1. Constipation Prince Sattam Bin AbdulAziz University College Of Pharmacy Mohammad Ruhal Ain R Ph, PGDPRA, M Pharm (Clin. Pharm) Department of Clinical Pharmacy E-mal: m.alain@sau.edu.sa Pharmaco-therapeutics 2

2. Case 1 Mr Johnson is a middle-aged man who occasionally visits your pharmacy. Today he complains of constipation, which he has had for several weeks. He has been having a bowel movement every few days; normally they are every day or every other day. His motions are hard and painful to pass. He has not tried any medicines as he thought the problem would go of its own accord. He has never had problems with constipation in the past.

3. He has been taking atenolol tablets 50 mg once a day, for over 1 year. He does not have any other symptoms, except a slight feeling of abdominal discomfort. You ask him about his diet; he tells you that since he was made redundant from his job at a local factory 3 months ago, he has tended to eat less than usual; his dietary intake sounds as if it is low in fiber. He tells you that he has been applying for jobs, with no success so far. He says he feels really down and is starting to think that he may never get another job.

4. Define constipation ? Reduction in frequency of bowel movements relative to a patient’s normal frequency. characterized by difficulty with or incomplete evacuation, straining, or presence of hard, dry stools. Abdominal pain and distention may occur, as well as low back pain and anorexia.

6. Bowel habit ? Normal range for the bowel habit? Vary from three movements in 1 day to three in 1 week. Therefore an important health education role for the pharmacist is in reassuring patients that their frequency of bowel movement is normal Patients who are constipated will usually complain of hard stools which are difficult to pass and less frequent than usual. A sudden change, which has lasted for 2 weeks or longer, would be an indication for referral Patients who are constipated will usually complain of hard stools which are difficult to pass and less frequent than usual. A sudden change, which has lasted for 2 weeks or longer, would be an indication for referral

8. Associated symptoms ? obstruction or blockage that’s caused by constipation causing colicky abdominal pain, abdominal distension and vomiting. Most probably urgent referral is necessary as hospital admission is the usual course of action There are other causes of obstruction. Other causes such as bowel tumours or twisted bowels (volvulus) require urgent surgical intervention

9. Associated symptoms ? Blood in the stool Alarming but not necessarily serious (haemorrhoids)(anal fissure) cause less bleeding but much more severe pain on defaecation Blood mixed in with the stool has usually originated higher in the GI tract Fresh bright red blood usually comes from low down in the GI tract (Examples include fissures and haemorrhoids) Medical referral is advisable

11. Diet ? I.Insufficient dietary fiber …………….> is a common cause of constipation. wholemeal cereals, bread, fresh fruit and vegetables. II.Changes in diet and lifestyle, e.g. following a job change, loss of work, retirement or travel, may result in constipation. III.Inadequate fluid intake may result in constipation. The recommended daily amount of fluid is 1500-2000 ml.

13. Medication ? Continuous use, especially of stimulant laxatives, can result in a vicious circle where the contents of the gut are expelled, causing a subsequent cessation of bowel actions for 1 or 2 days. This then leads to the false conclusion that constipation has recurred and more laxatives are taken and so on.

14. Medication ? Chronic overuse of stimulant laxatives can result in loss of muscular activity in the bowel wall (an atonic colon) and thus further constipation.

16. When to refer a patient with constipation ? Referral for further evaluation may be required for some patient populations. a. Symptoms for more than 1–2 weeks despite treatment b. Considerable pain or cramping c. Pregnancy d. Presence of fever e. Blood in the stool e. Reduction in stool caliber f. Weight loss g. Paraplegia, quadriplegia Referral for further evaluation may be required for some patient populations. a. Symptoms for more than 1–2 weeks despite treatment b. Considerable pain or cramping c. Pregnancy d. Presence of fever e. Blood in the stool e. Reduction in stool caliber f. Weight loss g. Paraplegia, quadriplegia

17. Management Removal or treatment of underlying cause(s) if possible Nonpharmacologic interventionsPharmacologic interventions I.Increase fluid intake to 6–8 glasses of water per day if possible. II.Increase dietary fiber to 20–30 g/day. III.Incorporate or increase exercise to 3–5 days/week.

18. Management Removal or treatment of underlying cause(s) if possible Nonpharmacologic interventionsPharmacologic interventions A- Choose drug therapy on the basis of desired onset of action, patient preference, presence of potential contraindications, and use in special populations. B-. Provide patient education on alternative dose forms (enema, suppository).

22. Case 1 Mr Johnson is a middle-aged man who occasionally visits your pharmacy. Today he complains of constipation, which he has had for several weeks. He has been having a bowel movement every few days; normally they are every day or every other day. His motions are hard and painful to pass. He has not tried any medicines as he thought the problem would go of its own accord. He has never had problems with constipation in the past.

23. He has been taking atenolol tablets 50 mg once a day, for over 1 year. He does not have any other symptoms, except a slight feeling of abdominal discomfort. You ask him about his diet; he tells you that since he was made redundant from his job at a local factory 3 months ago, he has tended to eat less than usual; his dietary intake sounds as if it is low in fiber. He tells you that he has been applying for jobs, with no success so far. He says he feels really down and is starting to think that he may never get another job.

24. The pharmacist’s view Mr Johnson’s symptoms are almost certainly due to the change in his lifestyle and eating pattern ( the loss of his Job) To address the dietary problems, he could be advised to start the day with a wholegrain cereal and to eat at least four slices of wholemeal bread each day ( increase fiber ) I.Increase fluid intake to 6–8 glasses (2.5 litres each day) of water per day if possible. II.Increase dietary fiber to 20–30 g/day. III.Incorporate or increase exercise to 3–5 days/week To address the dietary problems, he could be advised to start the day with a wholegrain cereal and to eat at least four slices of wholemeal bread each day ( increase fiber ) I.Increase fluid intake to 6–8 glasses (2.5 litres each day) of water per day if possible. II.Increase dietary fiber to 20–30 g/day. III.Incorporate or increase exercise to 3–5 days/week To provide relief from the discomfort, a suppository of glycerin or bisacodyl could be recommended to produce a bowel evacuation quickly

25. The pharmacist’s view Mr Johnson’s symptoms are almost certainly due to the change in his lifestyle and eating pattern To address the dietary problems, he could be advised to start the day with a wholegrain cereal and to eat at least four slices of whole meal bread each day ( increase fiber ) I.Increase fluid intake to 6–8 glasses (2.5 litres each day) of water per day if possible. II.Increase dietary fiber to 20–30 g/day. III.Incorporate or increase exercise to 3–5 days/week To address the dietary problems, he could be advised to start the day with a wholegrain cereal and to eat at least four slices of whole meal bread each day ( increase fiber ) I.Increase fluid intake to 6–8 glasses (2.5 litres each day) of water per day if possible. II.Increase dietary fiber to 20–30 g/day. III.Incorporate or increase exercise to 3–5 days/week The longer term, dietary changes provide the key.

26. The pharmacist’s view Can beta blocker be the problem ? beta-blockers can sometimes cause constipation, he has been taking the drug for over 1 year with no previous problems. When should the patient see the doctor ? the doctor if the suppository does not produce an effect; if it works but the dietary changes have not been effective after 2 weeks,

27. Write about essential question about bowel habit when identifying the cause of constipation ? What’s the appropriate action when a petient have on bowel obstruction causing colicky abdominal pain, abdominal distension and vomiting ? Mention some causes of blood in the stool? What’s the appropriate action when the Blood mixed in with the stool ? Questioning a constpitated patient regarding his diet is important ! what would you ask him regarding his diet and what diet changes may cause constipation? What’s the common cause of constipation in relation with the DIET ? Referral for further evaluation may be required for some patient populations, mention four conditions? LogBook Questions

28. CCB (calcium channel blockers) can be a cause for constipation ? (T/F) When a patient have Symptoms of constipation for more than 1– 2 weeks despite treatment you’d treat him with senna (T/F) Nonpharmacoligical treatment of constipation include ( 1-……….. 2-………….. 3-……………) Onset of action Glycerine suppository? Onset of action of lactulose and side effect ? Onset of action of PEG and safety regarding pregnancy ? Drugs used to prevent opiod induced constipaion? …………………. (drug) preffered in chronic liver disease ……………………..(drug) used for Preoperative or preprocedure bowl preparation Answer the following Questions

29. References Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton and J. Blenkinsopp © 2009 Alison Blenkinsopp American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005;100:S1–S22. AGA Technical Review on Constipation. Gastroenterology 2000;119:1768–78. American Gastroenterological Association Medical Position Statement: guidelines on constipation. Gastroenterology 2000;119:1761–78.