Constipation Flashcards

Question

Qu'est-ce que le prucalopride?

Answer 1

C'est un agoniste sérotoninergique 5-HT₄. Il crée une neurotransmission cholinergique, nonadrénergique et noncholinergique qui cause une stimulation du réflexe péristaltique, de sécrétions intestinale et de la motilité intestinale. Il est contre-indiqué dans les situations suivantes: * Hypersensibilité * Dialyse * Obstruction ou perforation interstinale * Iléus obstructif * MII sévère Parmi les effets secondaires qu'on voit fréquemment avec ce médicament, on comprend: * les céphalées (22%) * les nausées (17%) / vomissement (5%) * des dlr abdo (12%) * des diarrhées (12%) * des flatulences (5%)

Answer 2

* Hypercalcémie * Hypokaliémie

Answer 3

Occlusion intestinale (grêle) * Dilatation d'anses grêles (notez les valvules conniventes qui traversent la lumière intestinale) * Niveaux hydro-aériques * Faible aération du côlon

Answer 4

Fréquence: 40 /min Rythme: irrégulièrement irrégulier Onde P: présente devant chaque QRS; PR constant Critères d'hypertrophie auriculaire: non (revoir les critères au besoin) PR: 200 ms; normal Axe: normal QRS: 80 ms Critères d'hypertrophie ventriculaire: non (revoir les critères au besoin) ST et repolarisation: normal QT/QTc: 420 / 340 ms Conclusion: bradycardie sinusale avec pauses sinusales

Answer 5

Leucocytose extrême avec bicytopénie. Il s'agit ici d'une leucémie lymphoïde chronique (LLC).

Answer 6

1. Establish that the patient is suffering from constipation and identify the predominant symptom. 2. Conduct a physical examination and rule out alarm features. 3. Identify and treat reversible causes. 4. Identify medications that might cause constipation. 5. Recommend lifestyle changes (ie, activity, fibre and fluid intake, regular toilet routine) for patients with deficiencies (eg, low fibre or fluid intake, inactivity) and when interventions are safe. 6. Initiate or alter laxative therapy and monitor efficacy and safety.

Answer 7

The Rome III Criteria for Adults are often cited in the literature for diagnosing constipation, but are used more in research than in clinical practice. Constipation is diagnosed when 1. 25% of bowel movements are associated with at least 2 of the following symptoms, occurring in the previous 3 mo with an onset of symptoms of at least 6 mo: * straining * hard or lumpy stools * a sense of incomplete evacuation * a sense of anorectal obstruction * the need for manual maneuvers * fewer than 3 defecations per wk 2. loose stools are rarely present without the use of laxatives 3. there are insufficient criteria for irritable bowel syndrome The Canadian Association of Gastroenterology defines constipation as symptom based, including a combination of **fewer than 3 stools per wk**, stool form that is mostly **hard or lumpy**, and **difficult stool passage** (need to strain or incomplete evacuation) for more than 6 mo. Questions to ask your patients to determine whether they are constipated: * What do you mean by constipation? * How long have you had your symptoms? * What about your symptoms worries you the most? * What do you hope to gain or achieve? The **Bristol Stool Scale** is a validated tool that correlates stool consistency with colonic transit time. The scale can be helpful for patient assessment and monitoring, and as a clinical communication aid to help patients discuss their bowel movements with their physicians. Stool types 1 and 2 indicate constipation, with types 3 and 4 being the ideal stools (especially the latter), as they are easy to defecate while not containing any excess liquid. Types 5, 6, and 7 tend toward diarrhea.

Answer 8

Most important questions to ask your patient: 1. Have you had any **fever**, had **unintentional weight loss**, had **blood** in or on your stool, felt any **masses** (abdominal or rectal), had **night symptoms**, or had any other unexplained symptoms? 2. Are you **vomiting**? 3. Do you have a **lot of abdominal pain**? 4. Are you still **passing gas**? 5. Do you have a **family history** of colon cancer or inflammatory bowel disease? Other alarm features: * Age **older than 50 y** with recent onset of symptoms * Abnormal laboratory bloodwork results (eg, **anemia or iron deficiency**)

Answer 9

1. **Cancer or cancer-related causes** * colorectal cancer, * dehydration, * intestinal radiation, * tumour compression of large intestine 2. **Endocrine causes** * hormonal changes, * hypothyroidism, * diabetes, * hyperparathyroidism 3. **Gastrointestinal disorders** * diverticulosis, * Hirschsprung disease, * irritable bowel syndrome, * megacolon, * pelvic floor dysfunction, * rectoceles, * strictures 4. **Metabolic causes** * hyp**_er_**calcemia, * hyp**_o_**calcemia, * hyp**_o_**kalemia, * hyp**_o_**magnesemia, * hyp**_o_**pituitarism, * panhyp**_o_**pituitarism, * uremia 5. **Neurologic causes** * ****autonomic neuropathy, * dementia, * multiple sclerosis, * muscular dystrophies, * pain secondary to anal fissures or hemorrhoids, * Parkinson disease, * spinal cord lesions, * stroke 6. **Psychological causes** * anxiety, * depression, * eating disorders 7. **Other causes** * older age, * chronic kidney disease, * pregnancy, * systemic sclerosis, * sexual abuse, * lack of privacy or time

Answer 10

1. **Analgesic drugs** * nonsteroidal anti-inflammatory drugs, * opioids (25% to 40% in noncancer patients and ≤90% in cancer patients) 2. **Anticholinergic drugs** * ****antipsychotic drugs, * benztropine, * oxybutynin 3. **Anti-Parkinson drugs** * ****amantadine, * bromocriptine, * pramipexole 4. **Anticonvulsant drugs** * gabapentin, * phenytoin, * pregabalin 5. **Antidepressant drugs** * tricyclic antidepressants, * paroxetine 6. **Antidiarrheal drugs** * ****diphenoxylate, * loperamide 7. **Antiemetic drugs** * dimenhydrinate, * ondansetron, * prochlorperazine, * promethazine, * scopolamine 8. **Antihistamine drugs** * diphenhydramine, * hydroxyzine 9. **Antihypertensive drugs** * alpha-adrenergic agonists (eg, clonidine), * beta-blockers, * calcium channel blockers (especially verapamil), * diuretics 10. **Antispasmodic drugs** * dicyclomine 11. **Cation agents** * aluminum, * bismuth, * barium, * calcium, * iron 12. **Chemotherapy** * vincristine, * cyclophosphamide 13. **Resins** * ****cholestyramine, * sodium polystyrene sulfonate

Answer 11

On **peut** les utiliser chez les personnes âgées. Ils incluent: * Psyllium * Inulin * Guar gum * Calciumpolycarbophil Leurs caractéristiques: 1. Can be used for the **prevention and treatment** of constipation 2. Onset of action: 12-72 h 3. Available in multiple dosage **forms** (powders, wafers, chewable tablets, capsules) 4. Might not aid constipation due to slow transit, pelvic floor dysfunction, or medication 5. Must be **taken with ≥ 250 mL water or juice to prevent fecal impaction and esophageal obstruction** 6. Avoid in patients with cognitive impairment, fluid restrictions, dehydration, dysphagia, or esophageal strictures, or in those who are bedridden 7. Suggested to **space by 2 h** from all other medications

Answer 12

* PEG 3350 without electrolytes * Lactulose * Glycerin suppositories Leurs caractéristiques: 1. PEG 3350 and lactulose can be used for the prevention and treatment of constipation; glycerin suppositories can be used for the treatment of constipation 2. Onset of action: * PEG 3350 48-96 h; * lactulose 24-48 h; * glycerin 15-60 min 3. Neither PEG 3350 nor lactulose is absorbed and both lack electrolytes; therefore, these are **good options for patients with renal impairment, cardiac dysfunction, or diabetes** * ****Lactulose by-products (1 tbsp has \< 1.6 g galactose and \< 1.2 g lactose) are not absorbed; however, encourage patients with diabetes to report any signs or symptoms of hyperglycemia 4. Dose-dependent nausea, abdominal bloating, cramping, diarrhea, and flatulence can occur with both PEG 3350 and lactulose; however, PEG 3350 has a **higher incidence of diarrhea** in elderly patients but a **lower incidence of flatulence** 5. Some find lactulose too sweet, but the taste can be masked by diluting it in water, fruit juice, milk, or desserts 6. PEG 3350 is a **tasteless**, odourless powder that is dissolved in 250 mL of water, juice, coffee, or tea 7. Lactulose is **less expensive** at starting doses (15 mL every night costs $13/mo) compared with PEG 3350 ($24/mo) 8. Glycerin is less effective if stool is dry and hard

Answer 13

* Bisacodyl * Sennosides Leurs caractéristiques: 1. Can be used for the **prevention and treatment** of constipation 2. Onset of action: 6-12 h 3. Might provide benefit in neurogenic or slow-transit constipation 4. Tolerance can occur with slow-transit constipation but it is rare 5. Senna might discolour urine or feces yellow-brown or red-violet 6. Side effects include abdominal pain and cramping

Answer 14

Chronic constipation is a functional bowel disorder defined as **abnormal colonic transit** (fewer than 3 bowel movements per week that are mostly hard or lumpy i.e. Bristol stool scale type 1-2) and/or **defecatory dysfunction** (difficult stool passage i.e. straining, sensation of incomplete evacuation/obstruction/blockage, digital evacuation/support of the perineum). Pain or bloating may be present in patients with constipation, but it is _not a dominant symptom_; patients with constipation predominant **irritable bowel syndrome** (IBS-C) have abdominal discomfort or bloating as a major symptom, accompanied by constipation. There is significant overlap between chronic constipation and IBS-C in terms of clinical presentation and treatment.

Answer 15

Constipation may be due to a **primary functional disorder of colonic motility** (slow transit) and/or **dyssynergic defecation** (incoordination of rectal propulsion and anal sphincter relaxation). In the primary care setting, constipation is very often caused or compounded by **secondary effects of medications or their underlying diseases**.

Answer 16

Mechanical or structural causes of constipation (e.g. mass or stricture) are relatively **rare** in practice and can usually be discerned by clinical red flags or physical findings on abdominal and anorectal exam. There is no increase in prevalence of colorectal cancer in patients with constipation and, therefore, constipation is generally **not an indication for diagnostic colonoscopy**; however, colorectal cancer screening should be undertaken in patients with constipation according to age and family history. Constipation **in older adults** is a special category, which can be particularly challenging to assess and treat. **Secondary causes** are most often at play in the elderly due to multiple medical conditions and medications that predispose to constipation, limited physical activity, less control or attention to diet and fluid intake, and failure to maintain a bowel regimen or recognize the call to stool.

Answer 17

Routine laboratory testing is generally not recommended in patients with chronic constipation. Instead, a **thorough and detailed history, medication review, and physical examination** is of paramount importance and may then guide use of selected laboratory tests such as CBC, glucose, creatinine, calcium, and TSH to assess for anemia as a red flag or common contributory metabolic disturbances. There is **_no_ literature to support routine use of plain abdominal x-ray, radiopaque marker transit study, barium enema, or defecography** for assessment of constipation in primary care. An abdominal radiograph may be useful in some elderly patients with episodic diarrhea and fecal incontinence to evaluate the possibility of severe constipation with overflow in order to avoid erroneous prescription of antidiarrheals. Anorectal manometry, barostat, and balloon expulsion studies are reserved for patients with suspected for anorectal dyssynergy under evaluation by a Gastroenterologist.

Answer 18

A **complete and thorough medical assessment, patient reassurance and education, dietary changes, and increased physical activity and fluid intake along with bulk-forming laxatives** provide significant and prompt benefit in most patients. **Polyethylene glycol** and **stimulant laxatives** are used **in those who fail to respond** to initial conservative approaches. Addition of **linaclotide** or **prucalopride** should be considered for those with refractory constipation or for episodic use. **Gastroenterology referral** is appropriate if failed response to the above foundational treatments, presence of red flags, or strong suspicion of dyssynergic defecation at initial assessment.

Answer 19

A presumptive diagnosis of functional constipation can be made based on Rome IV criteria (2016). In order to apply these criteria, it is essential to collect a detailed **history of stool frequency and form** and **features of defecatory dysfunction**. It is well recognized that patients who meet these criteria for diagnosis of functional constipation commonly will also meet criteria for IBS-C and therefore additional approaches should be considered if significant abdominal bloating or discomfort co-exist with constipation. Important additional history includes: 1. duration and progression of symptoms (problem since childhood or more recent onset and worsening), 2. precipitating events (changes in diet, fluid intake, physical activity, medications introduced around symptom onset), 3. laxatives tried already (most products are accessible over-the-counter, noting type, duration, and combination of agents helps discern undertreated from treatment resistant cases), 4. alarm features.

Answer 20

Focused physical examination provides information about **mass or structural lesions** and clues about dysfunctional defecation, which would require specialist consultation. 1. **Abdomen:** * ****noting distention, focal discomfort, palpable mass, inguinal lymphadenopathy. 2. Inspection of **perineum**: * noting skin conditions, anal wink reflex and sensory deficits, * strain maneuvers to assess degree of perineal descent and elicit hemorrhoidal or rectal prolapse, seepage (écoulement); * apply traction to examine the anal canal for presence and location of fissure which usually evokes sharp localized pain. 3. **Digital anorectal examination**: * noting stricture, high resting anal sphincter tone and voluntary squeeze pressure, mass or irregularity of anal canal and distal rectum on circumferential finger sweep, and presence and form of stool or blood. A **rectocoele** is **prolapse of the anterior rectal wall into the vagina** and is associated with obstructive defecation. When the patient bears down during DRE (digital rectal exam), the anal sphincter and puborectalis sling (felt posteriorly) should relax and the perineum should descend. During DRE, high resting anal sphincter tone or, on bear down manoeuver, paradoxical contraction of the puborectalis and failure of the perineum to descend are clues to anorectal dyssynergy.

Answer 21

For Primary Care physicians, it is important to do a **thorough review of medications**. Netcare is a valuable tool to identify medications that could contribute to constipation. There are many medical conditions and their drug treatments that are associated with constipation and recognition of this may allow disease-specific intervention (e.g. hypothyroidism, diabetes).

Answer 22

There is a wide range of what is considered normal bowel function in adults. **Education, reassurance, management of expectations** Some patients believe they must have a bowel movement every day in order to be healthy. Reminding patients that a bowel movement every **2-3 days is considered within normal limits** and some variability of stool form is expected and normal. It is often helpful to show patients the Bristol Stool Scale to better quantify stool form and, in many patients, reveals normal or ideal stool form much of the time. Patients gain reassurance and hope in knowing that bowel function usually improves with very simple interventions, that the medical literature consistently shows that most patients with constipation do not require extensive initial investigation, and that **colonoscopy almost never reveals relevant abnormalities**. **Fibre, fluid, physical activity** There is a dose-response relationship between fibre and fluid intake and stool output, and it is important to quantify at initial visit, as patients with constipation whose fibre and fluid intakes are inadequate are most likely to benefit from this intervention. Most Canadians consume only 10-20g of fibre per day, which is far less than the **recommended 30g/d target**. It is challenging for most patients to achieve this amount of daily fibre intake due to palatability, adverse effects (intestinal gas and cramps), and lack of knowledge about what 30g/d of fibre looks like in practical terms. Although there is very little evidence of clinical effect, increased exercise may have favorable effects on intestinal fluid handling and motility and seems sensible in terms of overall patient well-being. Patient adherence to these principles of therapy for constipation tends to be poor and needs frequent monitoring, reinforcement, and enablement by Primary Care physicians. **Laxatives** _Bulk-forming agents_ are natural or synthetic polysaccharides that bind fluid in the gut to increase stool volume and mass. _Osmotic agents_ are poorly absorbed sugars that draw water into the bowel to loosen stool. _Stimulant laxatives_ increase secretory and propulsive activity in the intestine. _Surfactants_ soften stool by breaking surface tension on formed stool allowing water to penetrate.

Answer 23

Failure to improve after the above general approaches are exhausted is diagnostically useful, suggesting specific additional or dominant mechanisms underlying constipation in a particular patient. This may bolster clinical impression of IBS-C or defecatory dysfunction , or may indicate a subtype of constipation known as “slow transit” which guides next steps in helping these patients.

Answer 24

**Docusate de sodium** Le docusate est un **émollient fécal.** Le comprimé ou la capsule se dissout et demeure dans la lumière intestinale sans absorption systémique. Son action se fait principalement par contact direct avec la paroi intestinale qu’il lubrifie. C’est un médicament sécuritaire chez l’enfant (la suspension a cependant un gout peu invitant) et la femme enceinte. Cependant, selon l'Association des Pharmaciens du Canada, "Les données probantes sont **insuffisantes pour corroborer l'efficacité** des émollients fécaux (docusate sodique et docusate calcique) dans la prise en charge de la constipation, y compris la constipation induite par les opioïdes et la constipation fonctionnelle. Leur utilisation n'est donc pas recommandée".

Answer 25

**Lait de magnésie** **Risque d’hypermagnésémie** avec usage régulier du lait de magnésie **en insuffisance rénale**. En effet, le magnésium est absorbé dans la circulation systémique et son accumulation est dangereuse. * Hypermagnésémie légère : * souvent asymptomatique. * Parfois : nausée, paresthésies du visage * Hypermagnésémie sévère : * hypoventilation, hypotension artérielle, aréflexie, bradycardie, sédation et coma.

Answer 26

**Polyéthylène glycol 3350 avec électrolytes** Tous ces choix peuvent être utilisés pour la préparation d'un examen de l'intestin. Il est a noté que les recommandations ont grandement changé au courant des dernières années. Le PEG 3350 avec électrolytes est maintenant le premier choix. Il est recommandé de le boire en doses fractionnées soit 2 x 2 litres. De plus, il est souvent donné en association avec des comprimés de bisacodyl qui doivent être pris la veille de l’examen, en soirée (selon le protocole fourni par l’établissement de santé). Dans tous les cas, une bonne hydratation est requise lors de l’utilisation de ces produits. **LES PRÉPARATIONS** 1. _Le PEG 3350 avec électrolytes_ * Il produit son action par ses composantes isoosmotiques et électrolytiques. Il est généralement indiqué pour les patients à risque de déséquilibre électrolytique ou de déshydratation. Il constitue donc un bon choix chez les patients insuffisants cardiaques et rénaux, car il ne cause pas de déséquilibre électrolytique et limite les pertes d’eau. * Colyte® * Golytely® * Peglyte® 2. _Le citrate de magnésium_ * Il provoque une rétention osmotique, augmentant ainsi la distension de l’intestin et, par le fait même, la motilité. Il est souvent utilisé en association avec le bisacodyl (p. ex., la trousse RoyvacMD) ou de petits volumes de PEG, car une telle association permet d’obtenir un meilleur nettoyage du côlon. Le magnésium étant éliminé par les reins, il est _contre-indiqué chez les insuffisants rénaux_ et la prudence est de mise chez les personnes âgées. Il est aussi contre-indiqué chez les personnes suivant un régime hyposodique. * Citro-mag® 3. _Le picosulfate de sodium, acide citrique et hydroxyde de magnésium_. * Ces préparations contiennent plusieurs ingrédients actifs : picosulfate de sodium, acide citrique et oxyde de magnésium. Une fois reconstitués, l’acide citrique et l’oxyde de magnésium se combinent pour former du citrate de magnésium. Les divers ingrédients agissent en diminuant l’absorption d’eau et d’électrolytes et stimulent la motilité intestinale. Plusieurs médicaments peuvent être affectés par la prise de cette solution; la vigilance du pharmacien est donc requise. * Pico-salax® 4. _Solution orale aux phosphates de sodium_. * Les phosphates de sodium contenus dans la solution créent une rétention hydrique dans l’intestin et entrainent ainsi une purge importante des intestins. En décembre 2005, Santé Canada publiait un avis concernant l’innocuité des préparations orales à base de phosphate de sodium. En effet, sept cas d’insuffisance rénale et de néphrocalcinose ont été signalés à la suite de l’utilisation de ces solutions. Par la suite, des recommandations ont été émises concernant l’emploi du phosphate de sodium oral. * Fleet Phospho-Soda® 5. _Les lavements à base de phosphates_ * Ils sont utiles pour les examens digestifs bas comme la sigmoïdoscopie et la proctoscopie. Ils peuvent aussi être recommandés avant une biopsie de la prostate. Les phosphates contenus dans le lavement sont peu absorbés et causeront une rétention hydrique. Cet appel d’eau permet ainsi la liquéfaction des selles et le nettoyage au niveau du côlon descendant et du rectum. Pour ce qui est des lavements rectaux huileux, ils sont principalement employés pour la constipation et les fécalomes et non pour la préparation à un examen. * Fleet® * Enema®

Constipation Flashcards

(54 cards)