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– Penetrating ocular trauma, gonococcal conjunctivitis

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

If not resolved within 5 to 7 days, alternate diagnoses should be considered or consultation obtained, although some epidemic keratoconjunctivitis and other adenoviral conjunctivitis typically last 1 to 2 weeks.

Children may be excluded from school until eye is no longer red, if viral or bacterial, depending on school policy. Allergic conjunctivitis should be able to return to school with doctor’s note.

PATIENT EDUCATION

Patients should not wear contacts until their eyes are fully healed (typically 1 week).

Patients should discard current contacts.

Patients should discard eye makeup they had been using, especially mascara.

Cool, moist compress can ease irritation and itch.

PROGNOSIS

Viral: 5 to 10 days of symptoms for pharyngitis with conjunctivitis, 2 weeks with adenovirus

Herpes simplex: 2 to 3 weeks of symptoms

Most common bacterial—H. influenzae, Staphylococcus, Streptococcus: self– limited; 74–80% resolution within 7 days, whether treated or not

COMPLICATIONS

Corneal scars with herpes simplex

Lid scars or entropion with varicella zoster and chlamydia

Corneal ulcers or perforation, very rapid with gonococcal

Hypopyon: pus in anterior chamber

Chlamydial neonatal (ophthalmic): could have concomitant pneumonia

Otitis media may follow H. influenzae conjunctivitis.

Very rarely N. meningitidis conjunctivitis may be followed by meningitis.

REFERENCES

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1.Steeples L, Mercieca K. Acute conjunctivitis in primary care: antibiotics and placebo associated with small increase in the proportion cured by 7 days compared with no treatment. Evid Based Med. 2012;17(6):177–178.

2.Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev. 2015; (1):CD002898.

3.Castillo M, Scott NW, Mustafa MZ, et al. Topical antihistamines and mast cell stabilisers for treating seasonal and perennial allergic conjunctivitis.

Cochrane Database Syst Rev. 2015;(6):CD009566.

4.Herretes S, Wang X, Reyes JM. Topical corticosteroids as adjunctive therapy for bacterial keratitis. Cochrane Database Syst Rev. 2014;(10):CD005430.

5.Mammas IN, Theodoridou M, Kramvis A, et al. Paediatric virology: a rapidly increasing educational challenge. Exp Ther Med. 2017;13(2):364–377.

ADDITIONALREADING

Berger WE, Granet DB, Kabat AG. Diagnosis and management of allergic conjunctivitis in pediatric patients. Allergy Asthma Proc. 2017;38(1):16–27.

SEE ALSO

Rhinitis, Allergic

Algorithm: Eye Pain

CODES

ICD10

H10.30 Unspecified acute conjunctivitis, unspecified eye

H10.33 Unspecified acute conjunctivitis, bilateral

H10.32 Unspecified acute conjunctivitis, left eye

CLINICALPEARLS

Conjunctivitis does not alter visual acuity; decreased acuity or photophobia should prompt consideration of more serious ophthalmic disorders.

Culture the discharge in all contact lens wearers, consider referral, and remind patient to throw away current contacts and avoid contacts until eyes are fully

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healed.

Antibiotics are of no value in viral conjunctivitis (most cases of infectious conjunctivitis) and do not significantly alter the course of most types of bacterial conjunctivitis.

Treating symptomatically for 3 days before prescribing an antibiotic is appropriate for adults and children >1 month.

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CONSTIPATION

S. Mimi Mukherjee, PharmD Sandra Marwill, MD, MPH

BASICS

Unsatisfactory defecation characterized by infrequent stools, difficult stool passage, or both. Characteristics include <3 bowel movements a week, hard stools, excessive straining, prolonged time spent on the toilet, a sense of incomplete evacuation, and abdominal discomfort/bloating.

DESCRIPTION

System(s) affected: gastrointestinal (GI)

Synonym(s): obstipation

Geriatric Considerations

Colorectal neoplasms may be associated with constipation; new-onset constipation after age 50 years is a “red flag.” Use warm water enemas for impaction instead of sodium phosphate enema in geriatric patients. Sodium phosphate enemas have been associated with fatalities and severe electrolyte disturbances (1)[B].

Pediatric Considerations

Consider Hirschsprung disease (absence of colonic ganglion cells): 25% of all newborn intestinal obstructions, milder cases diagnosed in older children with chronic constipation, abdominal distension, decreased growth; 5:1 male-to- female ratio; associated with inherited conditions (e.g., Down syndrome)

Pregnancy Considerations

Avoid misoprostol. Always consider risks versus benefits when deciding on treatment.

EPIDEMIOLOGY

More pronounced in children and elderly

Predominant sex: female > male (2:1) Nonwhites > whites

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Incidence

5 million office visits annually

100,000 hospitalizations

Prevalence

16% of adults >18 years, rising to 33% of adults >60 years of age

3% of physician visits in children relate to constipation.

ETIOLOGYAND PATHOPHYSIOLOGY

As food leaves the stomach, the ileocecal valve relaxes (gastroileal reflex) and chyme enters the colon (1 to 2 L/day) from the small intestine. In the colon, sodium is actively absorbed in exchange for potassium and bicarbonate. Water follows the osmotic gradient. Peristaltic contractions move chyme through the colon into the rectum. Chyme is converted into feces (200 to 250 mL).

Normal transit time is 4 hours to reach the cecum and 12 hours to reach the distal colon.

Defecation reflexively follows once stool reaches the rectal vault. This reflex can be inhibited by voluntarily contracting the external sphincter or facilitated by straining to contract the abdominal muscles while voluntarily relaxing the anal sphincter. Rectal distention initiates the defecation reflex. The urge to defecate occurs as rectal pressures increase. Distention of the stomach also initiates rectal contractions and a desire to defecate (gastrocolic reflex).

Primary and secondary defecation disorders result from delay in colonic transit, altered rectal motor activity, and structural or functional problems with pelvic floor muscles (including paradoxical contractions, diminished ability to relax sphincter, and/or poor propulsion).

Genetics

Unknown but may be familial

RISK FACTORS

Very young and very old

Polypharmacy

Sedentary lifestyle or condition

Improper diet and inadequate fluid intake

GENERALPREVENTION

High-fiber diet, adequate fluids, exercise, and training to “obey the urge” to

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defecate

COMMONLYASSOCIATED CONDITIONS

General debilitation (disease or aging)

Dehydration

Hypothyroidism

Hypokalemia

Hypercalcemia Nursing home resident

DIAGNOSIS

ALERT

Red flags:

New onset after age of 50 years

Hematochezia/melena

Unintentional weight loss

Family history of colon cancer

Anemia

Neurologic defects

HISTORY

Assess onset of symptoms, number of bowel movements per week, straining, completeness of evacuation, use of manual manipulation.

Identify red flags; evaluate diet, lifestyle, prescription, and OTC medication use; identify reversible causes; ask about history of sexual abuse, illicit opioid use.

Bristol Stool Form Scale—seven categories of consistency (2)

Bowel and diet diary help to measure treatment response. Rome III criteria (3)[C]:

–At least two of the following for 12 weeks in the previous 6 months: <3 stools per week

Straining at least 1/4 of the time

Hard stools at least 1/4 of time

Need for manual assist at least 1/4 of time

Sense of incomplete evacuation at least 1/4 of time

Sense of anorectal blockade at least 1/4 of time

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–Loose stools rarely seen without use of laxatives

–Frequent constipation but does not meet irritable bowel syndrome (IBS) criteria

–Although there can be overlap, the history of primary constipation differs from constipation-predominant IBS.

In primary constipation, pain and bloating are relieved by adequate defecation. In IBS, pain and bloating predominate and are not readily relieved by defecation.

PHYSICALEXAM

Vital signs

Abdominal exam, previous surgical scars, hypoactive bowel sounds, tenderness and masses

Gynecologic exam: Evaluate for masses and rectocele.

Digital rectal exam: Evaluate for masses, pain, stool, fissures, hemorrhoids; assess sphincter tone.

Neurologic exam

DIFFERENTIALDIAGNOSIS

Primary constipation (primary problem is within the GI tract) four subtypes

–Normal colonic transit time most common subtype; can be difficult to differentiate from constipation-predominant IBS

–Slow colonic transit time

–Pelvic floor/anal sphincter dysfunction

–Combination pelvic floor/anal sphincter dysfunction and slow transit

Secondary constipation (outside the GI tract)

–Endocrine dysfunction (diabetes mellitus, hypothyroid)

–Metabolic disorder (increased calcium, decreased potassium)

–Mechanical (obstruction, rectocele)

–Pregnancy

–Neurologic disorders (Hirschsprung, multiple sclerosis, spinal cord injuries,

Parkinson disease)

Congenital

–Hirschsprung disease/syndrome

–Hypoganglionosis

–Congenital dilation of the colon

–Small left colon syndrome

Medication effect

– Anticholinergic effects (antidepressants, opioids antipsychotics)

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–Antacids (calcium, aluminum)

–Nondihydropyridine calcium channel blockers, especially verapamil

–Iron and multivitamins with iron

–Diuretics

–Overuse of antidiarrheal medications

DIAGNOSTIC TESTS & INTERPRETATION

Identify red flags, secondary causes, and reversible conditions. If none present, go to first-line treatment.

Initial Tests (lab, imaging)

CBC to screen for iron deficiency anemia

Consider tox screen if suspect illicit opioid use

Calcium, glucose, and thyroid function testing (TSH) based on history and exam. If red flags are present, refer for sigmoid/colonoscopy.

Follow-Up Tests & Special Considerations

For patients with pelvic floor dysfunction or exam abnormalities (e.g., rectocele) and/ or patients who are refractory to initial treatment, refer to an experienced subspecialist. An experienced biofeedback physical therapist can be very helpful.

Diagnostic Procedures/Other

Anorectal manometry (ARM)

Balloon expulsion testing (BET)

Scintigraphy

MRI

Defecography

Colonic marker studies

Test Interpretation

ARM and BET recommended for all refractory cases

If ARM and BET are negative, scintigraphy may help evaluate transit time. Some recommend biofeedback prior to scintigraphy.

TREATMENT

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Address immediate concerns:

Bloating/discomfort/straining: osmotic agents

Postoperative, after childbirth, hemorrhoids, fissures: stool softener to aid defecation

If impacted: manual disimpaction, then treat any underlying conditions.

GENERALMEASURES

In patients with no known secondary causes, conservative nonpharmacologic treatment is recommended.

Eliminate medications that cause constipation.

Increase fluid intake.

Increase soluble fiber in diet.

Encourage regular defecation attempts after eating.

Regular exercise

Enemas if other methods fail (avoid sodium phosphate enemas in geriatric patients)

MEDICATION

Nonprescription medications are first line. If patient goals are not reached, advance to prescription medications.

First Line

Bulking agents (accompanied by adequate fluids): Hydrophilic colloids (bulk-forming agents)

–Psyllium (Konsyl, Metamucil, Perdiem Fiber): 1 tbsp in 8-oz liquid PO daily up to TID

–Methylcellulose (Citrucel): 1 tbsp in 8-oz liquid PO daily up to TID

–Polycarbophil (Mitrolan, FiberCon): 2 caplets with 8-oz liquid PO up to QID

Stool softeners

– Docusate sodium (Colace): 50 to 100 mg PO TID Osmotic laxatives

–Polyethylene glycol (PEG) (MiraLax) 17 g/day PO dissolved in 4 to 8 oz of beverage (current evidence shows PEG to be superior to lactulose) (4)[B]

–Lactulose (Chronulac, Enulose) 15 to 60 mLPO QHS (flatulence, bloating, cramping)

–Sorbitol: 15 to 60 mLPO QHS (as effective as lactulose)

–Magnesium salts (milk of magnesia) 15 to 30 mLPO once daily; avoid in

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renal insufficiency.

Second Line

Stimulants (irritate bowel, causing muscle contraction; usually combined with a softener; work in 8 to 12 hours)

–Senna/docusate (Senokot-S, Ex-lax, Peri-Colace): 1 to 2 tablets or 15 to 30 mLPO at bedtime

–Bisacodyl (Dulcolax, Correctol): 1 to 3 tablets PO daily

Lubricants (soften stool and facilitate passage of the feces by its lubricating oily effects)

–Mineral oil (15 to 45 mL/day)

–Short-term use only; can bind fat-soluble vitamins, with the potential for deficiencies; may similarly decrease absorption of some drugs

–Avoid in those at risk for aspiration (lipoid pneumonia).

Suppositories

–Osmotic: sodium phosphate

–Lubricant: glycerin

–Stimulatory: bisacodyl

–Enemas: saline (Fleet enema)

Lubiprostone (Amitiza): a selective chloride channel activator; 24 µg PO BID Guanylate cyclase-C agonists (adult use only)

–Linaclotide (Linzess): dose: 145 µg PO once daily;

–Plecanatide (Trulance): dose: 3 mg PO once daily

Peripherally acting µ-opioid receptor antagonists, indicated for opioid-induced constipation

–Methylnaltrexone (Relistor): dose: 38 to <62 kg: 8 mg; 62 to 114 kg: 12 mg SC every other day PRN

–Naloxegol (Movantik): dose: 12.5 to 25.0 mg PO daily; discontinue other laxatives for 3 days when initiating naloxegol; avoid in patients on strong Cyp3A4 inhibitors due to increased naloxegol levels and risk of opioid withdrawal.

–Naldemedine (Symproic): dose: 0.2 mg PO daily; monitor for opioid withdrawal in patients on strong Cyp3A4 inhibitors or P-gp inhibitors.

Prokinetic agents (partial 5-HT4 agonists) have been withdrawn due to cardiac side effects; only available via IND protocols: tegaserod (Zelnorm), cisapride (Propulsid)

Other agents not approved by the FDA:

–Misoprostol (Cytotec): a prostaglandin that increases colonic motility

–Colchicine: neurogenic stimulation to increase colonic motility

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