W10. Consitpation

Question 1

What is constipation

Answer 1

*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

Question 2

Bristol Stool chart

Answer 2

should present type 3-5

Question 3

two maint ypes of contstipation

Answer 3

• 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

Question 4

what are the GI motor disorders that cause constipation

Answer 4

*dont respnond well to laxatives

Question 5

what diseases are associated with seocndary constipation

Answer 5

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

Question 6

causes of constipation in cnacer patients

Answer 6

• 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

Question 7

constipation and fatigue

Answer 7

• linked to prolonged fatigure states

so inc prevelance in mental health states like

depression, anxiety, chronic fatigue syndrome, fibromyalgia, IBS

Question 8

drugs related causes for constipation

Answer 8

anticholinergics

opiod: gut paralysis
diuretics: cause dehydration

Question 9

red falgs for constipation

Answer 9

• 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)

Question 10

Precipitating factors

quality

region

symp associated

time

to ask a patient with constipation

Answer 10

• 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?

Question 11

Patient analysis for constipation

Answer 11

• 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

Question 12

cycle of chornic constipation

Answer 12

Question 13

How do lifestylefactors are linekd to consstipation

Answer 13

• supressing of urge to deficate

inadequate fluid and fiber intake

chronic anxiety

acute eemotional distress

infrequent physical excercise

Question 14

non pharm methods for prevention

Answer 14

min vol 1.5L water to prev constipation *main method

• fiber, toilet routine, bowel retaining, excercise

Question 15

how much fiber is req for each age group

Answer 15

adult female need 25g fiber, male 30g

pregnant 28g

breastfeeding 29g

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

Question 16

diff types of fiber

Answer 16

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

Question 17

pre/probiotics and constiation

Answer 17

5 pro/pre biotics with level 1 evidence

• activia good option

BioGaia, Visbiome also good options

Question 18

what are the 5 classes of laxatives on market

Answer 18

bulk forming agents

osmotic agents

stool softeners

saline laxatives

stimulant laxatives

Question 19

bulkf forming agents

Answer 19

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!!!)

Question 20

Psyllium concern

Answer 20

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

Question 21

what line are bulk forming

what are contraindiactions

Answer 21

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

Question 22

osmotic agents for constipation

Answer 22

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

Question 23

best for fast acting product

Answer 23

glycerin suppository

Question 24

Lactulose and diabetes

Answer 24

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

can recommmend safely

Question 25

AE of osmotic agents

Answer 25

can cause diarrhea, so start low and go slow

Question 26

smotic agent of choice for constipation

Answer 26

PEG onset of action for 3 days best for kids too avoid high doses in children

Question 27

Purgative agents for constiaption

Answer 27

PEG with electrolytes - shoudl eb supervised by HC provider or caregiver - much higher dse, use for impacted bowl

Question 28

stool softeners for constipation

Answer 28

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

Question 29

saline laxative

Answer 29

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)

Question 30

who should not take saline laxatives

Answer 30

elderly, CHF, renal failure and young

Question 31

when shoudl enemas be used

Answer 31

only pre scope or is prescribed by a health care provide due to impaction

Question 32

Stimulant laxatives

Answer 32

- 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

Question 33

homeopathic/herbal ageents

Answer 33

- 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

Question 34

what are the goals of therapy

Answer 34

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