IBS / Diarrhea / Constipation / NV Flashcards
What is the Gastrocolic Reflex?
-Inherent urge to have a bowel movement 30mins after ingesting a meal.
-Colon has increased motility in response to stomach stretching with meal ingestion.
Role of PNS in gastric motility? Role of SNS in gastric motility?
PNS: Stimulate it.
SNS: Inhibit it.
How long can it take food to be completely processed by the digestive tract?
1-2d
What important hormone (95% of it) is produced in the Small Intestine?
Serotonin
In terms of a multiplying factor, how many more women suffer from digestive health issues on a weekly basis (relative to men)?
2x
On average, how many liters of fluid enter the Duodenum each day?
9L
-2L from Diet & 7L from Intestinal Secretions.
Approximately how many liters of fluid are absorbed by the Small Intestine each day? Large Intestine?
SI: 8L
Colon: 0.85L (850mL)
About how many mL’s of fluid are excreted in stool each day?
150mL
What could be some underlying causes as to why someone might have increasing constipation as they age?
-Disease States
-Drug Causes
-Immobile
-Fluid Intake (maybe)
Medically speaking, how is constipation defined?
< 3 bowel movements / week
What is the most common pattern of bowel movements (how many per day)?
1 per day (but pattern is seen in less than 50% of people)
Do most people have a bowel movement each day?
Nope (most people are irregular)
What are some major complications that can arise from constipation?
-Anal Fissures / Tears
-Rectal Bleeding
-Hemorrhoids
-Abdominal Swelling
-Bloating
Is constipation simply infrequent stool passages?
Nope… Can mean hard stools, difficulty passing stools (straining), or a sense of incomplete emptying after bowel movements.
Is pain a characteristic sign of constipation?
Nope… Consistent pain means start thinking of other conditions (ie. IBS).
How do anal fissures in kids bring upon constipation?
Induces withdrawal from performing normal bowel movements.
What is the most commonly encountered bowel type condition that we as Pharmacists encounter?
IBS (even more so than constipation).
After how many days should we expect to refer constipated patients to a Doctor (if OTC things don’t work)?
-7d (for lack of bowel movement)
-21d (for lingering constipation)
What are some red flags that can come about from being constipated?
-Change to Stool Texture
-Change to BM Routine
-Blood
-Hemorrhoids
-Weight Loss
-Reduced Appetite
-NV
-Frequent Pain
-Narrowing Stools
-Unresponsive to OTC Treatments
If left untreated, constipation can lead to what?
-Hemorrhoids
-Rectal Prolapse (part of Intestine pushes through Anus)
What are some causes of Large Bowel Obstruction?
-Growth / Tumor (most common cause)
-Volvulus
-Bowel Strictures caused by scar tissue formation
-Intussusception
-Impacted Stool
Symptoms of Large Bowel Obstruction?
-Belly Cramping
-Belly Swelling / Bloating
-Unable to Pass Gas
-Unable to Pass Stool
-Vomiting
Are Large Bowel Obstructions slow or quick in symptomatic progression?
Quick (& usually very dramatic, as those with LBO’s can’t pass Stools at all).
Is excessive fluid intake a good treatment option for someone with constipation?
Nope… Don’t need 2L of fluid intake per day (ingestion of 2L even through diet is fine). Just want to aim for normal hydration levels.
If I’m a chronic coffee drinker & have acute constipation, would I be in a fluid deficit (& thus require more fluid intake)?
Nope… Those who have coffee chronically are in no fluid deficits. Only those who don’t drink it & have one may be in slight fluid deficits.
Is upping fiber intake a good idea for treating constipation?
Not a bad move.
Some examples of foods that increase dietary fiber intake?
-Granola Bar (1g)
-1/4 cup Cashews (1g)
-Apple (3g)
-3/4 cup Bran Flakes (5g)
-3 tsp Metamucil (3.5g)
-Bran Muffin (4g)
Nursing Care plays a big role in ______ ________.
bowel retraining
What fruit is particularly effective as a natural laxative & contains both insoluble / soluble fiber (as well as antioxidants)?
Prunes
What agent contained within Prunes allows it to act as a natural laxative?
Sorbitol
For an adult wanting to use Prunes as a fiber enhancer, how much should they start by adding?
Approximately 4 Prunes (or 1/2 cup Prune Juice)
What are 1st line agents for constipative prevention?
Bulk Forming Agents… Forms of Soluble Fiber.
-Psyllium (Metamucil)
-Inulin
-Bran
Which one has a more gritty palatability to it: Inulin or Psyllium?
Psyllium
How many Oat Bran tablets per day are needed to be ingested in order to reach Bran Muffin levels of Fiber?
5-6tabs / day
How many days does it take for Bulk Forming Agents to work?
2-3d
How fast does Senna work? Enemas?
Senna: 6hrs
Enema: 15mins
How do Bulk Forming Agents work?
-Swell in Intestinal Fluid & create a gel-like substance (which facilitates passage).
Why should Psyllium be taken immediately with water?
-As it thickens upon standing (disgusting palatability & obstructive potential increases).
T or F: Psyllium administration requires a lot of additional water intake.
False… Isn’t a “jelly plug”. Regular water intake fine.
How should we start dosing Psyllium?
1 rounded tsp BID (then scale back every 3d until constipation is under management).
What does the body sometimes do to clear out Psyllium-Induced Obstructions (although very rare)?
Diarrhea (body attempts to generate more fluid to clear obstruction).
What was the original culprit of Psyllium-Induced Obstructions?
Formulation itself (used to come in granular form).
The Prodiem product with blue packaging contains what? Green packing contains what?
Blue: Sennosides (for acute relief of constipation).
Green: Polycarbophil (for prevention of constipation).
Prodiem Overnight Relief Therapy provides constipative relief in how many hours? Bulk Fiber Therapy provides relief in how many hours?
ORT: 6-12hrs
BFT: 12-72hrs
Product comparison: Psyllium vs. Inulin…
Psyllium: Thickens, OD-TID use, mix with water, lowers Cholesterol (5%).
Inulin: Non-Thickening, OD-TID use, add to fluid or food, lesser Cholesterol effects than Psyllium.
How do Metamucil Capsules differ from Metamucil Gummies (ie. Active ingredient used)?
Caps: Psyllium
Gummy: Inulin
How many Metamucil Capsules need to be taken each day to have the same effects as the powder?
6-8 Capsules
Why is Senna not favorable to use for chronic constipation flare-ups?
Alters normal gut etiology
Docusate is classified as a _____ ________.
stool softener
How does Docusate work?
Detergent (Micelle formation that allows better mixing of aqueous & fatty compounds)
What complaint does Jeff have about Docusate usage?
Vast majority of people underdosed (1-2 caps standard; should jump to using 4-8 caps instead).
For most people taking Docusate, when should we expect to see maximal effects (after how many days)?
1-2d (for some, up to 3-5d)
For Nursing Home patients, how many capsules of Docusate should they get each day? Palliative Care patients?
NH: 4 Caps / Day
PC: Up to 8 Caps / Day
Why is Mineral Oil contraindicated for concurrent use with Docusate?
Docusate greatly increases Serum Mineral Oil levels.
T or F: The brand name Docusate product Surfak (with 240mg Docusate Ca2+) is stronger / more effective than Colace (with 100mg Docusate Na+).
False… Are equipotent.
Are the Docusate concentrations in Senokot S effective?
Nope… 50mg (vs. 100mg in Colace) is sub-therapeutic.
What are the main problems with using Mineral Oil as a constipation lubricating agent?
-Anal Seepage
-Lipid Pneumonia (especially laying down)
No issues with fat-soluble vitamin absorption!
Why do we avoid bedtime dosing with Mineral Oil in order to treat constipation?
Risk of Lipid Pneumonia (that worsens when one lies down)
How long does orally administered Mineral Oil take to work?
6-8hrs
How do Osmotic agents such as Citro Mag work in the gut?
Formulation incorporates non-absorbable ions (ie. Mg2+ Citrate, MgOH), which remain in the gut & draws water towards them.
What are the primary indications for Osmotic / Saline agents?
-Bowel Evacuations (for Colonoscopies or acute constipative relief)
-Overnight Relief (Phillips)
How is Phillips MOM traditionally dosed for laxation? As an antacid agent?
Laxative: 30-60mL HS
Antacid: 5-15mL QID
What people should take caution using Osmotic Laxatives chronically?
-CHF & Chronic Renal Insufficiency (due to effects on electrolyte imbalances, fluid & salt overload).
Fleet Enemas provide constipative relief in how many mins?
2-5mins (extremely fast)
Non-Saline Osmotic agents include what sorts of products?
-Glycerin Suppositories
-Lactulose Syrup
-PEG 3350 (RestoraLAX)
What is the agent of choice for infants & children who have acute constipation and require quick relief?
Glycerin Suppositories (within 30mins)
How does Lactulose Syrup work within the Colon?
Lactic Acid metabolism in the Colon (via bacteria) draws water into the stool, thereby increasing osmotic pressure & stool volume.
How long does Lactulose Syrup take to work? What’s the OD dose given?
15-60mL; Works in 1-2d.
Can Lactulose Syrup be safely used in Diabetics?
Yep (sugars present in it are unabsorbed in the gut).
How much product is present in a capful of RestoraLAX?
17g
How long does PEG 3350 take to work?
Couple days
Jimmy is a 16yr old coming in for some acute constipative relief. He hasn’t seen a doctor yet, but is wanting to try RestoraLAX. What do you tell him?
Label states it shouldn’t be used < 18yrs (unless MD involved).
-Probably a safe agent to use, but on test don’t recommend under 18 (as the label says that) unless MD is involved.
How often should PEG 3350 doses be titrated up?
Every 2-3d (until dose that works alleviates the constipation).
Oral Stimulant agents such as Senna & Bisacodyl take around how many hours to relieve constipation?
6-12hrs
The old ExLax product contained what ingredient?
Phenolphthalein
What are some side effects of Stimulant agents used to treat constipation?
Diarrhea / Cramping
Where did Stimulant agents for constipation get a bad rap for overuse risk?
Anorexia world
How do we dose Senokot for constipation use?
2-4 tabs OD or BID
1-2 tabs OD or BID (if extra strength)
If somebody is taking T3s for pain relief & is put on Senakot for constipative relief, how might their dose on the first night differ if:
-T3 given late in 1st day?
-T3 given early in 1st day?
Late: 8mg 1st night
Early: 16mg 1st night
What really odd indication did Jeff discuss in class that a pregnant woman tried using Castor Oil for?
As a labor inducer
Colyte & PicoSalex are used for what?
Colonoscopy Flushing Agents
Probiotics: Good for acute constipation?
Nope (more used preventatively)
Constipative relief needed now… What’s better: Senna or PEG 3350?
Senna
Constipative prevention is desired… Senna or PEG 3350?
PEG 3350
When should we get concerned about elderly constipation?
-Unexplained New Onset (ie. Due to meds)
-Blood
-Weight Loss
-Fever
-NV
-History of Colorectal Cancer
In terms of bowel movement frequency, do breast fed or formula fed infants (on average) have more bowel movements?
Breast Fed > Formula Fed (3 vs. 2 / day)
Is there a reason to be concerned with an infant only having one bowel movement per week?
Nope (so long as no straining & stools aren’t dry & no sudden changes to the patterns of bowel movements).
When does infant type constipation usually rear its head?
Upon starting solid foods
What benefits would using a stool to prop the feet on have for kids undergoing a bowel movement?
Provides something to dig the feet into (provides straining power)
What’s a good rule of thumb to follow for upping a child’s fiber intake (as a preventative constipation measure)?
Age + 5 = Grams amount
Safe to use Senna & PEG 3350 in kids?
Absolutely
What is the lowest age that Pharmacists can recommend an Enema?
2yrs
For kids initiating PEG 3350, what should dosing be started at?
1/2 capful
Senna, MOM, Miralax or RestoraLAX… Are they safe to use in pregnancy?
100% (extremely minimal systemic absorption taking place)
-However, some concern with Senna & Bisacodyl (uterine contraction).
Are Bulk Forming Agents such as Psyllium & Inulin good for treating Opiate-Induced Constipation?
Nope… Slow OOA, Bloating, Gas as adverse side effects (& risk of obstruction rises).
Recommended 1st line prevention agent for Opiate-Induced Constipation?
PEG 3350
Common drug agents that can cause constipation?
-Opioid Pain Relievers
-Antihistamines
-TCAs
Which ABs are the main culprits of Drug-Induced Diarrhea?
-Fluoroquinolones
-Penicillins
-Cephalosporins
AB-Induced Diarrhea cases typically occur after how many days of therapy initiation?
2-3d (resolves when agent d/c)
Other commonly used drug agents that induce diarrhea?
-Antihypertensives
-H2 Receptor Antagonists
-NSAIDs
-PPIs
-SSRIs
Does Pepto Bismol have an indication for use in drug-induced diarrhea cases?
Nope
Probiotics good for prevention of drug-induced diarrhea?
Meh (evidence is still inconclusive but worth a shot if it’s a case of AB-induced diarrhea)
T or F: Actual incidence of food-related allergies is lower than the perceived incidence.
True (10% actual vs. 19% of Americans in a study believing to have them).
When do signs & symptoms of food poisoning rear their head?
Hrs - Even Weeks Later
MOA of Imodium?
Targets Meu Receptors in the gut & slows gastric motility.
Which products are better than Pepto Bismol as Antacids (although they take longer to work)?
Pepcid or Zantac
How does Kaopectate work to treat upset stomach from a disagreeable food?
Adsorbing agent… Attapulgite in it acts as a binding site to leach toxins out of the gut.
Culturelle Probiotics… Good for Food Intolerances?
Nope (might help with bacterial food poisoning but no help for food intolerances).
At what age do we not recommend using Imodium under? At what age is it C/I?
Not Recommend: 12yrs & Under
C/I: 2yrs & Under
VGE is most common in kids aged what?
3-24mths
Up to 50% of VGE cases are caused by what?
Rotavirus (sometimes Norovirus)
Typical length of time for a VGE infection?
1-3d (but gut needs 1wk to normalize)
How is the preventable Rotavirus Vaccine administered? When do kids get it?
-Orally (not via needle).
-Given at 2mths (1st dose) & 4mths (2nd dose).
In terms of % body weight loss, what is classified as mild pediatric diarrhea? Moderate? Severe?
Mild: Up to 5%
Mod: 6-9%
Severe: >/= 10%
In young infants (less than 18mths of age), what can be a telltale sign of cerebral dehydration?
Fontanelle Depression
What’s the rule for pediatric diarrhea referrals?
< 6mths: Refer!
1yr & less: 1d
1-3yrs: 2d
> 3yrs: 3d
When are Pedialyte solutions or Gastrolyte powders suitable add-ons?
Mild Diarrhea & dehydration is more of a concern (not needed if there are no signs of dehydration).
T or F: Anti-Emetics such as Gravol are recommended add-ons to mild diarrhea cases with concurrent vomiting.
False… Not recommended.
T or F: Kids should never drink juices during a VGE flu.
False… Osmotic force effects are blown way out of proportion.
T or F: Those on Infant Formulas must halt Lactose containing formulas for Lactose-Free ones during a case of VGE.
False… Old thinking was to go to Lactose-Free for a few weeks (but not necessary anymore).
Most common bug responsible for Traveler’s Diarrhea?
E. coli
T or F: The incidence of Traveler’s Diarrhea is higher in backpackers (vs. those staying at resorts), as well as with those on PPIs or H2 Blockers.
True!
What are some commonly prescribed ABs for Prevention of Traveler’s Diarrhea?
Azithromycin
Septra (TMP / SMX)
Preventative TD Pepto Bismol doses for people:
> 14yrs:
10-14yrs:
5-9yrs:
2-4yrs:
> 14yrs: 524mg QID
10-14yrs: 262mg QID
5-9yrs: 131mg QID
2-4yrs: 88mg QID
What does the Dukoral vaccine prevent?
Cholera Infection… Given to anyone over 2yrs (orally) & offers protection for 2yrs.
Treatment options once you get TD?
1) 1-3d AB + Loperamide
2) Loperamide alone
3) Pepto Tabs (2 x 262mg tabs q 0.5hrs up to 8 doses)
Once blood shows up in stool of a TD case, is Imodium a treatment option?
NOOOOOOOOO
In America, how low in age does Imodium packaging indicate use for?
6yrs & up (not allowed in Canada below 12yrs)
AB Prevention of TD didn’t work… Now what?
1) Switch to Pepto q 0.5hr dosing.
2) Switch to Loperamide.
Pepto Prevention for TD didn’t work… Now what?
1) 1-3d AB switch + Loperamide
Preventative treatment of Hep A & Hep B?
Vaccination! Twinrix is a dual vaccine that covers both (good idea to do).
What is the max amount of Imodium one can take / day?
16mg
North American _____ & Asian _____ more commonly have IBS.
women ; men
IBS symptoms?
-Over 6mths long
-Abdominal Pain / Spasm
-Bloating / Fullness
-Urgency
-Constipation / Diarrhea (spectrum of range)
-Mucous in stool (no bleeding)
T or F: IBS patients can have mixed stool patterning that changes over time.
True! Can be IBS-D & change to IBS-C (and vice versa).
What IBS symptom is much more prevalent in female cases (up to 75-90%)?
Bloating / Distention
What does “FODMAP” refer to?
Foods to avoid in IBS…
F - Fermentable
O - Oligosaccharides
D - Disaccharides
M - Monosacharides
P - Polyols
What type of IBS (C or D) is Psyllium recommended for?
IBS-C (some degree of helping with IBS-D but better for C).
How does Pinaverium work in IBS-D?
Ca2+ Channel Antagonist that induces muscle relaxation.
How does Trimebutine work in IBS-D?
Is an Opiate Receptor Agonist / 5HT-3 Receptor Antagonist.
Loperamide: Good for IBS-C or IBS-D?
IBS-D (2-4mg up to QID)
Inulin / Psyllium / PEG 3350 good for acute IBS-C flare-ups?
Nope… Too long to work. Use Senna instead!
Peppermint Oil: Good for IBS-C & IBS-D?
Meh (worth trying but taper expectations as evidence is inconclusive at best).
TCAs: Good for IBS-C or IBS-D?
IBS-D (as they have anti-cholinergic side effects & slow gut motility down).
SSRIs: Good for IBS-C or IBS-D?
IBS-C (as they have anti-constipative effects), but currently are of minimal value.
When would be the best time to put somebody with IBS-C on an SSRI?
If they also have depression (treats two conditions).
Alosetron: What’s its indication?
IBS-D women only (reduced diarrhea & pain by binding 5-HT3 receptors).
Tegaserod: What’s its indication?
IBS-C women only (prokinetic agent that agonizes 5-HT4 receptors).
Linaclotide treats mod-severe IBS-C… How does it work?
Guanylate Cyclase C Agonist… Stimulates GIT fluid secretions, increases colonic transit & reduces abdominal symptoms.
Viberzi (Eluxadoline)… How does it work to treat IBS-D?
Mu Opioid Agonist.
Solution for preventing nausea prior to taking Emergency Plan B?
1/2 - 1 tab Gravol
What’s the Benadryl salt derivative that has some value in Motion Sickness?
Dimenhydrinate
Can I give Gravol to kids < 6yrs (even if it has cough & cold ingredients in it)?
Absolutely safe to do so!
Can kids use Scopolamine patches?
Adult use only
Can 2nd gen AH agents such as Aerius or Claritin be used for Motion Sickness?
Nope… Only have AH component but we also require Anti-Cholinergic component.
T or F: Ginger has more proof for morning sickness use than motion sickness use.
True
Most cases of nausea / vomiting in pregnancy cease by how many weeks?
12wks
Major treatment of NV in pregnancy?
Diclectin (Doxylamine + Pyridoxine combo)
Gravol dosing for NV in pregnancy?
50-100mg q4-6hrs
