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Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
S
Constipation“I wish being famous prevented me from being
constipated”- Marvin Gaye
“Besides death, constipation is the big fear in hospitals”
- Robert McCrumm
-
James Rose, MDPeak Gastroenterology Associates, P.C.
CME Credit: 1.0
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Question
- Which patient has constipation?- A) 32yo woman who describes with every BM the need to strain and has hard
pebble-like movement- B) 46yo man with less than 3 BMs per week- C) 25yo man who requires a laxative every day in order to have a BM- D) 88yo women that says in order to have a BM, she will press her peri-anal area
to stimulate a BM- E) All of the above- F) None of the above
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Definition:
Rome 3
- Symptoms lasting >6months and
- Must include at least 2 of the following:
(1)At least 25% of bowel movements associated with- Straining
- Lumpy or hard stools
- Incomplete bowel evacuation
- Anorectal obstruction
- Need for manual manoeuvres
- < 3 bowel movements per week
(2)Loose stools rarely present without the use of laxatives
(3)Insufficient criteria for IBS
Patient Definition:• Hard Stools
• Infrequent stools (<3 per
week)
• Excessive straining
• Sense of incomplete bowel
emptying
• Excessive, unsuccessful
time spent on toilet
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Used in Clinical Trials
Correlates with symptoms of straining and difficult evacuation
Also correlates with colonic transit (Type 1 or Type 7 stool is correlated with slow or rapid colonic transit Degen LP, Phillips SF. How well does stool form reflect
colonic transit? Gut 1996;39:109-113.)
Majority of “constipated”patients have stools that are Type 1-3
University of Bristol, Scand J Gastroenterol, 1997
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Other Symptoms and Consequences of Constipation
Nausea +/- vomiting
Abdominal and Rectal
pain
Flatulence
Loss of appetite
Lethargy
Depression
Nausea and reduced appetite - weight
loss
Behavioral disturbances in dementia -
increased use of psychotropic medications
Extra staff time needed for increased
toileting needs
Overall increased number of medications
in the regime
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Epidemiology
- Medline 2010 literature search of 58 articles- North American prevalence 2 – 27% with mean of 16% (overall)- 33% in adults aged 60-101
- Using Rome 2, about 63 million Americans with chronic constipation
- Risks- Women (F:M=1.5:1), non-whites, >60’s, low income, little exercise, poor
education, institutionalized
- >65 years of age 26% men, 34% women
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Quality of Life (QOL)
- Impact as severe as Diabetes, IHD, Rheumatoid Arthritis
- Social and mental health particularly affected
- Estimates that > 13 million work days lost to constipation in USA/year
Systematic review: impact of constipation on quality of life in adults Belsey et al Alim, Ther & Pharm 2010
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Economic Costs
- UK National study- 2 x number of GP visits for pts between 65 – 74 yrs, 5 x number of visits for pts
> 75
- About 2.5 million Americans undergo Iaxatives for Constipation annually at a cost of $2700/pt (based on 1994 paper!)…85% of those pts will be prescribed long term laxatives
- In 1994, In US, about 90,000 pt hospitalized for constipation
- In 2004 (Levy et al), $660 million OTC Laxatives sold (US)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Principles
CONSTIPATION SIMPLIFIED
There are a lot of CAUSES
the PATHOLOGY and the PRINCIPLES
of TREATMENT are the SAME.
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Things to Ask
- Feces: Quality/Frequency/Effort/Associated Sx
- Foods and Fluids: Fiber and White Food
- Fast paced: esp. Calls Answered
- Flaccid: Daily Movement, Childbirth trauma
- Medical: Laxative Use, other Meds, Thyroid Sx
- RED FLAGS: rectal bleeding, abrupt weight loss, change in bowel habits, FHx of colon CA,IBS
- Tools: Bowel Diary (see Symptom Diary on web),
Transit time trial ... corn, beets, or other identifiable food
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
- Passenger: (hard or large or irritating)- too little (water or fiber) - too much (irritants, large proteins, bacteria)
- Push: Peristalsis impaired (slow transit)- dilated colon, meds, toxins-irritants-bacteria
- Passage: inflamed, irritated, weak, uncoordinated, dilated (pelvic floor dysfunction)- inhibits peristalsis- pelvic muscles weak- dilated colon does not work well
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Causes
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Labs
- Blood Work: most guidelines say optional- TSH, BG, CBC if concern of CA
- Consider- Barium Enema or Flexible Sigmoidoscopy in more serious
cases- Radiology: Bowel Score (most say not needed)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Categories of Treatment
- Passenger:- Bulk/hydrophilic agents – fiber
- “make it bigger” - Surfactants/Emollients – stool softeners
- “make it slippery” (colace, some psyllium-bulk)- Osmotic laxatives – not absorbed
- “don’t let the water leave” (Mg/lactose/sorbitol/PEG)
- Push- Peristaltic irritants
- stimulants (dulcolax/senna)- “make it go faster”
- Others: prokinetic, prosecretors (probiotics)
- Passage- exercises, position, biofeedback
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Steps of Treatment
1.Treat Cause
2.Clear out Bowel
3.Restore Normal Function
4.Then Wean down or off of therapies…
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
1. Treat Causes
- Food: Insufficient Fiber (?too much White Stuff)- Trial of no dairy products!- Psyllium Husks/prunes-prune juice/other
- Fluids: not enough- Especially warm relaxing drink in the morning- Water (minimum= ½ oz per # of Body Wt/QD)
- Fast Paced: - Chew Food 20-30x (stimulates peristalsis)- Cut out or decrease Caffeine, ETOH- Answer “Call of the Bowels”- Discuss relaxation- Treat Anxiety, Depression, OCD-tendencies
- Flaccid: get more movement
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
2. Clear out the Bowel
- From Above- Mild: Magnesium, Vitamin C and Oils- Moderate: Senna or MOM- Severe: Sorbitol, Lactulose or Miralax
- From Below- Enema (Fleets, Oil, Milk, etc)- Suppository (glycerine, dulcolax)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
3. Restore Normal Function
- Remove Causes - consider further elimination diet
- Special Exercises - peristalsis/pelvic strength- Position (raise feet)
- Digestive Enzymes and Betaine HCL- improves digestion especially in high protein diets/elderly
- Probiotics: (peristalsis)
- Biofeedback (dysynergy)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
4. Wean Down
- Elimination - Dairy: 22% tolerated at 6 months vs 88% after a year
- Use Clear Out only prn - Senna, Sorbitol, Lactulose or Miralax- Dulcolax/Enemas
- What if they need long term stool softeners- No proven down side to most- Largely unknown.
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Treatment in Outpatient Setting
4 Steps
1. Treat Cause: stop dairy, drink fluids, increase fiber (metamucil or flax)
2. Clear out Bowel: Magnesium products/Vitamin C
3. Restore Normal Function: teach exercises/digestive enzymes
4. Then Wean down or off of therapies…see if they can stop Mg or Vit C or PEG, then metamucil or flax
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Treatment in Hospitalized Patient
4 Steps
1. Treat Cause (activity or may not be able)
2. Clear out Bowel: Bisacodyl 10mg PO or use PR, MOM (Mag-Hydroxide) 5-15mL QID or Mag Citrate, if hard stool then Colace
3. Restore Normal Function (may not be as much a focus for now)
4. Then wean down or off of therapies…(later)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Severe (Impaction Treatment)
- Main focus is on step 2 (clear out bowels)- Disimpact (manually or with enemas)- Mineral oil enema then…
- Fleets x 3 days +/- Polyethelene Glycol until colon clear- Then: Lactulose, Sorbitol, PEG …
- IF no BM in 2 daysBisacodyl or Glycerin suppository
- Then focus on steps 1 (cause) and 3 (restore)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Lifestyle Changes
- Aerobic Exercise 30 minutes, 3-5/week- sedentary folks are three times more likely to report constipation- need to increase fluids
- Retraining: - Sit on toilet at same time every day (ie. After eating breakfast, upon rising,
after every meal)- Defecate when urge arises
- Deep Breathing on toilet (relaxation)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
COFFEE
Caffeinated coffee stimulates colonic motor activity.- Its magnitude is similar to a 1000 kcal meal- 60% stronger than water - 23% stronger than decaffeinated coffee.- N = 12Coffee increases rectosigmoid motor activity within 4 min after ingestion
in some people.
Scand J Gastroenterol Suppl. 1999;230:35-9. Eur J Gastroenterol Hepatol. 1998 Feb;10(2):113-8. Gut. 1990 Apr;31(4):450-3
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Other Dietary Supplements
- Prunes- High fiber, 6 gm fiber/10 prunes
• sorbitol • neochlorogenic acid
- How much: 50 grams bid in one study: 14 prunes (but 281 kcals!)• Slightly more BMs/week cp to psyllium
- Antioxidant benefit, ORAC value = 6463- Tamarindo – tambien possible ayuda
- Vitamin C- Dose: 1000 mg vitamin C tid before meals- Often rec to take to “bowel tolerance”- Or rec w/ Chitosan
- Fiber composed of chitin, a component of the shell of shellfish. - Six 500-milligram (mg) capsules of chitosan- Vit C helps transform chitosan in the stomach and intestine into a fat-absorbing gel.
Nature Reviews Gastroent and Hep 2011; 8: 306-307Bowes & Church’s Food Values of Portions Commonly Used, 17th Ed.
http://www.lef.org/protocols/gastrointestinal/constipation_01.htm
Life Extension Foundation Accessed 9/24/11
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Classes of Treatment
- Causes water evacuation in 1 – 6 hours- Saline cathartics, PEG solutions, Castor Oil
- Causes soft/semisoft stools in 6 – 8 hours- Bisacodyl
- Causes softening of stool in 1 – 3 days- Docusate, Psyllium, Lactulose, Mineral Oil
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Bulk Forming Agents/Fiber
- “Just add water”: Swell in intestines, lubricate and soften stool. - Note: Water necessary, or risk choking/obstruction!
- Best Evidence- mucilage from Ispaghula seeds (Plantago ovata, aka Psyllium, aka Metamucil)
- Dosing: start 1 tsp, titrate to effect (~1T).
- If Flatulence, consider…- Methyl-Cellulose (Citrucel)- Calcium polycarbophil (FiberCon; Fiber-Lax)- Wheat dextrin (Benefiber®), - Chia seeds, flax, others
Aliment Pharmacol Ther 1998, J Am Geriatr Soc 1995, J Am Geriatr Soc 1995;43:666–9.10, Curr Med Res Opin 1998.
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Probiotic Supplements
- Five RCTs : 377 subjects - adults (three RCTs, n = 266) - children (two RCTs, n = 111)
- In adults, - some organisms favorable effect on defecation frequency and stool
consistency.
- In children- some organisms showed a beneficial effect.
Systematic review of randomised controlled trials: probiotics for functional constipation. - Chmielewska A - World J Gastroenterol - 7-JAN-2010; 16(1): 69-75 (MEDLINE® is the source for the citation and abstract of this record )Children: L. casei rhamnosus Lcr35, but not L. rhamnosus GG, Adults: Bifidobacterium lactis DN-173 010, Lactobacillus casei Shirota, and Escherichia coli Nissle 1917
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Magnesium
- HIGH Efficacy (used as bowel prep!) – only caution is renal failure (risk of mag toxicity) generally above 3 grams a day.
- Milk of magnesia (1-3 tsp QID)- Antacid activity in low doses: all OH- entering the stomach used to
neutralize stomach acid. - Laxative effect at high doses: OH- moves past stomach to intestines
attract and retain water, thereby increasing intestinal movement (peristalsis) and inducing the urge to defecate
- Mag Citrate (Short Term Use) 120-300mL x 1 or 2
- Mag oxide/citrate pills 400-500mg QD
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Stool Softeners
- Docusate (Colace) 250 BID – oral use may take 1-3 days to cause effect, enema works within 20-60 min
- Emulsifier/emollient: Lowers surface tension of stool (also used as a pesticide and as oil dispersing agent in oil spills…)
- However…- Less effective than psyllium- Likely ineffective in chronically ill elderly - Not recommended for long-term use/chronic constipation by Up-To-Date or the American
College Gastroenterology Chronic Constipation Taskforce- Psyllium is superior to docusate sodium for treatment of chronic constipation.
Aliment Pharmacol Ther. 1998;12:491–7 J Pain Symptom Manage. 2000;19:130–6. Am J Gastro 2005
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Stimulant Laxatives
- Increase peristalsis by irritating colon- Bisacodyl (Correctol®, Dulcolax®)- Senna (Senokot®, ex-lax)
- Long Term Use can lead to - dependency “lazy bowel”- electrolyte disorders (hypo K, Hyper Na)
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Per Rectum Medications
- Enemas- Fleets- Mineral Oil- Milk
- Suppositories- Glycerin
- Commonly used in children. Digital stimulation may be actual mechanism.
- Bisacodyl/Dulcolax - Stimulant laxative
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Other Treatments
- Biofeedback- Extremely (75%) effective for
Pelvic-Floor Dysfunction and outlet-inertia.
- Massage- small number trials positive- Baby massage
- Herbs (lots)
- Colchicine
- Misoprostol
- Botulinum Toxin Injection
- Zelnorm (is back) 5HT4
- Surgery
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Intestinal Secreatogues
- Lubiprostone (Amitiza)- Bicyclic fatty acid derivative- Works on CIC2 Chloride channel activating prostaglandin receptors and CFTR to
increase intestinal fluid- Dosages
- 24micrograms BID for chronic constipation and 8micrograms BID for IBS-C in women
- Linaclotide (Linzess)- 14-amino acid peptide homolog to heat-stable endotoxin- Acts on Guanylyl cyclase C which acts on CFTR to increase intestinal fluid secretion- Dosages
- 145-micrograms daily in chronic constipation and 290-micrograms daily in IBS-C
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
- Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship
- Buddha
- “The best and most beautiful things in the world cannot be seen nor touched – they must be felt in the heart” - Helen Keller
Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
Questions?
James E. Rose, MDPeak Gastroenterology Associates, P.C.
www.peakgastro.com719.636.1201