W10. Consitpation Flashcards

1
Q

What is constipation

A

*must include 2 symptoms at 25% of defecation

straining

lumpy or hard stools

sensation of incomplete evacuation

sesation of anorectal obstruction/blockage

  • <3 movements/week
  • manual maneuvers to facilitate defication
  • loose stores rate

*DISCOMFORT NOT PAIN

*IBS is not part of this, usually includes pain of defication

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2
Q

Bristol Stool chart

A

should present type 3-5

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3
Q

two maint ypes of contstipation

A
  • Primary, functional or idopathic constipation
    • idopathic = unknown
    • linked to GI motor disorders
    • normally see normal transit constipation: colonic nolility is unaltered or normal, but the stool is very hard and diff to pass
      • patient exp bloating, discomfort and difficulty passing
      • they respond best
      • 60% of cases
    • Other grup is slow retention constipation
      • leads to fecal retention, stool forms hard mass and leakage around stool plug. common in children
  • Secondary constipation
    • disease or mediaction linked
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4
Q

what are the GI motor disorders that cause constipation

A

*dont respnond well to laxatives

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5
Q

what diseases are associated with seocndary constipation

A
  • as age becomes more prevelant
  • but when suffer from dementia risk doubles
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6
Q

causes of constipation in cnacer patients

A
  • 50% of cancer patients

usual mechs: Tumor compression of the large intestine, i nterference with colonic neural innervation

  • also caused by

¨Hypercalcemia secondary to bone metastases

¨Hormonal changes

¨Chemotherapy, either directly or indirectly due to poor hydration and nutritional status resulting from nausea and vomiting

¨Direct intestinal radiation

¨Opioid use

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7
Q

constipation and fatigue

A
  • linked to prolonged fatigure states

so inc prevelance in mental health states like

depression, anxiety, chronic fatigue syndrome, fibromyalgia, IBS

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8
Q

drugs related causes for constipation

A

anticholinergics

opiod: gut paralysis
diuretics: cause dehydration

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9
Q

red falgs for constipation

A
  • unintented weight oss > 10 lbs

onset of symptoms >50

family history of colrectal cancer or IBS
N/V/adbonimal pain, fever, balck tar stools (melina)

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10
Q

Precipitating factors

quality

region

symp associated

time

to ask a patient with constipation

A
  • P
    • Any recent changes in her medications?
    • What are her eating and exercise patterns?
    • What has she tried for the constipation?
  • Q:
    • Consistency of BM?
    • Ability to pass?
    • Frequency of BM
  • R
    • Is there bloating, gas, or tenderness in abdominal area
  • S
    • Is there any black tarry stool or blood in the stool?
    • Any pain when defecating?
  • T
    • Time since last BM?
    • How long has this been occurring?
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11
Q

Patient analysis for constipation

A
  • Is the client suffering from primary or secondary constipation?
  • Are the signs and symptoms related to disease or drug? Or both?
  • Does she require drug treatment? (think of req, bloating, faltulance, discomfort)
  • Is current therapy effective?
  • What would happen if not treated?

*constiaption is hgihger incidence in women, diruetic is common secondary cause of cosntipation

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12
Q

cycle of chornic constipation

A
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13
Q

How do lifestylefactors are linekd to consstipation

A
  • supressing of urge to deficate

inadequate fluid and fiber intake

chronic anxiety

acute eemotional distress

infrequent physical excercise

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14
Q

non pharm methods for prevention

A

min vol 1.5L water to prev constipation *main method

  • fiber, toilet routine, bowel retaining, excercise
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15
Q

how much fiber is req for each age group

A

adult female need 25g fiber, male 30g

pregnant 28g

breastfeeding 29g

*aim for 12-15% fiber on nutritional face label

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16
Q

diff types of fiber

A

soluble fiber: gel like and soften stool: lentils, peas, oats, barely

insoluble: adds bulk helps to pass, green veg and strigny veg
- lots of fruits have sortibol which is also fiber source

want 3 insoluble:1 isoluble

17
Q

pre/probiotics and constiation

A

5 pro/pre biotics with level 1 evidence

  • activia good option

BioGaia, Visbiome also good options

18
Q

what are the 5 classes of laxatives on market

A

bulk forming agents

osmotic agents

stool softeners

saline laxatives

stimulant laxatives

19
Q

bulkf forming agents

A

insoluble fibers that inv voluem of stool in intestinal llumen

act like sponges and abs volume in intestinal tract to help soften stool

due to water retention is it V important to keep drinkign 1.5L of water, if not can act like cement and worsen constipation

  • type main ingredients: Psyllium (laxa day) and Inulin(Canada)/ Wheat dextran(US) aka (metamucil),

*metamucil is very gritty, adherence is low, not aial in capsule and wafer form (not gluten free!!!)

20
Q

Psyllium concern

A

18% of aptients exposed in HC setting notted to have an allergic anaphylactic rxn: asthma attack or other allergic reaction

  • do not inhale the powder form
21
Q

what line are bulk forming

what are contraindiactions

A

1st line

constaindicatin: gastic obstruction, fecel impaction, swallowing difficulties

*woudl make fecal impaction must worse

*if patient not passing gas and no bowel movement in 4-5 days dont use this as the first agent, can maybe add on for maintenance later on

22
Q

osmotic agents for constipation

A

unqiue mechanism

  • non abs ions or mol that are broken down by gut flora
  • acidifies the intestinal lumen and then creates and osmotic gradient where water is drawn from body into intestinal lumen, this softens stools
  • only laxative family with grade A evidence to inc stool freq and consistenct
  • PEG is the first line agents for pediatricts
    ex: glycerin suppository (fast acting), lactulose, sorbitol 70%, PEG (restoralax, miralax, Lax a day)

*glycerin is good for fast res (acute cases), the others better for maintenance *only targets last bit of digestive tract

23
Q

best for fast acting product

A

glycerin suppository

24
Q

Lactulose and diabetes

A
  • sweet but not abs systemically so will not alter their sugar

can recommmend safely

25
AE of osmotic agents
can cause diarrhea, so start low and go slow
26
smotic agent of choice for constipation
PEG onset of action for 3 days best for kids too avoid high doses in children
27
Purgative agents for constiaption
PEG with electrolytes - shoudl eb supervised by HC provider or caregiver - much higher dse, use for impacted bowl
28
stool softeners for constipation
act is surfactats and softed stool acting as surfactants \*no RCT - not actually efficacious, not better than placebo - ex: docusate sodium and calcium, - Ex: lubricants: mineral oil (oral and enema form) -\> AVOID IN CHILDREN AND ELDERLY bc large risk of aspiration - patients feel like they work because they have been on forever - dont recommend ever! - some very small evidence for use postpartum to prevent hemrhoids
29
saline laxative
create osmotic gradient through electrolyte imablance - faster acting oral: Mg hydroxide, Mg citrate, sodial phosphate oral, milk of magnesium enemas: tap water, soap suds, mg enema, phosphate soda, saline enema, mineral oil (used for release of impaction lower in intestinal tract, or before a scope) \*dont use tap water or soap suds anymore bc of irritation - mechanism is also downfall, \*only consider for young health patients that need fast relief for short term (enema works in 5-10 min, be near a toilet, and go at first sense of urgency)
30
who should not take saline laxatives
elderly, CHF, renal failure and young
31
when shoudl enemas be used
only pre scope or is prescribed by a health care provide due to impaction
32
Stimulant laxatives
- produce rhythmic contractions in the intestines - senna, bisacodyl, cascara castor - use in case of slow transit bowel to enhance paristallisis and with opiod usage to prevent constipation - can cause lazy bowel and dependency with overusage Myth: melanosis Coli has not been shown to be statistically significant Ex-lax Anthraquinone has been removed from products so not longer a risk
33
homeopathic/herbal ageents
- no randomized control trails and little evidence to suport - aloes, bitter orange, buckthorn, dandelion, elderberry, flaxseed, lavender, licorish, rhibarb, soy - flexseed is a soluble fiber that is an effective laxative - yellow dock is an effective laxative but its safety has not been detinitvely established
34
what are the goals of therapy
requirements: * Eliminate impaction * Improve stool consistency * Return frequency to normal or minimum \>3/ week. * Reduce bloating or discomfort * Improve quality of life, behavioral modification * Avoid complications of constipation * Use laxatives appropriately for prevention \*minimize use of ineffective treatment, minimzie cost, maximize quality of life, increase patient satisfaction of patient, empowerment, self confidence