GI case studies Flashcards
Mr Frank is an 80 year old male who comes in requesting help with constipation. What guideline might you refer to in his case?
RxFiles- Constipation in older adults
Describe the stepwise approach to constipation
1) Establish patient is suffering from constipation and identify predominant symptom
2) Conduct a physical exam and rule out alarm features
3) Identify and treat reversible causes
4) Identify medications that might cause constipation
5) Recommend lifestyle changes
6) Initiate or alter laxative therapy and monitor efficacy and safety
What questions might you ask Mr Frank to determine if he is constipated?
What do you mean by constipation? How long have you had symptoms? What about your symptoms worry you the most? What do you hope to achieve?
You conduct a physical exam and want to rule out alarm features. What features would be alarming?
Physical: Masses, strictures, abnormal sphincter tone, feal impaction
History: fever, unintentional weight loss, blood in stool, if patient has felt masses, any night symptoms, vomiting, a lot of abdo pain, not passing gas, hx of colon ca or IBD, older than 50 with recent onset of symptoms, abnormal labs
Mr Frank states experiencing hard stools every 3 days (Bristol type 1) with straining. There are no alarm features in his history or physical exam. What would you prescribe for him, if anything?
Don’t prescribe yet! Follow the step wise guideline. We will ID and treat reversible causes, identify meds that might cause constipation, and recommend lifestyle changes first.
You assess Mr Frank for conditions/ disease that can cause constipation. Give some examples of diseases you are looking for.
Cancer/ cancer related
Endocrine (hypothyroid, dm, hyperparathyroid)
GI (diverticulosis, IBS, pelvic floor dysfunction, …. )
Metabolic
Neurologic (including dementia, MS, PD, SCI, stroke)
Psych
Other (i.e., lack of time for toileting)
What medications could cause constipation?
Analgesics (opioids, NSAIDS), anticholinergics, anti- parkinson, anticonvulsant, antidepressant, antidiarrheal, antihistamine, antihypertensives, antispasmodics, cation agents, chemo, resins
What lifestyle changes might you suggest to relieve constipation?
activity, fiber and fluid intake, regular toilet routine
You review lifestyle factors with Mr Frank. Can we send him home now?
For discussion.
You decide to initiate Mr Frank on a laxative. What drug and dose would you start him on?
constipation in older adults guideline (rx files) recommends bulk forming agent (then followed by osmotic laxative followed by a stimulant laxative if needed)
Psyllium (metamucil) 3.4 g PO with at least 1 cup of fluids. Space 2 hours apart from other medications.
Mr Frank actually realizes he does take metamucil every day! He asks if there is something else he could try.
Next step- osmotic laxatives.
i.e., PEG 3350 17g po daily in 250ml of fluid
Mr Frank is happy to try PEG, but wonders- how fast will it work? Are there any side effects?
48- 96 hours
Dose dependant nausea, abdo bloating, cramping, diarrhea, flatulence
(Rx files)
Mr Frank is wondering- should he take this medication every day from now on?
For discussion.
I think ideally not. I think the idea here would be to use it until he has a bowel movement, while working on incorporating lifestyle factors?
Mr Frank is wondering if he could try Milk of Magnesia instead! His friend says it works very well.
What should you consider?
This is an osmotic laxative.
It has a faster onset (0.5-6 hours)
It is contraindicated in renal and cardiac impairment, so would want to assess for these.
Mr Franks other friend uses Docusate for his constipation- should he try this instead?
There is likely a better option. Docusate (stool softener) has insufficient evidence for treatment of constipation, less effective than other agents.
