Constipation
By:
Dr. Shahram Ala
(Pharm.D, BCPS)
Constipation is a symptom, not
a disease
Some causes:
IBS,
Diabetes Mellitus,
Hypothyroidism
Patients definition & concept about
constipation can be different
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Patients definition:
Straining 52%, hard stools 44%, infrequent
stool 32%
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Misconception:
62% believe that daily defecation is necessary
to good digestive health
What is the right number of daily
or weekly bowel movements?!
Clinical definition
Any of two of following symptoms for at least 3
month (not necessarily consecutive) in a year
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Straining
Hard or lumpy stool
Sensation of incomplete evacuation
Fewer than 3 defecation per week
Causes of constipation
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↓ fiber :(most common)
↓ liquid ( 8 glasses/d is needed for constipated)
↓ Exercise : bedridden, coma
Ignoring urge to defecate
Systemic: Hypothyroidism, DM, Uremia,
pregnancy, hypercalcemia, Hypokalemia
Neurological: Stroke, Parkinsonism, Multiple
sclerosis
Causes of constipation (Cont.)
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GI-related: IBS, Hemorrhoid, Anal fissure,
Anorectal & Colorectal carcinoma ,obstruction
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Medication: Opiate, Anticholinergics, Al(OH)3
Iron, cholestyramine, Antihypertensive drugs
(CCBs, diuretics), relaxants, chronic use of
laxatives, Antiepileptics, progestron
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Uncertain: idiopathic chronic constipation
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Rate of empting: carbohydrate>protein>Lipid
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Fear, Pain Inhibit and exitation stimulate
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Clinical manifestation:
Pale- Icteric-Anorexia-Headache-Abdominal pain,
Diagnosis
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Good history is enough for most cases
(Duration, frequency, Consistency, blood in the
stool, weight loss, Diet, Exercise, Toilet habits,
Laxative use (what), other drugs)
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Basic laboratory tests:
CBC, Electrolytes, BS, BUN, Cr, TSH
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Structural:
Barium enema, Sigmoidoscopy, Colonoscopy
Treatment
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Treatment of underlying disease
(Malignancies, Hypothyroidism,…)
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Alteration of lifestyle (Diet, Exercise, Liquids)
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Laxatives
Acute constipation
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Glycerin suppository
Sorbitol powder
Bisacodyl
Anthraquinones ( C-lax)
Saline laxative (MOM)
Tap-water enema
If laxative treatment is required for > 1 week,
refer to a physician
Chronic constipation
Most common in bedridden or geriatrics
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Choice: Psyllium (with enough liquids)
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Low doses of other laxatives:
C-lax, MOM, Sorbitol, Lactulose
Constipation in hospitalized patients
May be related to general anesthesia or opiates
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Glycerin suppository
Milk of magnesium
Tap water enema
Constipation in infants & children
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If constipation is a persistent problem:
Consider neurological, metabolic or anatomical
abnormalities
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If No:
Approach as adults
Drug classes
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Those causing water evacuation in 1-6 hr
Caster oil, Saline cathartics, PEG lavage solutions
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Those causing soft or semi fluid stool in 6-8 hr
C-lax, Bisacodyl
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Those causing softening of stool in 1-3 days
Psyllium, Lactulose, Mineral oil, Decussate
Bulks
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Psyllium, musillium
Increase Volume of intestine
Stimulate natural intestine peristaltic
Anti Diarrhea & constipation
Lasts 12-24 h (even 3 days)
Drink freely water unless obstruction
Emullients
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Docusate Na cap: 500mg
Anionic surfactants
Decrease stool surface tension, increase Fluide
secration into intestine
Lasts 1-3 days
SE: GI cramp
Lubricants
Liquid Parafine
 Inhibition of fluide reabsorbtion from colon,
Softener of stool, stimulate peristaltic
 Post MI, Post surgery
 lasts 6-8 h
 15-45 ml PO, or rectal
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SE: Aspiration (neonate, Geriatrics, before sleep),
malabsorbtion (lipid soluble Vit.), Anal pruritis, staining
Stimulant laxatives
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Bisacodyl
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Stimulates mucosal nerve plexus of the colon
(myentric)
Intermittent use for constipation
Oral: 6-8hr Supp: 15-60min
Interactions: Milk, Antacids (EC)
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SE: Cramp, fluid and electrolyte imbalance,
Contraindication: pregnancy, lactation,
appendicitis
Caster oil
Usually for bowel preparation
 Active metabolite: Ricinoleic acid
 Onset: 1-3 hr
Saline
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MOM, mgso4
Indications: Antacid (5-15 ml PRN), Laxatives
(30-60 ml HS)
Mg: Osmotic, Release cholecystokinin
Onset: 3-6 hr
Interactions: Quinolones, Tetracycline, Fe,
EC drugs (bisacodyl, sulfasalazine)
Breast-feeding: can be used
CRF?
Hyperosmotics
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Glycerin, Lactulose, mannitol, Sorbitol
Lactulose: Acetic acid, Formic acid, Lactic acid
Encephalopathy ( lasts :24-48 h)
SE: flatulence, abdominal cramp, diarrhea,
electrolyte imbalance
Glycerin
Is very safe and acceptable for intermittent
basis particularly in infants
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Supp: 1g, 3g
Onset: less than 30 min
Mannitol
Tap-water enema
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200 ml results in a bowel movement within
0.5hr
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Soapsuds are no longer recommended
(proctitis, colitis)
Drugs for chronic idiopathic constipation
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Cisapride (also for Parkinson's disease)
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Erythromycin
Summary
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Underlying causes of constipation should be
considered
Foundation of treatment is diet and psyllium
Acute constipation may be treated with tapwater enema or glycerin suppository, if needed,
oral sorbitol, low dose bisacodyl or C-Lax
Approach for chronic constipation is use of
psyllium and if needed, intermittent low-doses
of other drugs