Constipation Karol L. Gordon, DO, CAQG, CMD Edward Warren, MD, CAQG, CMD January 2012

GOAL To understand constipation, its causes and management in patients.

Learning Objectives List the impacts of constipation. (slide 5) Define constipation. (slide 6) State normal stool frequency. (slide 7) State the cause of diarrhea in constipation. (slide 8) List the relationships of diet, activity, and pregnancy to constipation. (slide 9) List the steps in the vicious cycle of laxative abuse. (slide 9) List systemic medical conditions causing constipation. (slide 10) List colon lesions causing constipation. (slide 11)

Learning Objectives List GI medical conditions causing constipation. (slide 12) List anal conditions causing constipation. (slide 13) List medications causing constipation. (slide 14) List red flags indicating something more serious is going on as well. (slide 17) List common risk factors for constipation. (slide 18) State the steps in the proper workup for constipation. (slides 19 – 20) List the various treatments for constipation. (slides 21 – 24) Define and characterize impaction. (slide 25) OMM techniques are in an accompanying Power Point.

Constipation Common in children and older age About 2% of the population suffers from chronic constipation. The number of physician visits for constipation increases after age 65 Associated with anxiety, depression, and poor health perception. PRUNES Are 3 enough?... 5 too many?

Constipation - Definition infrequent bowel movements typically <3 times per wk difficulty during defecation (straining during more than 25% of bowel movements or a subjective sensation of hard stools) the sensation of incomplete bowel evacuation.

Hmmm… wonder what’s the normal # ? ANSWER: “NORMAL” ranges from 3 - 4 BM’s/day to 1 every 3 - 4 days!

Constipation Constipation can also cause diarrhea confusing the diagnosis The liquid stool is able to come around the solid stool presenting as diarrhea. This is easily misdiagnosed!!!! Physical exam is key: Abdomen soft with good to hyper bowel sounds? Not likely constipation Abdomen firm to hard with decreased bowel sounds? Likely constipation

Constipation Various conditions can cause constipation: Poor diet Inactivity Pregnancy Irritable bowel syndrome Various medications can cause constipation: Overuse of laxatives, a vicious circle  more use causes more need Opioids Anticholinergics

Causes of Constipation Various medical conditions: Hypothyroidism Multiple sclerosis Lupus Parkinson's disease Stroke Spinal cord injuries Spinal cord disorder Diabetes Thyroid diseases Uremia Amyloidosis Scleroderma

Causes of Constipation Colon polyp Colon tumor Colon cancer

Causes of Constipation Intestinal obstruction Intestinal adhesions Diverticulosis Intestine tumors Colorectal stricture Hirschsprung's disease Chronic idiopathic constipation (type of Constipation) Vitamin B deficiency - causing colon muscles to have dysfunction.

Causes of Constipation Anorectal conditions Anorectal dysfunction Anismus (pelvic floor spasms) Rectal prolapse Painful defecation - any cause of painful defecation, may cause patients to hold back a bowel movement leading to constipation. Hemorrhoids Anal fissure

Causes of Constipation-Medications Laxative overuse * Opioids Antacids with aluminum Antispasmodics Antidepressants Calcium supplements Diuretics Anticonvulsants (some) - esp. for epilepsy Calcium channel blockers Beta blockers Cholestyramine Certain tranquilizers

SIDE NOTE Aluminum that causes constipation is mixed with magnesium that causes diarrhea in products like Mylanta for an antacid that does not cause such side effects. Cholestyramine that causes constipation is most commonly used for treatment of chronic diarrhea. It is seldom used for hyperlipidemia.

Joke break Q. Well, did you hear about the constipated accountant? A. He couldn't budget. Q. Did you hear about the constipated composer? A. He couldn't finish the last movement.

Red Flags Bleeding, unless hemorrhoids present Fever Weight loss Persistent severe pain Malnutrition. New Onset Constipation = Colon cancer until proven otherwise!

Constipation- Risk Factors Low fluid intake Low level of activity Medications Especially opioids Poor diet

Constipation Work Up Laboratory Studies TSH - to rule out hypothyroidism Basic metabolic profile - to assess electrolyte imbalance Fecal occult blood - to assess an obstructing neoplasm of the colon. CBC - helps to give an indication that the constipation is related to blood loss.

Constipation Work Up In the acute situation with a patient at low risk who usually is not constipated, no further evaluation is necessary. Consider sigmoidoscopy, colonoscopy, or barium enema for colorectal cancer screening in patients older than 50 years. Counsel the patient regarding the appropriate dietary prophylaxis with follow-up visits on an outpatient basis. If the patient experiences further episodes of constipation, a more detailed evaluation may then become appropriate.

Constipation Treatment Diet Increase fiber Increase fluid intake Increase activity Decrease intake of milk, coffee, tea, and alcohol

Constipation Treatment Bulk-forming agents (fibers) Fiber is the best medication for long-term treatment Metamucil- 15-60 g/d PO with at least 8 glasses of water Citrocel- 15-60 g/d fiber PO with at least 8 glasses of water Emollient stool softeners Docusate sodium- 50-360 mg/d PO Osmotic laxatives Magnesium hydroxide- 2.4-4.8 g/day PO qd or divided Magnesium citrate- 11-18 g/day PO qd or divided Magnesium sulfate- 10-30 g/day PO qd or divided Lactulose- 20-30 g (30-45 mL) PO q1-2h; adjust dose slowly to produce 2-3 soft stools daily in liver failure Polyethylene glycol (Miralax)- 17 g/d PO in 8 oz of water

Constipation Treatment Lubricant laxatives Mineral oil - 15-45 mL PO as 1-time dose or qd or as retention enemas Stimulant laxatives Senna- 0.12-0.25 g/d PO Bisacodyl (Bisac-Evac, Bisco-Lax, Dulcolax, Dacodyl)- 5-15 mg PO as single dose 10 mg PR as single dose Lubiprostone (Amitiza)- 24 mcg PO bid with food Opioid reversal Methylnaltrexone – 0.15 mg/kg sq qod prn

Constipation Treatment Stimulant laxatives Senna- 0.12-0.25 g/d PO Bisacodyl (Bisac-Evac, Bisco-Lax, Dulcolax, Dacodyl) 5-15 mg PO as single dose 10 mg PR as single dose

Fecal Impaction Impaction of hard stool in the bowel Requires manual disimpaction (removal) May be high in the colon Serious complication May result in bowel perforation!

References Foundations for Osteopathic Medicine, 2nd edition,pp.400-407,1052-1055, copyright 2003 Arch Surg,2003;138:206-214 Clinics in Family Practice - Volume 6, Issue 3 (September 2004) http://emedicine.medscape.com/article/184704-treatment American Family Physician Volume 67 • Number 10 • May 15, 2000 Copyright © 2003 American Academy of Family Physicians Brocklehurst’s Textbook of Geriatric Medicine and Gerontology 6th edition