W10. Consitpation Flashcards
What is constipation
*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
Bristol Stool chart
should present type 3-5
two maint ypes of contstipation
- 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
what are the GI motor disorders that cause constipation
*dont respnond well to laxatives
what diseases are associated with seocndary constipation
- as age becomes more prevelant
- but when suffer from dementia risk doubles
causes of constipation in cnacer patients
- 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
constipation and fatigue
- linked to prolonged fatigure states
so inc prevelance in mental health states like
depression, anxiety, chronic fatigue syndrome, fibromyalgia, IBS
drugs related causes for constipation
anticholinergics
opiod: gut paralysis
diuretics: cause dehydration
red falgs for constipation
- 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)
Precipitating factors
quality
region
symp associated
time
to ask a patient with constipation
- 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?
Patient analysis for constipation
- 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
cycle of chornic constipation
How do lifestylefactors are linekd to consstipation
- supressing of urge to deficate
inadequate fluid and fiber intake
chronic anxiety
acute eemotional distress
infrequent physical excercise
non pharm methods for prevention
min vol 1.5L water to prev constipation *main method
- fiber, toilet routine, bowel retaining, excercise
how much fiber is req for each age group
adult female need 25g fiber, male 30g
pregnant 28g
breastfeeding 29g
*aim for 12-15% fiber on nutritional face label
diff types of fiber
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
pre/probiotics and constiation
5 pro/pre biotics with level 1 evidence
- activia good option
BioGaia, Visbiome also good options
what are the 5 classes of laxatives on market
bulk forming agents
osmotic agents
stool softeners
saline laxatives
stimulant laxatives
bulkf forming agents
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!!!)
Psyllium concern
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
what line are bulk forming
what are contraindiactions
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
osmotic agents for constipation
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
best for fast acting product
glycerin suppository
Lactulose and diabetes
- sweet but not abs systemically so will not alter their sugar
can recommmend safely
AE of osmotic agents
can cause diarrhea, so start low and go slow
smotic agent of choice for constipation
PEG
onset of action for 3 days
best for kids too
avoid high doses in children
Purgative agents for constiaption
PEG with electrolytes
- shoudl eb supervised by HC provider or caregiver
- much higher dse, use for impacted bowl
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
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)
who should not take saline laxatives
elderly, CHF, renal failure and young
when shoudl enemas be used
only pre scope
or is prescribed by a health care provide due to impaction
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
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
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
