Constipation and Diarrhea PDF

Constipation  Constipation It is characterized by the passage of hard, dry stools less frequently than by the person’s normal pattern. (Define) Details of bowel habit:  In fact, the normal range may vary from three movements in 1 day to three in 1 week.  A sudden change, which...

Constipation  Constipation It is characterized by the passage of hard, dry stools less frequently than by the person’s normal pattern. (Define) Details of bowel habit:  In fact, the normal range may vary from three movements in 1 day to three in 1 week.  A sudden change, which has lasted for 2 weeks or longer, would be an indication for referral.  Associated symptoms 1- Abdominal obstruction  Constipation is often associated with abdominal discomfort, bloating and nausea.  In some cases constipation can be so severe as to obstruct the bowel (This evident by colicky abdominal pain, abdominal distension and vomiting….urgent referral is necessary). 2-Blood in the stool:  It is not necessarily serious.  blood may arise from piles (haemorrhoids) or a small crack in the skin on the edge of the anus (anal fissure).  Both these conditions caused by a diet low in fiber  If piles …. discomfort on defecation.  A fissure … less bleeding but much more severe pain on defecation. 3-Bowel cancer:  Large bowel cancer may also present with a persisting change in bowel habit.  The average age at diagnosis is 60–65 years.  Diet: Insufficient dietary fiber Changes in diet and lifestyle inadequate fluid intake  The recommended daily amount of fluid is 2.5 liters a day for adults and not all of this need to be in the form of water. Medication:  Continuous use, especially of stimulant laxatives, can result in a vicious circle where the contents of the gut are expelled, causing a subsequent cessation of bowel actions for 1 or 2 days.  This then leads to the false conclusion that constipation has recurred and more laxatives are taken and so on.  Chronic overuse of stimulant laxatives can result in loss of muscular activity in the bowel wall (an atonic colon) and thus further constipation. Many drugs can induce constipation; 1- Analgesics and opiates… Dihydrocodeine, codeine 2- Antacids…. Aluminium salts 3- Anticholinergics… Hyoscine 4- Anticonvulsants… Phenytoin 5- Antidepressants… Tricyclics, selective serotonin reuptake inhibitors 6- Antihistamines… Chlorpheniramine, promethazine 7- Antihypertensives… Clonidine, methyldopa 8- Anti-Parkinson… Levodopa 9- Beta-blockers… Propranolol 10- Diuretics …Bendroflumethiazide 11- Iron 12- Laxative abuse 13- Monoamine oxidase inhibitors 14- Antipsychotics… Chlorpromazine 5- Failure of OTC medication.  Treatment timescale: If one week’s use of treatment does not produce relief of symptoms, the patient should see the doctor. Management: Increasing the amount of dietary fiber, maintaining fluid consumption and doing regular exercise. In the short term, a laxative may be recommended to ease the immediate problem. When we refer to GP: 1- Change in bowel habit of 2 weeks or longer. 2- Presence of abdominal pain, vomiting, bloating. 3- Blood in stools. 4- Prescribed medication suspected of causing symptoms.  1- Stimulant laxatives (e.g. sennosides and bisacodyl) work by direct stimulation to enteric nervous system causing increasing peristalsis. (Mechanism of action) All stimulant laxatives can produce griping/cramping pains. It is advisable to start at the lower end of the recommended dosage range, increasing the dose if needed. The intensity of the laxative effect is related to the dose taken. Stimulant laxatives work within 6–12 h when taken orally. They should be used for a maximum of 1 week. 1- Bisacodyl tablets are enteric coated and should be swallowed whole because bisacodyl is irritant to the stomach. If it is given as a suppository, the effect usually occurs within 1 h and sometimes as soon as 15 min after insertion. 2- senna pods and cascara They are non-standardized, should be discouraged because the dose and therefore action are unpredictable. 3- Castor oil is a traditional remedy for constipation, which is no longer recommended since there are better preparations available.  2- Bulk laxatives (e.g., methylcellulose ) Bulk laxatives are those laxatives of choice. Such agents are especially useful where patients cannot increase their intake of dietary fiber. Bulk laxatives work by swelling in the gut and increasing fecal mass so that peristalsis is stimulated. The laxative effect can take several days to develop. The sodium content of bulk laxatives (as sodium bicarbonate) should be considered in those requiring a restricted sodium intake.  the pharmacist should advise that an increase in fluid intake would be necessary. In the form of granules or powder, the preparation should be mixed with a full glass of liquid (e.g. fruit juice or water) before taking. Fruit juice can mask the bland taste of the preparation. Intestinal obstruction may result from inadequate fluid intake in patients taking bulk laxatives Examples: 1. psyllium (Metamucil) 2. methylcellulose (Citrucel) 3. polycarbophil (Fibercon).  3- Osmotic laxatives (e.g. lactulose, Epson salts): 1- Lactulose works by maintaining the volume of fluid in the bowel. It may take 1–2 days to work. One or two glasses of fluid should be taken with the daily dose. Lactulose and lactitol can cause flatulence, cramps and abdominal discomfort. 2- Epson salts (magnesium sulphate) is a traditional remedy that, while no longer recommended, is still requested by some older customers. It acts by drawing water into the gut; the increased pressure results in increased intestinal motility. A dose usually produces a bowel movement within a few hours. Repeated use can lead to dehydration. 3- Glycerin suppositories have both osmotic and irritant effects and usually act within 1h. They may cause rectal discomfort.  4- Lubricant laxative e.g: Mineral oils  Encourage the bowel movements by coating the bowel and the stool mass with water proof film  This keeps moisture in the stool , remains soft and easier passage. (mechanism of action)  Do not take within 2 hr of meal  (due to interference with food digestion & absorption of nutrients & vitamins K, D, E, A).  Do not give to young children (up to 6 ys) or bed ridden elderly people  (because, pneumonia which may be caused by inhalation of oil droplets in lung)  Taken at bed time  5- Stool softener (Emollient) e.g. Docusate  Encourage bowel movement by helping liquids mix in to the stool and prevent dry, hard stool masses. (mechanism of action)  Also allow patient to have bowel movement without straining.  Take with milk or fruit juice to improve flavor.  Emollients give results 1-2 days after dose, some patients after 3-5 days. Constipation in elderly: Constipation is a common problem in elderly patients for several reasons. Elderly patients are less likely to be physically active; they often have poor natural teeth or false teeth and so may avoid high-fiber foods that are more difficult to chew; multidrug regimens are more likely in elderly patients, who may therefore suffer from drug-induced constipation. If a bulk laxative is to be recommended for an elderly patient, it is of great importance that the pharmacist give advice about maintaining fluid intake to prevent the possible development of intestinal obstruction. Constipation in pregnancy: Constipation commonly occurs during pregnancy; hormonal changes are responsible. Dietary advice concerning the intake of plenty of high- fiber foods and fluids can help. Oral iron, often prescribed for pregnant women, may contribute to the problem. Stimulant laxatives are best avoided during pregnancy; bulk-forming laxatives are preferable. How to Prevent Constipation in Include More Water Children? Serve More High - Fiber Foods Develop a Regular Toilet Routine Encourage Exercising Review Your Child’s Medications A single glycerin suppository together with dietary advice may be appropriate Laxative abuse: Two groups of patients are likely to abuse laxatives:  Those with chronic constipation who get into a vicious circle by using stimulant laxatives, which eventually results in damage to the nerve in the colon  Those who take laxatives in the belief that they will control weight, e.g. those who are dieting or, more seriously, women with eating disorders (anorexia nervosa or bulimia), who take very large quantities of laxatives. Diarrhea  Diarrhea is an increase in the number of bowel movements or bowel movements are more watery and loose than normal. How it happen?  If the intestines push stools through the bowel before the water in the stool can be reabsorbed, diarrhea occurs.  when inflammation of the bowel lining causes excess fluid to leak into the stool.  Abdominal cramps, nausea, vomiting, or a fever may occur along with the diarrhea. Diarrhea has many causes:  stomach flu (gastroenteritis) or food poisoning (E. coli )  Drinking or using untreated water parasitic infections, (Giardia lamblia). (Diarrhea is quickly clearing viruses, bacteria, or toxins from the digestive tract. Since most cases of diarrhea are viral, they will clear up in a few days with good home treatment).  Many prescription and nonprescription medicines can cause diarrhea.  Antibiotics may cause mild diarrhea that usually clears up without treatment. A more serious type of diarrhea caused by the bacteria Clostridium difficile (sometimes called C-diff) may occur while taking or finishing the antibiotic.  Laxatives, may cause diarrhea.  Using too much of products that contain sorbitol (such as chewing gum) or fructose can cause diarrhea.  Some people get diarrhea while traveling (traveler's diarrhea).  For some people, emotional stress, irritable bowel syndrome,  food digestion problems (such as lactose intolerance)  Repeated diarrhea may be caused by inflammatory bowel disease, malabsorption problems and certain types of cancer. Health risks that may increase the seriousness symptoms.  Pregnancy-Related Problems.  Abdominal pain or severe discomfort that is not relieved by passing stools or gas  Stools black or bloody  a fever, Nausea and vomiting  Previous severe diarrhea  symptoms of mild to moderate dehydration Home Treatment to avoid other related problems, such as dehydration.  Take frequent, small sips of water or a rehydration drink and small bites of salty crackers.  eating mild foods.  Avoid spicy foods, fruits, alcohol, and caffeine until 48 hours after all symptoms have disappeared.  Avoid chewing gum that contains sorbitol.  Avoid dairy products for 3 days after symptoms disappear. Milk products may be harder for your body to digest when you have diarrhea. Nonprescription medicines for diarrhea  If you are pregnant, talk with your doctor before taking any medicines for diarrhea.  Use nonprescription antidiarrheal medicine if you have diarrhea for longer than 6 hours.  Do not use nonprescription antidiarrheal medicines if you have bloody diarrhea, a high fever, or other signs of serious illness.  Long-term use of nonprescription antidiarrheal medicine is not recommended. To avoid constipation  If your child or teen gets chickenpox or flu, do not treat the symptoms with over-the-counter medicines that contain bismuth subsalicylate (such as Pepto-Bismol and Kaopectate). Subsalicylate has been linked to Reye's syndrome, a rare but serious illness. (If your child has taken this kind of medicine and he or she has changes in behavior with nausea and vomiting, call your doctor. These symptoms could be an early sign of Reye's syndrome). Antidiarrheal medicines:  those that absorb water and thicken the stool, and those that slow intestinal spasms.  Thickening mixtures, such as psyllium, This gives the stool more bulk.  Antispasmodic antidiarrheals, such as Imodium A-D and Pepto Diarrhea Control, slow intestinal spasms.  Some products contain both thickening and antispasmodic ingredients.  Probiotics, such as Lactobacillus, are available in either pills or powder. This bacteria occurs naturally in the intestine and may help with digestion. When diarrhea is present, the number of these bacteria is reduced. Symptoms to Watch For During Home Treatment  Signs of dehydration develop.  Severe diarrhea (large, loose bowel movements every 1 to 2 hours) develops.  Diarrhea is present for longer than 1 to 2 weeks.  Black or bloody stools develop.  A fever develops.  Your symptoms become more severe or more frequent. Prevention  Food poisoning is a common cause of diarrhea in children and adults. Most cases of food poisoning may be prevented by taking a few precautions when preparing and storing food at home.  Also, precautions should be taken in case of pregnant, have an impaired immune system or a chronic illness, or other high-risk groups, such as young children or older adults.. Answer the following questions:  How long have you had diarrhea?  How many times per day are you having diarrhea?  What does your diarrhea look like? Describe the color, consistency (watery, mushy), and other characteristics (contains blood or mucus)?  When was your last episode of diarrhea?  Have you recently increased the amount of fiber in your diet (more fresh fruit, vegetables, or other high-fiber foods)?  What prescription and nonprescription medicines do you take?  Are you taking any new medicine?  Did you recently increase the dose of a medicine?  Have you taken any antibiotics recently?  Did you recently receive an antibiotic while in the hospital?  Do you routinely use laxatives or stool softeners?  Have you been under an unusual amount of stress at home, work, or both?  Does anyone you live with or work with have diarrhea?  Did your diarrhea start after eating at a restaurant? Has anyone who ate there with you become ill?  Did you drink lake or stream water or untreated well water?  Have you recently visited a foreign country or taken a ship cruise?  Do you have any risk factors that make you more susceptible to diarrhea, such as irritable bowel syndrome?  What home treatment measures have you tried? Be sure to include any nonprescription medicines you have taken.  Do you have other symptoms, such as vomiting, fever, or dehydration?  Do you have any health risks?