© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION SECTION V © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR GastroenterologyDISTRIBUTION NOT FOR SALE OR DISTRIBUTION Constipation 1,2,3,4 © Jones & Bartlett Learning, LLC Definition © Jones & Bartlett Learning, LLC Constipation is a disturbance in bowel function, characterized by NOT FOR SALE OR DISTRIBUTIONinfrequent or difficult defecation.NOT FOR SALE OR DISTRIBUTION Causes 1 ,2,3,5,6,7 • Functional disorders • Normal colonic transit, slow transit constipation, © Jones & Bartlettdyssynergic Learning,defecation (e.g., LLC anismus or pelvic fl oor © Jones & Bartlett Learning, LLC NOT FOR SALEdysfunction) OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Medications • Opioids, anticholinergics, calcium channel blockers, iron supplementation, antacids • Neurological disorders © Jones & Bartlett Learning,• Parkinson’s LLC disease, multiple sclerosis, spinal© Jones cord injury, & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONdementia NOT FOR SALE OR DISTRIBUTION • Metabolic disorders • Hypothyroid, diabetes, hypercalcemia • Blockages of the colon • Colon cancer, stricture or narrowing • Mood-related disorders © Jones & Bartlett Learning, LLC • Depression, anxiety © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Risk Factors 1 ,2,3,6,7 Risk factors of constipation coincide with causes, • Advanced age • Female sex © Jones &• Bartlett More than twiceLearning, as common LLC than men © Jones & Bartlett Learning, LLC NOT FOR• ReducedSALE mobilityOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Low-fluid intake © tofutyklein/Shutterstock 145 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 145 11/6/18 12:55 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Gastroenterology © Jones & Bartlett Learning,• Low-fiber LLCdiet © Jones & Bartlett Learning, LLC • Low socioeconomic status NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Signs & Symptoms1,2,3,4,6 • Have ≤ three stools/week. • Rectal fullness or feeling of inadequate bowel emptying. • Straining with defecation. © Jones & Bartlett Learning, LLC • Hard or lumpy stools. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONTests1,2,3,4,6,7 NOT FOR SALE OR DISTRIBUTION Tests are warranted if constipation has no clear etiology. • Complete blood count (CBC) • The presence of anemia suggests a secondary cause and © Jones & Bartlettshould be investigated. Learning, LLC © Jones & Bartlett Learning, LLC • Thyroid-stimulating hormone (TSH) NOT FOR •SALE Checks ORfor the DISTRIBUTION presence of hypothyroidism (secondary NOT FOR SALE OR DISTRIBUTION cause of constipation). • Basic metabolic panel (BMP), magnesium, and fasting glucose • Checks for electrolyte imbalance (hypercalcemia, low magnesium, and/or potassium) and hyperglycemia, which © Jones & Bartlett Learning,are secondary LLC causes of constipation. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Plain abdominal radiography NOT FOR SALE OR DISTRIBUTION • Checks for significant stool retention. • Colonoscopy • Recommended if warning signs are present (e.g., anemia, unexplained weight loss, positive fecal occult blood, gas- trointestinal [GI] bleeding, or constipation refractory to © Jones & Bartlett Learning, LLC treatment). © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Treatment & Management1,2,3,4,6,7 • Nonpharmacological and nursing interventions: • Identify and treat potentially reversible causes of constipation. © Jones & Bartlett• Increase dietaryLearning, fiber to LLC25–35 g per day. © Jones & Bartlett Learning, LLC • Encourage adequate fluid intake (goal of 1.5–2 L/day). NOT FOR SALE• Increase OR physical DISTRIBUTION activity. NOT FOR SALE OR DISTRIBUTION 146 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 146 11/6/18 12:55 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Gastroenterology © Jones & Bartlett Learning,• Monitor LLC for warning signs of possible malignancy.© Jones & Bartlett Learning, LLC • Constipation presenting acutely, anemia, abdominal NOT FOR SALE OR DISTRIBUTIONpain, unintentional weight loss, rectal bleeding,NOT FOR or a SALE OR DISTRIBUTION family history of colorectal cancer. • Schedule bathroom time. • Make time to have a bowel movement and ensure privacy. • Remind patients that the best potential for a bowel © Jones & Bartlett Learning, LLC movement is in the© morning Jones and &about Bartlett 45 minutes Learning, fol- LLC NOT FOR SALE OR DISTRIBUTION lowing a meal. NOT FOR SALE OR DISTRIBUTION • Do not postpone having a bowel movement if there is an urge to defecate. • Educate patients on constipation. • If there are minimal to no constipation symptoms, in- © Jones & Bartlettstruct patient Learning, to stop taking LLC laxatives. © Jones & Bartlett Learning, LLC • Being obsessed over bowel movements is not good; NOT FOR SALEhaving OR a daily DISTRIBUTION bowel movement is not necessary. NOT FOR SALE OR DISTRIBUTION • Patients need to engage in exercise and increase their fiber intake. • Biofeedback • Effective treatment for dyssynergic defecation. © Jones & Bartlett Learning,• Pharmacological LLC and other interventions:© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONConsider discontinuing medications that NOThave a sideFOR effect SALE OR DISTRIBUTION of constipation (if appropriate). • Bulking agents (e.g., psyllium [Metamucil]). • Example: psyllium 1 tsp (3.4 g) QD-TID with fluids PRN. • Promotes softer stool by increasing the bulk of the stool. © Jones & Bartlett Learning, LLC Will need to drink plenty© Jones of water & for Bartlett a better outcome. Learning, LLC NOT FOR SALE OR DISTRIBUTION • Not recommended NOTas first-line FOR agent SALE in patients OR onDISTRIBUTION high-dose opioids or with dysphagia. • May cause bloating or flatulence. • Stool softeners (e.g., docusate sodium [Colace]). • Example: Colace 100 mg PO BID. © Jones & Bartlett• Not to be Learning, used as chronic LLC treatment or in patients tak- © Jones & Bartlett Learning, LLC ing opioids. NOT FOR SALE• Well toleratedOR DISTRIBUTION and can be combined with a bulking agent. NOT FOR SALE OR DISTRIBUTION 147 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284153828_CH05.indd 147 11/6/18 12:55 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Gastroenterology © Jones & Bartlett Learning,• Osmotic LLC agents (e.g., lactulose [Kristalose],© polyethyleneJones & Bartlett Learning, LLC glycol [Miralax], magnesium citrate) NOT FOR SALE OR DISTRIBUTION• Example: lactulose 15–30 mL PO QD-BID.NOT FOR SALE OR DISTRIBUTION • Lactulose recommended in those residing in nursing homes. • Consider when bulking agents and stool softeners are ineffective. © Jones & Bartlett Learning, LLC • May cause bloating© and/or Jones flatulence. & Bartlett Magnesium Learning, ci- LLC NOT FOR SALE OR DISTRIBUTION trate should be avoidedNOT with FOR renal impairment.SALE OR DISTRIBUTION • Stimulants (e.g., senna [Peri-Colace, Senokot], or bisaco- dyl [Dulcolax]) • Example: bisacodyl 5–15mg PO QD. • Should be used short term and avoided with bowel ob- © Jones & Bartlettstruction. Learning, Used when osmotic LLC agents are ineffective. © Jones & Bartlett Learning, LLC • Increases peristaltic contractions and can have unfa- NOT FOR SALEvorable OR side DISTRIBUTION effects such as abdominal cramping. NOT FOR SALE OR DISTRIBUTION • Secretagogues (i.e., lubiprostone [Amitiza] and lina- clotide [Linzess]) • Example: lubiprostone 24 mcg PO BID. • Recommended as monotherapy and not with other © Jones & Bartlett Learning,laxatives. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• They are usually well-tolerated; howeverNOT may causeFOR GI SALE OR DISTRIBUTION disturbances (e.g., nausea, abdominal distention). Di- arrhea is the main side effect of linaclotide. • Alvimopan (Entereg) or methylnaltrexone (Relistor) • Treats opioid-induced