{"version":"1.0.0","segments":[{"startTime":0.527,"endTime":3.152,"body":"[upbeat intro music]"},{"startTime":3.152,"endTime":5.72,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.152,"endTime":5.72,"body":"to Harrison's PodClass,"},{"startTime":5.72,"endTime":8.767,"body":"where we discuss important"},{"startTime":5.72,"endTime":8.767,"body":"concepts in internal medicine."},{"startTime":8.767,"endTime":9.912,"body":"I'm Cathy Handy."},{"startTime":9.912,"endTime":11.75,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.912,"endTime":11.75,"body":"Wiener and we're coming to you"},{"startTime":11.75,"endTime":13.85,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.76,"endTime":16.668,"body":"[Dr. Handy] Hi, everyone."},{"startTime":16.668,"endTime":20.572,"body":"Today's episode is a"},{"startTime":16.668,"endTime":20.572,"body":"72-year-old with constipation."},{"startTime":20.572,"endTime":22.553,"body":"[Dr. Wiener] Cathy, today we"},{"startTime":20.572,"endTime":22.553,"body":"have a case that's relevant"},{"startTime":22.553,"endTime":24.2,"body":"to both of our clinical activities."},{"startTime":24.2,"endTime":25.052,"body":"[Dr. Handy] All right."},{"startTime":25.052,"endTime":28.495,"body":"[Dr. Wiener] So a 72-year-old"},{"startTime":25.052,"endTime":28.495,"body":"woman has stage 4 ovarian"},{"startTime":28.495,"endTime":32.46,"body":"cancer and she has known"},{"startTime":28.495,"endTime":32.46,"body":"diffuse peritoneal study."},{"startTime":32.46,"endTime":34.763,"body":"She's developing increasing"},{"startTime":32.46,"endTime":34.763,"body":"pain in her abdomen"},{"startTime":34.763,"endTime":37.47,"body":"and is admitted to the"},{"startTime":34.763,"endTime":37.47,"body":"hospital for pain control."},{"startTime":37.47,"endTime":39.572,"body":"She previously has been"},{"startTime":37.47,"endTime":39.572,"body":"treated with oxycodone"},{"startTime":39.572,"endTime":42.27,"body":"10 mg orally every six hours as needed,"},{"startTime":42.27,"endTime":44.345,"body":"and she's on no other home meds."},{"startTime":44.345,"endTime":47.605,"body":"On admission, she's initiated"},{"startTime":44.345,"endTime":47.605,"body":"on intravenous morphine"},{"startTime":47.605,"endTime":51.298,"body":"via a PCA or patient-controlled analgesia."},{"startTime":51.298,"endTime":53.882,"body":"She begins to complain"},{"startTime":51.298,"endTime":53.882,"body":"about increasing bloating"},{"startTime":53.882,"endTime":56.348,"body":"and constipation over the next day or two"},{"startTime":56.348,"endTime":59.08,"body":"since starting the increased"},{"startTime":56.348,"endTime":59.08,"body":"doses of narcotics."},{"startTime":59.08,"endTime":60.222,"body":"[Dr. Handy] Okay. Just to summarize,"},{"startTime":60.222,"endTime":62.305,"body":"a patient with stage 4 ovarian cancer"},{"startTime":62.305,"endTime":65.983,"body":"who has new abdominal complaints"},{"startTime":62.305,"endTime":65.983,"body":"and is receiving narcotics."},{"startTime":65.983,"endTime":67.107,"body":"[Dr. Wiener] So what's"},{"startTime":65.983,"endTime":67.107,"body":"your general approach"},{"startTime":67.107,"endTime":68.542,"body":"in these types of patients?"},{"startTime":68.542,"endTime":70.53,"body":"[Dr. Handy] Well, I often"},{"startTime":68.542,"endTime":70.53,"body":"find these difficult,"},{"startTime":70.53,"endTime":73.07,"body":"because as we know narcotics"},{"startTime":70.53,"endTime":73.07,"body":"can cause constipation"},{"startTime":73.07,"endTime":75.127,"body":"or even functional bowel obstruction,"},{"startTime":75.127,"endTime":77.068,"body":"but patients, especially"},{"startTime":75.127,"endTime":77.068,"body":"with advanced cancer,"},{"startTime":77.068,"endTime":79.605,"body":"can also develop acute abdominal issues"},{"startTime":79.605,"endTime":81.15,"body":"either related to their tumor,"},{"startTime":81.15,"endTime":83.578,"body":"their therapy, their history of surgery."},{"startTime":83.578,"endTime":85.748,"body":"And she's been receiving"},{"startTime":83.578,"endTime":85.748,"body":"narcotics for a while"},{"startTime":85.748,"endTime":87.243,"body":"but these symptoms are new,"},{"startTime":87.243,"endTime":90.308,"body":"so before just ascribing"},{"startTime":87.243,"endTime":90.308,"body":"any new clinical complaint"},{"startTime":90.308,"endTime":91.75,"body":"to constipation,"},{"startTime":91.75,"endTime":93.56,"body":"I do want to make sure that"},{"startTime":91.75,"endTime":93.56,"body":"I'm not missing something"},{"startTime":93.56,"endTime":95.548,"body":"that requires another intervention."},{"startTime":95.548,"endTime":98.247,"body":"So in this woman I'd want to"},{"startTime":95.548,"endTime":98.247,"body":"know more about her vitals,"},{"startTime":98.247,"endTime":100.507,"body":"especially her physical exam, labs,"},{"startTime":100.507,"endTime":103.478,"body":"and since she's an inpatient,"},{"startTime":100.507,"endTime":103.478,"body":"maybe some imaging."},{"startTime":103.478,"endTime":106.135,"body":"[Dr. Wiener] Okay, well"},{"startTime":103.478,"endTime":106.135,"body":"on exam she has no fever,"},{"startTime":106.135,"endTime":107.89,"body":"hypotension or tachycardia."},{"startTime":107.89,"endTime":109.873,"body":"She reports that she feels full"},{"startTime":109.873,"endTime":112.342,"body":"and does feel like she feels constipated."},{"startTime":112.342,"endTime":114.277,"body":"Overall, her vitals are normal."},{"startTime":114.277,"endTime":117.193,"body":"Her abdominal examination"},{"startTime":114.277,"endTime":117.193,"body":"shows no overt distension,"},{"startTime":117.193,"endTime":118.347,"body":"but she does have a little bit"},{"startTime":118.347,"endTime":120.852,"body":"of reduced bowel sounds,"},{"startTime":118.347,"endTime":120.852,"body":"but they're present."},{"startTime":120.852,"endTime":123.987,"body":"She's not tender focally and"},{"startTime":120.852,"endTime":123.987,"body":"has no rebound tenderness."},{"startTime":123.987,"endTime":126.368,"body":"Her labs reveal no"},{"startTime":123.987,"endTime":126.368,"body":"change in her hemoglobin,"},{"startTime":126.368,"endTime":128.96,"body":"and her white blood"},{"startTime":126.368,"endTime":128.96,"body":"cell count is unchanged."},{"startTime":128.96,"endTime":130.18,"body":"[Dr. Handy] Well, that's all reassuring."},{"startTime":130.18,"endTime":132.938,"body":"Did she get any imaging, abdominal X-ray?"},{"startTime":132.938,"endTime":134.143,"body":"[Dr. Wiener] In fact, she did."},{"startTime":134.143,"endTime":137.735,"body":"It shows no free air nor"},{"startTime":134.143,"endTime":137.735,"body":"abnormal air fluid levels."},{"startTime":137.735,"endTime":140.99,"body":"It does, in fact, show extensive"},{"startTime":137.735,"endTime":140.99,"body":"stool throughout the colon."},{"startTime":140.99,"endTime":142.56,"body":"[Dr. Handy] Okay, so"},{"startTime":140.99,"endTime":142.56,"body":"certainly this could be"},{"startTime":142.56,"endTime":144.66,"body":"narcotic-induced constipation."},{"startTime":144.66,"endTime":146.232,"body":"[Dr. Wiener] So let's"},{"startTime":144.66,"endTime":146.232,"body":"talk more about that."},{"startTime":146.232,"endTime":148.189,"body":"[Dr. Handy] Well, constipation"},{"startTime":146.232,"endTime":148.189,"body":"is reported in up to"},{"startTime":148.189,"endTime":151.418,"body":"70-100% of patients"},{"startTime":148.189,"endTime":151.418,"body":"requiring palliative care."},{"startTime":151.418,"endTime":153.77,"body":"Although hypercalcemia and other factors"},{"startTime":153.77,"endTime":155.175,"body":"can cause constipation,"},{"startTime":155.175,"endTime":157.575,"body":"it is most frequently a"},{"startTime":155.175,"endTime":157.575,"body":"predictable consequence"},{"startTime":157.575,"endTime":160.377,"body":"of the use of opioids for"},{"startTime":157.575,"endTime":160.377,"body":"pain and dyspnea relief."},{"startTime":160.377,"endTime":163.3,"body":"It can also be related to"},{"startTime":160.377,"endTime":163.3,"body":"the anticholinergic effects"},{"startTime":163.3,"endTime":165.575,"body":"of medicines like"},{"startTime":163.3,"endTime":165.575,"body":"tricyclic antidepressants,"},{"startTime":165.575,"endTime":169.057,"body":"as well as other factors like"},{"startTime":165.575,"endTime":169.057,"body":"inactivity and poor diet,"},{"startTime":169.057,"endTime":171.78,"body":"which are common among"},{"startTime":169.057,"endTime":171.78,"body":"seriously ill patients."},{"startTime":171.78,"endTime":174.346,"body":"At a minimum, it can be"},{"startTime":171.78,"endTime":174.346,"body":"uncomfortable for the patient,"},{"startTime":174.346,"endTime":175.68,"body":"and if left untreated,"},{"startTime":175.68,"endTime":178.535,"body":"constipation can cause"},{"startTime":175.68,"endTime":178.535,"body":"substantial pain and vomiting,"},{"startTime":178.535,"endTime":180.517,"body":"essentially bowel obstruction."},{"startTime":180.517,"endTime":183.052,"body":"It is also associated with"},{"startTime":180.517,"endTime":183.052,"body":"confusion and delirium,"},{"startTime":183.052,"endTime":185.26,"body":"which we know is a"},{"startTime":183.052,"endTime":185.26,"body":"negative prognostic factor"},{"startTime":185.26,"endTime":187.785,"body":"in all patients, but"},{"startTime":185.26,"endTime":187.785,"body":"particularly the elderly."},{"startTime":187.785,"endTime":189.84,"body":"[Dr. Wiener] Okay, so"},{"startTime":187.785,"endTime":189.84,"body":"let's get to the question."},{"startTime":189.84,"endTime":191.28,"body":"The question asks,"},{"startTime":191.28,"endTime":193.327,"body":"all of the following are"},{"startTime":191.28,"endTime":193.327,"body":"reasonable treatment options"},{"startTime":193.327,"endTime":196.285,"body":"for this patient's constipation, except?"},{"startTime":196.285,"endTime":198.38,"body":"So four true and one false,"},{"startTime":198.38,"endTime":201.698,"body":"and the options are, A. bisacodyl;"},{"startTime":201.698,"endTime":203.992,"body":"option B. is docusate;"},{"startTime":203.992,"endTime":206.198,"body":"option C. is fiber;"},{"startTime":206.198,"endTime":208.798,"body":"option D. is magnesium citrate;"},{"startTime":208.798,"endTime":211.087,"body":"and option E. is prune juice."},{"startTime":211.087,"endTime":212.13,"body":"[Dr. Handy] The answer is C."},{"startTime":212.13,"endTime":214.65,"body":"You should not use a fiber"},{"startTime":212.13,"endTime":214.65,"body":"supplement such as psyllium"},{"startTime":214.65,"endTime":217.893,"body":"to treat constipation in"},{"startTime":214.65,"endTime":217.893,"body":"patients receiving opiates."},{"startTime":217.893,"endTime":220.988,"body":"They do not relieve constipation"},{"startTime":217.893,"endTime":220.988,"body":"and may make it worse."},{"startTime":220.988,"endTime":223.25,"body":"Fiber agents are used"},{"startTime":220.988,"endTime":223.25,"body":"to increase stool bulk,"},{"startTime":223.25,"endTime":225.053,"body":"which is meant to promote peristalsis"},{"startTime":225.053,"endTime":226.508,"body":"by distending the colon."},{"startTime":226.508,"endTime":228.629,"body":"However, narcotics inhibit peristalsis,"},{"startTime":228.629,"endTime":231.452,"body":"and fiber agents can"},{"startTime":228.629,"endTime":231.452,"body":"worsen distension and pain."},{"startTime":231.452,"endTime":234.22,"body":"Furthermore, fiber agents"},{"startTime":231.452,"endTime":234.22,"body":"can also exacerbate symptoms"},{"startTime":234.22,"endTime":235.587,"body":"in the presence of dehydration,"},{"startTime":235.587,"endTime":237.498,"body":"which can be present in these patients."},{"startTime":237.498,"endTime":240.332,"body":"[Dr. Wiener] Okay, so what should"},{"startTime":237.498,"endTime":240.332,"body":"be the clinician's approach?"},{"startTime":240.332,"endTime":242.16,"body":"[Dr. Handy] Whenever opioids"},{"startTime":240.332,"endTime":242.16,"body":"and other medications"},{"startTime":242.16,"endTime":243.99,"body":"known to cause constipation are used,"},{"startTime":243.99,"endTime":245.748,"body":"preemptive treatment for constipation"},{"startTime":245.748,"endTime":248.013,"body":"should be instituted at the same time."},{"startTime":248.013,"endTime":249.225,"body":"Although physical activity"},{"startTime":249.225,"endTime":251.083,"body":"and adequate hydration can be helpful,"},{"startTime":251.083,"endTime":252.822,"body":"each is limited in its effectiveness"},{"startTime":252.822,"endTime":254.957,"body":"for the most seriously ill patients."},{"startTime":254.957,"endTime":258.062,"body":"So stimulant and osmotic"},{"startTime":254.957,"endTime":258.062,"body":"laxative stool softeners,"},{"startTime":258.062,"endTime":261.402,"body":"fluids and enemas are"},{"startTime":258.062,"endTime":261.402,"body":"the mainstays of therapy."},{"startTime":261.402,"endTime":263.64,"body":"[Dr. Wiener] The question"},{"startTime":261.402,"endTime":263.64,"body":"lists some specific examples."},{"startTime":263.64,"endTime":264.552,"body":"Can you run through them?"},{"startTime":264.552,"endTime":267.35,"body":"[Dr. Handy] Sure. So prune juice"},{"startTime":264.552,"endTime":267.35,"body":"and bisacodyl are stimulants"},{"startTime":267.35,"endTime":270.352,"body":"to promote peristalsis and"},{"startTime":267.35,"endTime":270.352,"body":"inhibit water reabsorption"},{"startTime":270.352,"endTime":271.43,"body":"from the colon."},{"startTime":271.43,"endTime":273.872,"body":"Magnesium citrate or polyethylene glycol"},{"startTime":273.872,"endTime":276.028,"body":"are non-absorbed osmotic agents,"},{"startTime":276.028,"endTime":278.585,"body":"they promote retention"},{"startTime":276.028,"endTime":278.585,"body":"of water in the colon."},{"startTime":278.585,"endTime":281.531,"body":"Docusate is a stool softener,"},{"startTime":278.585,"endTime":281.531,"body":"it works as a detergent"},{"startTime":281.531,"endTime":283.865,"body":"to increase water content of the stool."},{"startTime":283.865,"endTime":285.125,"body":"Now all of these may be helpful"},{"startTime":285.125,"endTime":286.932,"body":"in patients receiving narcotics."},{"startTime":286.932,"endTime":288.832,"body":"[Dr. Wiener] Okay, so the"},{"startTime":286.932,"endTime":288.832,"body":"teaching point in this case"},{"startTime":288.832,"endTime":290.733,"body":"is that patients receiving narcotics"},{"startTime":290.733,"endTime":293.397,"body":"are very likely to develop"},{"startTime":290.733,"endTime":293.397,"body":"substantial constipation"},{"startTime":293.397,"endTime":295.602,"body":"that can be notably symptomatic."},{"startTime":295.602,"endTime":297.177,"body":"It's worth treating patients"},{"startTime":297.177,"endTime":299.26,"body":"receiving regular doses of narcotics,"},{"startTime":299.26,"endTime":302.912,"body":"however fiber supplementing"},{"startTime":299.26,"endTime":302.912,"body":"agents should not be used."},{"startTime":302.912,"endTime":305.825,"body":"Also, in a patient with new symptoms,"},{"startTime":305.825,"endTime":308.753,"body":"make sure to rule out other"},{"startTime":305.825,"endTime":308.753,"body":"causes of abdominal pathology"},{"startTime":308.753,"endTime":311.63,"body":"before simply ascribing"},{"startTime":308.753,"endTime":311.63,"body":"everything to constipation."},{"startTime":311.63,"endTime":312.967,"body":"[Dr. Handy] And you can"},{"startTime":311.63,"endTime":312.967,"body":"read more about this"},{"startTime":312.967,"endTime":316.256,"body":"in Harrison's chapter on"},{"startTime":312.967,"endTime":316.256,"body":"diarrhea and constipation."},{"startTime":316.256,"endTime":320.506,"body":"[upbeat outro music]"},{"startTime":320.506,"endTime":323.26,"body":"[Mr. Shanahan] This is Jim"},{"startTime":320.506,"endTime":323.26,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":323.26,"endTime":325.047,"body":"Harrison's PodClass is brought to you"},{"startTime":325.047,"endTime":327.06,"body":"by McGraw Hill's AccessMedicine,"},{"startTime":327.06,"endTime":329.087,"body":"the online medical resource that delivers"},{"startTime":329.087,"endTime":332.222,"body":"the latest trusted content from"},{"startTime":329.087,"endTime":332.222,"body":"the best minds in medicine."},{"startTime":332.222,"endTime":334.943,"body":"Go to accessmedicine.com to learn more."}]}