Constipation and Diarrhea

In order to diagnose a pt with constipation-- two or more of what symptoms/criteria is needed for at least 3 mos?

•Hard stools at least 25% of the time

•Two or fewer bowel movements per week

•Difficulty passing (straining) at least 25% of the time

•Incomplete evacuation at a minimum of 25% of the time

What are some common symptoms of constipation?

nausea

abd pain

urinary incontinence

diarrhea

What are some alarming symptoms for constipation?

abd pain

N/V

Blood in the stool

change in bowel habits >2wks

worsening despite tx

treatment >7d

What are some condition/disease induced causes for constipation?

MS, Spinal Cord Injury, Parkinson Disease

Diabetes

IBS

Pregnancy

Hypokalemia

Hypothyroidism

What are some common medication causes of constipation?

Iron

Opioids (hydro/oxy)

Diuretics

Anticholinergics (diphenhydramine, antipsychotics)

CCB

Calcium-containing antacids (Tums)

What are some nonpharm treatments for constipation?

-Encourage fluids

-Activity as tolerated

-Encourage fiber in diet as tolerated

(25 - 30g per day)

-Avoid constipating medications if possible

-Provide a comfortable and private environment for defecation

-Educate about the appropriate use of laxatives to minimize laxative abuse syndrome

What is an OTC 1st line oral therapy for constipation that acts by absorbing water and increasing fecal mass, and has an onset of 12-72hrs?

Bulk-Forming Agents (Psyllium/Meta-Mucil)

What is a 2nd line OTC oral treatment for constipation that works by increasing salt/sugar in GI tract to increase water movement-- onset in 24-96hrs?

Osmotic (Lactulose and Polyethylene glycol)

What is the drug group of polyethylene glycol (Miralax)?

osmotic

What is a 2nd or 3rd line for oral constipation tx that works by increasing concentrations of intestinal walls by stimulating nerves?

stimulants (Senna and Bisacodyl)

Senna and Bisacodyl are in what drug group for treating constipation?

stimulants

What are some possible SEs for Bulk forming agents used to treat constipation?

bloating, cramping, flatulence

What are some possible SEs of Osmotic OTC oral treatment for constipation (Miralax)?

•Nausea

•Cramping

•Flatulence

•Electrolyte disturbances

What are some possible SEs of OTC Stimulants used for constipation treatment (Senna and Bisacodyl)?

•Nausea

•Cramping

•Electrolyte disturbance

What drug group is used as oral tx for constipation that works by increasing the mixing of fatty materials in stool ?

Surfactants (Docusate Sodium--- Colase/Stool Softener)

What are some possible SEs of Surfactants used to treat constipation?

(Docusate Sodium)

•Cramping

•Fecal soiling

•Relatively safe

What is a Stimulant suppository used for constipation tx that takes 15-60min to work and can cause rectal irritation?

Bisacodyl

What is a Suppository used for constipation tx that takes 15-60min to work and can cause rectal irritation?

Glycerin

What is a Fleet Enema used for constipation tx that takes 5-15min to work and can cause hypocalcemia or rectal irritation?

Sodium Phosophate

What is a Saline Enema used for constipation tx that takes 5-15 min to work and can cause rectal irritation?

Warm Saline

C!

Which of the following is considered a “stool softener” and works by mixing of aqueous and fatty material within intestinal tract? ID = 010006

A. Sodium phosphate enema

B. Polyethylene glycol (Miralax)

C. Docusate (Colace)

D. Senna

What is the definition for diarrhea?

3>= unformed stools per 24hrs and/or the passage of frequent loose stools with urgency

What is this classification of diarrhea:

14d or less

acute

What is this classification of diarrhea:

14-30d

persistent

What is this classification of diarrhea:

over 30d

chronic

What are some medications associated with causing diarrhea?

ABX

Laxatives

Magnesium Antacids

Chemotherapy

What are some exclusions for self- treatment for diarrhea?

1.High grade fever

2.Recent antibiotic use - concern for cdiff

3.Severe abdominal pain

4.Pregnancy or child < 6 months

5.Patient is or is at risk for severe dehydration

6.Immunocompromised or severe chronic illness

7.If persists longer than 72 hours or if gross blood or pus is present in stool

What is an OTC diarrhea treatment that is often considered drug of choice because of its efficacy, potency, and that it cannot cross the BBB?

Loperamide (Imodium)

What drug is used for these indications:

•Traveler’s diarrhea

•Nonspecific acute diarrhea

•Pt has low grade fever no bloody stools

Loperamide (Imodium)

If C. diff is suspected, should we treat diarrhea with Loperamide (Imodium)?

NO

What is an opioid diarrhea tx used in combination to reduce abuse potential?

Diphenoxylate with Atropine (Lomotil)

Can you use anticholinergics for diarrhea treatment?

NO!

What treatment for diarrhea replaces colonic microflora and restores normal intestinal function?

Probiotics (Lactobacillus)

A pt presents with feeling weak, uncomfortable and has abd cramps with diarrhea. She states she recently traveled-- what is the likely dx?

traveler's diarrhea

What are some prevention tips for avoiding travelers diarrhea?

- avoid raw or undercooked meat, seafood, and vegetables

- avoid water and milk from questionable sources

What abx can be used as a preventative for travelers diarrhea for a pt who is at high risk?

Ciprofloxacin 500mg PO daily for 4 days

What are the treatment options for travelers diarrhea?

1.Oral rehydration therapy

2.Loperamide (Imodium) for sx management

3.Fluoroquinolone if treatment necessary

What are some abx treatment options for Travelers diarrhea?

FQs - 1st line

Azithromycin (1st line in children or alt)

What is the MC cause of infectious diarrhea in hospitalized pts?

C. Diff

C. diff is associated with use of what broad spectrum abx?

-Ampicillin

-Clindamycin

-Cephalosporins

-Fluoroquinolones

What are some high risk pts for developing C. diff?

elderly, cancer pts, GI surgical pts, pts with NG tubes, and medications to reduce gastric acid (PPIs)

For a pt presenting with mild, moderate, or severe C. diff infection for an FIRST LINE initial episode-- what are you treating them with?

Fidaxomicin 200mg 2xd for 10d

- expensive

What is a cheaper alternative to treating an initial episode of C. diff infection used as an alternative?

Vancomycin 125mg PO 4xd for 10d

What is the mild tx for C. diff when Vanco or Fidaxo is not available?

Metronidazole 500mg PO TID for 10-14d

What defines severe C. diff infection?

WBC ≥ 15,000 cells/mm3 or SCr ≥ 1.5 mg/dL

What is the tx for severe C. diff infection?

vanco+ Metronidazole

What is the first line tx option and alt option for a first RECURRENCE of C. diff infection?

Fidaxomicin 200mg BID x10d

Alt: vanco 125mg PO TID x14d

A!

In addition to avoidance of certain food products, which of the following treatments is recommended in diarrhea-predominant IBS for moderate symptoms? ID = 010006

A. Loperamide

B. Rifaximin

C. Polyethylene Glycol

D. Lactulose