

153
Q

What meds should you AVOID during lactation?

A

Castor oil
Mineral oil

154
Q

What percentage of patients experience constipation while taking opioids?

A

40%

155
Q

Why do opioids cause constipation?

A

Opioids bind to bowel and CNS receptors to decrease GI motility and intestinal secretions

This causes longer retention time of fecal matter and consequent drying of the stool

156
Q

Does opioid formulation matter when it comes to constipation?

A

Oral agents are generally more constipating that parenteral agents

Transdermal fentanyl patches are less constipating than oral agents

157
Q

Medications for acute opioid induced constipation

A

Saline laxative or rectally administered

158
Q

What may be needed for acute opioid induced constipation?

A

Preparations may be needed for acute evacuation

159
Q

What is most commonly recommended in chronic constipation?

A

Stimulants

160
Q

What is typically NOT effective in chronic constipation?

A

Stool softeners alone

161
Q

Combination treatment for chronic constipation

A

Emollient (stool softeners) and a stimulant

162
Q

What can excessive use of laxatives cause?

A

Acute diarrhea/vomiting
Fluid/electrolyte loss (hypokalemia)
Dehydration

163
Q

Risk factors for laxative overuse

A

Patients without symptoms of constipation but take laxatives for regular (daily) BMs or those wanting softer stool

People using laxatives to “detox the system”

Patients w/ eating disorders (anorexia, bulimia)

Elderly patients

Patients w/ misconceptions about normal frequency

Patients w/ fear of constipation

OTC (28 decks)

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