chronic constipation and laxative abuse
DESCRIPTION
A case study presentation focusing on laxative abuse in older adultsTRANSCRIPT
LAURA HUTCHINSONDIETETIC INTERN
BENEDICTINE UNIVERSITY
Chronic Constipation and Laxative Abuse
Patient Profile
Age: 84Gender: FemaleRace: CaucasianHeight: 4’11Weight: 95 lbChanges in Weight: 5# weight loss in previous 2
months.BMI: 19.1 (WNL)Social hx: Married, Jewish, retired, lives at home.Current medical diagnoses: Small bowel obstruction
d/t adhesions, chronic renal insufficiency, chronic constipation/obstipation
Patient Hx
Past dx: B12 deficiency anemia, pure hypercholesterolemia, chronic kidney disease stage III, gastric ulcer, osteoporosis, depression, closed Colles’ fx of right arm, hiatal hernia, breast cancer, endometrial cancer, hypertension
Nutrition hx: Follows Kosher diet. Severe, chronic constipation x 10 years.
Interrelationships of Medical Dx
Hypertension CKD Stage III Anemia Osteoporosis Increased Age Fluid Restriction Small Stature Mobility
Depression Chronic Constipation Laxative Abuse?
Nutrition Diagnoses
Altered GI Function related to Chronic Constipation/Obstipation as evidenced by patient need to supplement with Colace, Senna, and Glycerine suppositories to have a normal bowel movement.
Inadequate oral intake related to poor appetite secondary to abdominal distension and chronic constipation as evidenced by 25-50% intake at meals per patient and dietitian.
Altered GI Function related to Small Bowel Obstruction as evidenced by CT scan of pelvis/abdomen.
Back to this Nutrition Dx..
Altered GI function related to chronic constipation/obstipation as evidenced by patient needs to supplement with Colace, senna, and glycerine suppositories to have a normal bowel movement.
Is this normal laxative use?
What is Laxative Abuse?
Laxative abuse is the repeated misuse and overuse of laxatives involving Dosing too frequently Overdosing Using laxatives for non-intended reasons (such as weight
loss) Using multiple types of laxatives at once Using the wrong type of laxative (such as a purgative
laxative when a stool softener would have been appropriate)
Overuse can lead to dependency and a decrease in bowel function
(Fruit Eze)
Types of Laxatives
Bulk-Forming LaxativesSaline LaxativesOsmotic LaxativesSurfactant Laxatives LubricantsStimulant Laxatives
Diphenylmethane derivatives Anthraquinone derivatives
(Roerig)
Profile of a Laxative Abuser
Eating Disorder patients Histrionic personality traits Lower self-esteem Lower “self-liking” Weight and shape concerns Depression
Middle aged or older adults Perceived poor physical health
Athletes in sports with weight limits
Factitious disorder patientsComorbidities
(Roerig, Steffen, Pryor, Harari, Surgenor, Weltzin)
Complications
A Vicious Cycle –with dehydration, the renin-angiotensin system kicks in, following by rehydration and water weight gain
(Roerig)
Complications
Electrolyte Disturbances
Metabolic Disturbances
Bowel Disturbances
Kidney Disturbances
(Roerig, Cummings, Copeland)
Diagnosis
Practitioner’s suspicionMelanosis ColiGI symptomsSerum hypokalemiaFecal electrolytes
Stool osmotic gap : 290 – 2* (Stool Na + Stool K)
(Roerig)
Role of the Registered Dietitian
Identify patient’s bowel patterns.
Identify type and frequency of laxative use. Be specific – patients will not
always willingly offer this information.
Check labs, electrolytes, and fluid status.
Monitor for disordered eating patterns or disordered bowel regimens.
Treatment/Monitoring
EducationAppropriate treatment for eating disordersRisks?Goals of treatment:
Stop laxative abuse Maintain healthy GI Function
Weight trendsLabs and other nutritional parameters
Is this patient abusing laxatives?
YES. But, is it an eating disorder, or is she just an older adult with constipation?
Anxiety/depression issuesRigid bowel regimenRenal failureAgingPoor appetite
References
Copeland PM. Renal failure associated with laxative abuse. Psychother Psychosom. 1994;62:200-202.Cummings JH, Sladen GE, James OF et al. Laxative-induced diarrhoea: a
continuing clinical problem. BMJ. 1974;23:537-541.Escott-Stump S. Nutrition and Diagnosis Related Care Seventh Edition.
2012. Baltimore: Lippincott, Williams, and Wilkins.Fruit-Eze. Laxative Abuse and the Laxative Habit. 2003. Retrieved on May
7, 2013 from http://web.pdx.edu/~sujata/FruitEzeWeb/education/laxative/habit.htmlHarari D, Gurwitz JH, Avor J et al. Constipation: assessment and management in an institutionalized elderly population. J Am Geriatric Soc. 1994;42:947-952.Mahan LK, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition Care Process Thirteenth Edition. 2010. St. Louis: Elsevier Saunders.Mikrut R, Groetsma C et al. Clinical Dietetic Reference Pocket Guide. 2010. Hines: Edward Hines Jr. Hospital Department of Veterans AffairsPagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference
Tenth Edition. 2011. St. Louis: Elsevier Mosby.
References
Pronsky ZM, Crowe JP. Food Medication Interactions Seventeenth Edition. 2012. Birchrunville: Food Medication Interactions.
Pryor T, Widerman MW, McGilly B. Laxative Abuse Among Women With Eating Disorders: An Indication of Pathophysiology? Int J Eat Disord. 1996;20(1):13-18.Roerig JL, Steffen KJ, Mitchell JE, Zunker C. Laxative Abuse: Epidemiology,
Diagnosis, and Management. Drugs. 2010;70(12):1487-1503.Steffen KJ, Mitchell JE, Roerig JL. The eating disorders medicine cabinet
revisited: a clinician’s guide to ipecac and laxatives. Int J Eat Disord 2007;40:360-368.
Surgenor LJ, Maguire S, Russel J, et al. Self-liking and aself-competence: relationship to symptoms of anorexia nervosa. Eur Eat Disord Rev. 2007;15:139-145.
Weltzin TE, Bulik CM, McConaha CW et al. Laxative withdrawal and anxiety in bulimia nervosa. Int J Eat Disord. 1995;17:141-146.Wilson BA, Shannon MT, Shields KM. Pearson Nurse’s Drug Guide. 2013.
Upper Saddle River: Pearson Education.