130 Exam (Post-Midterm)

Constipation is less than ____ bowel movements per week

3

True or false. Pain is an associated symptom with constipation

False

What type of constipation is mainly focused on in the lecture?

Primary- normal transit/functional

Which of the following is not part of the criteria for chronic constipation?

- Lumpy or hard stools (Bristol Stool Scale 1-4)

- Sensation of incomplete evacuation

- Straining

- Manual maneuvers

Lumpy or hard stools (Bristol Stool Scale 1-4).

Only 1-2 are considered constipation

2 or more symptoms for more than 25% of defecations for at least 3 months with symptom onset at least 6 months prior to the diagnosis describes this condition

Chronic constipation

Which of the following would not be a cause of chronic constipation

- Diabetes mellitus

- Hypothyroidism

- Dementia

- Acute opioid use

Acute opioid use

Which is not a risk factor for constipation?

- Men

- Older adults

- Lack of exercise

- Low fiber intake

Men

Which of the following is not a red flag for constipation?

- Children under 2

- Blood in the stool

- No bowel movement in 7 days without laxative use

- Fever

- Abdominal pain

No bowel movement in 7 days without laxative use

It would be a red flag if this occurred in spite of laxative use

Which of the following is not a red flag for constipation?

- Vomiting

- Symptoms begin at age 50+

- Dizziness

- Eating disorder

- All of the above warrant a referral

All of the above warrant a referral

Why is diarrhea alternating with constipation a red flag?

May indicate IBS

True or false. Non-pharm strategies are first line for constipation

True

Insoluble fibre

Insoluble fibre does not break down which creates a bulk through the GI tract and helps food pass

Women need ___ grams of fibre per day and men need ___ grams of fibre per day

25; 38

Soluble fibre

Helps with the consistency of stools

True or false. Activia may be recommended for constipation for its probiotic content

True

True or false. Psyllium is an insoluble fibre

False

Bulk forming laxatives (psyllium) mechanism of action

Absorb water into the gut and form a bulk which increases stool volume and mass

What is not a concern with psyllium?

- Sufficient water intake (risk of obstruction)

- Flatus

- Bloating

- Black stools

Black stools

Which is not a bulk forming laxative?

- Metamucil

- Bran

- Colace

- Inulin

Colace (stool softener)

Stool softeners and bulk forming laxatives have a _________ (slow/fast) onset of action

Slow (12-72 hours)

True or false. Stool softeners like colace are no more effective than placebo

True

Why is mineral oil not recommended as a stool softener?

May cause lipid aspiration (lipid pneumonia)

Osmotic laxatives mechanism of action

Poorly absorbed ions will increase motility

True or false. PEG is generally preferred to lactulose as an osmotic laxative because it is better tolerated and can be used long term

True

Which of the following osmotic laxatives is good for PRN use?

a) Milk of magnesia

b) Lactulose

c) Glycerin suppository

d) A and C

e) All of the above

A and C (milk of magnesia and glycerin)

Why is milk of magnesia 2nd line as an osmotic laxative

Lengthier side effect profile and contraindicated with cardiac or renal disease and/or dehydration

Which of the following is not an osmotic laxative?

- Glycerin suppository

- Lactulose

- PEG

- Magnesium citrate

Magnesium citrate

Which purgative should not be recommended due to risk of kidney injury?

Sodium phosphate

When are enemas typically used for constipation?

Endoscopic or surgical procedures

Older adults should take a __________________ enema

Mineral oil

This is because the phosphate enema may cause issues if they have kidney problems

Stimulant laxatives mechanism of action

Increase peristalsis by producing muscle contraction

Which is not true about stimulant laxatives?

- Usually used long term

- Recommended if osmotic laxatives fail

- For opioid-induced constipation

- Includes senna and bisacodyl

Usually used long term

These are usually for short term use and have quick onset of action

Bisacodyl is activated in the _______________________ whereas senna is activated in the _________________________

Small intestine; colon

This laxative cannot be combined with milk, antacids, proton pump inhibitors

Bisacodyl (dulcolax)

What laxative is first line for long term use in patients with chronic constipation?

Psyllium (metamucil)

Prucalopride can be used in ____________ (men/women) who have not seen success with laxatives

Women

Prucalopride mechanism of action

Binds to the 5-HT receptors which releases ACh and leads to colonic peristalsis and movement

Constella (linaclotide) mechanism of action

Acts on guanylate cyclase-C receptor to increase fluid in the gut and increase number of BMs

True or false. The majority of constipation in children is not due to an underlying cause but rather avoidance of the toilet (functional constipation)

True

Why is fiber not first line for constipation in children?

It may cause gassiness and discomfort

First line therapy for constipation in children

Adequate fluid intake, balanced diet, physical activity, toilet routine, foot stool to provide support, journaling, encouraging child

First line therapy for constipation in infants

Sorbitol containing juice

True or false. Only treat infants for constipation if they have been sent by a doctor for a drug, otherwise refer

True

Second line therapy for constipation in infants

Glycerin suppositories

Which constipation treatments should be avoided in pregnant patients

Milk of magnesia and mineral oil. Consider Psyllium as first line

When should you follow up for acute constipation?

Based on the onset of the agent selected

When should you follow up for chronic constipation?

Once a week for 4-6 weeks if possible

Pinworm larvae hatch in the __________________________, mature in the _________________________, and then lay eggs in the ___________________ region

Small intestine; large intestine; perianal

True or false. Patients with pinworms tend to be itchiest at night because pinworms lay eggs at night

True

True or false Pinworm eggs can be found on undergarments, linen, or stool

False. Eggs can only be visualized under a microscope

True or false. Over half of pinworm infestations are asymptomatic

True

Which is not a symptom of pinworms in children?

- New onset of bedwetting

- Anal dermatitis

- Anal/perianal itch

- Insomnia

Anal dermatitis

True or false. Pinworms can cause systemic infection in rare cases

False. They do not get absorbed into the bloodstream

Which is not a red flag of pinworms?

- Dysuria

- Insomnia

- Loss of appetite

- GI distress

Insomnia

What confirmatory test for pinworms can be done that does not require a microscope?

Flashlight test

Which is not non-pharm treatment for pinworms?

- Wash sheets every 3-7 days for 3 weeks

- Keep fingernails short and clean

- Wash toilet seat

- Taking baths

Taking baths

Showering is preferred to prevent reinfestation

Which pharm treatment for pinworms is indicated for a patient that is 14 months old?

Pyrantel pamoate (Combantrin)

True or false. For pinworm treatment, mebendazole is dosed based on weight whereas pyrantel pamoate is not

False

Mebendazole has ___ doses at 2 week interval(s) whereas pyrantel pamoate has ___

3; 2

True or false. All household contacts for pinworms should be treated, even if asymptomatic.

True

True or false. It is best to delay pinworms treatment until after delivery but it can be considered in the second and third trimesters

True

What pharm treatment is preferred for pregnancy and pinworms?

Pyrantel pamoate is the preferred agent as it has minimal systemic absorption

When should you follow up on pinworms if pharm treatment was given?

After 7 days after the second/third dose

When should you follow up on pinworms if only non-pharm advice was given?

8 weeks

True or false. No resolution of itch after follow-up for pinworms is a referral

True

Refer all diarrhea lasting ___ days or more

14

Diarrhea is over __ loose or watery stools (type 5, 6, 7 on Bristol scale) in 24 hours

3

___________ diarrhea is less than 14 days

____________ diarrhea is between 14-28 days

____________ diarrhea is 28+ days

Acute; persistent; chronic

Which is not a secondary cause of chronic diarrhea?

- Chronic infection

- Long term opioid use

- Hyperthyroidism

- IBS

Long term opioid use

Osmotic or solute-induced acute diarrhea

Osmostically active solutes present in the gut lumen decrease the osmotic gradient and decrease water absorption (eg. lactose intolerance, large intake of fructose, osmotic laxatives)

Lactose intolerance causes what type of diarrhea

Osmotic or solute-induced acute diarrhea. People with lactose intolerance can not convert lactose to something that can be absorbed and absorb less water

Peristaltic acute diarrhea

Stimulation of enteric nervous system increases peristalsis and decreases the time for water absorption (can include stress, caffeine, and abrupt cessation of opioids)

Secretory or electrolyte-related diarrhea

Ion transport across the intestinal membrane is reversed (i.e. ions are secreted into gut lumen). This decreases the osmotic gradient and decreases water absorption (maybe even pulling water out of the body). It is also combined with increased peristalsis

Causes of secretory or electrolyte-related diarrhea

Bowel ischemia, misoprostol, viral enterotoxins (rotavirus, norovirus), and bacterial enterotoxins (cholera, e.coli)

What type of diarrhea tends to be the most serious?

Secretory or electrolyte-related diarrhea

Gastroenteritis

inflammation of the stomach and intestines causing diarrhea

Traveler's diarrhea is of _____________ (viral/bacterial/parasitic) origin

Bacterial

Most common cause of gastroenteritis in developed countries

Viral (aka stomach flu)

Giardia lamblia is a ____________________ (viral/bacterial/parasitic) cause of diarrhea

Parasitic

Which is not a red flag for diarrhea?

- Worsening over time

- Recent antibiotic use

- Patient is immunocompromised

- Patient is under 6

Patient is under 6.

We refer children under 2 because it is difficult to identify dehydration in this population

The most common complication of acute diarrhea

Dehydration

Which is not a population we refer when it comes to diarrhea?

- Diabetics

- Frail elderly

- Immunocompromised

- These are all populations we refer

These are all populations we refer

True or false. Over 6 episodes per day for over 2 days indicates severe diarrhea (and a referral)

True

True or false. Most dehydration cases come from not drinking enough fluids

False. Dehydration occurs when the body uses or loses too much water.

True or false. Constipation is a symptom of late stage dehydration

True

Skin turgor test

Pinching the skin on the back of the hand or forearm. If it does not immediately go back down, there may be dehydration.

Which is not a late stage symptom of dehydration?

- Tachypnea

- Bradycardia

- Hypotension

- Sunken eyes

Bradycardia

Fever is a sign of dehydration in __________________ (adults/infants) but not typically in _____________________ (adults/infants)

Infants; adults

For what causes does diarrhea need treatment?

Infectious or food-borne

What is first line therapy for mild-moderate acute infectious diarrhea

Oral rehydration therapy

What is oral rehydration therapy

Solution of sugar and salt (glucose enhances sodium absorption)

True or false. Oral rehydration therapy is contraindicated with prolonged vomiting

True

Which is not a treatment of mild acute infectious diarrhea?

- Loperamide

- Psyllium

- Bismuth subsalicylate

- Oral rehydration therapy

Loperamide

Loperamide should be used to treat moderate-severe

True or false. Psyllium can be recommended as a treatment for both constipation and diarrhea

True

For children with diarrhea, WHO/UNICEF recommends _______ supplementation for 10-14 days for children

Zinc

Diarrhea should be referred after 48 hours of unsuccessful ____________________________ and 24 hours of unsuccessful _______________________

Oral rehydration therapy; loperamide

Chronic Idiopathic Constipation (CIC)

Constipation occurring chronically that does not have drug, anatomic or physiologic causes

True or false. Treatment of upper respiratory tract infections of bacterial origin is in pharmacist scope of practice in Ontario

False

Which is not a test for pinworms?

- Scotch Tape test

- Perianal itch assessment

- Flashlight test

- Paddle test

Perianal itch assessment

Most common virus in viral rhinitis

Rhinoviruses (fall and spring)