Constipation

Cengiz Pata Gastroenterology Department Yeditepe University

Constipation
   

Epidemiology of Constipation Objectives of self-treatment selfNondrug Measures OTC medications for the relief of constipation

Constipation
Signs and Symptoms include:  A decrease in the frequency of fecal elimination  Difficult passage of dry hard stools  Straining to have stool

Constipation
Common medications that can induce constipation are:  Narcotic analgesics  Calcium-or aluminum containing antacids Calcium Drugs with anticholinergic activity  Tricyclic antidepressants  Certain calcium channel blockers: ex. Verapamil

Constipation
Can be induced by one of the following diseases:  Hypothoroidism  Megacolon  Stricture  Diabetes Mellitus  Irritable Bowel Syndrome

A. .K.

A r

i kinlik Kab zl k

Irritable bowel syndrome (IBS)



IBS is a functional bowel disorder in which abdominal pain or discomfort is associated with defecation or a change in bowel habit, and with features of disordered defecation
10-20% adults in world, female predominant 10 Come and go over time, overlap with other FGID  Poor QoL, high heath care costs


Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

Enteric nervous system (ENS)

Brain imaging in rectal stimulation (fMR)

Normal visceral sensation:
1. Gender difference, ACC & PFC in females 2. Common FGID in females?

Grundy D, et al. Gastroenterology 2006;130:1391-1411.

VS

IBS in females

Sex hormones or gender impacts on brain-gut axis brain

Animals
  

Low threshold for visceromotor response in rat proestrus vs estrus phase potency of opiates to visceromotor response in male rats Modulation of response in afferent neurons of male GP CYP3A4: women clearing drugs quickly Slow GE in women Women experience greater pain to most stimuli Different areas of brain activation: males vs females Different polymorphism of 5-HT transporter promoter: 5males vs females

 

Drugs: estrogen/progesteron on P-450 system P

Humans
   

Ouyang A, et al. Am J Gastroenterol 2006;101:S602-9.

Diagnostic criteria for IBS, C1



Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following:
  

Improvement with defecation Onset associated with a change in frequency of stool Onset associated with a change in form (appearance) of stool

Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis


Discomfort: uncomfortable sensation not described as pain

Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

Diagnostic criteria for IBS

 

Organik sebepleri d la Roma II criteria  Son 12 ayda en az 12 hafta olan abdominal a r ve huzursuzluk ve d k lama al kanl nda de i iklik olacak  Ve a a dakilerden en az ikisi e lik edecek  defakasyonla rahatlama  d k n n k vam nda de i iklik  d k n n eklinde de i iklik

A a daki semptomlar n bulunmas art de ildir, fakat bunlardan ne kadar o u mevcutsa, tan o kadar kesinle ir: ir:  Anormal d k lama s kl (>3/gn veya <3/hafta) (>3/gn <3/hafta)
   

Anormal d k ekli Anormal d k pasaj Mukus pasaj i kinlik veya abdominal distansiyon hissi

SubSub-typing IBS by predominant stool pattern



Subtype (absent use of antidiarrheals or laxatives) laxatives)



IBSIBS-C (IBS with constipation): hard or lumpy stools >25% and loose (mushy) or watery stools <25% of BMs IBSIBS-D (IBS with diarrhea): loose (mushy) or watery stools >25% and hard or lumpy stool <25% of BMs IBSIBS-M (mixed IBS): hard or lump stools >25% and loose (mushy) or watery stools > 25% of BMs IBSIBS-U (unsubtyped IBS): insufficient abnormality of stool consistency to meet criteria for IBS-C, D, or M IBS-

Stool form: Bristol scale

Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

Alarm symptoms in IBS diagnosis

        

Age of onset over 50 yrs Progressive or very severe non-fluctuating symptoms nonNocturnal symptoms waking from sleep Persisted diarrhea, recurrent vomiting Rectal bleeding, anemia Unexplained BW loss Family history of colon cancer Fever Abnormal physical examinations

Talley NJ, et al. Lancet 2002;360:555-564.

Patient Assessment atient

 

Obtain lifestyle and medical history before making any recommendations Determine the reason for use of a laxative product
1. To relieve constipation 2. To evacuate the bowel prior to an upcoming radiologic or endoscopic examination

Inquire about the patients current and past use of laxative products

Refer When
 

Symptoms have persisted for more than 2 weeks Have recurred after previous dietary or lifestyle changes or laxative use Patients who admit to blood in the stool

Objectives for Self Treatment

To relieve constipation and restore normal bowel functioning using:  Dietary and Lifestyle measures  Using OTC medications for the relief of constipation

Nondrug Measures include



  

High fiber diet: foods high in wheat grains, oats, or fruits & vegetables Adequate fluid intake Exercise Avoid foods that cause constipation: processed cheeses & concentrated sweets

Non Prescription Medications

     

Types of laxatives: laxatives: Bulk Forming Laxatives Emollient Lubricant Saline Hyperosmotic Stimulant

Bulk Forming Laxatives

 

 

Derived from agar, or psyllium seed Synthetic examples used today are methylcellulose & carboxymethyl cellulose sodium Dissolve in the intestinal fluid, thus creating emollient gels that increase passage of the intestinal contents Stimulate peristalsis No systemic absorption

Bulk Forming Laxatives

 

Onset of action is 12-24hrs 12Resemble the physiologic mechanism in promoting evacuation Are the FIRST choice of therapy for constipation Examples are: Citrucel powder, Metamucil, Mitrolan Chewable Tablets

Bulk Forming Laxatives



 

Use caution in patients that are younger than 6 yrs of age Avoid in pts with intestinal ulcerations, stenosis Interact with anticoagulants, digitalis glycosides, and salisylates Not used for a fast clearing effect before a diagnostic procedure

Emollient Laxatives


  

 

Are anionic surfactants that eventually lead to the softening of the stool Are systemically absorbed (solid) Onset of action (oral) 24-72hrs 24Major use is as a stool softener, & to prevent constipation and maintain regularity Example : Docusate sodium Avoid in pts with who have nausea, vomiting, or undetermined abdominal pain

Lubricant Laxatives


    

Prevent colonic absorption of fecal water, thus soften the stool Are minimally absorbed Onset of action (oral) 6-8 hrs, (rectal) 5-15 min 65Avoid prolonged use Can cause malabsorption of fat-soluble vitamins fatExample: Mineral oil ( only)

Saline Laxatives


    

Nonabsorbable cations & anions that draw water into intestine causing an increase in intraluminal pressure, which stimulates intestinal motility Are systemically absorbed Onset of action (oral)30min-3 hrs,(rectal) 2-5min (oral)30min2Used ONLY when fast clearance of the bowel is required Ex:Citroma, Fleet Ready-to-Use Enema Ready-toAvoid in pts with CHF, ileostomy, renal function impairment, or younger than 6 yrs old

Hyperosmotic Laxatives


    

Combine an osmotic effect with local effect of sodium sterate, which draws water into rectum rectumbowel movement Onset of action (rectal) 30 min Used in suppository form Minimal side effects Example: Glycerin suppositories (only) Avoid in pts with rectal irritation

Stimulant Laxatives
 

   

Come from 2 classes: anthraquinone (ex:senna) & diphenylmethane ( bisacodyl) Increase the propulsive peristaltic activity of the intestine by local irritation of the mucosa which leads to increased motility Onset of action senna (PO) 8-12 hrs 8For Bisacodyl: oral/rectal 15-60min, 15Are systemically absorbed Major use: for thorough evacuation of the bowel prior to GI surgery or examination

Stimulant Laxatives
    

Examples: Sennakot, Sennakot S (with sodium docusate), Exlax, Dulcolax Interact with H1 blockers, antacids if administered within 1 hr Avoid in pregnancy Pts who are breast feeding & taking senna laxative have reported a brown discoloration of breast milk Adverse effects with regular use are severe cramping, electrolyte & fluid deficiencies, metabolic acidosis/alkalosis, and others

Patient Counseling


Laxative use to treat constipation should be only on a temporary measure If laxatives are not effective after 1 week, a physician should be consulted