Management of Constipation in Adults Stephen Aglubat, MD May 2012

Objectives Define Constipation Treatment options for constipation

Case 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? A. Lactulose B. Senna C. Docusate D. Weekly tap water enemas

Definition Rome III criteria: 2 of the below defines constipation Straining Lumpy Hard Stools Incomplete Evacuation Use of Digital Rectal Maneuvers Sensation of Anorectal Blockage < 3 Bowel Movements per week

Pathophysiology I Constipation is caused by: Primary Colorectal dysfunction Slow Transit Dyssnerygic Defacation Irritable Bowel Syndrome Slow Transit caused by myopathy, neuropathy Dyssynergic defecation (DD) is caused by difficulty with or inability expelling stool from the anorectum.

Pathophysiology II Constipation is caused by: Secondary Causes Endocrine/Metabolic Neurologic Myogenic Disorders Medications Obstruction Chronic Idiopathic Constipation (CIC) Secondary causes: Important to rule out secondary causes through history. Alarm symptoms include: Rectal bleeding, Hemoccult positive stools, obstructive symptoms, recent onset of constipation, weight loss, a change in stool caliber CIC is classified as not meeting IBS criteria. IBS criteria includes: Recurrent abdominal discomfort in at least 3 days/month in the last 3 months associated with 2 of the following: 1. Abdominal discomfort improved with defacation. 2. Onset associated with change in frequency of stool. 3. Onset associated with change in Form/appearance of stool.

Stimulant laxatives and PEG (Osmotic Laxatives) will be discussed at later slides.

Management Initial treatment of Chronic Functional Constipation Lifestyle modification Diet and fiber

Lifestyle Modifications Increased fluid intake Exercise Establish regular bowel regimen pattern Increased fluid intake allows the stools to be hydrated and easier to pass. Exercise has shown to stimulate colonic motility. Establish regular pattern: Normal bowel patterns expel stool around the same time every day

Diet and fiber Fiber increases bulk/distension >25 g of fiber/day Distention causes stool propulsion. >25 g of fiber/day Effect may take weeks. Adverse effects: Bloating, flatulence

Laxatives I Stimulant Laxatives Senna Bisacodyl Stimulants affect electrolyte transport across mucosa to enhance colonic transport and motility

Laxatives II Bulk forming laxatives Psyllium (Metamucil) Methylcellulose (Citrucel) Polycarbophil (FiberCon) Dextran (Benefiber) Bulk laxatives are natural, absorb water, increase fecal mass, causing distention, causing propulsion

Laxatives III Osmotic Laxatives Polyethylene glycol Lactulose Sorbitol Magnesium Hydroxide Osmotic Laxatives: Trial of osmotics should be considered in patients not responding to bulking agents Polyethylene Glycol side effects associated with abdominal pain, bloating, cramping, flatulence. Older patients susceptible to these symptoms as well as metabolic disturbances: hypokalemia, hyponatremia.

Other therapies Colonic secretagogues Lubipristone Lubipristone activates Type II chloride channels secreting Cl and water into the gut lumen Best reserved for patients with severe constipation where other approaches were unsuccessful.

Polyethylene glycol, or other osmotic laxatives would be preferred after dietary and stimulant laxatives have been given.

Summary Constipation in the older adult may be due to chronic constipation, secondary etiologic factors A thorough history must be obtained to rule out secondary causes. Therapy includes: Diet/lifestyle Stimulant Laxatives Osmotic Laxatives

Case 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? A. Lactulose B. Senna C. Docusate D. Weekly tap water enemas

Case 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? A. Lactulose B. Senna C. Docusate D. Weekly tap water enemas After diet, fluid and bulk-forming laxatives have been added, Stimulant laxatives are the preferred next treatment for constipation. Lactulose is an osmotic laxatives, and would be given after the stimulant laxative has failed. C. Docusate is stool softener. Although Docusate is a good adjunct medication with Senna, a stimulant laxative like Senna would be preferred over Docusate. Although stool softeners have few side effects, they are less effective than laxatives. D. Tap water enemas would be given after stimulant and osmotic agents have been tried with no improvement. Patient preference would also contribute to this choice.

References 1. Management of chronic constipation in older adults. Wald, Arthur. Uptodate.com. March 2012