1. constipation Definition *is adecrease in the frequency of fecal elimenation *hard / dry and somtime painfull stools *normal stool range from three time daily to three time per week

2. Epidemiology *age : higher in people more than 65 years *gender : higher in women

3. causes *insufficient dietary fiber *inadequate fluid intake *lack of exercise *medication: narcotic analgesic / anti cholinergic( anti depresent, anti spasmodic, anti histamine) *pregnancy : the increase size of uterus,hormonal change, *organic proplem such tumer or irritable bowel syndrome

4. Practitioners shuold question patient about *normal stool frequency *duration of constipation *frequency of constipation episodes *exercise routine *amount of dietary fiber and fluid intake *current medication *medication used to relieve constipation

5. Treatment nonpharmacological *increase intake of fluid and fiber *increase exercise to increase bowel tone

6. Pharmacological 1: bulk forming laxative : natural or synthetic polysaccharide derivatives that adsorb water to soften the stool and increase bulk which stimulate peristalsis *work on both small and large intestine *onset of action 12-24 and up to 72 hours *best used to prevent constipation rather than treat

7. Natural bulk forming laxative 1: psyllium Adult 3.5g one to three time daily Children: half the adult dose 2: malt soup extract Adult 8-16g two to four time daily Children : 16g one to two time daily

8. Synthetic bulk forming laxative 1: methyl cellulose Adult : 1-2g one to three time daily Children :.5g one to three time daily 2: polycarbophil Adult : 1g one to four time daily Children :.5g one to three time daily Calcium polycarbophil may impair absorption of tetracyclines

9. Administration guidelines *must be given with water *some may contain sugar

10. Adverse effect *abdominal cramping and flatulence

11. 2 : saline and osmotic laxatives *Creat an osmotic gradient to pull water into the small and large intestine, this increase volume and increase peristalsis and bowel motility *increase the activity of cholecystokinin- pancreozyme that increase the secretion of fluid into GI *rectal formulation (enemas,supp) 5-30 onset *oral : 3-6 hour

12. Salaine laxative *sodium and magnesium salt *may cause hyper magnesemia *magnesium citrate *magnesium hydroxide *magnesium sulfate *sodium phosphate

13. Osmotic laxative A: glycerin : rectal product ( supp.enemas) safe *rectal burning, local irritant effect may occur B : lactulose : only by prescreotion *may cause flatulence and cramping and must take with fruite juice

14. C : polyetheleneglycol by prescreption *more effective than lactulose and less abd cramp D : sorbitol : nonabsorbable sugar similar in efficacy to lactulose and can be taken orally or rectally *flatulence, cramping, abd pain are adverse effect

15. Stimulent laxative Work on small and large intestine to stimulate bowel motility and increase fluid secretion into the bowel *oral preparation 6-12hr onset of action *rectal preparation 15-60min *should not be used more than one week *abd cramp, fluid def, hypokalemia

16. A: anthraquinone laxative *include senna *discoloration of the urine( red, brown) *cascara and casanthranol : carcinogenic *include sennoside :potent and causes cramps

17. B: bisacodyl *enteric coated tablet not chewed *not taken with antacids and milk

18. C: castor oil 2-6 hr onset of action *work primarily on small intestine *cathartic effect may lead to dehydration *not used in pregnant

19. Emollient laxatives Act as surfactant by allowing absorption of water into stool *slow onset of action *diarrhea and cramps 1: docusate sodium 2: docusate calcium 3: docusate potassium

20. Lubricant laxatives mineral oil Work at the colon to increase water retintion to soften the stool *should be taken in empty stomach because of possible aspiration of mineral oil into the lung not taken at bed time May cause anal seepage result in itching

21. Trade name laxinglycerin imlaxlactulose Lax-raysenna Laxative compIpecac + belladona laxadinbisacodyl dilaxbisacodyl Glycerine suppglycerin Konsyl orangepsyllium