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