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GI Exam 2
Long Constipation
| Question | Answer |
|---|---|
| Constipation is if a pt has < than? | < 3 bowel movements/week, but normal bowel patterns may vary |
| Constipation is considered chronic if? | >/= 3 months |
| Constipation variable definition is? | difficult or infrequent passage of stool +/- straining of a feeling of incomplete evacuation (American Gastroenterology Association) |
| Risk factors for constipation? Mainly | increased age ⭐️; Red text: inactivity/Lack of exercise; lower income, depression, anxiety, stress, low fiber diet/poor fluid intake, medications, presence of chronic diseases |
| Why are elderly at more risk for constipation? | increased Colonic Transit time ⭐️; Others: decreased perception of urge to defecate; inactivity/immobility; failure to establish BM (bowel movement) schedule, abuse of stimulate laxatives; poor dentition—> inadequate chewing; low fiber diet/poor fluid intake; miltiple meds, chronic diseases |
| The number one reason is that the elderly have an increase in? | Colonic transit time (the time it takes for stool to move through the colon) NOT THE SAME AS RATE (inversely related) so the longer it takes the stool to move throughout the body, that means that the rate is lower (the rate of movement is slower) |
| As the stool moves its way down the GI tract, water is being _____ into the body | reabsorbed (meaning that the stool is getting harder) which also means the longer it takes to move through the GI tract, meaning higher risk for constipation |
| VERY IMPORTANT TO KNOW WHAT MEDICATIONS CAN JUMPSTART CONSTIPATION—> Ones to really focus on are? | Opiates, Iron (oral is more problematic than IV iron, disrupts organisms in GI tract), Anticholinergics ⭐️ Slow the passage of stools |
| Other medications that can cause constipation are? | CCBs, Clonidine, Diuretics, Neuromuscular blockers, NSAIDs, Polystyrene Sodium Sulfonate |
| There are 3 major types of constipation which are? | Normal transit, Slow transit, and Pelvic floor Dysfunction |
| Normal transit (also known as Functional Constipation) is the _____ ______ ______ of the 3. | Most common type; Long: studied and forgot to take a sip of water and are now constipated |
| Slow transit is more so with the elderly population. This is a? | prolonged gastrointestinal transit time/ slow motility and with infrequent defecation *takes longer for the stool to make its way through the GI tract |
| Pelvic floor dysfunction is also known as Disordered Defecation. What is the most common cause? Population? | dysfunction of pelvic floor muscles and/or anal sphincter, which CONTRACT DURING DEFECATION INSTEAD OF RELAXING—> impede stool evacuation *mainly infant population where they haven’t figured out what to do; *dont know how to get the stool out of their body so they contract everything instead of relaxing and letting it go and therefore stays in longer, water gets reabsorbed, and it gets harder to pass. |
| Why do we care about constipation—> Because it can lead to significant complications such as? | Blood pressure irregularities, cardiac rhythm disturbances, Hemorrhoids* and rectal prolapse |
| What are we going to do—> Treatment strategy: | 1. Identify and treat causes (if possible) while minimizing laxative reliance/Adverse effects) (IBD, cancer? OTC?) 2. Manage potential dietary causes 3. Relieve symptoms 4. Restore normal bowel habits 5. Prevent morbidity and mortality |
| In terms of the major types of constipation, pts may have >/= to ___ | >/= 1 type of constipation |
| Another MOST IMPORTANT SLIDE—> What are the Self-Treatment Exclusions? *Cannot be treated over the counter—> REFER | ⭐️ BLOOD in stool (dark, tarry stool) Black stool, anemia ⭐️; severe abdominal pain, unexplained flatulence, N/V/ *fever; *weight loss *Persistent/chronic constipation -⭐️ >/= 2 weeks ⭐️; reoccurs over 3 months -Change in stool consistency -*Hx of family hx of IBD/colon cancer -*Paraplegia or quadriplegia (very complicated to treat) Long note—> If abrupt onset, may indicate malignancy *constipation should not come with fever and we assume the immune system is involved—> refer IBD not constipation |
| Long notes: Anytime there is unexplained weight loss (15 lbs and pt changed nothing) we automatically think? | cancer and refer |
| Pt comes in and is constipated for 3 weeks? | Refer because its persistent/chronic constipation for greater than 2 weeks |
| Which of the following pts that come to your pharmacy should be referred instead of given an OTC recommendation? A. Batman, who hasn’t had a bowel movement in 3 days B. Catwoman, who hasn’t noticed some blood in her stools C. Wonder Woman, who has mild stomach pain due to constipation D. Iron Man, who mentions a recent 5 lb weight gain when explaining his constipation | B. Catwoman, who has noticed some blood in her stools |
| Symptomatic therapy consists of? | -Adjust diet to increase fiber intake and increase fluid intake (up to 1.5-2L/day) -D/C medication causes if possible -Increase exercise/movement if possible -Schedule toileting -Administer pharmacologic therapy *if applicable -Be patient-specific: what has worked for them in the past? *If pt states, I’ve tried this and it didnt work, that is not the answer to keep trying it* |
| Dietary management: remember that alcohol can cause _____ or ______ | constipation or diarrhea; known to be a diuretic and pulling fluid out of GI into renal system (process and fatty food have a low fiber diet and so we recommend healthy food -Prunes—> old people |
| So we are going to increase ____ in the GI tract and bulk up the stool. Fiber is ______ matter not digested by human GI tract (stays in the GI tract and bulks up the stool to make it more “fluffy and easier to pass.” | FIBER; Vegetable *Fiber keeps the water in the stool and increases the rate of transit to decrease the time its spending in the GI tract |
| Increase fiber to: -increase stool bulk -increase retention of stool water -increase RATE of stool transit IN ORDER TO—-> | -increase defecation frequency and decrease intraluminal pressures in colon/rectum |
| Dosing of Fiber—-> we want to do this ______ (Increasing daily fiber intake to 20-25g —> FYI) | Gradually |
| We want to tell them to take in fiber very gradually because there is a risk of? | GI obstruction (we don’t want to increase the stool so much that it can’t move) |
| Biggest side effect we see with fiber is? | (GAS and bloating) abdominal distension + flatulence |
| Why don’t you think that fiber intake doesn’t work well with pelvic floor dysfunction? What’s the issue with this type of constipation? | It’s the muscle, that they’re contracting instead of relaxing (not how long the stool is taking to go through, not what’s in the stool and the makeup, it’s purely the MUSCLES 💪. *having more fiber isnt going to really help the muscles. |
| Pharmacologic therapy for constipation consists of what kind of agents? | Bulk-forming agents; Emollients; Osmotic Laxatives; Stimulant Laxatives; Opioid Receptor Antagonists |
| Our Bulk-forming agents for constipation are? | Psyllium; Methylcellulose; Polycarbophil |
| Bulk forming agent properties are similar to dietary fiber with similar effects such as? | -increase stool water content leading to increased stool weight bulk -Increase rate of stool transit |
| Bulk-forming agents should relieve constipation symptoms within ____ days* | 3 days ⭐️ *GOOD COUNSELING POINT to tell patients how fast it will work; will not work immediately |
| Bulk-forming agents are well-tolerated (not systemically absorbed) SE are? | Flatulence, bloating, abdominal distension |
| ⭐️ IMPORTANT side effects to remember about our bulk forming agents are? | -Can result in BOWEL OBSTRUCTION —-> TAKE WITH FLUIDS **Remember to separate other medications by 1-2 hours |
| Bulk forming agents are preferred in _______ and ________ patients | elderly; Pregnant |
| T/F: Bulk-forming agents are OTC products | True |
| The brand name for our bulk-forming agents to remember is? | Metamucil |
| Metamucil comes as a _____ and forces patient to take it with water | powder |
| Our emollients (Stool softener) agent is? Brand name? | Docusate (Colace) |
| T/F: Docusate is OTC | True |
| How does docusate work? | facilitates mixing of water and lipids in intestinal tract (increases water and electrolyte secretion in bowels —> increased stool moisture—> softer |
| Our Emollient (stool softener) docusate should relieve constipation symptoms within how many days? | 3 days |
| LONG: Claim to fame about Docusate use alone is to prevent? | constipation/straining *softening to make it easier to pass the stool |
| Docusate can also be used commonly with ______ to treat constipation giving us the bowel regime “MUSH and PUSH combo” | Senna |
| One big thing to remember about Docusate is to AVOID in children <2 yo due to risk of _______ _________ ________ | Benzyl alcohol toxicity (which can lead to respiratory distress or difficulty breathing) *one of the make-up ingredients *well-tolerated and no significant medication interactions |
| Other option for Emollients (LUBRICANT) is what agent? | Mineral oil |
| How does Mineral Oil work? How fast should it relieve constipation symptoms? | Lubricates the stool; within 6-8 hours* ⭐️ |
| Mineral oil can be given as an _____ or ______ | oral, rectal (enema) |
| ⭐️ Adverse effects of mineral oil are mainly gastrointestinal consisting of? | Nutritional deficiencies (decreasing absorption of Vitamins ADEK) -Risk of ASPIRATION ⭐️—> lipid pneumonia ⭐️ Avoid long term use, bedtime administration, and bedridden patients (more likely to aspirate it) since laying down)** |
| Very dangerous risk of taking mineral oil orally (risk of Aspiration) meaning that instead of swallowing it into their esophagus, they inhale it into their? | lungs (oil is a fat) so they would get lipid pneumonia if they aspirated it (very hard to treat) *CANNOT use it long term |
| Xavier is a 55 yo male w/ no sig. PMH. He comes to the pharmacy and asks which product he can get to fix his constipation. He states he has been constipated for about a month and he is tired of feeling this way. What do you recommend? -Metamucil -Docusate -Mineral oil -All -None | None of the above *issue is constipated for a month—> REFER |
| Our Osmotic laxatives are? | Polyethylene glycol (PEG, Miralax, GoLytely) and Lactitol (Pizensy), and Lactulose (Constulose) |
| PEG’s mechanism as an osmotic laxative is? | causes water retention in the stool, increases stool frequency |
| How fast does PEG work? | typically produces a bowel movement in 1-3 days; -⭐️ DON’T use for > 1-2 weeks |
| Dosing of PEG for adults is? GoLytely dose is? | 17 grams PO DAILY -*bowel prep (dose of 170 g) |
| Adverse effect of PEG is? | Nausea, Vomiting, Flatulence, abdominal cramping |
| Lactitiol (Pizensy) our other Osmotic laxative is a? How fast does Lactitol (Pizensy) take to work? | monosaccharide that causes water influx into the small intestine -typically produces a bowel movement in 1-2 days |
| Adverse effects of Lactitol (Pizensy) are? | flatulence and diarrhea |
| ⭐️ Lactitol (Pizensy) is contraindicated in? | ⭐️ mechanical GI obstruction and galactosemia **Separate from other medications by 2 hours _so patient that has galactosemia (can’t break down sugars) should NOT take it |
| Lactulose (Constulose) works as a? | non-absorbable disaccharide metabolized by gut bacteria -causes water retention, increases colonic peristalsis, increases stool frequency |
| Lactulose (Constulose) should relieve constipation within how many HOURS? | 1-6 hours |
| Patients typically gag with Lactulose so may mix it with? | Juice, water, or milk for oral consumption; -may dilute with water/normal saline to be administered as an enema “rocket booster and works in 30-60 min. |
| Adverse effects of Lactulose (Constulose) are? | diarrhea; ELECTROLYTE imbalances |
| What medication is used more often in CIRRHOTIC patients for hepatic encephalopathy? | Lactulose (Constulose) |
| Aside from Polyethylene glycol, Lactitol, and Lactulose, our other osmotic agents are Saline laxatives that contain? | Magnesium hydroxide, phosphate, citrate (i.e. milk of magnesia); Sodium phosphate products (Fleet enema) |
| These magnesium and sodium products are also known as ______ laxatives -How long do they take to produce a bowel movement? | saline *keeps electrolytes in colon—> water retention in the stool increasing peristalsis -1-3 hours |
| Adverse effects of our saline laxatives are? | fluid and electrolyte depletion, accumulation of magnesium/sodium in renal dysfunction ⭐️ REMEMBER to maintain hydration and monitor electrolytes ⭐️ Caution in patients < 2 yo, pregnancy, renal dysfunction, and CHF |
| Alladin is a 57 yo male with constipation and a PMH significant for CHF. Which osmotic laxative is the best option for him? -Milk of magnesia -Fleet Enema -Miralax | Miralax |
| Our stimulant laxative agents are? | Bisacodyl (Dulcolax), Senna (Senokot, Ex-Lax) These are our PUSH agents and remember our MUSH is Docusate (stool softener) |
| How do our stimulant laxatives work? | Stimulates the enteric nervous system; fluid/electrolyte colonic secretion |
| How fast do the stimulant laxatives take to work? | should relieve constipation symptoms within 8-12 hours (dosed at night) |
| Senna (Senokot, Ex-lax) comes as a syrup and tablets, what is the dosing? | 17.2 mg PO once daily (adults) ⭐️ |
| Bisacodyl (Dulcolax) comes as a tablet or suppository, what is the dosing? | 5-15 mg PO once daily; 10 mg PR (adults) ⭐️ *PR for rectal suppository |
| T/F: We use stimulant laxatives in pediatric patients | FALSE; Causes electrolyte abnormalities (making stool move quickly and body doesn’t have a chance to absorb) |
| AE that we need to know for our stimulant laxatives are? | cramping, ⭐️ electrolyte abnormalities (malabsorption) if long-term use ⭐️ ANTACIDS—> may cause early release of BISACODYL which decreases efficacy *LONG won’t state “antacid” but may give us name of antacid we were tested on previously |
| Miscellaneous agents that Dr. Long mentioned that may be used for constipation but are followed up with lectures later in GI are? | Lubiprostone; Linaclotide |
| Constipation from _______ is their #1 side effect | Opioids |
| Pt started on an opioid medication, you are also going to start them on a? | stool softener and a stimulant *huge intervention for pharmacy (most commonly done by students) |
| We are doing the docusate + Senna combo in order to prevent? | opioid-induced consitpation (mush and PUSH |
| What agent would we not use for opioid induced constipation or start on a new pt that just got an opioid regimen? | Bulk-forming agents ⭐️ AVOID bulk-forming agents (i.e psyllium) due to OBSTRUCTION RISK |
| First line TREATMENT for OIC (Opioid-induced constipation) is a? | Laxative (Osmotic stimulant laxatives such as as PEG, LActulose, Bisacodyl, Senna) needs something stronger than Docusate to treat it |
| Additional pharmacologic options if needed (remember NOT first line) for OIC are? | PAMORA (Peripherally Acting mu Opiod Receptor Antagonist) medications |
| PAMORA (Peripherally Acting mu Opiod Receptor Antagonist) medications are? | Naloxegol (Movantik); Naldemedine (Symproic); Methylnaltrexone (Relistor) |
| For OIC, what medication is not recommended by the guidelines? | Lubiprostone or Linaclotide *Save these for IBS |
| Our “N” Opioid Receptor Antagonists (*remember not first line) for OIC are? | Naloxegol (Movantik) and Naldemedine (Symproic) |
| Naloxegol (Movantik) AND Naldemedine (Symproic) may be less effective if receiving opioids for less than _____ weeks. | 4 |
| Naloxegol (Movantik) is contraindicated if? | obstruction suspected, severe liver impairment, or taking strong CYP3A4 inhibitors ⭐️ |
| Naldemedine (Symproic) is contraindicated if? | obstruction suspected or severe LIVER impairment ⭐️ |
| Difference between Movantik and Symproic is that? | Movantik requires that its taken on an empty stomach and requires DOSE ADJUSTMENT if they have renal dysfunction or taking strong CYP 3A4 inhibitor *Movantik—> with an M for High Maintenance (extra things to worry about |
| Dose of Movantik is? | 25 mg PO daily on empty stomach; half-dose if abdominal pain or CrCl < 60 |
| Dose of Naldemedine (Symproic) is? | 0.25 mg PO daily WITHOUT regard to meals |
| Methylnaltrexone (Relistor) is? | Antagonist of peripheral mu opioid receptors; Indications: Use in PALLITATITVE CARE and OIC |
| ⭐️Methylnaltrexone (Relistor) is Contraindicated if? | obstruction suspected |
| ⭐️ Dosing of Relistor is? | Pallitative care: weight-based SQ dosing QOD OIC: SQ/PO daily dosing PO: with water on empty stomach >/= 30 mins before first meal Renal/hepatic dosing adjustments |
| AE of Relistor include? | abdominal pain and flatulence |
| Hemorrhoids are? | internal or external SWOLLEN veins around the anus that may bleed and/or be painful |
| Hemorrhoids occur when a pt is? | *straining Seen in obesity, pregnancy, and in liver disease |
| for hemorrhoids you can try conservative treatment which is? | increase fiber and water intake; stool softeners (prevent hemorrhoid from getting worse); warm water sitz bath (pt sits in warm water alleviating some of the inflammation) |
| Hemorroid treatment is primarily OTC, what’s very important about hemorrhoid treatment is that this needs to be _______ and the combination agents work the _____ | topical; best |
| Combination of TOPICAL ingredients for hemorrhoids are? | Astringent (i.e. Witch hazel) Protectant (i.e. zinc oxide) Vasoconstrictor (i.e phenylephrine—> only topical not taken internal) Corticosteroid (hydrocortisone) Topical anesthetic (Benzocaine, NO internal use) |
| Some OTC products we’ll see are _____ pads or ________ H | TUCKS; Preparation H (H for hemorroid) |
| Remember to avoid internal ___________ in HTN, DM, BPH, thyroid/heart disease, depression | Phenylephrine |
| Long did not mention this RX treatment: 0.4% topical _______ ointment; topical _______ (* must be compounded); Botulinum toxin injection | nitroglycerin; nifedipine |
| What are the Contraindications to self-care Treatment for Hemorrhoids? | Prolapse; Rectal 🩸; Age < 12 yo; Duration > 7 DAYS (If their hemorrhoids are sticking around longer than a week) ⭐️; Pregnancy |
| CI due to pregnancy for self-care hemorrhoid treatment? | Caution due to possible absorption—> fetal toxicity; AVOID suppositories; AVOID internal ointments (long applicator tubes) Long note: Most likely population we will see asking this; any of these drugs if absorbed internally can be very problematic to the fetus—> SEND to Doctor |
| When counseling pts on Metamucil, when should you tell them their constipation symptoms should be relieved by? -w/in 1 hr -w/in 12 hr -w/in 3 days -w/in 1 wk | within 3 days |
| Who should you avoid docusate in? -Abby, a 57 yo woman -John, a 79 yo man -Mackenzie, an 18 month old girl -Dylan, a 15 yo boy | Mackenzie, an 18 month old girl *emollient (stool softener and cannot be used in <2yo b/c of benzyl alcohol toxicity and can cause difficulty breathing |
| Which of these medications CAN be used for long-term use? -Psyllium -Mineral Oil -Bisacodyl (remember stimulant) | Psyllium (can be used in pregnancy, children, elderly |
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Xander635
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