1. Constipation in the Older Patient Hassan Saadatnia M.D Professor of medicine & Gastroenterology MUMS, Mashad, Iran

2. Burden of the problem Constipation: 20 %of all people and (30-40 ) %of olrders have constipation women are more affected Majority of patients have no underlying disease

3. Definition Research criteria vs “patient’s impression” Patients describe: –Hard stools, infrequent stools, excessive straining, a sense of incomplete bowel evacuation, and excessive time spent on the toilet or in unsuccessful defecation Rome III describes: –Inability to evacuate stool completely and spontaneously three or more times per week for at least 3 month

4. Risk factors for Constipation Acquired neuromuscular disorders Metabolic disease Pathophysiologic changes with aging Medications Physical inactivity Depression Low dietary fiber

5. Risk Factors: Disease Neurologic: Parkinson’s disease; Multiple sclerosis, CVA, paraplegia Metabolic: diabetes mellitus, Hypokalemia, hypercalcemia, hypothyroidism Structural: tumors, strictures, extrensic pressure, diverticula anal fissure, painfull hemorrhoids

6. Medications Opiates - codeine,morphine Anticholinergics - Artan Antipsychotics - chlorpromazine Antidepressants - tricyclics Antiparkinson - levodopa Antispasmodics - dicyclomine, hyocine Antihistamines - diphenhydramine Ca blockers - verapamil

7. Is colonic transit slow in constipated patients? –Normal-transit (59 %) –Slow-transit ( colonic inertia 13%) –Impaired rectal evacuation (25%) –Mixed (3%)

9. Normal-Transit Constipation Stool transit is normal, frequency is normal, yet patients believe they are constipated Perceived difficulty with evacuation or the presence of hard stools Bloating, abdominal pain or discomfort, increased psychosocial distress Symptoms of constipation usually respond to therapy with dietary fiber alone or with the addition of a laxative.

10. Slow-Transit Constipation (colonic inersia ) Patients with slow transit may benefit from stimulant laxatives if neuromuscular function is intact If neuromuscular function severely impaired: may need surgery

11. Impaired Rectal Evacuation Dyssynergic defecation Important to identify because treatment is different – laxatives may not be effective Dysfunction of the pelvic floor or anal sphincter May be associated with structural problems –Anal fissure –Rectocele

12. Back to the clinic: History Screen for secondary causes, Medication use Prolonged straining, unusual postures, support of perineum, digitations of rectum, posterior vaginal pressure –Suggests anorectal dysfunction

13. Physical Examination “ Rectal Exam” Inspection –Anal pathology: hemorrhoids, prolapse, Fissures –Ask patient to strain: anus moves laterally, ballooning of perineum (rectocele) –mucosal prolapse or anterior rectal wall defect –Ask to strain: perineum descends on finger

14. Laboratory Tests ? Thyroid function tests Potassium Calcium CBC

15. GCC 9/5/06 Does patient needs colonoscopy New onset constipation, age above 50 Years –Weight loss,macroscopic or microscopic blood, FH of colon CA, anemia, undiagnosed abdominal pain Chronic constipation: –Anemia, weight loss, change in stool pattern, undiagnosed abdominal pain F.R.S and Barium enema for young patients ?

16. Additional Examination Anoscopy –fissure, fistula, stricture, carcinoma in rectum If you suspect defecatory disorder –Anorectal manometry & balloon expulsion test –Defecography if above equivocal or suspect structural abnormality

17. Management : Patient education Increase physical activity Take more fluids Take fibers Pay attention to gastrocolic reflex in the morning Take a glass of cold or hot drink in the morning

18. Anorectal dysfunction Biofeedback Therapy -- Success rate is up to ~70 percent with biofeedback -- The benefits appear to be long-lasting --Not available to all Patients --Suppositories and enema are superior to oral laxatives

19. Bulk forming laxatives -- Increases colonic residue stimulating peristalsis -- Psyllium,Wheat Bran : takes about two weeks to act, Coarse bran is superior –Side effects: flatulence, distention, bloating, and unpleasant taste

20. Osmotic agents PEG, MOM, Lactulose, Sorbitol If fiber doesn’t work, or patient is “very constipated” - use an osmotic laxative Increase dose gradually over several days until loose stools are formed

21. Osmotic laxatives In patients with renal insufficiency or cardiac dysfunction, may cause electrolyte and volume overload from absorption of sodium, magnesium

22. Stimulant laxatives C- lax ( sena ), Caster oil, Bisacodyl Increase intestinal motility and secretion Effective within hours and may cause abdominal cramps Long term use may cause cathartic colon (loss of haustration and dilatation of the colon) Oral versus suppository

23. Stimulant Laxatives Useful in multifactorial refractory constipation without obstruction Diphenylmethane derivatives –Bisacodyl :Tabs, suppository Castor oil - Ricinoleic acid may cause cathartic colon

24. New drugs –Lubiprostone –Linactodide –Misoprostol ? –Colchicine?

25. Lubiprostone Selectively activates type 2 chloride channels (ClC-2) in apical membrane of the gastrointestinal tract Increased fluid secretion into lumen No significant systemic absorption

26. Linactodide An agonist of guanylate cyclase –C receptor Stimulates intestinal fluid secretion and transit

27. “Prokinetic Drugs” Cisapride Increased risk of cardiac arrhythmias

28. Does patient needs Surgery Less than 5 % of of all patients are selected for surgery After extensive W/U in tertiary referral centers and for STC Total or subtotal colectomy Anal fissures, Hemorrhoids, Cancer and strictures, Rectocele, Cystocele

29. Surgery For refractory constipation Total colonic resection and ileorectostomy Colonic resection is generally reserved for patients with slow-transit constipation 40 – 70 % improvement, only relieves constipation Very little data in older patients [

30. Complications Fecal impaction : A serious condition

31. GCC 9/5/06