Constipation (management)
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Transcript of Constipation (management)
CONSTIPATION
CONSTIPATION
DR BHAVIN MANDOWARA
MANAGEMENT
Lifestyle modification Diet and fiber Laxatives - Bulk forming laxatives - Osmotic laxatives - Stimulant laxatives Stool softeners, suppositories, and enemas Other therapies for chronic constipation - Colonic secretagogues - Opioid antagonists - 5HT(4) receptor agonists
APPROACH CONSIDERATIONS
Manual disimpaction of stool should be considered only after critical illness asocaited constipation has been ruled out
Medical care should focus on dietary change and exercise . Correctionof dietary deficiency and aerobic exercise
Surigcal care is generally restricted to evaluation of underlying causes or management of acute complication of constipation.
HIGH RISK FACTORS
UNCERTAIN DIAGNOSIS
EVIDENCE OF INTRA-ABDOMINAL CATASTROPHE
SEVERE ABDOMINAL PAIN
FEVER , CHILLS
LOWER GI BLEED
INSTABILITY OF VITAL SIGNS
ABSENCE OF BOWEL SOUNDS
ACUTE RECENT CHANGE IN BOWEL SOUNDS
DIETARY AND LIFESTYLE MEASURES
FIBER : NATURAL -->FRUITS , VEGETABLES , AND CEREALS
FIBER SUPPLEMENT : WHEAT , PSYLLIUM OR METHYLCELLULOSE
DAILY FIBER OF ABOUT 20-25G/DAY IS RECOMMENDED
FIBERS ARE GOOD FOR LONG TERM USE AS COMPARED TO STOOL SOFTNERS IN WHICH TACHYPHYLAXIS DEVELOPS .
FIBRES SHOULD BE GRADUALLY TITRATED UP AS TO PREVENT SIDE EFFECTS OF FLATULENCE AND BLOATING
PATIENT MUST BE EXPLAINED THAT IT HAS TO BE TAKEN DAILY AS ONSET OF ACTION MAY TAKE WEEKS .
INCREASE FLUID INTAKE OF ATLEAST 8 GLASSES PER DAY , DECREASE MILK , TEA , COFFE , ALCOHOL
PHARMACOLOGIC THERAPY
BULK FORMING AGENTS/LAXATIVES includes psyllium ,methylcellulose , wheat dextran, act by absorbing water and increasing fecal mass , best , least expensive but has to be used for long term
EMOLLIENT STOOL SOFTNERS - eg include docusate which acts as a surfactant . It is easier to use but lose effectiveness with long term administeration and hence are reserved for short term setting like post op narcotic prescription
RAPIDLY ACTING LUBRICANTS includes PEG(polyethylene glycol , bisacodyl and sodium picosulfate v , long term term riskof habituationor toxicity is there
PROKINETICS cisapride , tegaserod are 5HT4 antagonist , increase colonic motility and decrease transit time . They have been withdrawn
LAXATIVES
Laxative usage in the older adults should be individualizedkeeping in mind the patient's history (cardiac and renal comorbidities),drug interactions, cost, and side effects
OSMOTIC LAXATIVES : USED IN PATIENTS NOT RESPONDING TO BULK LAXATIVES
PEG: Low-dose polyethylene glycol (PEG) (17 g/day) has been demonstrated to be efficacious and well tolerated in older patients . However,high-dose PEG (34 g/day) is associated with abdominal bloating, cramping,and flatulence, and older adults may be more susceptible to these side effects
LACTULOSE increases stool frequency, decreases the severity of constipation symptoms, and reduces the need for other laxatives in older adult patients
SORBITOL : less expensive and better tolerated
LAXATIVES
Saline laxatives such as magnesium hydroxide have not been examined in older adults, and should be used with caution because of the risk of hypermagnesemia.
Stimulant laxatives Stimulant laxatives affect electrolyte transport across the intestinal mucosa and enhance colonic transport and motility.
OSMOTIC AGENTS/COLONIC SECRETAGOGUES
Lubiprostone is an oral bicyclic fatty acid that activates the type 2 chloride channels on the intestinal epithelial cells,thus secreting chloride and water into the gut lumen .It is best reserved for patients with severe constipation in whom other approaches have been unsuccessful.
IT HAS BEEN APPROVED BY FDA FOR CHRONIC IDIOPATHIC CONSTIPATION , IBS-C , OPIOD INDUCED CONSTIPATION
ADVERSE EFFECTS INCLUDE FLATULENCE , NAUSEA AND DIARRHOEA
other agent Linaclotide is a guanylate cyclase C receptor agonist that stimulates intestinal fluid secretion and transit . Approved by the FDA for use in the treatment of chronicidiopathic constipation, the long-term risks and benefits of linaclotide,especially in older adults, remain to be determined
OPIOD ANTAGONIST
Opioid antagonists Two peripherally acting mu opioid receptor antagonists, alvimopan and methylnaltrexone , may have a role in treatment of narcotic-induced constipation and paralytic ileus, but data are lacking among older adults. As these opioid receptor antagonists act peripherally and do not cross the blood brain barrier, they do not impair the analgesic effects of opioids.
SURGICAL CORRECTION OF CAUSE AND COMPLICATIONS
FOR EVALUATION OF UNDERLYING CAUSE -LARGE BOWEL OBSTRUCTION , VOLVULUS ,INTRABDOMINAL INFECTION/ISCHEMIA , HEMORRHOIDAL THROMBUS
RECTAL OUTLET OBSTRUCTION , RECTOCELE , RECTAL PROLAPSE , RECTAL INTUSSUSCEPTION
HYPOMOTILE COLON REFRACTORY TO MEDICAL THERAPY.
MANAGEEMNT IN SPECIAL PATIENTS
PREGNANCY :
CAUSE : DIETARY CHANGES ,
ANATOMIC IMPINGEMENT BECAUSE OF LARGE UTERUS PRESSING ON RECTOSIGMOID
HEMORRHOIDS BECAUSE OF VENOUS CONGESTION
TREATMENT : FIBRE , WATER , GENTLE EXERCISE , OCCASIONAL LACTULOSE
IF HEMORRHOIDS ARE THERE THEN SUPPOSITOERY AND SITZ BATH WILL BE REQUIRED
MANAGEMENT IN SPECIAL PATIENTS
ELDERLY : MEDICATIONS ARE TO BE ESPECIALLY ASKED WHICH CAUSE CONSTIPATION AND ALSO SELF REPORTED CONSTIPATION IS HIGH
TREAMENT INCLUDIING DIET AND EXERCISE IS USUALLY INSUFFICIENT AND CHRONIC LAXATIVE USE IS OFTEN REQUIRED .
MENTALLY INCAPACITATED INDIVIDUALS THERE IS PATTERN OF BOWEL RETENTION IN WHICH SHORT TERM USE OF LAXATIVE OR STOOL SOFTENERS IS REQUIRED
MANAGEMENT IN SPECIAL PATIENTS
OPIOD INDUCED CONSTIPATION(OIC)
40-80% EXPERIENCE CONSTIPATION
SOME HAVE SEVERE ENOUGH TO STOP OPIODS ALSO
MECHANISM: OPIOD BINDS TO PERIPHERAL OPIOD RECEPTOR AND DECREASES GI TRACT FLUID
TREATMENT : LUBIPROSTONE- ADULTS WITH OIC WITH NON CANCER PAIN INHIBITS CIC-2 CL- CHANNEL
OTHER AGENTS INCLUDE NALOXEGOL AND METHYLNALTREXONE
SURGICAL CONSULTATION
LARGE BOWEL OBSTRUCTION
COLONIC ILEUS SECONDARY TO INTRABDOMINAL PROCESS
ANORECTAL COMPLICATIONS
HEMORRHOIDS , FISSURE
ACUTE HEMORRHOIDAL THROMBOSIS
CHRONIC NON HEALING FIISURE
PERIRECTAL ABSCESS AND FISTULA
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