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What is the 3/3 rule of constipation?
It is normal to go 3 times per week or 3 times per day or anything in between
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What are the 3 Fs?
Fiber, fluid and fun
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What are the drugs that can cause constipation
- analgesics and anticholinergics
- antihistamines, antispasmodics, antidepressants, antipsychotics
- Cation containting supplements: iron, calcium, aluminum
- neurally active agents: opioids antihypertensives
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What is an Enterocele?
Weakness in the tissue that holds the bowel in place and the bowel falls down behind the uterus and into the vagina
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What are some things that can weaken the wall and cause an enterocele?
Straining, manual labor, child birth
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What is an anterior rectocele?
Rectum that pushes the wall of the vagina, pelvic floor dysfunction
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What are the Alarm symptoms for constipation that might be colon cancer?
- Over 50
- unexplained weight loss
- anemia
- evidence of GIB
- perisistent or progressive pain
- FH colon cancer
- fasting nocturnal or large volume diarrhea
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what are B symptoms
- wt loss
- low grade fever
- night sweats
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A Gaping or asymetric anal opening (i.e. a �gaping asshole�) is a sign of what type of disorder?
Neurologic disorder impairing sphincter function
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Having the patient strain during the rectal exam is useful for diagnosing patients with what?
Dyssynergic defication, rectal prolapse
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How do you do a physical examination for a rectocele?
Have female patient strain with the examining finger oriented anteriorly
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In a patient with constipation you can do a barium X ray to identify what 4 disorders
obstruction, megarectum, megacolon, hirshsprungs disease
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Atonic Colon
loss of normal colonic relfexes and sensation
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Adynamic colon
colon that is dialated and the patient is unable to move through the colon, thus they are dependent on more and more laxitives for defecation
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Dyssynergistic defication
- in coordination of contraction of colonic and rectal muscles and internal and external sphincters
- leads to attempts to defecate against closed anal sphincters
- with or without difficulty deficating strain even with soft stools
- on examination they are inable to voluntarily relax the external sphincters on request
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Megacolon
- Lifelong constipation
- occasional passage of an enormous formed stool
- causes are congenital (hirschsprung disease) or aquired defects in the intrinsic innervation of the colon
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What are some bowel diseases that can cause constipation
IBS, slow colonic transit, pelvic floor dysfunction
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what are some neurological conditions that can cause constipation?
Parkinson's, MS, colon surgery, spinal cord injury, diabetes mellitus, pseudo-obstruction
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What are some complications of chronic constipation
- urinary obstruction/infection
- spontaneous perforation
- stercolar ulcer � ischemia on bowel wall
- fecaliths- appendix
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What anticonstipation medications should be avoided unless nessisary?
Prokinetics, lubricating agents, routine enemas
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What medications should be used for constipation
- stool softeners/ bulking agents
- osmotic agents
- stimulating agents
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what are some lifestyle/diet modifications that can help constipation
- fiber fluids fun
- D/C or change offending meds if possible
- bowel retraining
- educations and reassurance
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What must you give with fiber/bulk laxitives?
WATER
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How do surfactants work?
Lower stool surface tension and soften so that more water enters more easily not as good as laxatives
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What are osmotic agents?
- Non-absorbable agents to promote fluid shift
- intestinal water secretion increases
- increases stool frequency
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Name some osmotic agents
PEG, Lactulose, Saline
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How do stimulant laxatives work?
Alter electrolyte transit at mucosa and increase motor activity
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What is a fecal impaction?
- Large mass of bulky dry hard stool in the rectum secondary to chronic constipation
- watery stool may form higher in the bowel and leak around the impaction causing soiling or diarrhea
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What are some complications of fecal impaction
- dilitation- toxic megacolon
- rectal tears
- rectal tissue necrosis
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What are some symptoms of fecal impaction?
- Urge to deficate without ability to have a BM
- abdominal pain
- bloated or hard abdomen
- anorexia
- nausea and vomiting
- rectal discomfort
- generally ill feeling
- confusion
- leakage of wet stool or thin/pencil stool
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What is a contraindication to manual disimpaction, suppositories and enemas for fecal impation?
Patients who are myelosuppressed or have altered bleeding times
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What are some motility tests that can be done for a patient with chronic constipation
- anorectal manometry
- defecography
- pelvic floor electromyography
- anal endosonography
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Anal fissures found on the sides of the anus are indicative of what diseases?
- Chron's disease
- ulcerative colitis
- syphillis
- TB
- leukemia
- cancer
- HIV
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Anal fissures that are in the verticle plain of the rectum (the top and bottom) are indicative of what?
Acute and chronic anal fissures
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Your patient has a tearing pain with defecation and sometimes a throbbing pain following defecation. They also report blood on the toilet paper after they go. You diagnose
Anal fissure
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Hematochezia
blood on toilet paper or stool
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Chronic fissures
- can ulcerate with internal sphincter fibers seen at base
- may develop sentinel pile or sentinel tag
- may require surgery
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Which hemorrhoids are painful internal or external
external
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what are some risk factors for hemorrhoids
pregnancy, obesity, chronic diarrhea, loss of muscle tone, chronic constipation, portal hypertension, professions with lots of sitting
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First degree hemorrhoids
dont prolapse
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second degree hemorrhoids
prolapse through anus on straining but spontaneous reduction
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Third degree hemorrhoids
Prolapse and may require manual/digital reduction
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Fourth degree hemorrhoids
Cannot be reduced just hang out all the time
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What are some treatments for internal hemorrhoids
- rubber band ligation
- infrared coagulation
- bipolar diathermy
- laser photocoagulation
- sclerotherapy
- cryotherapy
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Treatment for a bleeding hemorrhoid
fiber
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Treatment for a iritation and pruritus from a hemorrhoid
analgesic creams hydrocortisone suppositories sitz baths
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Treatment for thrombosed hemorrhoids
acute may require surgical intervention if significant symptoms
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