PooPoo Flashcards
Functional Constipation
- Cause
- criteria for irritable bowel syndrome not sufficiently met*
associated with difficult or delayed evacuation, hard stools, abdominal bloating or discomfort
≥ 2 of the following:
- straining during ≥ 25% of defecations
- lumpy or hard stools during ≥ 25% of defecations
- feeling of incomplete evacuation during ≥ 25% of defecations
- feeling of anorectal obstruction or blockage during ≥ 25% of defecations
- manually facilitating defecation during ≥ 25% of defecations
- < 3 unassisted bowel movements/week
Slow Transit Constipation
- cause
- treatment
-associated with prolonged time between bowel movements, lack of urge to defecate, abdominal distention, bloating, and discomfort
1st- Hyperosmotic laxatives [miralax, lactulose]
Senna, bisacodyl and other stimulants are SECOND line
outlet dysfunction (or defecatory disorder)
associated with excessive straining and feeling of incomplete evacuation due to mechanical causes such as Hirschsprung disease, anal stricture, cancer, prolapse, rectoceles, or pelvic floor dysfunction
Secondary Constipation
due to diet, lifestyle, pregnancy, advanced age, medications or underlying medical conditions
Constipation Alarm Signs
acute onset (especially in elderly)
fever
nausea and/or vomiting
unintentional weight loss > 10 lbs (4.5 kg)
anemia
hematochezia
melena
positive fecal occult blood test
change in bowel habits
symptoms refractory to conventional therapy (regardless of age)
family history of colon cancer or inflammatory bowel disease
emollient (stool softener)
mechanism - decreases surface tension allowing water to enter stool more easily; Facilitate mixing of aqueous and fatty materials in the intestinal tract
agents - dioctyl sodium sulfosuccinate (docusate sodium, Colace) 100 mg orally twice daily, Peri-Colace
usually well tolerated
may be useful in bed bound patients at risk of fecal impaction
*****Used for prevention, NOT treatment.
Commonly prescribed with medications that may cause constipation (chronic opiate use, iron supplementation)
**Safe in pregnancy
Bulk Laxative
mechanism - hydrophilic, colonic bacteria produce osmotically potent metabolites
agents - Fibercon 2 tablets orally 1-4 times/day with 8 ounces water after each dose, Citrucel or Metamucil 1 Tablespoon orally 1-3 times/day with 8 ounces water after each dose
usually well-tolerated, may cause flatulence and bloating
contraindicated if partial mechanical obstruction
Administer 240 mL of water with each dose to prevent esophageal / GI obstruction and worsening symptom
**Physical binding of other substances including medications
*Safe in pregnancy
saline laxative
mechanism - increase colonic motility via release of cholecystokinin; Osmotic effects to retain fluid in GI tract (hyperosmolar)
agents - milk of magnesia 30 mL/day, magnesium citrate 30 mL/day, Fleet enema 1 enema (118 mL) rectally
- magnesium-containing laxatives risk hypermagnesemia with chronic use in renal insufficiency
- phosphate-containing laxatives risk hypocalcemia with high doses
enemas risk traumatic and toxic damage to rectum
**May be used occasionally to treat constipation in otherwise healthy adult
****ADRs: fluid and electrolyte disturbances: Mg (renal dysfunction) or Na (CHF) accumulation
hyperosmolar laxative
mechanism - metabolized by colonic bacteria to hydrogen and organic acids, causing osmotic effect
agents - lactulose 1-2 Tablespoons orally 1-2 times/day; PEG; glycercin; Sorbitol
usually well-tolerated, may cause transient bloating, may alter electrolyte transport and colonic motility
stimulant laxative
mechanism - direct stimulation of myenteric plexus of colon; induce fluid and electrolyte secretion or induce peristalsis
agents - castor oil 30-60 mL/day, bisacodyl (Dulcolax) 5-15 mg/day, phenolphthalein 1-2 tablets/day
may affect electrolyte balance, may precipitate hypokalemia, fluid and salt overload, diarrhea; other adverse effects specific to stimulant used
-SHORT TERM
PEG
Hyperosmolar
not absorbed and lacks electrolytes, good option for patients with renal or cardiac dysfunction
Safe in pregnancy
Lubricant Laxative
Coats stool to allow easy passage / Prevents colonic water absorption
Systemic absorption – can generate immune response
Aspiration – may lead to lipoid pneumonia
Decreases absorption of fat-soluble vitamins
***DO NOT use in pregnancy
meds that CAUSE blocked poopie
Opiates Anticholinergics (eg. tricyclic antidepressant (amitryptiline), diphenhydramine, benztropine, etc) NDHP-CCB (eg verapamil) Oral iron preparations Calcium or aluminum antacids NSAIDs Clonidine Diuretics
those who need to avoid straining (eg hemorrhoids, hernia, MI)
Stool softeners or PEG
Children Tx for Constipation
1) Diet, fluid exercise
2) Avoid under 6 years without evaluation
3) Glycerin suppository, docusate
Diarrhea Treatment (Self vs Not-self)
self treat
—- <3-9% body weight; <5 poopies; minimal s/e
NOT self-treat
—- > 9% body weight loss; +6 poopies; fever, low BP, dizzy, severe abd pain
Diarrhea Treatment Goals
Goal of treatment: Identify and Treat primary cause, Manage secondary causes, prevent electrolyte & acid/base disturbances & dehydration , provide symptomatic relief
Note the primary goal is NOT ALWAYS to stop diarrhea (see below, Infectious diarrhea)!
- -Non-pharmacological
- —- Rehydration , oral preferred
- ———Avoid Soda products, Gatorade*, broth, Tea
- —-Diet
- ———Resume age-appropriate diet once rehydrated
- —–Secondary causes can include medications. An evaluation of medications an possible substitution of offending medications should be considered (if possible)
- ———Magnesium containing antacids, metformin (1/3 of patients), antibiotics (25% incidence), anti-inflammatory / anti-gout agents (eg. colchicine), etc
Opiates and derivatives; AKA Antimotility / Antiperistaltic agents
- Acts on peripheral (eg loperamide (Immodium)) and central (eg diphenoxylate/atropine (Lomotil)) opioid receptors depending on the agent.
- **[ atropine avoided to avoid abuse]
- **Those that act on central mu receptors are control substances and prescription only
- Noninfectious diarrhea (acute & chronic)
- -Adverse effects: constipation, fatigue, dizziness
Adsorbents
APolycarbophil calcium
Works through non-selective adsorption, providing bulk in digestive tract
-Not systemically absorbed
- Binds 60 times its weight in water
- –Also used for constipation (absorbs water / fluids)
- Can also bind drugs leading to altered drug bioavailability
Antisecretory agents (2)
Bismuth subsalicylate
-for acute diarrhea
Contraindications
- ASA allergy
- Nursing or pregnant women
- GI bleeding
- Immunocompromised patients
Drug interactions
- Decrease protein binding of warfarin
- Decrease absorption of TCN, quinolones
Octreotide
-severe secretory diarrhea assc with chemo, HIV, DM, GI tumor etc.
- SQ or IV 50 mcg TID
S/E: nausea, bloating, gallstones
Crofelemer
FDA approved for symptomatic relief of non-infectious diarrhea in patients with HIV/AIDS on anti-retroviral therapy
Probiotics (diarrhea)
- Help maintain normal GI flora, reduce colonization of disease-causing bacteria
Evidence - Vary based on intended use (acute treatment, prevention, antibiotic associated, adults, children), strain of bacterium and timing of administration
Digestive enzymes
Lactaid
Use in patients with lactase deficiency who are lactose intolerant
Clostridium difficile (3)
- cessation of the inciting antibiotic as soon as possible
- NONsevere tx:
- –oral metronidazole
- -s/e-> dose-dependent peripheral neuropathy; nausea and metallic taste.
——-» oral vancomycin for pregnant, breast feeding,
flagyl allergy
Rifaximin— Small case series have suggested that sequential therapy with vancomycin followed by Rifaximin may be effective for the treatment of recurrent CDI
Traveler’s diarrhea and tx
Mild / severe
Escherichia coli
–self-limited with symptoms lasting for approximately one to five days
For mild to moderate disease, anti-motility drugs(eg. loperamide) may be used as monotherapy
- **Antibiotics are warranted to treat diarrhea in those who develop severe diarrhea, characterized by
- ****- more than four unformed stools daily, fever, or blood, pus, or mucus in the stool.
- —-In addition, some travelers desire antibiotic treatment for milder disease if the illness is a large burden on a business trip or vacation.
For sever disease, anti-motility drugs(eg. loperamide) may be used cautiously as adjunctive therapy
use in combination with simethicone may provide faster relief of symptoms
