Tuohy - Diarrhea/Constipation & Anorectal Disorders

This lecture by Dr. Kevin Tuohy occurred on Monday, September 27th.

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Study Materials
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Handouts Constipation/Diarrhea/Anorectal Disorders

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Define constipation and diarrhea know its classifications
Constipation is defined as the abnormally slow movement of feces through the colon. Characterized by: Diarrhea is defined as an increased frequency of bowel movements. Characterized by: Diarrhea can also be classified by its various causes
 * Hard Stools
 * Fewer than 3 bowel movements per week
 * Inability to expel stool
 * Possible bowel distention/bowel discomfort
 * ³3 bowel movements in 24 hours
 * Decreased stool consistency
 * +/- Increased stool weight. (>200g in 24 hours)
 * Osmotic- Unabsorbed solutes in intestines increase luminal osmotic load, retarding fluid absorption
 * Secretory- Stimulation of crypt cells produces net flow of electrolytes (most notably chloride) and fluids into intestinal lumen. This also draws in water
 * Exudative- Impaired fluid absorption and leaking of mucus, blood, and pus into lumen caused by inflammation of intestinal mucosa (e.g. IBD) or bacterial infection (i.e. dysentery...remember dying of dysentery in Oregon Trail?)
 * Motor- Abnormally rapid intestinal transit time reduces contact time between luminal contents and absorptive areas of intestinal wall

Recognize the epidemiology associated with constipation and diarrhea
Constipation epidemiology Diarrhea epidemiology
 * Most common digestive complaint in U.S.
 * Causes 2.5 million physician visits per year
 * Prevalent in 2-28% of the general population and more common in older adults >65
 * It is estimated that 10-20% of otherwise healthy individuals report one or more symptoms of chronic constipation
 * 3 million people are prescribed cathartics each year
 * estimated healthcare cost >$200 million
 * Sales of laxatives >$750 million in 2009, projected at $850 million in 2010
 * More common that constipation, but reported less often

Identify the two basic mechanisms for both constipation and diarrhea
Constipation is caused by either Diarrhea is basically caused by
 * A functional mechanism (i.e. decreased neural regulation and motor function of the intestine)
 * An anatomical mechanism (i.e. a tumor or volvulus where the colon gets blocked/twisted)


 * decreased absorption of water and electrolytes from the food


 * increased secretion of water into the colon

Define the difference between acute and chronic constipation and diarrhea
Constipation is acute when it lasts less than 6 weeks, and chronic when it lasts >6 weeks

Diarrhea is acute when it lasts less than 72 hours, and chronic when episodes last longer than 3 days

Identify risk factors for constipation and diarrhea
Constipation is more likely to occur with:


 * pediatric and elderly patients


 * Females (although it may be that they are simply more likely to report symptoms


 * Malnourished patients (deficient in calories, carbs, and/or fiber)]


 * Dehydrated patients (will pool all the water they can from stools until they are dried out)


 * Pain medications, especially opioids, can induce narcotic bowel syndrome

Psychogenic factors can cause constipation:
 * Lack of physical activity
 * Pregnancy

Coexisting disease states that cause constipation: Diarrhea is more likely to occur with
 * Anorexia
 * Depression
 * Conscious efforts to withhold stool
 * Cerebrovascular disorders
 * Degenerative neurological disease
 * Diabetes Mellitus
 * Disorder of bowel structure/function
 * Irritable Bowel Syndrome (IBS) - can technically cause either constipation or diarrhea
 * Multiple Sclerosis
 * Paraplegia/Quadriplegia
 * Parkinsonism
 * Thryroid Disease (hypothyroidism) - untreated, it causes a slowdown of many metabolic symptoms including colon transit time
 * Age <5 years (pediatric patients)
 * Females (although again this may be due to to the fact that women are more likely to report symptoms)
 * Poor Diet
 * Pain
 * Certain Medications
 * cholinergics
 * metformin
 * quinidine (not commonly prescribed but known as the "king" of all diarrhea causing medications
 * Coexisting medical diseases
 * Alcoholism
 * Cerebrovascular disorders
 * Degenerative neurological diseases
 * Diabetes Mellitus
 * Disorder of bowel structure/function
 * Immunosuppressive disease (HIV/Aids)
 * Irritable Bowel Syndrome (IBS) - can technically cause either constipation or diarrhea
 * Ischemic Bowel Disease
 * Malabsorption Syndrome
 * Thyroid Disease (hyperthyroidism) - causes metabolism to proceed too quickly for proper absorption

Identify pharmacologic and nonpharmacological treatment for constipation and diarrhea including mechanisms of action, indications and side effects
The treatment options for Diarrhea and Constipation may involve simple lifestyle changes, or medications

Non-Pharmacologic Treatments
Identify any intolerance experienced to drugs and modify therapy appropriately Diarrhea can sometimes be treated/prevented without medication
 * Encourage a diet high in fluid intake and Fiber
 * Between 32-128 ounces of liquid a day (milk, a constipating agent, does not count)
 * Between 20-35 grams of fiber a day
 * Children less than >2 years of age should get ≥their age in fiber + 5grams
 * Encourage Activity
 * Avoid Processed Cheese, concentrated sweets, and other substances that would change the osmotic gradient in the colon and push out water.
 * Identify any intolerance experienced to drugs and modify therapy appropriately
 * Encourage fluid and proper diet (to replace water thats been lost from diarrhea)
 * Avoid foods with artificial sweetners:
 * sorbitol
 * mannitol
 * fructose
 * Instruct patients to take food with medications, if allowable
 * Instruct patients to eat frequent small meals instead of one or two big meals
 * Bannanas
 * Rice
 * applesauce
 * toast
 * Instruct patients to eat low fat meals. (fat contributes to stool lubrication)

Pharmacologic Treatments for Constipation
Constipation can be treated by the following types of OTC medications. The best treatment usually depends on whether the symptoms are acute or chronic.

Bulk Forming Laxatives
Mechanism of Action:


 * Drugs dissolve and swell in the intestinal fluid


 * increase stool weight


 * modify stool consistency

Site of Action: small and large intestines
 * allow for easier passage

Indications (best use as a preventative medicine for patients with chronic constipation) Adverse effects: Products:
 * Patients on low fiber diets (people who don't get enough fruits/veggies
 * Postpartum
 * Older adults
 * Patients with colostomies, IBS, or diverticular disease
 * Abdominal cramping
 * flatulence
 * Esophageal obstruction (older adults) - when taken orally, if the medicine becomes lodged in the back of the throat it will still do its job and swell, potentially dangerous. Tell the patient to drink plenty of water when swallowing!
 * Methylcellulose (Citrucel)
 * Calcium Polycarbophil (FiberCon)
 * Psyllium (Metamucil / Konsyl)
 * Wheat dextran (Benefiber)

Emollient Laxatives (stool softners)
Mechanism of action:


 * Emollient Laxatives generally have surfactant properties
 * increase the wetting efficiency of intestinal fluid

Site of Action: Small and large intestines
 * facilitate a mixture of aqueous and fatty substances to soften the fecal mass
 * hence the name "stool softeners"

Indications: Adverse Effects Products
 * Patients who have undergone or are to undergo surgery (to help prevent post surgery constipation)
 * Hemorrhoids or other rectal disorders
 * Those who need to avoid straining - patients with cardiac arrythmias or weak cardiovascular systems that should not be using too much effort when they defacate
 * A patient who is taking long term opioid medications and narcotic bowel syndrome needs to be prevented
 * Diarrhea
 * Mild Abdomminal cramping
 * Docusate Sodium (Colace) - most common, and less expensive than Docusate potassium
 * Docusate Potassium (Kaopectate)

Hyperosmotic Laxatives
Mechanism of Action: Site of Action: Large intestine only
 * Exerts an osmotic effect to pull water into the colon
 * stimulates colonic motility

Indications: Adverse Effects: Products:
 * Patients who need a lower bowel evactuation (due to acute constipation or colonoscopy)
 * Rectal irritation (happens especially with glycerin)
 * Hypovolemia - pt loses fluid to the colon and may become dehydrated
 * Diarrhea
 * Abdominal cramping
 * Bloating/gas
 * Glycerin (available as suppositories for adults and pellets for infants
 * Lactulose - a sugar not absorbed by the body
 * Sorbitol - a sugar not absorbed by the body
 * PolyEthylene Glycol 3350 (Miralax) - usually dosed once a day
 * Go-lytely - a higher dose of PEG

Saline Laxatives
Mechanism of Action: Site of action: Small and Large intestines
 * essentially work the same way as hyperosmotic laxitives
 * attract and retain water in the intestinal lumen
 * also increase intraluminal pressure
 * stimulate colonic motility
 * oral doses usually work within 24-72 hours, although enemas work faster

Indications: Adverse Effects: Products:
 * Patients needing an acute evacuation of the bowel
 * Prolonged constipation that needs immediate assistance
 * Electrolyte abnormalities are possible, including high levels of phoshates, sodium, and magnesium
 * Abdominal cramping
 * excessuve diuresis/dehydration
 * nausea/vomiting
 * Caution! Avoid in patients with renal impairment
 * Magnesium Citrate (Citroma)
 * Magnesium Hydroxide
 * Dibasic and Monobasic sodium phosphate (Fleet's enema)

Lubricant Laxatives
Mechanism of action: Facilitates fecal transit by coating feces with something oily

Site of Action: Large Intestine Only

Indications: Maintains stool softness and avoids the need for straining, useful for patients with Adverse Effects: Products:
 * hernia
 * aneuryism
 * hypertension
 * myocardial infarction
 * CVA
 * aspiration pneumonia
 * impaired absorption of the fat soluble vitamins ADEK
 * Mineral Oil
 * Mineral Oil enema (Fleet's Mineral oil enema) usually a better choice

Stimulant laxatives
Mechanism of action:
 * stimulate intestinal motor activity
 * stimulate net intestinal secretion
 * increase stool volume/weight
 * induces urge to defecate

Site of Action: large intestine only

Indications: a mainstay of therapy for many constipated patients Adverse Effects: Products:
 * used before radiologic or endoscopic examination of the GI tract and GI surgery
 * Chronic constipation induced by medications like opiods, or calcium channel blockers like Verapamil and Diltiazem
 * Severe cramping
 * electrolyte and fluid deficiencies
 * enteric loss of protein
 * malabsorption
 * hypokalemia from excreting too much potassium
 * Senna (Senokot, ExLax) - is better for chronic constipation and a little gentler
 * Bisacodyl (Dulcolax, Corretol) - is better for actue constipation
 * Castor oil - very rarely used
 * Senna with docusate sodium (Senokot-S, PeriColace) - a good combination of a stimulant laxitive and an emolient laxative. Also drug of choice for patients on long term opioid therapy.

Miscellaneous OTC constipation treatments
Homemade Enemas
 * Soap suds
 * Milk and Molasses

Pharmacologic Treatments for Diarrhea
Several medications can be used to treat Diarrhea symptoms.

Loperamide
Mechanism of Action: Indications: Adverse effects
 * Synthetic opioid agonist
 * stimulates opioid receptors located on the intestinal circular muscles
 * slows intestinal motility
 * allows for adequate time to absorb excess water and electrolytes
 * Traveler's diarrhea
 * nonspecific acute diarrhea
 * chronic diarrhea associated with IBS
 * Dizziness
 * Constipation
 * abdominal pain
 * abdominal distention
 * nausea
 * vomiting
 * dry mouth
 * fatigue
 * hypersensitivity reactions

Bismuth subsalicylate (Pepto bismol, Kaopectate)
Mechanism of action Indications: Adverse effects
 * The drug acts with HCl in the stomach to form bismuth oxychloride and salicylic acid
 * further explanation needed
 * management of acute diarrhea
 * traveler's diarrhea
 * only indicated in patients >12 years of age
 * consult physician if patients are <12 years of age - increased risk of reye's snydrome when using salicylates in children
 * Nausea, heartburn, indigestion, upset stomach, diarrhea, yay
 * Contraindicated in nursing and pregnant woman
 * Tinnitus
 * black staining of stools
 * hairy tongue snydrome with chronic use

Digestive Enzymes
Mechanism of action
 * increase normal flora of the body
 * lactobacillus - probiotics supposedly confer a therapeutic or preventative health benefit, but this is controversial
 * not terribly effective for diarrhea

Oral Replacement Therapy
Mechanism of action: replaces electrolytes and liquids lost with diarrhea

Products
 * anything with sugar, water, salts
 * gatorade/powerade
 * pedialyte

Identify the anatomical areas that are involved in the development of hemorrhoids.


Hemorrhoids may be internal or external

Internal hemorrhoids External hemorrhoids
 * Occur above the dentate line and lack sensory fibers
 * graded by severity of prolapse into anal canal (1st-4th degree)
 * May protrude into the anal canal (temporarily or permanently
 * Develope below the dentate line and have sensory fibers
 * Frequently are bluish lumps at the external or distal boundary of the anal canal

Describe the pathophysiology and etiology of hemorrhoids.
Hemorrhoids are abnormally large, bulging, and symptomatic conglomerates of hemorrhoidal vessels, supporting tissues, and overlapping mucous membranes or skin in the anorectal regoin.

Pathophysiology and Etiology involves Risk Factors
 * Weakening of muscle fibers
 * downward pressure during defacation
 * increased pressure on hemorrhoidal veins
 * Constipation - hard stools can increase the irritation to this area
 * Diarrhea - passing stools too often can also cause irritation (burning pain)
 * Pregnancy - increases pressure in the hemorrhoidal veins
 * Erect Posture (prolonged standing)
 * Lack of Dietary Fiber
 * Heavy lifting with straining
 * Bowel habits - straining during defecation or prolonged sitting on the toilet >5 minutes

Recommend nonpharmacologic interventions for the treatment and prevention of hemorrhoids.
The following lifestyle changes may help prevent hemorrhoids or their reduce symptoms if already present
 * Avoid heavy lifting - if unavoidable, use legs, not back
 * Avoid foods that may irritate or aggravate symptoms - spicy, rough foods
 * Increase dietary fiber
 * Increase excercise
 * Proper bowel habits - avoid sitting on the toilet too long
 * Good hygiene - keep the perianal area clean
 * Sitz bath

Explain the rationale of nonprescription drug therapies for hemorrhoids
Eliminating activities that produce strain on the area (heavy lifting, constipation, prolonged standing) will prevent the hemorroidal blood vessels from becoming damaged by too much pressure. Also, proper diet will prevent damage to the area by frequent bowel movements or stools that are too hard to pass.

Identify patients that are candidates for self-care of hemorrhoids and patients that require referral to a healthcare provider.
Patients are usually candidates for self care when they experience: More than pharmacological intervention is required (see a doctor) when a patient experiences Patients should also not treat hemorroid-like symtpoms if they suspect or know they have any of the following GI diseases:
 * Mild Pain/Discomfort
 * Itching
 * Irritation
 * Burning
 * Inflammation
 * swelling
 * <12 years of age\
 * acute onset of symptoms
 * Intense pain
 * Bleeding
 * Seepage
 * Change in bowel patterns
 * Rectal prolapse
 * Thrombosis
 * syptoms persisting after 7 days of self-treatment
 * abcesses
 * fistulas
 * neoplasms
 * polyps
 * IBS
 * family history of colon cancer

Goals of therapy

 * 1) Relieve Symptoms of hemorrhoids
 * 2) Prevent complications that may lead to more serious conditions

Treatment Approaches
Remember, nonprescription products are intended to provide temporary relief of minor symptoms such as:
 * 1) Establish if patient is a candidate for self-care
 * 2) Identify concurrent medical conditions or medications that may be contraindicated for the patient
 * 3) Assist patient in selecting a nonprescription produc
 * 4) Reccomend nonpharmacologic strategies that assist in the treatment and prevention of hemorrhoids
 * 5) counsel patients to seek medical attention if alarm symptoms develop or if symptoms persist after 7 days of self-treatment
 * burning
 * itching
 * mild pain
 * mild discomfort
 * swelling
 * irritation

Local Anesthetics
Mechanism of action: reversibly block the transmission of nerve impulses

Indications: temporary pain relief

Cautions:


 * Watch for allergic reactions, discontinue if product causes symptoms to worsen

Products:
 * Systemic absorption is minimal unless perianal skin is abraded
 * Pramoxine - used to numb the area
 * Dibucaine - less common but cost effective

Vasoconstrictors
Mechanism of action Indications: Cautions: Adverse reactions: rare when used in topical hemorrhoidal preparations Produts: Phenyleprhine - should avoid oral use if patient has hypertension
 * stimulate alpha-adrenergic receptors in vascular beds, resulting in vasoconstriction and transient decrease in swelling
 * also have an anesthetic affect (mechanism unknown)
 * swelling
 * pain relief
 * diabetic patients
 * thryoid disease
 * hypertension - especially those taking antihypertensives
 * angina pectoris
 * enlarged prostate
 * patients taking antidepressants - especially TCA's
 * patients taking cardiac medications
 * nervousness
 * tremor
 * sleeplessness
 * loss of appetite

Protectants
Mechanism of action: Products:
 * Prevents irriation of the anorectal area and water loss from the stratum corneum by forming a physical barrier on the skin
 * may soften the dry anal mucosal lining
 * Cocoa butter (used in suppositories)
 * mineral oil
 * glycerin
 * petrolatum/white petrolatum
 * shark liver oil - found in preparation H
 * Zinc oxide

Astringents
Mechanism of action: Promote tightening of skin cells; which protects the underlying tissues and dries up excess moisture.

Cautions: Witch hazel contains alcohol which may cause slight local stinging and potential contact dermatitis

Products:
 * Witch hazel
 * Zinc Oxide

Corticosteroids
Mechanism of Action Indications: Products: Hydrocortisone
 * Vasoconstrictor and antipruitic
 * onset of action may take up to 12 hours, but effect is longer in duration
 * Itching
 * Swelling

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