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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