Constipation and Diarrhea_Treatment – Flashcards
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Diarrhea Goals of Therapy
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? Manage the Diet. ? Prevent Excess Water, Electrolyte and Acid-Base Disturbances. ? Provide Symptomatic Relief. ? Treat Curable Causes. ? Manage Secondary Causes.
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Clinical Presentation: *Acute*
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? Abrupt onset of N/V, abdominal pain/cramping, HA, fever, chills, malaise. ? Frequent, non-bloody bowel movements. ? Self-limiting, Subsides in ~72 hours.
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Clinical Presentation: *Chronic*
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? Acute presentation with:History of previous episodes, weight loss, anorexia, chronic weakness. ? Frequent episodes over extended time period.
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Treatment of *Acute* Diarrhea
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? Usually self-limiting within 3-7 days. ? *Positive* for fever or systemic symptoms then stool studies. • Stool Studies If *positive*, initiate *antibiotics and symptomatic therapy.* If *negative*, initiate *symptomatic therapy* ? *Negative* for fever or systemic symptoms • Symptomatic Therapy Fluid/electrolyte replacement. Anti-Diarrheal. Diet.
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Treatment of *Chronic* Diarrhea
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*Differential Diagnosis* • Intestinal Infection, IBD, Malabsorption, Secretory Hormonal Tumor, Medications, Motility Disturbance *Stool Sample Analysis, Sigmoidoscopy, Intestinal Biopsy.* *Treat Cause and Symptomatic Therapy.*
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Symptomatic Therapy
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1. Dietary Management. 2. Water and Electrolytes.
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Symptomatic Therapy: Dietary Management
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? Discontinue Solid Foods & Dairy x 24hrs. ? Osmotic Diarrhea or Uncontrolled Vomiting -> Fasting is Best. ? Re-Initiate a Bland Diet when BMs Decrease. ? Oral Rehydration Solutions (ORS). *Children.* ? Feeding Should Continue and ORS. • Less Morbidity and Mortality.
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Symptomatic Therapy: Water and Electrolytes
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? Dehydration d/t small intestines retaining glucose which actively carries Na+, H2O. ? Rehydrate and Maintain Water & Electrolytes. ? Sports drinks are not recommended. ? Parenteral and Enteral Routes (Enteral is preferred).
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Pharmacologic Therapy
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? Anti-motility agents. ? Adsorbents. ? Anti-Secretory Compounds. ? Probiotics.
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Contraindications for pharmacological therapy
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? Abdominal pain in the absence of diarrhea. ? Bacterial diarrhea (bloody diarrhea, fever). ? Infants less than 24 months old. ? Acute ulcerative colitis.
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Anti-Motility Agents: Opiates and Opioid Derivatives
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? Delay transit of intraluminal content. ? Increase gut capacity, prolong contact and absorption. ? Enkephalins -> Regulate fluid movement, stimulate absorption.
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Adsorbents: *MOA*
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MOA: Absorb nutrients, toxins, drugs, digestive juices. ? Used for Symptomatic Relief. ? Safe but Effective?
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Adsorbents: *Agents*
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*Calcium Polycarbophil*: 1000mg QID; MAX 6g/day. *Kaolin-Pectin (Kaopectate®)*:30-120ml after each loose stool. Not in market d/t efficacy. *Attapulgite*: 1200-1500mg after each loose BM.
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Antisecretory: *Bismuth Subsalicylate (Pepto-Bismol®)*
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*Bismuth Subsalicylate (Pepto-Bismol®)* *MOA*: Anti-secretory, anti-inflammatory, and anti-bacterial effects. *Use*: Indigestion, abdominal cramps, acute diarrhea, and traveler's diarrhea (secretory and infectious also?). *Dose*: 2 tabs/ 30ml Q 30min-1hr PRN; MAX: 8 doses/day. *SE*: Black tongue, stools, ringing on ear. *Interactions*: anti-coagulants, gout, children, ASA allergy, Probiotics/ Lactase Enzymes
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Antisecretory: *Octreotide (Sandostatin®)*
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*Octreotide (Sandostatin®)* *MOA*: inhibits many hormones to control diarrhea and secretions. *Use*: Diarrhea due to tumors or chemotherapy. *Dose*: Injection; varies with indication, disease severity, and pt response. *SE*: cholelithiasis, nausea, diarrhea, abdominal pain, injection pain, high doses -; steatorrhea.
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Probiotics: *Lactobacillus sp.*
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*MOA*: Replaces colonic flora to restore normal. function and suppress the growth of pathogenic micro-organisms. *Use*: Antibiotic associated diarrhea, traveler's diarrhea, or non-specific acute diarrhea in children. *Dose*: 2 tabs TID-QID w/ milk, juice, or water. *SE*: Gas, burping, diarrhea, vomiting.
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*Constipation* Goal of Therapy
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*Prevent further episodes with TLC.* ? Increase daily fiber, water, and physical activity. *Alleviate acute constipation symptoms.* ? Bulk-Forming Laxatives,. ? Emollients Docusate,. ? Mineral Oil, Lactulose. ? Stimulant Laxatives: Bisacodyl, Senna. ? Saline, castor oil, PEG.
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Constipation: Non-Pharmacologic Therapy
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Dietary Modification (atleast 10g of fiber). Assess Toileting Habits. Increase Physical Activity. Adequate Fluid Intake. Surgery. Biofeedback.
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Agents that cause softening of feces in *1-3 days.*
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Bulk forming agents methylcellulose. Polycarbophil. Psyllium. Emollients docusate sodium. Calcium. Potassium.
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Agents that result in soft or semisolid stool in *6-12 h.*
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Bisacodyl po, phenolphthalein, cascara sagrada, Senna, magnesium sulfate
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Agents causing *water evacuation in 1-6 hrs.*
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? Magnesium citrate, magnesium hydroxide, magnesium sulfate, sodium phosphates, bisacodyl rectal. ? Polyethylene glycol - electrolyte lavage solution.
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Emollient Laxatives:*Docusate Salts*
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Docusate Salts ? Surfactant; works by facilitating mixing of aqueous and fatty materials within the intestinal tract. ? Increase water and electrolyte secretion in the small and large bowel. Softens the stool within 1-3 days. Usually used to prevent constipation.
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Lubricants MOA
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? Works by coating the stool and allowing easier passage. ? Inhibits colonic absorption of water. ? *Increase* stool weight and *decrease* stool transit time.
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Lubricants characteristics
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? Mineral oil. ? Works in 2-3 days. ? Usually used to prevent constipation for short periods of time ? AE Mineral Oil > AE Docusate (*Docusate Preferred*)
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Stimulant Laxatives: *Bisacodyl and Senna*
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MOA: GI irritant; stimulates colon nerve plexuses to stimulate peristalsis and a BM. ? Produces a BM within 6-12 hours. ? Not recommended for daily use. ? *SE*: abdominal cramping, electrolyte imbalances. *Stimulant laxatives are DOC for acute constipation.*
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Osmotic Agents: *Lactulose and Sorbitol*
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? Metabolized by colonic bacteria resulting in osmotic effects (fluid is retained in the colon) • Lowers the pH and increases peristalsis ? Sorbitol is recommended over Lactulose d/t lower cost and similar efficacy.
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*Castor Oil*
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? Works in the small intestine: Stimulates secretory processes, decreases glucose absorption, and promotes intestinal motility. ? Results in a BM within 1-3 hours. ? Should not be used chronically.
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*Glycerin*
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? *MOA*: osmotic effects in the rectum. ? Administered as a 3g supp. ? Produces a BM within 30 minutes. ? Considered very safe, but still only use on an intermittent basis (May be used in children).
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*PEG*
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*MOA*: causes retention of water in the stool resulting in a softer stool and more frequent bowel movements. ? Whole bowel irrigation (PEG-ELS) for bowel cleansing prior to colonic procedures: 4L is consumed over 3 hours until BM is clear.
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PEG: Polyethylene Glycol 3350 (Miralax)
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17 g/day (about 1 heaping tbsp) dissolved in 4 to 8 ounces of water, juice, soda, coffee, or tea. Used for acute and chronic constipation.
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*Lubiprostone (Amitiza)*
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? Newly FDA Approved ? Chloride Channel Activator ? Approved for chronic idiopathic constipation in adults ? Dose: 24mcg Cap BID with Food ? SE: HA, diarrhea, nausea, delayed gastric emptying
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Laxative Abuse Syndrome
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? Occurs in pts trying to maintain daily bowel function or controlling body weight. ? *S/Sx*: diarrhea, weight loss, vomiting, abdominal pain, weakness, thirst, edema, bone pain. ? *Consequences*: fluid and electrolyte imbalances and syndromes like colitis. ? Most common in middle aged women.
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Saline Laxatives: *Milk of Magnesia (MOM) or Fleet Phospho-Soda* (Fetena).
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*MOA*: Osmotic actions, draws fluids into the GI tract to shorten stool transit time. ? Enema formulations are useful for fecal impactions. ? Results in a BM in 1-6 hours. ? *Fastest of all agents.*
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*Diarrhea Review Questions* This type of diarrhea occurs when a stimulating substance either increases secretion or decreases absorption of water and electrolytes: A) Osmotic B) Exudative C) Secretory D) Transitory E) Hydrostatic
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C) Secretory
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This type of diarrhea is distinguishable from other types because it ceases if the patient resorts to a fasting state: A) Osmotic B) Exudative C) Secretory D) Altered intestinal motility
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A) Osmotic
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Which statement about acute diarrhea is true? A) It is self-limiting, usually subsiding within 72 hours B) It is secondary to diseases such as diabetes C) It is treatable with bulk-forming laxatives D) It is a long-term condition that waxes and wanes throughout life gastrointestinal disease
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A) It is self-limiting, usually subsiding within 72 hours
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Which of the following drugs or measures are not advocated for prevention of travelers diarrhea? A) Special care with drinking water B) Bismuth subsalicylate (BSS) C) Special care with fresh vegetables D) Avoidance of meat products E) Antibiotic prophylaxis
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D) Avoidance of meat products
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If diarrhea occurs, therapeutic goals include all of the following except: A) Prevent excessive water and electrolyte loss B) Provide symptomatic relief C) Manage the diet D) Treat curable causes E) Stop the diarrhea at all costs
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E) Stop the diarrhea at all costs
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This antisecretory agent used to treat diarrhea can interact with anticoagulants, interfere with tetracycline absorption, and interfere with some gastrointestinal radiographic studies: A) Polycarbophil B) Bismuth subsalicylate C) Loperamide D) Paregoric E) Diphenoxylate with atropine
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B) Bismuth subsalicylate
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*Constipation Review Questions* Which of the following statements about constipation is true? A) Lack of daily bowel movements leads to buildup of toxic substances B) Daily BMs are required for health and well-being C) Inadequate diet is a major cause of constipation in the United States D) Normal healthy pts pass at least 6 stools per week E) Constipation should be treated initially with castor oil
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C) Inadequate diet is a major cause of constipation in the United States
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Factors found to correlate with selfreported constipation include all of the following except: A) Presence of hemorrhoids B) Greater frequency in females C) Total number of drugs taken D) Age of subject E) Greater frequency in males
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E) Greater frequency in males
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Known causes of constipation include: A) Metabolic disorders (diabetes) B) Endocrine disorders (hypothyroidism) C) Disorders of the large bowel (irritable bowel syndrome) D) Disorders of the upper GI tract (ulceration, cancer) E) All of the above
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E) All of the above
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Drugs affecting gastrointestinal function that can cause constipation include all of the following except: A) Anticholinergics B) Magnesium antacids C) Opiates D) Aluminum antacids E) All of the above are known to cause constipation
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B) Magnesium antacids
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The cornerstone of therapy in the treatment of constipation should be: A) Decrease fluid intake B) Increase in dietary fiber C) Biofeedback therapy D) Prolonged use of laxatives E) Anticholinergic drugs
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B) Increase in dietary fiber
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Products such as psyllium, methylcellulose, and polycarbophil are known as: A) Stimulant laxatives B) Bulk-forming agents C) Cathartics D) Lubricants E) Diphenylmethane derivatives
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B) Bulk-forming agents
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To prevent constipation, patients should be advised to include this amount of fiber in their daily diet: A) 10-25 g B) 30-35 g C) 50-55 g D) 100-110 g E) 150-160 g
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A) 10-25 g
