Constipation By Dr Shahram Ala Pharm D BCPS
Constipation By: Dr. Shahram Ala (Pharm. D, BCPS)
Constipation is a symptom, not a disease Some causes: IBS, Diabetes Mellitus, Hypothyroidism
Patients definition & concept about constipation can be different n Patients definition: Straining 52%, hard stools 44%, infrequent stool 32% n Misconception: 62% believe that daily defecation is necessary to good digestive health
What is the right number of daily or weekly bowel movements? !
Clinical definition Any of two of following symptoms for at least 3 month (not necessarily consecutive) in a year Straining n Hard or lumpy stool n Sensation of incomplete evacuation n Fewer than 3 defecation per week n
Causes of constipation ↓ fiber : (most common) n ↓ liquid ( 8 glasses/d is needed for constipated) n ↓ Exercise : bedridden, coma n Ignoring urge to defecate n Systemic: Hypothyroidism, DM, Uremia, pregnancy, hypercalcemia, Hypokalemia n Neurological: Stroke, Parkinsonism, Multiple sclerosis n
Causes of constipation (Cont. ) n GI-related: IBS, Hemorrhoid, Anal fissure, Anorectal & Colorectal carcinoma , obstruction n Medication: Opiate, Anticholinergics, Al(OH)3 Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestron
n Rate of empting: carbohydrate>protein>Lipid n Fear, Pain Inhibit and exitation stimulate n Clinical manifestation: Pale- Icteric-Anorexia-Headache-Abdominal pain,
Diagnosis n 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) n Basic laboratory tests: CBC, Electrolytes, BS, BUN, Cr, TSH n Structural:
Treatment n Treatment of underlying disease (Malignancies, Hypothyroidism, …) n Alteration n Laxatives of lifestyle (Diet, Exercise, Liquids)
Acute constipation Glycerin suppository n Sorbitol powder n Bisacodyl n Anthraquinones ( C-lax) n Saline laxative (MOM) n Tap-water enema n If laxative treatment is required for > 1 week, refer to a physician n
Chronic constipation Most common in bedridden or geriatrics n Choice: Psyllium (with enough liquids) n Low doses of other laxatives: C-lax, MOM, Sorbitol, Lactulose
Constipation in hospitalized patients May be related to general anesthesia or opiates Glycerin suppository n Milk of magnesium n Tap water enema n
Constipation in infants & children If constipation is a persistent problem: Consider neurological, metabolic or anatomical abnormalities n If No: Approach as adults n
Drug classes n Those causing water evacuation in 1 -6 hr Caster oil, Saline cathartics, PEG lavage solutions n Those causing soft or semi fluid stool in 6 -8 hr C-lax, Bisacodyl n Those causing softening of stool in 1 -3 days
Bulks Psyllium, musillium n Increase Volume of intestine n Stimulate natural intestine peristaltic n Anti Diarrhea & constipation n Lasts 12 -24 h (even 3 days) n Drink freely water unless obstruction n
Emullients Docusate Na cap: 500 mg n Anionic surfactants n Decrease stool surface tension, increase Fluide secration into intestine n Lasts 1 -3 days n SE: GI cramp n
Lubricants Liquid Parafine n Inhibition of fluide reabsorbtion from colon, Softener of stool, stimulate peristaltic n Post MI, Post surgery n lasts 6 -8 h n 15 -45 ml PO, or rectal n n SE: Aspiration (neonate, Geriatrics, before sleep), malabsorbtion (lipid soluble Vit. ), Anal pruritis, staining
Stimulant laxatives Bisacodyl n Stimulates mucosal nerve plexus of the colon (myentric) n Intermittent use for constipation n Oral: 6 -8 hr Supp: 15 -60 min n Interactions: Milk, Antacids (EC) n SE: Cramp, fluid and electrolyte imbalance, n Contraindication: pregnancy, lactation, appendicitis n
Caster oil Usually for bowel preparation n Active metabolite: Ricinoleic acid n Onset: 1 -3 hr
Saline MOM, mgso 4 n Indications: Antacid (5 -15 ml PRN), Laxatives (30 -60 ml HS) n Mg: Osmotic, Release cholecystokinin n Onset: 3 -6 hr n Interactions: Quinolones, Tetracycline, Fe, EC drugs (bisacodyl, sulfasalazine) n Breast-feeding: can be used n
Hyperosmotics Glycerin, Lactulose, mannitol, Sorbitol n Lactulose: Acetic acid, Formic acid, Lactic acid n Encephalopathy ( lasts : 24 -48 h) n n SE: flatulence, abdominal cramp, diarrhea, electrolyte imbalance
Glycerin Is very safe and acceptable for intermittent basis particularly in infants Supp: 1 g, 3 g n Onset: less than 30 min n
Mannitol
Tap-water enema n 200 ml results in a bowel movement within 0. 5 hr n Soapsuds are no longer recommended (proctitis, colitis)
Drugs for chronic idiopathic constipation n Cisapride (also for Parkinson's disease) n Erythromycin
Summary Underlying causes of constipation should be considered n Foundation of treatment is diet and psyllium n Acute constipation may be treated with tap -water enema or glycerin suppository, if needed, oral sorbitol, low dose bisacodyl or C-Lax n Approach for chronic constipation is use of n
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