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

ConstipatiConstipationon

By:By:

Dr. Shahram AlaDr. Shahram Ala (Pharm.D, BCPS)(Pharm.D, BCPS)

Constipation is a Constipation is a symptom, not a diseasesymptom, not a disease

Some causes:Some causes:

IBS,IBS,

Diabetes Mellitus, Diabetes Mellitus, HypothyroidismHypothyroidism

Patients definition & Patients definition & concept about constipation concept about constipation

can be differentcan be different

Patients definition:Patients definition:

Straining 52%, hard stools 44%, Straining 52%, hard stools 44%, infrequent infrequent stool 32%stool 32%

Misconception: Misconception:

62% believe that daily defecation 62% believe that daily defecation is necessary to good digestive healthis necessary to good digestive health

What is the right number What is the right number of daily or weekly bowel of daily or weekly bowel

movements?!movements?!

Clinical definitionClinical definition

Any of two of following symptoms for at Any of two of following symptoms for at least 3 month (not necessarily least 3 month (not necessarily consecutive) in a yearconsecutive) in a year

StrainingStraining Hard or lumpy stoolHard or lumpy stool Sensation of incomplete evacuationSensation of incomplete evacuation Fewer than 3 defecation per weekFewer than 3 defecation per week

Causes of constipationCauses of constipation

↓ ↓ fiber :fiber :(most common)(most common) ↓ ↓ liquidliquid ( 8 glasses/d is needed for ( 8 glasses/d is needed for

constipated)constipated) ↓ ↓ Exercise Exercise : bedridden, coma: bedridden, coma Ignoring urge to defecateIgnoring urge to defecate Systemic:Systemic: Hypothyroidism, DM, Uremia, Hypothyroidism, DM, Uremia,

pregnancy, hypercalcemia, Hypokalemiapregnancy, hypercalcemia, Hypokalemia Neurological:Neurological: Stroke, Parkinsonism, Stroke, Parkinsonism,

Multiple sclerosisMultiple sclerosis

Causes of constipation Causes of constipation (Cont.)(Cont.)

GI-related:GI-related: IBS, Hemorrhoid, Anal fissure, Anorectal & IBS, Hemorrhoid, Anal fissure, Anorectal & Colorectal carcinoma ,obstructionColorectal carcinoma ,obstruction

Medication:Medication: Opiate, Anticholinergics, Al(OH)3 Opiate, Anticholinergics, Al(OH)3 Iron, cholestyramine, Antihypertensive drugs (CCBs, Iron, cholestyramine, Antihypertensive drugs (CCBs,

diuretics), relaxants, chronic use of laxatives, Antiepileptics, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestron progestron

Uncertain:Uncertain: idiopathic chronic constipation idiopathic chronic constipation

Rate of empting: Rate of empting: carbohydrate>protein>Lipidcarbohydrate>protein>Lipid

Fear, Pain Inhibit and exitation Fear, Pain Inhibit and exitation stimulatestimulate

Clinical manifestationClinical manifestation::

Pale- Icteric-Anorexia-Headache-Pale- Icteric-Anorexia-Headache-Abdominal pain,Abdominal pain,

DiagnosisDiagnosis Good history is enough for most casesGood history is enough for most cases

(Duration, frequency, Consistency, blood in (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs)habits, Laxative use (what), other drugs)

Basic laboratory testsBasic laboratory tests::

CBC, Electrolytes, BS, BUN, Cr, TSHCBC, Electrolytes, BS, BUN, Cr, TSH

Structural: Structural:

Barium enema, Sigmoidoscopy, ColonoscopyBarium enema, Sigmoidoscopy, Colonoscopy

TreatmentTreatment Treatment of underlying disease Treatment of underlying disease

(Malignancies, Hypothyroidism,…)(Malignancies, Hypothyroidism,…)

Alteration of lifestyle (Alteration of lifestyle (Diet, Exercise, Diet, Exercise, Liquids)Liquids)

LaxativesLaxatives

Acute constipationAcute constipation

Glycerin suppositoryGlycerin suppository Sorbitol powderSorbitol powder BisacodylBisacodyl Anthraquinones ( C-lax)Anthraquinones ( C-lax) Saline laxative (MOM)Saline laxative (MOM) Tap-water enemaTap-water enema If laxative treatment is required for If laxative treatment is required for

> 1 week, refer to a physician> 1 week, refer to a physician

Chronic constipationChronic constipation

Most common in bedridden or Most common in bedridden or geriatricsgeriatrics

Choice:Choice: Psyllium (with enough Psyllium (with enough liquids)liquids)

Low doses of other laxatives:Low doses of other laxatives:

C-lax, MOM, Sorbitol, LactuloseC-lax, MOM, Sorbitol, Lactulose

Constipation in hospitalized Constipation in hospitalized patientspatients

May be related to general anesthesia May be related to general anesthesia or opiatesor opiates

Glycerin suppositoryGlycerin suppository Milk of magnesiumMilk of magnesium Tap water enemaTap water enema

Constipation in infants & Constipation in infants & childrenchildren

If constipation is a persistent If constipation is a persistent problem:problem:

Consider neurological, metabolic or Consider neurological, metabolic or anatomical abnormalitiesanatomical abnormalities

If No:If No:

Approach as adultsApproach as adults

Drug classesDrug classes

Those causing water evacuation in 1-6 hrThose causing water evacuation in 1-6 hr

Caster oil, Saline cathartics, PEG lavage Caster oil, Saline cathartics, PEG lavage solutionssolutions

Those causing soft or semi fluid stool in 6-8 hrThose causing soft or semi fluid stool in 6-8 hr

C-lax, BisacodylC-lax, Bisacodyl

Those causing softening of stool in 1-3 Those causing softening of stool in 1-3 daysdays

Psyllium, Lactulose, Mineral oil, DecussatePsyllium, Lactulose, Mineral oil, Decussate

BulksBulks

Psyllium, musilliumPsyllium, musillium Increase Volume of intestineIncrease Volume of intestine Stimulate natural intestine Stimulate natural intestine

peristalticperistaltic Anti Diarrhea & constipationAnti Diarrhea & constipation Lasts 12-24 h (even 3 days)Lasts 12-24 h (even 3 days) Drink freely water unless Drink freely water unless

obstructionobstruction

EmullientsEmullients

Docusate Na cap: 500mgDocusate Na cap: 500mg Anionic surfactantsAnionic surfactants Decrease stool surface tension, Decrease stool surface tension,

increase Fluide secration into increase Fluide secration into intestineintestine

Lasts 1-3 daysLasts 1-3 days SESE: GI cramp: GI cramp

LubricantsLubricants Liquid ParafineLiquid Parafine Inhibition of fluide reabsorbtion from colon, Inhibition of fluide reabsorbtion from colon,

Softener of stool, stimulate peristalticSoftener of stool, stimulate peristaltic Post MI, Post surgeryPost MI, Post surgery lasts 6-8 hlasts 6-8 h 15-45 ml PO, or rectal15-45 ml PO, or rectal

SESE: : Aspiration (neonate, Geriatrics, before sleep), Aspiration (neonate, Geriatrics, before sleep), malabsorbtion (lipid soluble Vit.), Anal pruritis, malabsorbtion (lipid soluble Vit.), Anal pruritis, stainingstaining

Stimulant laxativesStimulant laxatives BisacodylBisacodyl Stimulates mucosal nerve plexus of Stimulates mucosal nerve plexus of

the colon (myentric)the colon (myentric) Intermittent use for constipation Intermittent use for constipation Oral: 6-8hr Supp: 15-60minOral: 6-8hr Supp: 15-60min InteractionsInteractions: Milk, Antacids (EC) : Milk, Antacids (EC)

SESE: Cramp, fluid and electrolyte imbalance: Cramp, fluid and electrolyte imbalance,, Contraindication: pregnancy, Contraindication: pregnancy,

lactation, appendicitislactation, appendicitis

Caster oilCaster oil

Usually for bowel preparationUsually for bowel preparation Active metabolite:Active metabolite: Ricinoleic acid Ricinoleic acid Onset:Onset: 1-3 hr 1-3 hr

Saline Saline

MOM, mgso4MOM, mgso4 Indications: Indications: Antacid (5-15 ml PRN), Antacid (5-15 ml PRN),

Laxatives (30-60 ml HS)Laxatives (30-60 ml HS) Mg:Mg: Osmotic, Release cholecystokinin Osmotic, Release cholecystokinin Onset:Onset: 3-6 hr 3-6 hr Interactions:Interactions: Quinolones, Tetracycline, Quinolones, Tetracycline,

Fe, Fe,

EC drugs (bisacodyl, sulfasalazine)EC drugs (bisacodyl, sulfasalazine) Breast-feeding:Breast-feeding: can be usedcan be used CRF?CRF?

HyperosmoticsHyperosmotics

Glycerin, Lactulose, mannitol, Glycerin, Lactulose, mannitol, SorbitolSorbitol

LactuloseLactulose: Acetic acid, Formic acid, : Acetic acid, Formic acid, Lactic acidLactic acid

Encephalopathy ( lasts :24-48 h)Encephalopathy ( lasts :24-48 h)

SESE: flatulence, abdominal cramp, : flatulence, abdominal cramp, diarrhea, electrolyte imbalancediarrhea, electrolyte imbalance

GlycerinGlycerin

Is very safe and acceptable for Is very safe and acceptable for intermittent basis particularly in intermittent basis particularly in infantsinfants

Supp:Supp: 1g, 3g 1g, 3g Onset:Onset: less than 30 min less than 30 min

MannitolMannitol

Tap-water enemaTap-water enema

200 ml results in a bowel 200 ml results in a bowel movement within 0.5hrmovement within 0.5hr

Soapsuds are no longer Soapsuds are no longer recommended (proctitis, colitis)recommended (proctitis, colitis)

Drugs for chronic idiopathic Drugs for chronic idiopathic constipationconstipation

CisaprideCisapride (also for Parkinson's (also for Parkinson's disease)disease)

ErythromycinErythromycin

SummarySummary

Underlying causes of constipation should Underlying causes of constipation should be consideredbe considered

Foundation of treatment is diet and Foundation of treatment is diet and psylliumpsyllium

Acute constipation may be treated with Acute constipation may be treated with tap-water enema or glycerin suppository, tap-water enema or glycerin suppository, if needed, oral sorbitol, low dose if needed, oral sorbitol, low dose bisacodyl or C-Laxbisacodyl or C-Lax

Approach for chronic constipation is use Approach for chronic constipation is use of psyllium and if needed, intermittent of psyllium and if needed, intermittent low-doses of other drugslow-doses of other drugs