Constipation Cengiz Pata Gastroenterology Department Yeditepe University.
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Transcript of Constipation Cengiz Pata Gastroenterology Department Yeditepe University.
ConstipationConstipation
Cengiz PataCengiz Pata
Gastroenterology DepartmentGastroenterology Department Yeditepe UniversityYeditepe University
ConstipationConstipation
Epidemiology of ConstipationEpidemiology of Constipation Objectives of self-treatmentObjectives of self-treatment Nondrug MeasuresNondrug Measures OTC medications for the relief of OTC medications for the relief of
constipationconstipation
ConstipationConstipation
Signs and Symptoms include:Signs and Symptoms include: A decrease in the frequency of fecal A decrease in the frequency of fecal
eliminationelimination Difficult passage of dry hard stoolsDifficult passage of dry hard stools Straining to have stoolStraining to have stool
ConstipationConstipation
Common medications that can induceCommon medications that can induce constipation are: constipation are:
Narcotic analgesicsNarcotic analgesics Calcium-or aluminum containing Calcium-or aluminum containing
antacidsantacids Drugs with anticholinergic activityDrugs with anticholinergic activity Tricyclic antidepressantsTricyclic antidepressants Certain calcium channel blockers: ex. Certain calcium channel blockers: ex.
VerapamilVerapamil
ConstipationConstipation
Can be induced by one of the Can be induced by one of the following diseases:following diseases:
HypothoroidismHypothoroidism MegacolonMegacolon StrictureStricture Diabetes MellitusDiabetes Mellitus Irritable Bowel SyndromeIrritable Bowel Syndrome
A.Ş.K. Ağrı Şişkinlik Kabızlık
Irritable bowel syndrome Irritable bowel syndrome (IBS)(IBS)
IBS is a functional bowel disorder in IBS is a functional bowel disorder in which abdominal pain or discomfort is which abdominal pain or discomfort is associated with defecation or a change associated with defecation or a change in bowel habit, and with features of in bowel habit, and with features of disordered defecationdisordered defecation 10-20% adults in world, female 10-20% adults in world, female
predominantpredominant Come and go over time, overlap with other Come and go over time, overlap with other
FGIDFGID Poor QoL, high heath care costsPoor QoL, high heath care costs
Longstreth GF, et al. Gastroenterology 2006;130:1480-91.
Enteric nervous system (ENS)Enteric nervous system (ENS)
Brain imaging in rectal Brain imaging in rectal stimulation (fMR)stimulation (fMR)
Normal visceral sensation: 1. 1. Gender Gender difference, difference, ACC & ACC & PFC in femalesPFC in females 2. Common FGID2. Common FGID in in females?females?
Grundy D, et al. Gastroenterology 2006;130:1391-1411.
IBS in IBS in females females
VS
Sex hormones or gender Sex hormones or gender impacts on brain-gut axisimpacts on brain-gut axis
Animals Animals Low threshold for visceromotor response in rat proestrus Low threshold for visceromotor response in rat proestrus
vsvs estrus phase estrus phase potency of opiates to potency of opiates to visceromotor response in male visceromotor response in male
ratsrats Modulation of response in afferent neurons of male GPModulation of response in afferent neurons of male GP
Drugs: estrogen/progesteron on P-450 systemDrugs: estrogen/progesteron on P-450 system CYP3A4: women clearing drugs quicklyCYP3A4: women clearing drugs quickly
HumansHumans Slow GE in womenSlow GE in women Women experience greater pain to most stimuliWomen experience greater pain to most stimuli Different areas of brain activation: males Different areas of brain activation: males vsvs females females Different polymorphism of 5-HT transporter promoter: Different polymorphism of 5-HT transporter promoter:
males males vsvs females females
Ouyang A, et al. Am J Gastroenterol 2006;101:S602-9.
Diagnostic criteria for Diagnostic criteria for IBS, C1IBS, C1
Recurrent abdominal pain or discomfort at Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months least 3 days per month in the last 3 months associated with 2 or more of the following:associated with 2 or more of the following: ImprovementImprovement with defecation with defecation Onset associated with a change in frequency of stoolOnset associated with a change in frequency of stool Onset associated with a change in form (appearance) Onset associated with a change in form (appearance)
of stoolof stool Criteria fulfilled for the last 3 months with Criteria fulfilled for the last 3 months with
symptom onset at least 6 months prior to symptom onset at least 6 months prior to diagnosisdiagnosis Discomfort: uncomfortable sensation not described as Discomfort: uncomfortable sensation not described as
painpain
Longstreth GF, et al. Gastroenterology 2006;130:1480-91.
Diagnostic criteria for Diagnostic criteria for IBSIBS Organik sebepleri dışlaOrganik sebepleri dışla
Roma II criteriaRoma II criteria Son 12 ayda en az ≥12 hafta olan abdominal ağrı Son 12 ayda en az ≥12 hafta olan abdominal ağrı
ve huzursuzluk ve dışkılama alışkanlığında ve huzursuzluk ve dışkılama alışkanlığında değişiklik olacak değişiklik olacak
Ve aşağıdakilerden en az ikisi eşlik edecekVe aşağıdakilerden en az ikisi eşlik edecek defakasyonla rahatlamadefakasyonla rahatlama dışkının kıvamında değişiklikdışkının kıvamında değişiklik dışkının şeklinde değişiklikdışkının şeklinde değişiklik
Aşağıdaki semptomların bulunması şart değildir, fakat bunlardan ne kadar Aşağıdaki semptomların bulunması şart değildir, fakat bunlardan ne kadar
çoğu mevcutsa, tanı o kadar kesinleşirçoğu mevcutsa, tanı o kadar kesinleşir:: AAnormalnormal dışkılama sıklığı dışkılama sıklığı (>3/ (>3/güngün veyaveya <3/ <3/haftahafta)) AAnormalnormal dışkı şekli dışkı şekli AAnormalnormal dışkı pasajı dışkı pasajı Mukus pasajıMukus pasajı ŞŞişkinlik işkinlik veya veya abdominal distansiyon abdominal distansiyon hissihissi
Sub-typing IBS by Sub-typing IBS by predominant stool predominant stool
patternpattern Subtype Subtype ((absent use of antidiarrheals or absent use of antidiarrheals or
laxativeslaxatives)) IBS-C (IBS with constipation):IBS-C (IBS with constipation): hard or lumpy stools hard or lumpy stools
>>25% and loose (mushy) or watery stools <25% of BMs25% and loose (mushy) or watery stools <25% of BMs IBS-D (IBS with diarrhea):IBS-D (IBS with diarrhea): loose (mushy) or watery loose (mushy) or watery
stools stools >>25% and hard or lumpy stool <25% of BMs25% and hard or lumpy stool <25% of BMs IBS-M (mixed IBS):IBS-M (mixed IBS): hard or lump stools >25% and hard or lump stools >25% and
loose (mushy) or watery stools > 25% of BMsloose (mushy) or watery stools > 25% of BMs IBS-U (unsubtyped IBS):IBS-U (unsubtyped IBS): insufficient abnormality of insufficient abnormality of
stool consistency to meet criteria for IBS-C, D, or Mstool consistency to meet criteria for IBS-C, D, or M
Stool Stool form:form: BristolBristol scale scale
Longstreth GF, et al. Gastroenterology 2006;130:1480-91.
Alarm symptoms in IBS Alarm symptoms in IBS diagnosisdiagnosis
Age of onset over 50 yrsAge of onset over 50 yrs Progressive or very severe non-fluctuating Progressive or very severe non-fluctuating
symptoms symptoms Nocturnal symptoms waking from sleepNocturnal symptoms waking from sleep Persisted diarrhea, recurrent vomitingPersisted diarrhea, recurrent vomiting Rectal bleeding, anemiaRectal bleeding, anemia Unexplained BW lossUnexplained BW loss Family history of colon cancerFamily history of colon cancer FeverFever Abnormal physical examinationsAbnormal physical examinations
Talley NJ, et al. Lancet 2002;360:555-564.
Patient AssessmentPatient Assessment
Obtain lifestyle and medical history Obtain lifestyle and medical history before making any recommendationsbefore making any recommendations
Determine the reason for use of a Determine the reason for use of a laxative productlaxative product1. To relieve constipation1. To relieve constipation2. To evacuate the bowel prior to an 2. To evacuate the bowel prior to an upcoming radiologic or endoscopic upcoming radiologic or endoscopic examinationexamination
Inquire about the patient’s current Inquire about the patient’s current and past use of laxative productsand past use of laxative products
Refer When……Refer When……
Symptoms have persisted for more Symptoms have persisted for more than 2 weeksthan 2 weeks
Have recurred after previous dietary Have recurred after previous dietary or lifestyle changes or laxative useor lifestyle changes or laxative use
Patients who admit to blood in the Patients who admit to blood in the stoolstool
Objectives for Self Objectives for Self TreatmentTreatment
To relieve constipation and restore To relieve constipation and restore “normal” bowel functioning using:“normal” bowel functioning using:
Dietary and Lifestyle measuresDietary and Lifestyle measures Using OTC medications for the relief Using OTC medications for the relief
of constipationof constipation
Nondrug MeasuresNondrug Measuresincludeinclude
High fiber diet: foods high in wheat High fiber diet: foods high in wheat grains, oats, or fruits & vegetablesgrains, oats, or fruits & vegetables
Adequate fluid intakeAdequate fluid intake ExerciseExercise Avoid foods that cause constipation: Avoid foods that cause constipation:
processed cheeses & concentrated processed cheeses & concentrated sweetssweets
Non Prescription Non Prescription MedicationsMedications
Types of laxativesTypes of laxatives:: Bulk Forming LaxativesBulk Forming Laxatives EmollientEmollient LubricantLubricant SalineSaline HyperosmoticHyperosmotic StimulantStimulant
Bulk Forming LaxativesBulk Forming Laxatives
Derived from agar, or psyllium seedDerived from agar, or psyllium seed Synthetic examples used today are Synthetic examples used today are
methylcellulose & carboxymethyl methylcellulose & carboxymethyl cellulose sodium cellulose sodium
Dissolve in the intestinal fluid, thus Dissolve in the intestinal fluid, thus creating emollient gels that increase creating emollient gels that increase passage of the intestinal contentspassage of the intestinal contents
Stimulate peristalsis Stimulate peristalsis No systemic absorptionNo systemic absorption
Bulk Forming LaxativesBulk Forming Laxatives
Onset of action is 12-24hrsOnset of action is 12-24hrs Resemble the physiologic Resemble the physiologic
mechanism in promoting evacuation mechanism in promoting evacuation Are the FIRST choice of therapy for Are the FIRST choice of therapy for
constipationconstipation Examples are: Citrucel powder, Examples are: Citrucel powder,
Metamucil, Mitrolan Chewable Metamucil, Mitrolan Chewable Tablets Tablets
Bulk Forming LaxativesBulk Forming Laxatives
Use caution in patients that are Use caution in patients that are younger than 6 yrs of ageyounger than 6 yrs of age
Avoid in pts with intestinal Avoid in pts with intestinal ulcerations, stenosisulcerations, stenosis
Interact with anticoagulants, Interact with anticoagulants, digitalis glycosides, and salisylates digitalis glycosides, and salisylates
Not used for a fast clearing effect Not used for a fast clearing effect before a diagnostic procedure before a diagnostic procedure
Emollient LaxativesEmollient Laxatives
Are anionic surfactants that eventually Are anionic surfactants that eventually lead to the softening of the stoollead to the softening of the stool
Are systemically absorbed (solid) Are systemically absorbed (solid) Onset of action (oral) 24-72hrsOnset of action (oral) 24-72hrs Major use is as a stool softener, & to Major use is as a stool softener, & to
prevent constipation and maintain prevent constipation and maintain regularityregularity
Example : Docusate sodium Example : Docusate sodium Avoid in pts with who have nausea, Avoid in pts with who have nausea,
vomiting, or undetermined abdominal pain vomiting, or undetermined abdominal pain
Lubricant LaxativesLubricant Laxatives
Prevent colonic absorption of fecal water, Prevent colonic absorption of fecal water, thus soften the stoolthus soften the stool
Are minimally absorbedAre minimally absorbed Onset of action (oral) 6-8 hrs, (rectal) 5-15 Onset of action (oral) 6-8 hrs, (rectal) 5-15
minmin Avoid prolonged useAvoid prolonged use Can cause malabsorption of fat-soluble Can cause malabsorption of fat-soluble
vitaminsvitamins Example: Mineral oil ( only) Example: Mineral oil ( only)
Saline LaxativesSaline Laxatives Nonabsorbable cations & anions that draw Nonabsorbable cations & anions that draw
water into intestine causing an increase in water into intestine causing an increase in intraluminal pressure, which stimulates intraluminal pressure, which stimulates intestinal motilityintestinal motility
Are systemically absorbedAre systemically absorbed Onset of action (oral)30min-3 hrs,(rectal) 2-Onset of action (oral)30min-3 hrs,(rectal) 2-
5min5min Used ONLY when fast clearance of the bowel Used ONLY when fast clearance of the bowel
is required is required Ex:Citroma, Fleet Ready-to-Use Enema Ex:Citroma, Fleet Ready-to-Use Enema Avoid in pts with CHF, ileostomy, renal Avoid in pts with CHF, ileostomy, renal
function impairment, or younger than 6 yrs old function impairment, or younger than 6 yrs old
Hyperosmotic LaxativesHyperosmotic Laxatives
Combine an osmotic effect with local Combine an osmotic effect with local effect of sodium sterate, which draws effect of sodium sterate, which draws water into rectumwater into rectumbowel movementbowel movement
Onset of action (rectal) 30 minOnset of action (rectal) 30 min Used in suppository formUsed in suppository form Minimal side effectsMinimal side effects Example: Glycerin suppositories Example: Glycerin suppositories
(only)(only) Avoid in pts with rectal irritationAvoid in pts with rectal irritation
Stimulant LaxativesStimulant Laxatives Come from 2 classes: anthraquinone Come from 2 classes: anthraquinone
(ex:senna) & diphenylmethane ( bisacodyl)(ex:senna) & diphenylmethane ( bisacodyl) Increase the propulsive peristaltic activity Increase the propulsive peristaltic activity
of the intestine by local irritation of the of the intestine by local irritation of the mucosa which leads to increased motilitymucosa which leads to increased motility
Onset of action senna (PO) 8-12 hrs Onset of action senna (PO) 8-12 hrs For Bisacodyl: oral/rectal 15-60min, For Bisacodyl: oral/rectal 15-60min, Are systemically absorbedAre systemically absorbed Major use: for thorough evacuation of the Major use: for thorough evacuation of the
bowel prior to GI surgery or examinationbowel prior to GI surgery or examination
Stimulant LaxativesStimulant Laxatives Examples: Sennakot, Sennakot S (with Examples: Sennakot, Sennakot S (with
sodium docusate), Exlax, Dulcolaxsodium docusate), Exlax, Dulcolax Interact with H1 blockers, antacids if Interact with H1 blockers, antacids if
administered within 1 hradministered within 1 hr Avoid in pregnancyAvoid in pregnancy Pts who are breast feeding & taking senna Pts who are breast feeding & taking senna
laxative have reported a brown laxative have reported a brown discoloration of breast milkdiscoloration of breast milk
Adverse effects with regular use are severe Adverse effects with regular use are severe cramping, electrolyte & fluid deficiencies, cramping, electrolyte & fluid deficiencies, metabolic acidosis/alkalosis, and othersmetabolic acidosis/alkalosis, and others
Patient CounselingPatient Counseling
Laxative use to treat constipation Laxative use to treat constipation should be only on a temporary should be only on a temporary measuremeasure
If laxatives are not effective after 1 If laxatives are not effective after 1 week, a physician should be week, a physician should be consultedconsulted