Constipation

3. Constipation By: Dr. Shahram Ala (Pharm.D, BCPS)

4. Constipation is a symptom, not a disease Some causes: IBS, Diabetes Mellitus, Hypothyroidism

5. Patients definition & concept about constipation can be different • Patients definition: Straining 52%, hard stools 44%, infrequent stool 32% • Misconception: 62% believe that daily defecation is necessary to good digestive health

6. What is the right number of daily or weekly bowel movements?!

7. Clinical definition Any of two of following symptoms for at least 3 month (not necessarily consecutive) in a year • Straining • Hard or lumpy stool • Sensation of incomplete evacuation • Fewer than 3 defecation per week

8. Causes of constipation • ↓ fiber :(most common) • ↓ liquid ( 8 glasses/d is needed for constipated) • ↓ Exercise : bedridden, coma • Ignoring urge to defecate • Systemic: Hypothyroidism, DM, Uremia, pregnancy, hypercalcemia, Hypokalemia • Neurological: Stroke, Parkinsonism, Multiple sclerosis

9. Causes of constipation (Cont.) • GI-related: IBS, Hemorrhoid, Anal fissure, Anorectal & Colorectal carcinoma ,obstruction • Medication: Opiate, Anticholinergics, Al(OH)3 Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestron • Uncertain: idiopathic chronic constipation

10. Rate of empting: carbohydrate>protein>Lipid Fear, Pain Inhibit and exitation stimulate Clinical manifestation: Pale- Icteric-Anorexia-Headache-Abdominal pain,

11. Diagnosis • Good history is enough for most cases (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs) • Basic laboratory tests: CBC, Electrolytes, BS, BUN, Cr, TSH • Structural: Barium enema, Sigmoidoscopy, Colonoscopy

12. Treatment • Treatment of underlying disease (Malignancies, Hypothyroidism,…) • Alteration of lifestyle (Diet, Exercise, Liquids) • Laxatives

13. Acute constipation • Glycerin suppository • Sorbitol powder • Bisacodyl • Anthraquinones ( C-lax) • Saline laxative (MOM) • Tap-water enema • If laxative treatment is required for > 1 week, refer to a physician

14. Chronic constipation Most common in bedridden or geriatrics • Choice: Psyllium (with enough liquids) • Low doses of other laxatives: C-lax, MOM, Sorbitol, Lactulose

15. Constipation in hospitalized patients May be related to general anesthesia or opiates • Glycerin suppository • Milk of magnesium • Tap water enema

16. Constipation in infants & children • If constipation is a persistent problem: Consider neurological, metabolic or anatomical abnormalities • If No: Approach as adults

17. Drug classes • Those causing water evacuation in 1-6 hr Caster oil, Saline cathartics, PEG lavage solutions • Those causing soft or semi fluid stool in 6-8 hr C-lax, Bisacodyl • Those causing softening of stool in 1-3 days Psyllium, Lactulose, Mineral oil, Decussate

18. Bulks Psyllium, musillium Increase Volume of intestine Stimulate natural intestine peristaltic Anti Diarrhea & constipation Lasts 12-24 h (even 3 days) Drink freely water unless obstruction

21. Emullients Docusate Na cap: 500mg Anionic surfactants Decrease stool surface tension, increase Fluidesecration into intestine Lasts 1-3 days SE: GI cramp

23. Lubricants Liquid Parafine Inhibition of fluidereabsorbtion from colon, Softener of stool, stimulate peristaltic Post MI, Post surgery lasts 6-8 h 15-45 ml PO, or rectal SE: Aspiration (neonate, Geriatrics, before sleep), malabsorbtion (lipid soluble Vit.), Anal pruritis, staining

24. Stimulant laxatives • Bisacodyl • Stimulates mucosal nerve plexus of the colon (myentric) • Intermittent use for constipation • Oral: 6-8hr Supp: 15-60min • Interactions: Milk, Antacids (EC) • SE: Cramp, fluid and electrolyte imbalance, • Contraindication: pregnancy, lactation, appendicitis

27. Caster oil Usually for bowel preparation • Active metabolite:Ricinoleic acid • Onset: 1-3 hr

28. Saline • MOM, mgso4 • Indications: Antacid (5-15 ml PRN), Laxatives (30-60 ml HS) • Mg: Osmotic, Release cholecystokinin • Onset: 3-6 hr • Interactions:Quinolones, Tetracycline, Fe, EC drugs (bisacodyl, sulfasalazine) • Breast-feeding:can be used • CRF?

29. Hyperosmotics Glycerin, Lactulose, mannitol, Sorbitol Lactulose: Acetic acid, Formic acid, Lactic acid Encephalopathy ( lasts :24-48 h) SE: flatulence, abdominal cramp, diarrhea, electrolyte imbalance

30. Glycerin Is very safe and acceptable for intermittent basis particularly in infants • Supp: 1g, 3g • Onset: less than 30 min

32. Mannitol

33. Tap-water enema • 200 ml results in a bowel movement within 0.5hr • Soapsuds are no longer recommended (proctitis, colitis)

34. Drugs for chronic idiopathic constipation • Cisapride (also for Parkinson's disease) • Erythromycin

37. Summary • Underlying causes of constipation should be considered • Foundation of treatment is diet and psyllium • Acute constipation may be treated with tap-water enema or glycerin suppository, if needed, oral sorbitol, low dose bisacodyl or C-Lax • Approach for chronic constipation is use of psyllium and if needed, intermittent low-doses of other drugs