Week 2

Question 1

Definition of constipation from Canadian Association of Gastroenterology?

Answer 1

• symptom based
• fewer than 3 stools per week
• mostly hard/lumpy stool
• difficult stool passage (straining, incomplete evacuation) x 6 months

Question 2

Constipation

Risk factors

Answer 2

• female
• physical inactivity
• medications
• depression
• poor dietary intake
• frailty, bed bound

Question 3

Common medications that cause constipation

Answer 3

NSAIDs
opioids
Anticholinergic drugs (think SSRIs, TCAs, paroxetine, oxybutynin)
Antihistamines

BP meds: Beta blockers, calcium channel blockers (esp verapamil), diuretics

OTC: aluminum, calcium, iron

Question 4

Constipation

3 subtypes of primary causes

Answer 4

1. slow transit (reduced colon motility)
2. Dyssynergic defecation (unable to expel stool)
3. IBS-C (visceral hypersensitivity, associated with abdo pain)

Question 5

What Bristol stool type is considered:

• constipation
• diarrhea

Answer 5

constipation: 1-2
diarrhea: 6-7

Question 6

Constipation

what to assess on physical exam

Answer 6

DRE: impaction, mass, fissures, sphincter tone, hemorrhoids

women: posterior vaginal mass
men: prostate hypertrophy

Question 7

Constipation red flags

Answer 7

age over 50
change in stool calibre
weight loss (over 10 lbs)
hematochezia
obstructive symptoms
night symptoms
family hx colon cancer of IBD

Question 8

What is ROME IV criteria definition of functional constipation

Answer 8

Functional constipation: 2 or more of the following:

• straining
• lumpy hard stools
• sensation of incomplete evacuation
• use of digital maneuvers to relieve symptoms
• sensational of anorectal obstruction or blockage with 25% of bowel movements
• decrease in stool frequency (<3 BM per week)

2+ symptoms must be present for last 3 consecutive months
Onset of any symptom for 6 months before making diagnosis of constipation(!)
Symptoms do not meet criteria for IBS

Question 9

What is ROME IV criteria of IBS-constipation?

Answer 9

IBS-C definition:
-recurrent abdo pain or discomfort for at least 3 days per month in the last 3 months
-onset of symptoms 6+ months before diagnosis
Associated with at least 2 of the following:
-improvement of pain or discomfort upon defecation
-onset of symptoms associated with changes in frequency of stool
-onset of symptoms associated with change in stool form or appearance

Question 10

Constipation

lab and imaging workup if no red flags?

Answer 10

CBC and ferritin
(if new onset iron def –> colonoscopy)
TSH, Ca, glucose, selective screening

XR

Question 11

Constipation

recommended daily fibre amount?

Answer 11

20-35 g/day 
increase slowly (5g / week) or bloating

Question 12

Constipation

bulk-forming laxatives

• patient education
• caution with?

Answer 12

• need to increase fluid intake or constipation will be worse
• take 2 hours before/after meds

Not recommended for: high dose narcotic, dysphagia, surgical resection, possible bowel obstruction, suspected rectal mass, unable to increase fluids, cognitive impairment

Question 13

Constipation

osmotic laxatives

• examples?
• common side effects?

Answer 13

PEG 3350 or lactulose or glycerin suppositories
PEG more effective, glycerin less effective if stool is dry and hard

s/e: bloating, cramping, diarrhea, flatulence

CAUTION do not give PEG with electrolytes to pts with CHF or CKD (PEG without lytes ok)

Question 14

Constipation

What laxatives should be avoided or used with caution?

Answer 14

• docusate (no effect)
• mineral oil po (aspiration)
• sodium phosphate enema (electrolyte imbalance)
• PEG With electrolytes (electrolyte imbalance, do not give if CHF or CKD)