Constipation & diarrhea

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Constipation & Diarrhea

Constipation & DiarrheaDr Gaurav Gupta

BRISTOL STOOL CHART

Am College of Gastroenterology Unsatisfactory defecation, characterized by infrequent stools and/or difficult stool passage

Brandt 2005

4DEFINE CONSTIPATION

I bet these folks met in ____ rather than Rome - very practical approach!4

What is constipation?Constipation is generally defined as infrequent and/or unsatisfactory defecation fewer than 3 times per week.Patients may define constipation as passing hard stools or straining, incomplete or painful defecation.Constipation is a symptom, NOT a disease. Constipation has many causes and may be a sign of undiagnosed disease.

Normal Colonic Transit TimeA meal reaches the ileo-cecal valve in 4 hoursthe sigmoid colon 12hours later then slows to the anus.Plastic pellets with a meal 70% recovered in 3 days; remainder in a week!

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Most with primary constipation suffer from which one of the following?

Slow colonic transit timePelvic floor/anal sphincter dysfunctionFunctional normal transit time and sphincter function7

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Most with primary constipation suffer from which one of the following?

Slow colonic transit timePelvic floor/anal sphincter dysfunctionFunctional normal transit time and sphincter function

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Secondary ConstipationEndocrine dysfunction (DM, hypothyroid)Metabolic disorder ( Ca, K)Mechanical (obstruction, rectocele)PregnancyNeurologic disorders (Hirschsprungs, multiple sclerosis, spinal cord injuries)9

Metabolic dysfunctions slow transit time so think therapies that would speed up the flow for example stool softeners unlikely to help unless there is a defecation problem. Many neurological disorders both slow transit and mechanical/pelvic floor defecation problems.. Mrs. G taking Tums daily worried about osteoporosis - Calcium phosphate (Posture) and calcium citrate (Citracal) tend to be less constipating. 9

At risk of constipation fiber :(most common) liquid ( 8 glasses/d is needed for constipated) Exercise : bedridden, comaIgnoring urge to defecateSystemic: Hypothyroidism, DM, Uremia, pregnancy, hypercalcemia, HypokalemiaNeurological: Stroke, Parkinsonism, Multiple sclerosis

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Medicines causing of constipationOpiate, Anticholinergics, Al(OH)3 Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestrone 11

Prevention of constipationHigh fibre diet Minimum fluid consumption of 1500mL dailyRegular, private toilet routineHeed the urge to defecateUse of a laxative if using constipating medication or in presence of diseases associated with constipation

DiagnosisGood history is enough for most cases (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs)

Am Gastroenterological Assn (AGA) guidelines:CBC, Glucose, TSH, calcium, creatinine Sigmoid/colonoscopy if red flags are present.

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Im constipated, now what?Two approaches to consider:

Non-drug ApproachDrug Approach

Treatment Behavioral Toileting program to take advantage of natural reflexesObey the urge Gastro-colicDefecation reflex

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Bfast out the door suppress the urge, lunchtime public restroom! Suppress the urge after dinner doing the dishes cant go to the bathroom now! All that time the colon is busy doing what it does naturally, absorbing water from the stool resulting in hard, packed feces15

Im constipated, now what?Non-Drug Measures:

Have a regular bowel regimen: patients should attempt to have a bowel movement at the same time each day especially after breakfast since colonic activity is highest at that time. Dont spend prolonged periods of time at the toilet. Placing a footstool in front of the toilet helps elevate the thighs, thus placing the pelvis in the optimum position for defecation.Consume a high fibre diet: the target is 25-28g of fibre daily Eat more fruits: apples, pears, and prunes contain the natural laxative sorbitolExercise: inactivity is associated with constipationWeight loss: want BMI to be between 18.5-24.9

Im constipated, now what?Drug Measures:

There are many different types of drugs that can be used for constipation:Bulk-forming AgentsEmollients/Stool SoftenersOsmoticsStimulants

Im constipated, now what?Bulk-Forming Agents:Examples: Metamucil, Benefiber, FiberSureAre considered the safest agents and are suitable for long-term useEach dose of a bulk-forming laxative should be administered with a full glass of water or juiceDo not use if patient is dehydrated or fluid restrictedAre the drug of choice for prevention; not for immediate relief

Im constipated, now what?Emollients/Stool SoftenersExample: DocusateUsed for prevention; not for immediate reliefUsed very often but lack of data showing it actually worksCompany says that this product makes it easier to go

Im constipated, now what?Osmotics:Examples: Glycerin Suppositories, Lactulose Syrup, Lax-a-Day (PEG 3350), Milk of MagnesiaPEG produces the loosest stool and overall greatest efficacy compared to other members in this class. Daily use of PEG is safe and does not have significant side effects. May take 2-4 days to see an effect. This is the drug of choice in almost all situations!Lactulose is very safe to use long term. May see increase in gas and bloating compared to other options. Takes 1-2 days to work.Glycerin suppositories have a quicker onset of action (usually 30-60 minutes). They are less effective if the stool is dry and hard.

Im constipated, now what?Stimulants:Examples: Senokot, Dulcolax (bisacodyl)This group produces rhythmic muscle contractions in the intestines and may be recommended if osmotic laxatives fail or are not tolerated.Are usually given at bedtime and they usually provide overnight relief (work within 8-12 hours).

Practical management of Constipation

Address Immediate ConcernsBloating/discomfort/straining Osmotic agent like PEG Post-op, childbirth, hemorrhoids, fissuresStool softener to make defecation easier Stimulants and suppositories acutelyManual disimpaction as needed

then approach the chronic condition.

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Start with Lifestyle Changes Exercise, increase fluids and fiber to 25 grams/day over a period of 6 weeks.* Fiber must be accompanied by sufficient fluidInitial approach fruits and vegetablesAdd commercial bulking agentsObey the Urge!For children trial of rice vs cows milk* Uncontrolled studies support fiber for normal transient constipation. Am J Gastroenterol. 1999; G Nutr 4/2010

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If No ImprovementAdd osmotic laxative adjust dose slowly until stools are soft take several days to workcaution if CHF or renal insufficiencyAdd stimulant laxatives

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Diarrhea

What is Diarrhea?

Classification as per duration

Causes of Acute Diarrhea

Desired outcome

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Antimicrobial agents

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41Sensitivity pattern of the microbial agents should be checked to select an appropriate antibiotic.

Chronic diarrheaLasts longer than 4 weeks Reasons can be: stress, food intolerance (e.g. lactose intolerance), disorders of pancreas/liver/gallbladder, chronic intestinal infections (Morbus Crohn, Colitis ulcerosa), bowel cancer42

ComplicationsLoss of water: dehydration (dizzyness, unconsciousness)Loss of electrolytes: crampsIn severe cases both can lead to death

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Quiz

QuizWhat are the 4 types of diarrhea?

QuizWhat are the 4 types of diarrhea?Secretory, osmotic, exudative (inflammatory), and altered intestinal transit (Dysmotile)

What are the characteristics of Secretory Diarrhea?

What are the characteristics of Secretory Diarrhea?Watery, large volume outputs, that are typically painless, persist with fasting,

Causes of Secretory diarrhea?Stimulant laxatives; bowel resection, disease, or fistula, hormone-producing tumors (carcinoid, pancreatic, medullary cancer of the thyroid),Addison's dx

How to clinically differentiate osmotic / secretory diarrhea?

How to clinically differentiate osmotic / secretory diarrhea?Fasting

Some agents that cause osmotic diarrhea?

Some agents that cause osmotic diarrhea?Osmotic laxatives (Mg2+); lactase deficiencies; nonabsorbable carbohydrates (sorbitol, lactulose, polyethylene glycol); intraluminal maldigestion (pancreatic exocrine insufficiency, bariatric surgery, liver disease);mucosal mal-absorption (celiac sprue, ischemia of colon, whipple's disease)

What symptoms accompanies exudative (inflammatory diarrhea)?

What symptoms accompanies exudative (inflammatory diarrhea)?pain, fever, bleeding, or other manifestations of inflammation

What are characteristics of dysmotile diarrhea?

What are characteristics of dysmotile diarrhea?Diarrheal pattern is rapid, small, coupling burst of waves, see this a lot with IBS.

What are some causative agents of dysmotile diarrhea?

What are some causative agents of dysmotile diarrhea?IBS; Hyperthyroidism; Intestinal resection, bypass surgery;Prokinetic agents such as metoclopramide or prostaglandins; Diabetic diarrhea (may be accompanied by peripheral and generalized autonomic neuropathies)

How does the American Gastroenterology Association (AGA) defines functional constipation?

How does the American Gastroenterology Association (AGA) defines functional constipation?difficult, infrequent, or seemingly incomplete defecation

Complications of constipation?

Complications of constipation?Hemorrhoidsanal fissuresrectal prolapsefecal impactio

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