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Constipation

Constipation. Cengiz Pata Gastroenterology Department Yeditepe University. Constipation. Epidemiology of Constipation Objectives of self-treatment Nondrug Measures OTC medications for the relief of constipation. Constipation. Signs and Symptoms include:

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Constipation

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  1. Constipation Cengiz Pata Gastroenterology DepartmentYeditepe University

  2. Constipation • Epidemiology of Constipation • Objectives of self-treatment • Nondrug Measures • OTC medications for the relief of constipation

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

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

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

  6. A.Ş.K. Ağrı Şişkinlik Kabızlık

  7. 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 • Come and go over time, overlap with other FGID • Poor QoL, high heath care costs Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

  8. Enteric nervous system (ENS)

  9. 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.

  10. VS IBS in females

  11. Sex hormones or gender impacts on brain-gut axis • 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 • Drugs: estrogen/progesteron on P-450 system • CYP3A4: women clearing drugs quickly • Humans • 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: males vs females Ouyang A, et al. Am J Gastroenterol 2006;101:S602-9.

  12. 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.

  13. Diagnostic criteria for IBS • Organik sebepleri dışla • Roma II criteria • Son 12 ayda en az ≥12 hafta olan abdominal ağrı ve huzursuzluk ve dışkılama alışkanlığında değişiklik olacak • Ve aşağıdakilerden en az ikisi eşlik edecek • defakasyonla rahatlama • dışkının kıvamında değişiklik • dışkının şeklinde değişiklik Aşağıdaki semptomların bulunması şart değildir, fakat bunlardan ne kadar çoğu mevcutsa, tanı o kadar kesinleşir: • Anormal dışkılama sıklığı (>3/günveya <3/hafta) • Anormal dışkı şekli • Anormal dışkı pasajı • Mukus pasajı • Şişkinlik veya abdominal distansiyon hissi

  14. Sub-typing IBS by predominant stool pattern • Subtype (absent use of antidiarrheals or laxatives) • IBS-C (IBS with constipation): hard or lumpy stools >25% and loose (mushy) or watery stools <25% of BMs • IBS-D (IBS with diarrhea): loose (mushy) or watery stools >25% and hard or lumpy stool <25% of BMs • IBS-M (mixed IBS): hard or lump stools >25% and loose (mushy) or watery stools > 25% of BMs • IBS-U (unsubtyped IBS): insufficient abnormality of stool consistency to meet criteria for IBS-C, D, or M • Stool form:Bristol scale Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

  15. Alarm symptoms in IBS diagnosis • Age of onset over 50 yrs • Progressive or very severe non-fluctuating symptoms • Nocturnal 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.

  16. Patient Assessment • 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 patient’s current and past use of laxative products

  17. 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

  18. 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

  19. Nondrug Measuresinclude • 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

  20. Non Prescription Medications Types of laxatives: • Bulk Forming Laxatives • Emollient • Lubricant • Saline • Hyperosmotic • Stimulant

  21. 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

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

  23. 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

  24. Emollient Laxatives • Are anionic surfactants that eventually lead to the softening of the stool • Are systemically absorbed (solid) • Onset of action (oral) 24-72hrs • Major 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

  25. 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 • Avoid prolonged use • Can cause malabsorption of fat-soluble vitamins • Example: Mineral oil ( only)

  26. 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 • Used ONLY when fast clearance of the bowel is required • Ex:Citroma, Fleet Ready-to-Use Enema • Avoid in pts with CHF, ileostomy, renal function impairment, or younger than 6 yrs old

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

  28. 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 • For Bisacodyl: oral/rectal 15-60min, • Are systemically absorbed • Major use: for thorough evacuation of the bowel prior to GI surgery or examination

  29. 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

  30. 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

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