3. Constipation By: Dr. Shahram Ala (Pharm.D, BCPS) (Pharm.D, BCPS)

4. Constipation is a symptom, not a disease Some causes: IBS, IBS, Diabetes Mellitus, Hypothyroidism Diabetes Mellitus, Hypothyroidism

5. Patients definition & concept about constipation can be different Patients definition: Patients definition: Straining 52%, hard stools 44%, infrequent stool 32% Straining 52%, hard stools 44%, infrequent stool 32% Misconception: Misconception: 62% believe that daily defecation is necessary to good digestive health 62% believe that daily defecation is necessary to good digestive health

6. What is the right number of daily or weekly bowel movements?!

7. Clinical definition Any of two of following symptoms for at least 3 month (not necessarily consecutive) in a year Straining Straining Hard or lumpy stool Hard or lumpy stool Sensation of incomplete evacuation Sensation of incomplete evacuation Fewer than 3 defecation per week Fewer than 3 defecation per week

8. Causes of constipation ↓ fiber :(most common) ↓ fiber :(most common) ↓ liquid ( 8 glasses/d is needed for constipated) ↓ liquid ( 8 glasses/d is needed for constipated) ↓ Exercise : bedridden, coma ↓ Exercise : bedridden, coma Ignoring urge to defecate Ignoring urge to defecate Systemic: Hypothyroidism, DM, Uremia, pregnancy, hypercalcemia, Hypokalemia Systemic: Hypothyroidism, DM, Uremia, pregnancy, hypercalcemia, Hypokalemia Neurological: Stroke, Parkinsonism, Multiple sclerosis Neurological: Stroke, Parkinsonism, Multiple sclerosis

9. Causes of constipation (Cont.) GI-related: IBS, Hemorrhoid, Anal fissure, Anorectal & Colorectal carcinoma,obstruction GI-related: IBS, Hemorrhoid, Anal fissure, Anorectal & Colorectal carcinoma,obstruction Medication: Opiate, Anticholinergics, Al(OH)3 Medication: Opiate, Anticholinergics, Al(OH)3 Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestron Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestron Uncertain: idiopathic chronic constipation Uncertain: idiopathic chronic constipation

10. Rate of empting: carbohydrate>protein>Lipid Rate of empting: carbohydrate>protein>Lipid Fear, Pain Inhibit and exitation stimulate Fear, Pain Inhibit and exitation stimulate Clinical manifestation : Clinical manifestation : Pale- Icteric-Anorexia-Headache-Abdominal pain, Pale- Icteric-Anorexia-Headache-Abdominal pain,

11. Diagnosis Good history is enough for most cases (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs) Good history is enough for most cases (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs) Basic laboratory tests: Basic laboratory tests: CBC, Electrolytes, BS, BUN, Cr, TSH CBC, Electrolytes, BS, BUN, Cr, TSH Structural: Structural: Barium enema, Sigmoidoscopy, Colonoscopy Barium enema, Sigmoidoscopy, Colonoscopy

12. Treatment Treatment of underlying disease Treatment of underlying disease (Malignancies, Hypothyroidism,…) (Malignancies, Hypothyroidism,…) Alteration of lifestyle ( Diet, Exercise, Liquids) Alteration of lifestyle ( Diet, Exercise, Liquids) Laxatives Laxatives

13. Acute constipation Glycerin suppository Glycerin suppository Sorbitol powder Sorbitol powder Bisacodyl Bisacodyl Anthraquinones ( C-lax) Anthraquinones ( C-lax) Saline laxative (MOM) Saline laxative (MOM) Tap-water enema Tap-water enema If laxative treatment is required for > 1 week, refer to a physician If laxative treatment is required for > 1 week, refer to a physician

14. Chronic constipation Most common in bedridden or geriatrics Most common in bedridden or geriatrics Choice: Psyllium (with enough liquids) Choice: Psyllium (with enough liquids) Low doses of other laxatives: Low doses of other laxatives: C-lax, MOM, Sorbitol, Lactulose C-lax, MOM, Sorbitol, Lactulose

15. Constipation in hospitalized patients May be related to general anesthesia or opiates May be related to general anesthesia or opiates Glycerin suppository Glycerin suppository Milk of magnesium Milk of magnesium Tap water enema Tap water enema

16. Constipation in infants & children If constipation is a persistent problem: If constipation is a persistent problem: Consider neurological, metabolic or anatomical abnormalities If No: If No: Approach as adults

17. Drug classes Those causing water evacuation in 1-6 hr Those causing water evacuation in 1-6 hr Caster oil, Saline cathartics, PEG lavage solutions Caster oil, Saline cathartics, PEG lavage solutions Those causing soft or semi fluid stool in 6-8 hr Those causing soft or semi fluid stool in 6-8 hr C-lax, Bisacodyl C-lax, Bisacodyl Those causing softening of stool in 1-3 days Those causing softening of stool in 1-3 days Psyllium, Lactulose, Mineral oil, Decussate

18. Bulks Psyllium, musillium Psyllium, musillium Increase Volume of intestine Increase Volume of intestine Stimulate natural intestine peristaltic Stimulate natural intestine peristaltic Anti Diarrhea & constipation Anti Diarrhea & constipation Lasts 12-24 h (even 3 days) Lasts 12-24 h (even 3 days) Drink freely water unless obstruction Drink freely water unless obstruction

21. Emullients Docusate Na cap: 500mg Docusate Na cap: 500mg Anionic surfactants Anionic surfactants Decrease stool surface tension, increase Fluide secration into intestine Decrease stool surface tension, increase Fluide secration into intestine Lasts 1-3 days Lasts 1-3 days SE: GI cramp SE: GI cramp

23. Lubricants Liquid Parafine Liquid Parafine Inhibition of fluide reabsorbtion from colon, Inhibition of fluide reabsorbtion from colon, Softener of stool, stimulate peristaltic Softener of stool, stimulate peristaltic Post MI, Post surgery Post MI, Post surgery lasts 6-8 h lasts 6-8 h 15-45 ml PO, or rectal 15-45 ml PO, or rectal SE: Aspiration (neonate, Geriatrics, before sleep), malabsorbtion (lipid soluble Vit.), Anal pruritis, staining SE: Aspiration (neonate, Geriatrics, before sleep), malabsorbtion (lipid soluble Vit.), Anal pruritis, staining

24. Stimulant laxatives Bisacodyl Bisacodyl Stimulates mucosal nerve plexus of the colon (myentric) Stimulates mucosal nerve plexus of the colon (myentric) Intermittent use for constipation Intermittent use for constipation Oral: 6-8hr Supp: 15-60min Oral: 6-8hr Supp: 15-60min Interactions: Milk, Antacids (EC) Interactions: Milk, Antacids (EC) SE : Cramp, fluid and electrolyte imbalance, SE : Cramp, fluid and electrolyte imbalance, Contraindication: pregnancy, lactation, appendicitis Contraindication: pregnancy, lactation, appendicitis

27. Caster oil Usually for bowel preparation Usually for bowel preparation Active metabolite: Ricinoleic acid Active metabolite: Ricinoleic acid Onset: 1-3 hr Onset: 1-3 hr

28. Saline MOM, mgso4 MOM, mgso4 Indications: Antacid (5-15 ml PRN), Laxatives (30-60 ml HS) Indications: Antacid (5-15 ml PRN), Laxatives (30-60 ml HS) Mg: Osmotic, Release cholecystokinin Mg: Osmotic, Release cholecystokinin Onset: 3-6 hr Onset: 3-6 hr Interactions: Quinolones, Tetracycline, Fe, Interactions: Quinolones, Tetracycline, Fe, EC drugs (bisacodyl, sulfasalazine) EC drugs (bisacodyl, sulfasalazine) Breast-feeding: can be used Breast-feeding: can be used CRF? CRF?

29. Hyperosmotics Glycerin, Lactulose, mannitol, Sorbitol Glycerin, Lactulose, mannitol, Sorbitol Lactulose: Acetic acid, Formic acid, Lactic acid Lactulose: Acetic acid, Formic acid, Lactic acid Encephalopathy ( lasts :24-48 h) Encephalopathy ( lasts :24-48 h) SE: flatulence, abdominal cramp, diarrhea, electrolyte imbalance SE: flatulence, abdominal cramp, diarrhea, electrolyte imbalance

30. Glycerin Is very safe and acceptable for intermittent basis particularly in infants Is very safe and acceptable for intermittent basis particularly in infants Supp: 1g, 3g Supp: 1g, 3g Onset: less than 30 min Onset: less than 30 min

32. Mannitol

33. Tap-water enema 200 ml results in a bowel movement within 0.5hr 200 ml results in a bowel movement within 0.5hr Soapsuds are no longer recommended (proctitis, colitis) Soapsuds are no longer recommended (proctitis, colitis)

34. Drugs for chronic idiopathic constipation Cisapride (also for Parkinson's disease) Cisapride (also for Parkinson's disease) Erythromycin Erythromycin

37. Summary Underlying causes of constipation should be considered Underlying causes of constipation should be considered Foundation of treatment is diet and psyllium Foundation of treatment is diet and psyllium Acute constipation may be treated with tap- water enema or glycerin suppository, if needed, oral sorbitol, low dose bisacodyl or C-Lax Acute constipation may be treated with tap- water enema or glycerin suppository, if needed, oral sorbitol, low dose bisacodyl or C-Lax Approach for chronic constipation is use of psyllium and if needed, intermittent low-doses of other drugs Approach for chronic constipation is use of psyllium and if needed, intermittent low-doses of other drugs