Self Care: GI Part 3: Constipation + Diarhea + Anorectal

true/false: Constipation is defined by the number of bowel movements per day or week?

FALSE

• not based on speciifc number BUT your personal baseline

Consipation signs and symtpoms:

• decreased frequence of ______ ______ compared to baseline

• straining to have bowel movement

• passing _____, ___, ______ stools

• feeling as though bowel evacuation is incomplete

• reduced _________

• _____ _____ pain

• abdominal ________

• who is most commonly experiencing constipation?

• bowel movements

• dry, hard, small stools

• appetitie

• LOWER BACK pain

• distention

• women + elderly

What are some complications of contipations?

• hemmoroids

• fissures

• fecal impaction

What is the primary cause (idiopathic) of constipation?

• normal transit - difficulty passing hard stool

• slower transit - slower than normal movement of GI contents from proximal —> distal colon

How can you tell if primary idopathic constipation is caused by outlet obstruction?

• inability to adequately evacuate stool

• dysfunction of ______ floor or anal ______ muscles

• does not respond well to ______ therapy

• pelvic floor + anal spinchture muscles

• laxative therapy

What are some secondary causes of constipation?

• inadequate ______ and _____ intake

• _________

• ___________

• underlying diseases such as ______, _____, ______

• Medications such as (5)

• inadequate fiber and fluid intake

• IBD

• Pregnancy

• colon cancer + IBD + diabetes

medications:

1. NSAIDs

2. Iron supplements

3. anticholinergics

4. Calcium channel blockers

5. NON- potassium-sparing diuretics

What medications could cause constipation?

• Iron supplements

• Non-potassium sparing diuretics

• Analgesic (opiods, NSAIDs)

• Anticholinergics

• Calcium channel blockers

What are the treatment goals for constipation?

• relieve constipation : normal bowel function

• establish lifestyle habits to prevent recurrence (dietary ad exersize)

• promote safe and effective LAXATIVE use

  • avoid overuse (give correct durations)

Constipation: treatment approach

Steps 1-6

1, identify if they CAN be self-treated (look at exemptions)

2. dietary and lifestyle + consider BULK FORMING laxative (gentle)

3. saline or hypERosmotic laxatives

4. stimulant laxatives (more agressive)

5. stool softener to prevent straining may be considered at any point

6. tell patient not to use product longer than 7 days

What are the strengths of laxatives in terms of gentle to aggresive?

gentle = bulk forming laxatives

middle = hyperosmotic or normal saline

agressive= stimulant laxatives

You should not use an OTC laxative for more than ____ days

7

What are some Exclusions for Self-Treatment for Constipation?

• abdominal pain, DISTENTION, or cramping

• fever, nausea, vomiting

• para- quadriplegia (paralysis of limbs)

• IBD or colostomy

• blood in stool or DARK TARRY STOOLs

• daily laxative use

• persistent symptoms for more than 2 weeks or recur for 3+ months

• recurrent symptoms alter lifestyle changes or laxative use

What are some lifestyle changes you can recommend for patient with constipation?

• Gradually increase daily fiber

  • start w/ 2 servings/day and increase every 7-10 days

  • recommended intake = 14g per 1000kcal

  • from whole grains, wheat bran, fruits, vegetables

• Drink plenty of NON-caffeinated beverages

  • 32-128 ounces per day (2-8 water bottles/ day)

• aerobic exercise

• Calcium Polycarbophil (fibercon)

• Methylcellulose (citrucel)

• Psyllium (Metamucil)

These are examples of what type of laxatives?

BULK FORMING

• magnesium citrate

• magnesium hydroxide (milk of magensia)

• sodium phosphates

These are examples of what type of laxatives?

SALINE hypERosmotic laxative

• PEG3350 (MiraLAX)

• Glycerin suppositories

These are examples of what type of laxatives?

POLYER - Type HyperOSMOTIC

• senna (ex- lax)

• Dulcolax (bisacodyl)

• castor oil

Stimulant Laxatives - aggresive

• docusate sodium (Colace)

• docusate calcium

stool softoner - EMOLIENT

• mineral oil

stool softener - LUBRICANT

Bulk-Forming Laxatives:

• retain ______, which increases stool _____ content and intestinal bulk volume and stimulates peristalsis

• onset: within ____ - ___ hours

• adverse effects: abdominal pain + _________

• administration

  • do you have to take with fluid?

  • seperate dosing from other meds by at least ___ hours

• retain water —> increases water in stool

• 12-24 hours

• ADE: abdominal pain + flatulence

• YES take with fluid to prevent swelling in your throat

• seperate 2 hours from MEDS

What are the contraindications for bulk-forming laxatives?

DON’T GIVE TO PATIENTS!

• Difficulty swallowing (dysphagia)

• Fluid restriction (bc/ need to take w/ liquid)

• Intestinal ulcerations ( increased risk of fecal impaction or obstruction)

Hyperosmotic SALINE laxatives:

MOA: draw fluid into ________ via osmosis —> increased _______ ______- and GI motility

Onset: ____ to _____ (is this faster than bulk forming?)

What are some adverse effects?

• fluid into intestine —> increased INTRALUMINAL pressure and GI motility

• 30 minutes to 3 hours (Faster than bulk which is )

• abdominal cramping, dehydration, electrolyte disturbances

What are some contraindications for SALINE hyperosmotic laxatives?

• magensium containing products → renal failure

• sodium containing products —> congestive heart failure + cirrhosis

• avoid rectal administration if obstruction or colostomy

Hyperosmotic Laxative (Saline) BLACK BOX WARNING:

Which formulation is OTC vs. which is now prescription only?

• nephropothy in patients who were using them prior to colonoscopy

• OTC = enema

• prescription= oral tablet

Hyperosmotic laxatives (Polymer type):

• MOA: contain large _____ that draw water into the ______ through osmosis which stimulates bowel movement

• onset:

  • PEG3350 = ____ to ____ hours; may take up to ___ hours

  • Glycerin = ____ to ___ minutes

Which do we prefer PEG or Glycerin and why?

What are some adverse effects?

• ions —> colon

• PEG3350 = 12 to 72 hours (may be 96 hours)

• Glycerin = 15 to 30 minutes

• ADE: bloating, cramping, abdominal discomfort, flatulence

PEG bc/ even though it takes longer it is less aggressive that glycerin

Stimulant Laxatives:

MOA: stimulates _______ by local ______ irritation; increase intestinal secretion of _______ and __________

Onset: __ to hours, may take up to _ hours

What are some adverse effects?

MOA= stimulates PERISTALSIS by local MUCOUSAL irritation —> increases secretion of water + electrolytes

Onset: 6 to 10 hours —> 24 hours

ADEs: severe cramping, electrolyte and fluid deficiencies, malabsorption

Which stimulant causes

• discoloration of the urine (pink or red)

• chronic —> brown pigmentation of the colon wall (melanosis coli)

senna (ex-lax)

Which stimulant causes

• chronic —>

  • metabolic acidosis

  • alkalosis

  • hypocalcemia

  • malabsorption

bisacodyl (dulcolax)

Which stimulant is ONLY indicated for ACUTE BOWEL evacuation

• self care use is discouraged

castor oil

Stool Softeners (emollients):

MOA: anionic _________ that increase wetting efficiency of water in intestine to soften the fecal mass

Onset: 12 to 72 hours, up to __ to __days for full effects

What are some adverse effects of emollient stool softeners?

Emolients (docustate) can increase the absorption of _______ ____ which is why you should avoid use with

• surfractants

• 3 to 5 days

Adverse effects = mild abdominal cramps (generally well tolerated)

Mineral oil: SO don’t take docusate and mineral oil together bc/ docasate will increase mineral oil absorption

Lubricant Stool softner (Mineral oil):

• MOA: coats stool to prevent _____ _______ of fecal water

• 6 to 8 hours (oral admin); 5 to 15 minutes (rectal admin)

• What are the adverse effects of mineral oil?

• prevents colonic ABSORPTION of fecal water

ADE:

• Lipid pneumonia due to aspiration from oral administration

  • Do not take BEFORE LYING DOWN

• Foreign body reactions

  • avoid repeated and prolonged use

• May impair fat-soluble vitamins A, D, E, and K

Constipation: Special Populations

• the elderly are sensistive to shifts in _____ and _________ SO be cautious when using ______ laxatives. Which are preferred?

• What is the first-line treatment for pregnant women?

• shift in electrolytes + fluid so be cautious with saline hyperosmotic drugs > first choice for elderly is BULK

• Pregnancy = Dietary measures = first-line

What are some side effects a pregnant women on the following would experience?

• mineral oil (stool softner- lubricant)

• castor oil (stimulant)

• hyperosmotic agents (saline or polymer)

• mineral = decreased vitamin absorption

• castor oil = premature labor + uterine contraction

• hyperosmotic agents = electrolyte imbalances

Hemmoroids: clusters of inflamed swollen _____ _______ and ______ that project into bowel lumen during defecation

• Which type is painless (bright red blood on toilet paper)

• External hemorrhoids

• Swollen blood vessel + tissue

• Internal = painless w/ bright red blood

• External = painful with swelling

What is the clinical presentation for hemorrhoids?

• itching, disconfort, irritation, pain

• burning, soreness, inflammation

• dry anal tissue

• swelling in perianal area

What are the risk factors for hemorrhoids?

• age = older than ___

• ________

• constipation or diarrhea?

• prolonged time seated and straining on the toilet

• low _____ diet

• _________

• __________ lifestyle

• 45 olds

• pregnancy

• constipation

• low fiber

• dehydration

• sedentary lifestyle

Anorectal disorders in pregnant or breastfeeding women:

• Do you recommend internal or external agents? What is the exception?

• recommend EXTERNAL OTC products

• UNLESS internal with protectants except glycerin

What should you recommend for patients with the following disease states who also have ANORECTAL disorders:

• cardiovascular diseases

• hypertension

• thyroid disease

• diabetes

• BPH

• antidepressant use

AVOID vasopressors

What are some lifestyle modifications for anorectal disorders?

• avoid ________ heavy objects

• avoid foods that worsen symptoms. what are some examples?

• gradually increase intake of ______ up to __ - __ g/day

• increase _____ intake

• limit itme sitting on toilet __ - __minutes

• proper anal hygiene

• sitz bath for ___ - __ minutes 2-4 times per day

  • modest clinical data

• lifting

• alcohol, caffeine, citrus, fatty foods

• Dietary fiber intake 25 to 35 g/day

• water

• 10-20 minutes

What are the external application for anorectal disorders?

1. local anesthetic

2. keratolytics

3. analgesics/anesthetics/antipruritics

4. corticosteroids

What are the interal applications for anorectal disorders?

1. protectants

2. astringents

3. vasoconstors

External Application: Local Anesthetics

• What are some examples?

• Is it used for temporary or long-term relief?

• how many times a day do you apply them?

• can you apply them to open sores?

• what are some warnings?

• benzocaine, lidocaine, pramoxine hydrochloride

• temporary

• Up to 5-6 times a day

• NO: can’t use in open wounds because it could lead to rapid absorption—> preventing open wounds prevents systemic side effects

• May cause allergic reactions

External Application: Keratolytics

• What are some examples?

• cause _______ and _________ (sloughing) of epidermal surface cells leading to increased cell turnover

• How often do you apply?

• What are some resorcinol adverse effects?

• resorcinol, alcloxa (aluminum chlorhydroxyallanate)

• desquamation and debridement

• up to 6 times per days

• tinnitus, increased HR, diaphoresis, SOB, unconsciousness, seizures

• methemoglobinemia, exfoliative dermatitis, death in infants, myxedema in adults

External Application: Analgesics, Anesthetics, Antipruritics

• What are some examples?

• Produce a cool, warm, or ______ sensation to relieve external symptoms temporarily

• Is it temporary or long-term?

• menthol, juniper tar, camphor

• tingling

• temporary

External Applications: Hydrocortisone

• what are examples?

• is it temporary or long term?

what are some adverse effects if you use for 7 days?

• hydrocortisone

• temporary

• skin atrophy with use longer than 7 days

Internal Application Agents: Astringents

• What are some examples?

• Promote ________ of surface _____ in anorectal skin cells to prevent underlying tissue

• witch hazel (external), calamine, zinc oxide (external/internal)

• promote coagulation of surface protein

Internal Application Agents: Protectants

• What are some examples?

• provide protective physical barrier over inflamed tissue and soften the lining of _____ _______

• Is it absorbed systemically?

• glycerin (external only), cocoa butter, kaolin, lanolin, petrolatum, mineral oil, calamine, zinc oxide \

• soften lining of anal canal

• minimal to no systemic absorption

Internal application: vasoconstrictors

• What are some examples?

• stimulate _____ receptors in vascular beds to constrict arterioles

• How often do you apply?

• What are some adverse effects?

• Epinephrine (external only)- ephedrine sulfate and phenylephrine HCL (external/internal)

• alpha

• 4 times a day

• nervousness, tremors, nausea, appetite loss, sleeplessness

How to administer Phenylephrine (Preparation H):

1. Open tube by puncturing foil seal with pointed end of cap.

2. Attach applicator to tube and remove protective cover.

3. Test applicator by squeezing tube gently to see how much ointment comes

out. The amount you want is about length of tip of index finger

4. To lubricate applicator, squeeze some ointment onto tip of finger and put it on the end of the applicator.

5. Lie on your side with bottom leg straight and top leg bent toward stomach.

6. Lift top butt cheek and insert applicator from the front or back until it passes the sphincter muscle about 1 inch in.

7. Squeeze the tube using the same amount of pressure as when you tested the applicator.

8. Remain still for 5 min

• For extra relief, you can apply more cream to the external area using a finger.

9. Clean applicator with warm water and gentle soap.

• Thoroughly rinse and replace protective cover.

10 Wash hands with mild soap and warm water.

• Wait 1 hr before using bathroom

Diarhea:

• abdnormal increase in stool ______, _______, _______, or liquidity

• > ___ bowel movements with loose stools in 24 hours

• What is considered

  • acute diarrhea?

  • persistent diarrhea?

  • chronic diarrhea?

• Frequency, weight, volume

• 3+ bowel movements

• acute = <14 days

• persistent = 14 days to 4 weeks (2-4 weeks)

• chronic = 5+ weeks

What classifications of diarhea can you treat OTC?

• acute = can treat OTC (fluid and electrolyte repletion, dietary interventions, OTC meds)

• persistent + chronic = need REFERAL

What are some causes of diarhea?

• infections (virus + bacteria + protozoa)

• food poisoning

• food intolerance

Which medications can cause diarhea?

• Antibiotics

• Anticancer

• Colchicine

• Cholinergic

• Metformin

What are some Risk Factors for Infectious Diarrhea?

• Attendance or employment at a daycare center

• Occupation as a food handler or caregiver

• Congregate living conditions (nursing homes + prisons + multifamily dwellings)

• Unsafe foods (raw or undercooked meat, eggs, shellfish)

• HIV/AIDS

• diverticulitits

What are condition risk factors for diarhea?

• HIV/ AIDS

• Diverticulitis

How do you treatment diarhea?

1. prevent or correct fluid and electrolyte loss and acid-base disturbance

2. relieve symptoms

3. identify and treat the cause

4. prevent acute morbidity and mortality

Diarrhea: Treatment Approach

1. Identify if a candidate for self-treatment

2. Correction of ______ and ______ loss

3. _________ agent: ________________

4. ________ agent : _________________

5. Medical referral if condition worsens after 48 hours from onset

2. fluid and electrolyte loss

3. Antidiarrheal agent = loperamide (Imodium)

4. Antisecretory agent = bismuth subsalicylate (Pepto-Bismol)

What are the exclusions for self-treatment?

• CHRONIC or PERSISTENT diarrhea > _____ days

• ________ abdominal pain or cramping

• substantial _______ of diarrhea

• _____ _____ or _____ in stool

• severe _______ or suboptimal response to rehydration

• _____ vomiting

• What are some disease states where you SHOULD NOT be treated OTC?

• 14 days

• SEVERE

• volumes

• blood or mucus or pus in stool

• dehydration

• protracted

• Diabetes

• severe CVD or CKD

• multiple chronic medical conditions

• immunosupressed

What are some non-pharmacological therapies for diarhea?

1. Fluid + electrolyte management

2. Dietary modifications:

• Early feeding: do NOT withhold food for more than ____ hours

• NOT BRAT diet (Bananas Rice Apple Toast) bc/ not enough protein/fat/calories

• limit fatty or spicy foods

3. Preventative measures

• isolation + handwashing

What are the pharmacological treatment options for diarhea?

1. loperamide (immodium)

2. bismuth subsalicylate

Loperamide (Imodium):

What age group can use it?

What is the MOA?

6 +

SELECTIVE OPIOID AGONIST: works PERIPHERALLY in the gut

what are some adverse effects of Loperamide which is used for diarhea?

• BLACK BOX WARNINGS:

  • CV risks

  • Arrhythmia and death

What are some contraindications for loperamide?

• fecal leukocytes

• high fever

• blood or pus in stool

What is the dose for loperamide for diarhea?

4 mg PO intitially —> 2 mg after each loose stool

Loperamide:

• max dose?

• max duration?

• max dose = 8 mg/day

• max durations = 48 hours

4 mg PO initially —> 2 mg after each loose stool

Bismuth Subsalicylate:

• MOA: bismuth increases body’s absorption of ______ from the ____

• What does salicylate do?

• water from the gut

• Subsalicylate: COX inhibitor —> decreased prostaglandin formation —> reduced GI motility ( so not going as frequently)

What are the adverse effects of bismuth subsalycate?

• black tongue + stools

• bitter taste

• mild tinnitus = dose - dependent

• nausea

who should NOT take bismuth subsalicyate?

• alllergy

• taking other salicylates (aspirin)

• children w/ chickenpox or influenza illness or vaccine

Diarrhea:

• What are some major complications?

• Most mild episodes are self-limiting

• mainstay of therapy = oral _________ solution

• pharmacologic options : ______ and ______ ________ which reduce frequency and releive symptoms

• dehydration + fluid + electrolyte imbalances

• rehydration

• pharmacologic options = loperamide and bismuth subsalicylate

• reduce frequency and relieve symtpoms