Constipation/Diarrhea

Question 1

Constipation

Answer 1

• Infrequent stool passage: less than 3 bowel movement per weeks
• Straining, lumpy/hard stools, digital evacuation
• Most common digestive complaint in US (in kids too)

Question 2

CIC

Answer 2

• Chronic idiopathic constipation
• Persists for several weeks or longer
• No known cause

Question 3

IBS-C

Answer 3

• Irritable bowel syndrome with constipation

- Chronic/recurrent abdominal discomfort relieved by defecation (idiopathic)

Question 4

Constipating Causing Medical Conditions

Answer 4

• IBS
• Anal disorders (fissues, prolapse)
• MS
• CV events
• Parkinsons
• Spinal cord tumors
• Diabetes
• Hypothyroidism

Question 5

Non-Rx Tx

Answer 5

• Increase fluid intake
• Increase physical activity
• High fiber foods
• D/C constipating drugs if possible

Question 6

Constipation Causing Drugs

Answer 6

• Aluminum antacids (Maalox, Mylanta)
• Antichol. drugs or sim. meds (antispasmodics, UI meds, phenothiazines, antihistamines, etc.)
• Non-DHP CCB (VERAPAMIL, dilt.)
• Clonidine
• Colesevelam
• Iron
• Opioids
• Sucralfate (many Al+ ions)

Question 7

Most adults with constpation use…

Answer 7

• Fiber

- Ex: metamucil

Question 8

Most adults on opioids use…

Answer 8

• Stimulant laxatives

- Senna or bisacodyl suppository

Question 9

Pts with hard stools use…

Answer 9

• Stool softener
• Docusate
• Double check if opioid patients have hard stools

Question 10

Adults/kids that need to go soon…

Answer 10

• Glycerin suppository

- Gentle Option

Question 11

When to see a HC provider from constipation…

Answer 11

No improvement in <7 days

Question 12

Bulk-Forming Laxative

Answer 12

• Soluble/dietary fiber
• Usually first line, esp. for preggo
• Ex: psyllium (metamucil), methylcellulose (Citrucel)
• Absorb water from intestine to bulk up stool
• SE: gas, bloating

Question 13

Stimulant Laxatives

Answer 13

• Stimulate neurons in colon
• Good for OIC; can be given with stool softener
• Ex: senna (Ex-Lax, Senokot) or bisacodyl (Dulcolax)
• Usually take 6+ hours to work

Question 14

Stool Softener (Emollients)

Answer 14

• Given if stool is particularly hard
• Can be used for OIC, post-procedure
• Ex: docusate (Colace, + senna: Senna S or Plus)
• Decreases surface tension to increase oil/fat/water in stool
• Good for iron supplementation stool (black and hard)
• CI: use with mineral oil

Question 15

Osmotic Laxative

Answer 15

• Draws water from intestine to increase peristalsis
• Ex: Miralax (PEG 3350), MoM, glycerin
• PEG takes days to work, MOM takes hours to work, glycerin works stat
• SE: electrolyte imbalance (MoM esp.)

Question 16

Lubricant Laxative

Answer 16

• Coat bowel with waterproof film
• Ex: mineral oil
• Oral (6+ hours to work) and rectal enemas (fast) available
• Take fat-soluble meds at diff. time

Question 17

Whole Bowel Prep

Answer 17

• Many of the same products, just increase dose (ex: polyethylene glycol - GoLytely)
• Use extra caution in patients with CVD/renal disease; also pts using loop diuretics or NSAIDs (especially phos. containing prep - Osmoprep) due to fluid loss

Question 18

IBS-C Meds

Answer 18

• Pain and cramping => dicyclomine (bentyl)
• Lubiprostone (Amitiza), for women, and linaclotide (Linzess) are specifically approved for IBS-C
• PEG is also often used
• Amitiza causes nausea, take w/ food and water
• Linzess causes diarrhea

Question 19

PAMORAs

Answer 19

• Act on peripheral mu-receptors in GI tract
• Used for OIC and post-op
• 5HT4 agonist
• Ex: alvimopan (Entereg)
• Max of 15 doses
• ONLY short term use
• Box risk: MI with prolonged use

Question 20

Opioid Effect on Intestines

Answer 20

• Slows peristalsis
• Increases sphincter tone
• Decreases fluid in small intestine
• Increases water absorption in large intestine

Question 21

What to eat before colonoscopy…

Answer 21

• Clear liquid diet
• Water
• Clear broth
• Juice without pulp
• Nothing with blue/purple/red dye
• No milk/cream
• No solid foods

Question 22

Diarrhea

Answer 22

• Stool moving through too fast; watery and loose
• Often viral cause (E. Coli)
• SE: cramping, N/V, fever
• Take oral replacement solutions!
• Don’t self treat for >48 hours

Question 23

Traveler’s Diarrhea Prophylaxis or Non-infectious Diarrhea Tx

Answer 23

• Non-infectious diarrhea
• Symptomatic Relief
• Pepto-bismol (bismuth subsalicylate) or loperamide PRN

Question 24

IBS-D Tx

Answer 24

• Xifaxan: rifampin, abx approved for IBS-D
• Dicyclomine (Bentyl) is an antispasmodic which can help with cramping/pain: antichol. SE!
• Loperamide may also help with relief

Question 25

Lotronex

Answer 25

- Alosetron - For women only - Used for IBS-D - Risk for ischemic colitis

Question 26

Pepto-Bismol

Answer 26

- Bismuth subsalicylate - SE: Black tongue/stool, tinnitus (cut dose) - CI: salicylate allergy - Caution in patients on anticoagulant or renal insufficiency - NEVER in kids (Reyes Syndrome risk)

Question 27

Immodium A-D

Answer 27

- Loperamide - Max: 16 mg/d; OTC Max: 8 mg/d - Boxed warning: Torsades, cardiac arrest, death (don't exceed max doses!!) - CI: use in kids <2 yo

Question 28

Lomotil

Answer 28

- Diphenoxylate/atropine - CV - Atropine discourages abuse

Question 29

Viberzi

Answer 29

- Eluxadoline - CIV - CI: patients w/o gallbladder - Acting like an opioid to cause constipation/stool hardening w/o the opioid - For diarrheas