Opioid-Induced Bowel Dysfunction

Amanda Arthur, Dietetic Intern July 26, 2012

Presentation Overview

Patient Profile Pertinent Medical History Nutrition-Related Issues Nutritional Assessment Nutrition Diagnosis Disease and Treatment Nutrition Care Goals Nutritional Intervention Nutrition Monitoring Nutrition Evaluation Nutrition Follow-Up Conclusions

Patient Profile
Age:

72 Gender: Male Marital Status: Married Occupation: Manager of iron workers at TVA Retired for 15 yrs
Admitted:

7/12/12 for Chest Pain

Pertinent Medical History

First

headache at 5 years of age

Took three 500 mg Tylenol tablets every 2 hours for 5 years

Colonoscopy: Spinal Stents LAD

100% inactive colon

cord stimulator implant (11/10) placed in LAD vessels (11/11)

angioplasty (6/20/12) x 2 (7/19/12)

CABG

Nutrition-Related Issues
CAD HTN Hyperlipidemia GERD Chronic

Constipation

Nutritional Assessment: Anthropometrics

Height:

67 Current wt: 100 kg BMI: 34 IBW: 67 kg %IBW: 149

Nutritional Assessment: Abnormal Labs

7/12 7/16 7/17 7/18 7/19
Sodium Chloride CO2 Glucose Calcium Hemoglobin Hematocrit
134 -137 -138

7/20
138

100.3
27.4 106 9.7 13.6 38.2

----13.4 37.5

100.4
20 108 7.7 13.7 37.9

----13.9 39.6

107.8
21.6 121 8.3 12.3 35.5

110.2
23.1 78 7.8 10.3 28.9

Nutritional Assessment: Drug-Nutrient Interactions1

Aspirin: Take after meals to decrease GI irritation.

Increase foods rich in Vit-C and folic acid with LT high dose. gastric acid secretion & gastric pH, which may lead to diarrhea, nausea, vomiting & constipation. May cause nausea, dyspepsia, abdominal pain, flatulence, diarrhea & constipation. May cause dry mouth, nausea, vomiting, diarrhea, constipation, dyspepsia & flatulence.

Famotidine: Avoid alcohol, may decrease Fe, B12, and Ca absorption

Atorvastatin: Avoid grapefruit & related citrus products

Metoprolol: Take with food to increase bioavailability.

Polyethylene glycol: Take with high fiber and1.5-2 L to prevent constipation.

Not absorbed from GI tract nausea, bloating, cramps, flatulence, diarrhea & increase stool frequency w/ high dose.
May cause nausea, vomiting, constipation & black tarry stools

Heparin:

Nutritional Assessment: Nutrient Requirements

Estimated

energy needs

2000-2500 kcal (20-25 kcal/kg)

Estimated

protein needs

100-120 g protein (1-1.2 g/kg)

Fluid

needs

2000-2500 mL (1 mL/kcal)

Nutritional Assessment: Conclusions

DC

has an 100% inactive colon secondary to Tylenol overdose

Diet education
o o o

High fiber foods Fluid intake Laxative use

Nutrition Diagnosis
Altered

GI function related to changes in GI tract motility as evidenced by colonoscopic exam results.

Chronic Constipation2

Inadequate water and fiber intake Inadequate activity Stress Overuse of laxatives Antacid medicines Medicines

Characteristics of Opiates3
Decrease Reduce

gastrointestinal neural activity

propulsive activity

Delay

transit of contents through the small and large bowel

absorption of fluids

Enhance

Opioid-Induced Bowel Dysfunction

Opioid-induced bowel dysfunction: hard dry stools, straining, incomplete evacuation, bloating, abdominal distension and increased GERD

Opiates bind to intestinal -opiate receptors, which inhibit motility and decrease BMs.
Decreased peristalsis delays gut transit and lengthens contact between intestinal contents and the mucosa.

Site of Action Stomach

Pharmacological Action gastric motility

Clinical Effect Anorexia

pyloric tone pancreatic/biliary secretion

propulsion fluid absorption propulsion

Nausea/vomiting Delayed digestion

Delayed med absorption Hard, dry stool Straining, incomplete evacuation, bloating, abdominal distention, CONSTIPATION Spasm, abdominal cramps, pain Hard, dry stool Incomplete evacuation

Small intestine

Large intestine non-propulsive contractions fluid absorption anal sphincter tone

Treatment
Prevent
Start
o

symptoms vs. treat opioidinduced bowel dysfunction

a bowel regimen early
Fiber & water o Exercise & void after breakfast

Pharmacological

therapy4

Nutritional Treatment
No No

changes in diet previous diet education Cardiac diet

Received

Nutrition Care Goals

Relieve

constipation stable weight

Maintain Meet

nutritional needs

Nutritional Intervention
Prescription

Miralax mixed in room temperature green tea antacid Advantage

OTC

Digestive

Nutrition Monitoring
GI

Assessment PO intake I/Os Weight Electrolytes

Evaluation of Nutrition Intervention

Maintained Nutritional Labs

stable weight

needs met

relatively stable

Nutrition Follow-up
Management

of constipation

Select

appropriate nutritional interventions

Conclusions
Nutritional

Guidelines

High fiber diet with adequate water Miralax in room temp green tea

Will

need to follow heart healthy diet to prevent future cardiac events with PCP

Follow-up

References
1. 2.

3.

4.

Pronsky, ZM and Crowe, JP Sr. Food and Medication Interactions. 16th edition; 2010. Chronic Constipation: Tips and Treatment. WebMD. Available at: http://www.webmd.com/digestivedisorders/chronic-constipation-7/constipationcauses. Accessed July 17, 2012. Kurz, A and Sessler, DI. Opioid-Induced Bowel Dysfunction: Pathophysiology and Potential New Therapies. Drugs (2003); 63 (7): 649-671. Escott-Stump, S. Nutrition and Diagnosis-Related Care. 7th edition; 2011.

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