1. Management of Constipation in Family Medicine Meera Kaur, PhD, RD, CDE Assistant Professor, Family Medicine University of Manitoba, Canada http://home.cc.umanitoba.ca/~kaur/

2. 15 76 year old female with PMHx of HTN & DM-2, 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

3. Is a symptom, not a disease Is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry, and small, making them painful or difficult to pass Has varied meanings for different individuals, patients and care givers It is best when the stools are soft and passed at an hour customary to the patients when in health  Hippocrates 2 What is constipation?

4. Patients’ Definition – Straining 52%, hard stools 44%, infrequent stool 32% Misconception Misconception – 62% believe that daily defecation is necessary to good digestive health Ala, 2006 3 Patients definition & concept about constipation

5. 4 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 Rome III Criteria

6. 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 test – CBC, Electrolytes, BS, BUN, Cr, TSH Structural – Barium enema – Sigmoidoscopy – Colonoscopy 5 Diagnosis

7. Primary cause – Primary Colorectal dysfunction – Slow Transit – Dyssnerygic Defecation – Irritable Bowel Syndrome Secondary cause – Endocrine/Metabolic – Neurologic – Myogenic Disorders – Medications – Obstruction ) Chronic Idiopathic Constipation (CIC) 6 Causes

8. Initial Management of chronic functional constipation – Lifestyle changes Exercise Establishing regular bowel regimen pattern Early rising from bed – Diet High fibre (20-35 g/day including both soluble and insoluble components) ↑ Fluid intake ↓ soft drinks, caffeinated drink 7 Management…

9. Bulk forming agent – Metamucil – Citrucel – Konsyl – Serutan Osmotic agent – Milk of Magnesia –Fleet Phospho-Soda –Sorbitol –Cephulac –Miralax 8 Management…Medication…

10. Stool Softener – Colace – Docusate – Surfak Lubricants – Fleet – Zymenol 9 Management…Medication…

11. Stimulant – Correctol – Dulcolax – Purge – Senokot Chloride Channel Blockers – Lubiprostone (Amitiza) 10 Management…Medication…

13. Surgery Biofeedback Alternative and Complementary Medicine – Yoga – Warm water + Honey – Herbal preparation – Homeopathic and Ayurvedic treatment 11 Management

14. Hemorrhoid Anal Fissures Rectal Prolapse Fecal Impaction 12 Complication

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16. 14 References Books Journal articles published during 1990-2012 International, National and Provincial governments’ relevant websites Regulatory organizations’ websites and reports Other relevant organizations’ publications/reports Guidelines, and References are available on request

17. Thank you 15

18. 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 Bulk Forming agents Other therapy Summary

19. Questions? 16