Constipation, Diarrhea, and Hemorrhoids

• Introduction to constipation, diarrhea, and hemorrhoids.

Disclaimer

• The lecture notes were prepared for PHAR 1052 in the 2024-2025 academic year. The notes are complete and accurate as possible based on available resources at the time of preparation.
• Lecture slides alone may give an incomplete picture of the presenter's intended message. They are to be used with Ms. Larose's verbal lecture to understand the complete intended message.
• The notes are intended to supplement learning from the PBL case, and students should review content and build on their knowledge from anatomy and physiology courses.

Learning Objectives

• By the end of the lecture, the student should be able to
• Describe the pathophysiology, etiology, epidemiology, classification, and the diagnosis of constipation, diarrhea, and hemorrhoids.
• List known causes for secondary constipation and diarrhea and suggest reasoned management strategies for when they are significantly clinical.
• List red flags to refer patients who have constipation, diarrhea or hemorrhoids.
• List goals of therapy for constipation, diarrhea, and hemorrhoids.
• State the pharmacologic class, mechanism of action, efficacy and most common and serious adverse effects of pharmacologic agents used to treat constipation, diarrhea, and hemorrhoids.
• Recommend pharmacologic and nonpharmacologic alternatives for managing constipation, diarrhea, and hemorrhoids based on patient-specific factors and tolerability.
• Describe an approach to managing constipation, diarrhea, and hemorrhoids.
• Have increased comfort talking to patients about the "taboo topic of poo."

Pharmacist Prescribing (for Gastrointestinal Conditions)

• In British Columbia (BC), Alberta (AB), Manitoba (MB), Ontario (ON), New Brunswick (NB), Nova Scotia (NS), Prince Edward Island (PEI), Newfoundland and Labrador (NL), and Yukon (YT), pharmacists can prescribe for non-infectious diarrhea, dyspepsia (indigestion), and gastroesophageal reflux disease (heartburn).
• Pharmacists in British Columbia (BC), Alberta (AB), Manitoba (MB), Ontario (ON), New Brunswick (NB), Nova Scotia (NS), Prince Edward Island (PEI), Newfoundland and Labrador (NL), Yukon (YT), and Nunavut (NU) can prescribe medication for hemorrhoids.
• Threadworms and pinworms can be treated by pharmacists in only British Columbia. Vomiting/Nausea are not allowed pharmaceutical intervention.

Constipation Misconceptions

• There is a pervasive misconception in the Western world that you must have a DAILY bowel movement; anything less means constipation.
• The average number of bowel movements for adults and children (≥ 3 years) in the Western world varies from 3 daily to 1 every 3 days!

Constipation

• Constipation affects approximately 15% of adults and 33% of those over 60 years of age.
• Constipation cases increase with age.
• It is more common in black patients, those of lower socio-economic status, and in women.
• Other risk factors for chronic or acute constipation include:
• Living in rural, northern or mountainous areas in North America.
• Fewer years of formal education.
• Low caloric, fiber, or fluid intake.
• Greater number of medications used.
• Physical and/or sexual abuse.
• Sedentary lifestyle.
• Nursing home residence.
• Traveling.
• Toilet training.
• Ignoring the urge to defecate.
• Inverse association: smoking, alcohol.

Approach to Managing Constipation

• Step 1: Establish that the patient is suffering from constipation.
• Step 2: Rule out alarm features.
• Step 3: Identify causes.
• Step 4: Recommend non-pharmacologic options (+ monitor).
• Step 5: Initiate laxative therapy (+ monitor).

Step 1: Establish the Patient Suffering From Constipation

• Use definitions and tools to help diagnose constipation, such as:
• Definition of constipation.
• Bristol Stool Chart.
• ROME IV Criteria.
• It is important to understand what the patient means by "constipation," and what are their predominant symptoms when taking a history.
• Patients with impaired cognition or communication may present with nonspecific symptoms like agitation, anorexia, or decline in function, which puts them at a particular risk of fecal impaction, which is the inability to pass a hard collection of stool.

What is Constipation?

• Constipation is a symptom-based disorder, and the diagnosis relies on subjective criteria.
• Physicians often define constipation as fewer than 3 bowel movements per week.
• Patients have a broader set of symptoms, including:
• Hard stools.
• A feeling of incomplete evacuation.
• Abdominal discomfort.
• Bloating and distention.
• Other symptoms like excessive straining.
• Sense of anorectal blockage during defecation or needing help to defecate manually.

Bristol Stool Chart

• Type 1: Separate hard lumps, like nuts (hard to pass), indicates constipation.
• Type 2: Sausage-shaped but lumpy indicates constipation.
• Type 3: Like a sausage, but with cracks on the surface is considered an ideal stool.
• Type 4: Like a sausage or snake, smooth and soft is considered an ideal stool.
• Type 5: Soft blobs with clear-cut edges (passed easily), indicates diarrhea/urgency.
• Type 6: Mushy consistency with ragged edges indicates diarrhea/urgency.
• Type 7: Watery with no solid pieces, entirely liquid.

Rome IV Chronic Functional Constipation

• Chronic constipation that does NOT have drug, anatomic, or physiologic causes is termed functional constipation. Functional constipation is defined by the ROME IV criteria.
• Symptom onset must occur for a minimum of 6 months.
• It can be reviewed by keeping a bowel log by reviewing the results from the past 3 months.
• Presence of ≥2 of the following:
• Straining during > ¼ of defecations.
• Lumpy or hard stools (Bristol Stool Chart 1–2) > ¼ of defecations.
• Sensation of incomplete evacuation > ¼ of defecations.
• Sensation of anorectal obstruction/blockage > ¼ of defecations.
• Manual maneuvers to facilitate > > ¼ of defecations (e.g., digital evacuation, support of the pelvic floor).
• < 3 spontaneous bowel movements per week.
• Loose stools are rarely present (without the use of laxatives).
• Insufficient criteria for Irritable Bowel Syndrome:
• Presence of abdominal pain associated with defecation OR changes in stool frequency or form/appearance.

Constipation – Tests?

• Anorectal manometry measures physiologic parameters like resting pressure, squeeze pressure, rectoanal inhibitory reflex (absent in Hirschsprung disease), sensation, and in some labs, rectal compliance.
• Balloon expulsion testing measures the ability to evacuate a water-filled balloon; patients with pelvic floor dysfunction may need more time to expel the balloon or may not expel the balloon all.
• Scintigraphy uses radiolabeled material to assess colonic transit or evacuation but doesn't offer the ability to view anatomic defects. Functional magnetic resonance imaging uses magnetic resonance to assess pelvic floor anatomy and physiology; most offer this test in a supine position but it may offer a better assessment of bone landmarks and making measurements.
• Defecography involves barium paste placed into the rectum to assess the anorectal angle at rest and with defecation. It may detect pelvic floor dysfunction, including structural issues (rectocele, enterocele, perineal descent) that can affect expulsion.
• Colonic marker studies involve radiopaque markers that are swallowed to note position over time, allowing for estimates of colonic motility patterns.
• Wireless pH-pressure capsule measures motor activity in the colon but cannot assess propagation.
• Colonic manometry and barostat testing are mainly used in specialized centers, and are largely research tools with use in clinical practice not well-established.
• Electromyelography is used in treatment using biofeedback for dyssynergic defecation but it may be used as a diagnostic tool to assess muscle response to a defecatory effort.
• Tests are only reserved for patients:
• With suspected pelvic floor dysfunction.
• Who do not respond to therapy.
• The order is to further characterize the underlying pathophysiology and help inform therapy.

Step 2: Conduct an Assessment & Rule out Alarm Features

• Individuals with alarm features require additional investigations.
• Alarm features may indicate another condition.
• Red flags/alarm features include:
• Family history of colon cancer.
• Age ≥ 50 years (new onset).
• Hematochezia or melena.
• Anemia.
• Unintended weight loss.
• Palpable rectal or abdominal mass.
• Reduction in stool caliber.
• Fever or signs of infection.
• Recent abdominal surgery.
• Persistent abdominal pain.
• Vomiting.
• Unremitting nocturnal symptoms.
• Constipation for >2 weeks (or no BM for >7 days) despite the use of laxatives.
• Diarrhea alternating with constipation (could signify IBS).
• Severe pain upon defecation.
• Moderate to extreme thirst.
• Chronic illness assoc. w/ constipation.
• Eating disorders (e.g., bulimia nervosa).
• Age <1 month of age (consider if <2 years).

Step 3: Identify the Causes of Constipation

• Several diseases and conditions can cause or worsen constipation.
• Optimize the management of the noted diseases if possible, in an effort to lessen or resolve the constipation.
• Diseases and conditions that can cause constipation include (but are not limited to):
• Cancer/Cancer-related: colorectal cancer, dehydration, intestinal radiation, tumor compression of the large intestine.
• Endocrine: hormonal changes, hypothyroidism, diabetes, hyperparathyroidism.
• GI disorders: diverticulosis, Hirschsprung's disease, irritable bowel syndrome, megacolon, pelvic floor dysfunction, rectal prolapse.
• Metabolic: hypercalcemia, hypocalcemia, hypokalemia, hypomagnesemia, hypopituitarism, pan-hypopituitarism, uremia.
• Neurologic: autonomic neuropathy, dementia, multiple sclerosis, muscular dystrophies, pain secondary to anal fissures or hemorrhoids, Parkinson's disease, spinal cord lesions, stroke.
• Psychological: anxiety, depression, eating disorders.
• Activity levels: decreased mobility or activity, e.g. due to pain.
• Other: older age, chronic kidney disease, systemic sclerosis, sexual abuse, lack of privacy or time.

Step 3: Identify Causes such as Medications, Supplements etc.

• Balance the risk of constipation vs. the benefit of the medication(s).
• If possible, decrease the dose, discontinue the medication, or switch to another agent(with a lower incidence of constipation).
• Examples of medications that can cause constipation (the list is not exhaustive):
• Analgesics: NSAIDs and opioids.
• Anticholinergics: antipsychotics, benztropine, oxybutynin, and others.
• Antiparkinson: amantadine, bromocriptine, and pramipexole.
• Anticonvulsants: gabapentin, phenytoin, and pregabalin.
• Antidepressants: tricyclic antidepressants (e.g. amitriptyline), and paroxetine.
• Antidiarrheals: diphenoxylate and loperamide.
• Antiemetics: dimenhydrinate, ondansetron, prochlorperazine, promethazine, and scopolamine.
• Antihistamines: diphenhydramine and hydroxyzine.
• Antihypertensives: a-adrenergic agonists, B-blockers, and calcium channel blockers, diuretics.
• Antispasmodics: dicyclomine.
• Cation agents: aluminum, bismuth, barium, calcium, and iron.
• Resins: cholestyramine and sodium polystyrene sulfonate.

Medications and Conditions Associated with Chronic Constipation

• Medications associated with chronic constipation include 5-HT3 receptor antagonists such as Ondansetron, anticholinergics, antidepressants, anti-parkinson agents, anti-diarrheal agents, anti-epileptics, antihistamines, anti-hypertensives, and anti-nauseates.
• Other constipation causing pharmaceutical agents can be calcium, iron, resins, NSAIDs, and opioids.
• Conditions associated with chronic constipation include anatomic obstructions, cancer, chemotherapy-induced dehydration, hormonal changes, hypercalcemia, GI motor disorders, Hirschsprung disease, hyper/hypocalcemia etc.
• Constipation is primarily the result of decreased colonic motility. Any condition, intervention, activity, or exposure that impairs normal contraction rhythms or slows GI transit time can cause constipation through excessive water absorption.

Therapy Goals for Constipation

• Identify and correct secondary causes of constipation (when possible).
• Resolve current symptoms.
• Return the frequency of stool to the patient's previous normal or a minimum of ≥3 defecations per week.
• Eliminate symptoms of straining, incomplete emptying, bloating, pain, and obstruction.
• Improve QoL.
• Avoid complications of constipation (i.e., hemorrhoids, anal fissure, rectal prolapse, fecal impaction, and incontinence).
• Prevent adverse drug reactions (including laxative dependence).
• Prevent the recurrence of constipation and minimizing the cost of management.
• What is a reasonable parameter for this goal?
• Is there a reasonable time frame?
• Is there a goal specific to the patient?

Complications of Constipation

• Abdominal discomfort or cramps.
• Poor quality of life.
• Hemorrhoids.
• Anal fissures.
• Damage to the pelvic floor.
• Fecal incontinence.
• Urinary retention.
• Bowel perforation.
• Rectal prolapse.
• Volvulus.
• Anal fistula.

Step 4: Recommend Non-Pharmacologic Options.

• Consider where these options are safe and appropriate for the patient.
• There is limited evidence that lifestyle changes resolve constipation BUT lifestyle changes are still considered the 1st choice of treatment.
• Consider fitness/physical activity:
• Encourage maintaining a normal level of physical activity (+ will ↑ QoL in seniors).
• There is no evidence that fitness alone improves bowel function.
• Consider fluid intake:
• It is a Modern Day Myth to drink at least 8 glasses/2 liters of water daily.
• Provide little guidance on how much to drink – consider hydration status, comorbidities (ex OAB, CHF, RF).
• Consider fiber intake (dietary):
• Dietary intake is preferred over supplements (avoid in children).
• Provide a target intake of 3-7 years: ≥10g, 8-14 years: ≥15g, and adults: 25-48g.
• Consider a daily regimented bowel routine.
• In children and adolescents: Overconsume dairy and underconsume fiber in diet.
• Encourage trying to have a bowel movement at the same time each day (e.g., each morning).
• If you have the urge, go; waiting will cause problems and take the time to pass the entire stool.

Defecation Posture

• Squatting is overall preferable to sitting during bowel movements.

Step 5: Initiate/Alter Laxative Therapy + Monitor

• Assess where the therapy is safe and appropriate for the patient.

• There are no studies assessing a step-wise approach for the management of constipation.

• Guidelines, clinical practice, and patient-specific factors will inform the first choice of laxative

• Options include:

• Stool Softeners (docusate sodium/calcium).

• Bulk-forming Agents (e.g. Psyllium, inulin, calcium polycarbophil).

• Lubricants (e.g. Mineral oil).

• Osmotic Agents (e.g. PEG 3350, Lactulose, sorbitol, glycerin, and magnesium hydroxide).

• Stimulants (e.g. Bisacodyl and sennosides).

• Other Guanylate cyclase C agonist (Linaclotide, Plecanatide) and Serotonin 5-HT4 Receptor Agonists (Prucalopride) to be discussed in the IBS lecture.

Emollients/Stool Softeners

• They contain docusate sodium/calcium.
• The alleged mechanism is that it decreases stool surface tension and increases fluid penetration into the stool = soft stool.

Emollients/Stool Softeners Efficacy and Use

• Insufficient evidence supports use; it is unlikely to be effective, but also unlikely to cause harm.
• The alleged onset is 12-72 hours.
• Comes in capsules, drops, syrup and can be dosed once or twice daily.
• Is often prescribed post-surgery to minimize straining.
• Safety is well-tolerated. but can cause mild nausea and Gl Cramps.

Bulk Forming Agents Mechanism of Action

In the the colon:

• Gas formation (+ osmoreceptors).
• Increased osmotic load.
• Fecal water retention.
• This overall increases fecal volume and softens stool plus increases wall stress (*mechanoreceptors) Available options are Psyllium, inulin, and calcium polycarbophil.

Bulk-Forming Agents Efficacy and Use

• Generally recommended as a 1st line after lifestyle changes.
• Efficacy: Improves stool frequency and is beneficial for straining, incomplete evacuation and for normal transit constipation, the efficacy is similar to lactulose and is better than dietary fibre.
• Onset of action: 12 to 72 hours.
• Dosing: Typically 1-3 times daily, taken orally with ≥250mL of water/juice to prevent fecal impaction and esophageal obstruction.
• ADR: flatulence and bloating (titrate slowly), fecal impaction.
• Precautions/CI: AVOID if fluid restriction, dehydration, dysphagia, and esophageal strictures.
• Drug Interactions: suggests spacing from other medications by 2 hours.

Osmotic Laxatives Mechanism and Available Options

• Mechanism
• poorly absorbed ions/molecules create an osmotic gradient to draw fluid into and retain in the intestinal thus increasing motility.
• Available options: PEG 3350, Lactulose, magnesium hydroxide/sulfate/citrate, and sodium phosphate.

Osmotic Laxatives Efficacy and Use

• Efficacy: beneficial in individuals whose primary symptom is infrequent bowel movements and will also improve stool form and consistency.
• Onset: ~1-3 days (varies between agents).
• Adverse Drug Reactions: Well tolerated, but can cause diarrhea, flatulence, nausea, and fluid loss.
• Precautions/CI: pre-existing electrolyte imbalance, cardiac disease, and renal impairment.
• General Comparison: PEG > Lactulose in efficacy, palatability, tolerability; Lactulose >PEG in the speed of onset.
• additional MOA of glycerin is due to stimulating the defecation reflex.

Additional note on Lubricants ie: Mineral Oil

• Mechanism of action: lubricates the gastrointestinal tract to aid stool passage & slows the reabsorption of water.
• There are many safety concerns
• Risk of aspiration = lipid pneumonia (esp. in infants and bedridden or dysphagic patients).
• Impedes vitamin absorption.
• Is is no longer typically recommended and Safer and more effective alternatives are available.

Stimulant Laxatives Mechanism of Action

• Available Agents: Bisacodyl and Sennosides
• Mechanism of Action:
  • Prodrugs activated in the small or large intestine.

1. directly stimulate the intestinal mucosa → secrete water + electrolytes into the intestinal lumen.
2. directly stimulate myenteric nerve plexus → ↑ smooth muscle contraction → ↑p peristalsis.

Stimulant Laxatives Efficacy and use

• Can be referred to as “Rescue Therapy" because its not considered a 1st line agent for constipation
• Except for opioid induced constipation.
• Efficacy: Superior to osmotic agents (BUT more ADR).
• Onset: po = 6-12 hours | pr = 15-60 min.
• Dosing: typically PRN, some patients may require scheduled therapy (ex. opioid-users).
• Safety: Long-term efficacy & safety unknown (studies were of short duration ≤4 weeks). Tolerance may occur.
• Adverse Drug Reactions: abdominal discomfort, electrolyte imbalances (hyponatremia, hypokalemia and dehydration), allergic reactions and hepatotoxicity.

Enemas

• Evidence: anecdotal- may have some use in acute constipation.
• Main role: bowel cleansing prior to inspection or fecal impaction.
• Onset: 1-5 min (NaP) vs 2-15 min (Mineral oil).
• Mechanism of Action: (in addition to class action):
• Increase volume in the colon = increase pressure on the lumen wall which increases motility.
• Safety: Prefer mineral oil vs. sodium phosphate (due to risk of electrolyte imbalance).

Monitoring Constipation

• When monitoring, consider whether you are using
• a reasonable a parameter to this goal
• a reasonable a time frame
• a goal specific to the individual
• Return to "Normal" and keep record of frequency in daily logs.
• Acute Constipation: depends on agent chosen if patient should have a BM within 1-3 days.
• Chronic Constipation: ideally patient should have regular BM patterns after 1 month of therapy.
• Opioid-Induced Constipation: goal is to have a bowel movement at least every 3 days.
• Consider consistency using ideal stool using the Bristol Stool Chart
• Record bloating and cramping symptoms.
• Observe complications and potential causes of laxative abuse which can result in dehydration, diarrhea, dependence, and electrolyte imbalances.
• Also consider Quality of Life impacted by condition.

Diarrhea

• Diarrhea is the unusually frequent excretion of watery stools
• which is associated with loss of electrolytes and fecal rate > 200g /24Hours

Diarrhea incidence and sequelae.

• Diarrhea is believed to be under-reported.
• Worldwide, there are 2.8 billion episodes of diarrhea per year.
• 1.9 million has resulted in death for children under 5 causing it to be the second cause of death in the age group.
• The average person will experience 0.5-2 episodes per year.
• Complications include dehydration, electrolyte imbalances, hypotension, vascular collapse, metabolic acidosis, hypokalemia, hypomagnesemia, hemorrhoids, and rectal prolapse.
• Diarrhea impacts QoL due to an inability to perform daily activities.

Approach to managing diarrhea

• Step 1: Establish the patient suffering from diarrhea.
• Step 2: Rule out alarm features.
• Step 3: Identify causes.
• Step 4: Recommend non-pharmacologic options.
• Step 5: Consider laxative therapy.

Establishing patient diarrhea use definitions and tools

• Define the criteria of diarrhea
• And duration using the stool chart.
• It is important to consider if the definition and symptoms are troublesome depending on frequency.

What is Diarrhea

• Diarrhea is an unusually frequent excretion of watery stool associated with loss of electrolytes and fecal matter

• 3 loose or liquid tools of 24 hours

• Loose stool occurring >75% of stools decreasing consistency

• Acute < 14 days
• Prolonged >14 days
• Chronic > 4weeks.

Bristol Stool Chart

• Type 1: Separate hard lumps, like nuts (hard to pass), indicates constipation.
• Type 2: Sausage-shaped but lumpy indicates constipation.
• Type 3: Like a sausage, but with cracks on the surface is considered an ideal stool.
• Type 4: Like a sausage or snake, smooth and soft is considered an ideal stool.
• Type 5: Soft blobs with clear-cut edges (passed easily), indicates diarrhea/urgency.
• Type 6: Mushy consistency with ragged edges indicates diarrhea/urgency.
• Type 7: Watery with no solid pieces, entirely liquid.

Conduct assessment to rule out alarm features with other conditions and high risk of conditions.

• Red flag to consider are
• Blood / mucous in stools
• Severe abdominal pain or cramping
• Fever
• Server diarrhea
• Signs of dehydration
• Symptoms worsening.
• Pregnancy
• Frail elderly
• Immuno compromise
• Consider other symptoms/factors that lead to current dehydration and possible infectious diseases.

Identify medical conditions or diseases that call can worse diarrhea and what we will do to lessen or resolve

• Viral Infection: rotavirus, norwalk, adenovirus, calicivirus
• Bacteria: salmonella, camplylobacter, shigella, E.coli, giardia
• Nutrition : high nutrient defecins or nutrition deficiency
• Toxin and plants: arsenic and mushroom toxins, caffeine,
• GI Disorders: Chronse, ulcerative colitis or IBS
• Endocrine: Hypothyrodimse Addisons or diabetes
• Psychological: Anxiety and nervousness
• Other: Infection - fecal or cholecystectomy

Identifying Diarrhea Causes

• Balance the risk of diarrhea vs the benefit of the medication
• If possible lessen D/C medication
• The lists include many agents like
• Acetylcholinesterase
• Antihyperteensvise
• Anitmebaloiites
• Chemo agents
• Cholingieics and Lithium
• Opiods and Allopurinol

Therapy Goals for Diarrhea

• 1. what a reasonable parameters is for this goal
• Is there a reasonable time frame
• To be specific of the therapy being specific of that patients goal
• Also correct for secondary diarrhea with normal stools

Complications of Diarrhea

Rehydration and electrolyte maintenance should be the first stone step of therapy with Oral Therapy and rehydration of balanced electrolytes.

• There are only a few factors to consider because it can solve diarrhea.
• Amount is given by weight of children or the 2L/day as adults until resolves.

Contraindicators to watch out for Oral Retardation therapy

• Vomiting or comos
• Worsening diarrhea when lacking the ability to keep stool down.
• For the elderly make sure small amounts are eaten
• Make sure they only last shelf life
• Don't use excessive sugar when treating.
• ½tsp salt or 6tsp of sugar which can be better

Oral rehydration

• Started in 1969
• To treat of dehydrations and can also prevent
• Comes in liquid, dissolvable powder tablets and frezzies.
• Can in Lemonade or even orange flavours. For dosing follow proper directions depending on age or symptoms.

Physiology Review of Intestinal Absorption

• 3 mediators of ion transport for Intestinal Absorption
• Ion channel
• Movement depends on electrochemical gradient
• Solutes to cross membrane
• Allow 1+ substrates along for uphill transport
• Transporters which are the Cotransporters/exchangers which transport some Also for diarrhea to have glucose with balance

Diarrhea treatment with rehydration

• With the balance of diarrhea it needs to be the mostly to have and that absorption helps small Intestine with glucose

Oral Rehydration Ingredients

• Facilitates absorption of Sodium and h2o to small intentstive
• Na+/Ka to replace body loses of essentials ions with vomiting and diarrhea in body
• Citrate Product stabilizes
• Flavor to increase palatably
• Zinc with duration and more.
• There are hypo osmotic
• To stool reduction by.20%
• To decrease vomting.30.
• Maintain efficiency.

Consider laxative therapy where safe and appropriate with pharmacological treatments if symptomatic,

• Do antibiotics if Td self limited
• Do hydrophilic Agents
• No pro biotic
• No anti secretory
• No absorbents to aid fluid retention.

Is there Psyllium available for bulking

• Haven't we seen this before
• Liquid absorbed helps create stool for a slower passing.
• Not for Dysphasia

AntiSecretroy Agents

• Reduction in prostaglandin inhibits inflammation which will reduce hypertotliliy
• Inhbits secretions which will reabsorb sodium.b
• Cover all GI track to avoid toxins

Antisecretory Absorbing ingredients are Loperamide

• It stops the muscule to pull fluid back.

Antimotility

• effective can used multiple times a day.
• Caution take except when advise.

For monitoring ask yoursel about goals for therepy

• What's the defition of diarrhea
• Loose more

Hemorrhoids Intro

• Etiology any # of contributing factor leads to migration
• Lack of diet and straining help move around
• Diarrhea is pregnancy
• Epideimotloy is hard to esablish there not much but its there: Peak 44-65 years old

Clinical Presentaiotn to rembemer.

• Is the doctor not doing assessment is what will
• Hemorrhoids will come out of larger more enlarged
• Bleeding is blood more likely source
• Pain
• Anoderm is more snese than

Referral reasons include

• Under age 2
• More rectal issues
• Is pain to cause many

Goals of Therapy

• Realis symptoms of quality

Treatment to consider with non pharmacological

• diet helps get better
• Do it the right way Treatment to consider :
• Steroids and anesthetic help deal
• Avoid for long term issues
• Follow guidelines helps with that to ensure more better quality