Your SlideShare is downloading. ×
0
Constipation
“I wish being famous prevented me from being constipated”
- Marvin Gaye

“Besides death, constipation is the ...
Question

S Which patient has constipation?
S A) 32yo woman who describes with every BM the need to strain and has hard pe...
Definition:
Rome 3
S Symptoms lasting >6months and

Patient Definition:

S Must include at least 2 of the following:

•

H...
Used in Clinical Trials
Correlates with symptoms of straining and difficult evacuation
Also correlates with colonic transi...
Other Symptoms and Consequences of
Constipation
Nausea +/- vomiting

Nausea and reduced appetite

Abdominal and Rectal pai...
Epidemiology
S Medline 2010 literature search of 58 articles
S North American prevalence 2 – 27% with mean of 16% (overall...
Quality of Life (QOL)
S Impact as severe as Diabetes, IHD,

Rheumatoid Arthritis
S Social and mental health particularly

...
Economic Costs
S UK National study
S 2 x number of GP visits for pts between 65 – 74 yrs, 5 x number of visits for pts > 7...
Principles

CONSTIPATION SIMPLIFIED

There are a lot of CAUSES
the PATHOLOGY and the PRINCIPLES

of TREATMENT are the SAME...
Things to Ask
S

Feces: Quality/Frequency/Effort/Associated Sx

S

Foods and Fluids: Fiber and White Food

S

Fast paced: ...
S Passenger: (hard or large or irritating)
S too little (water or fiber)
S too much (irritants, large proteins, bacteria)
...
Causes

Copyright (c) 2014 James E. Rose, MD | Peak
Gastroenterology Associates, PC
Labs

S Blood Work: most guidelines say optional

S TSH, BG, CBC if concern of CA

S Consider

S Barium Enema or Flexible ...
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
S Passenger:
S Bulk/hydrophilic agents – fiber
S

“make it bigger”

S Surfactants/Emollients – sto...
Steps of Treatment

1.Treat Cause

2.Clear out Bowel
3.Restore Normal Function

4.Then Wean down or off of therapies…
Copy...
1. Treat Causes
S Food: Insufficient Fiber (?too much White Stuff)
S Trial of no dairy products!
S Psyllium Husks/prunes-p...
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
S From Above
S Mild: Magnesium, Vitamin C and Oils

S Moderate: Senna or MOM
S Severe: Sorbitol, La...
3. Restore Normal Function
S Remove Causes
S consider further elimination diet
S Special Exercises
S peristalsis/pelvic st...
4. Wean Down
S Elimination
S Dairy: 22% tolerated at 6 months vs 88% after a year

S Use Clear Out only prn
S Senna, Sorbi...
Treatment in Outpatient Setting

4 Steps
1. Treat Cause: stop dairy, drink fluids, increase fiber (metamucil or flax)
2. C...
Treatment in Hospitalized Patient

4 Steps
1. Treat Cause (activity or may not be able)
2. Clear out Bowel: Bisacodyl 10m...
Severe (Impaction Treatment)
S Main focus is on step 2 (clear out bowels)
S Disimpact (manually or with enemas)
S Mineral ...
Copyright (c) 2014 James E. Rose, MD | Peak
Gastroenterology Associates, PC
Lifestyle Changes
S Aerobic Exercise 30 minutes, 3-5/week
S sedentary folks are three times more likely to report constipa...
COFFEE

Caffeinated coffee stimulates colonic motor activity.
S Its magnitude is similar to a 1000 kcal meal
S 60% stronge...
Other Dietary Supplements
S

Prunes
S High fiber, 6 gm fiber/10 prunes
•
sorbitol
•
neochlorogenic acid
S How much: 50 gra...
Classes of Treatment
S Causes water evacuation in 1 – 6 hours
S Saline cathartics, PEG solutions, Castor Oil

S Causes sof...
Bulk Forming Agents/Fiber
S “Just add water”: Swell in intestines, lubricate and soften stool.
S Note: Water necessary, or...
Probiotic Supplements
S Five RCTs : 377 subjects
S adults (three RCTs, n = 266)

S children (two RCTs, n = 111)

S In adul...
Magnesium
S HIGH Efficacy (used as bowel prep!) – only caution is renal failure (risk of mag

toxicity) generally above 3 ...
Stool Softeners
S Docusate (Colace) 250 BID – oral use may take 1-3 days to cause effect, enema works

within 20-60 min
S ...
Stimulant Laxatives
S Increase peristalsis by irritating colon

S Bisacodyl (Correctol®, Dulcolax®)
S Senna (Senokot®, ex-...
Per Rectum Medications
S Enemas
S Fleets
S Mineral Oil
S Milk
S Suppositories
S Glycerin
S Commonly used in children. Digi...
Other Treatments

S Biofeedback
S

Colchicine

S

Misoprostol

S

Botulinum Toxin Injection

S small number trials positiv...
Copyright (c) 2014 James E. Rose, MD | Peak
Gastroenterology Associates, PC
Intestinal Secreatogues
S Lubiprostone (Amitiza)
S Bicyclic fatty acid derivative
S Works on CIC2 Chloride channel activat...
S Health is the greatest gift, contentment the greatest wealth, faithfulness the best

relationship
- Buddha

S “The best ...
Questions?

James E. Rose, MD

Peak Gastroenterology Associates, P.C.
www.peakgastro.com
719.636.1201

Copyright (c) 2014 ...
Upcoming SlideShare
Loading in...5
×

Dr. rose final protected

235

Published on

Clinical update on Constipation_CME Accredited Material_James E. Rose, MD_COPYRIGHTED MATERIAL

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
235
On Slideshare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
4
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

Transcript of "Dr. rose final protected"

  1. 1. 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, MD Peak Gastroenterology Associates, P.C. CME Credit: 1.0 S Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  2. 2. Question S Which patient has constipation? S A) 32yo woman who describes with every BM the need to strain and has hard pebble-like S S S S S 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
  3. 3. Definition: Rome 3 S Symptoms lasting >6months and Patient Definition: S Must include at least 2 of the following: • Hard Stools (1) At least 25% of bowel movements associated with • Infrequent stools (<3 per S S Lumpy or hard stools S Incomplete bowel evacuation S Anorectal obstruction S Need for manual manoeuvres S < 3 bowel movements per week week) Straining (2) Loose stools rarely present without the use of laxatives (3) Insufficient criteria for IBS • Excessive straining • Sense of incomplete bowel emptying • Excessive, unsuccessful time spent on toilet Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  4. 4. 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
  5. 5. Other Symptoms and Consequences of Constipation Nausea +/- vomiting Nausea and reduced appetite Abdominal and Rectal pain Behavioral disturbances in dementia Flatulence Loss of appetite Lethargy Depression weight loss 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
  6. 6. Epidemiology S Medline 2010 literature search of 58 articles S North American prevalence 2 – 27% with mean of 16% (overall) S 33% in adults aged 60-101 S Using Rome 2, about 63 million Americans with chronic constipation S Risks S Women (F:M=1.5:1), non-whites, >60’s, low income, little exercise, poor education, institutionalized S >65 years of age 26% men, 34% women Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  7. 7. Quality of Life (QOL) S Impact as severe as Diabetes, IHD, Rheumatoid Arthritis S Social and mental health particularly affected S 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
  8. 8. Economic Costs S UK National study S 2 x number of GP visits for pts between 65 – 74 yrs, 5 x number of visits for pts > 75 S 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 S In 1994, In US, about 90,000 pt hospitalized for constipation S In 2004 (Levy et al), $660 million OTC Laxatives sold (US) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  9. 9. 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
  10. 10. Things to Ask S Feces: Quality/Frequency/Effort/Associated Sx S Foods and Fluids: Fiber and White Food S Fast paced: esp. Calls Answered S Flaccid: Daily Movement, Childbirth trauma S Medical: Laxative Use, other Meds, Thyroid Sx S RED FLAGS: rectal bleeding, abrupt weight loss, change in bowel habits, FHx of colon CA,IBS S 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
  11. 11. S Passenger: (hard or large or irritating) S too little (water or fiber) S too much (irritants, large proteins, bacteria) S Push: Peristalsis impaired (slow transit) S dilated colon, meds, toxins-irritants-bacteria S Passage: inflamed, irritated, weak, uncoordinated, dilated (pelvic floor dysfunction) S inhibits peristalsis S pelvic muscles weak S dilated colon does not work well Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  12. 12. Causes Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  13. 13. Labs S Blood Work: most guidelines say optional S TSH, BG, CBC if concern of CA S Consider S Barium Enema or Flexible Sigmoidoscopy in more serious cases S Radiology: Bowel Score (most say not needed) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  14. 14. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  15. 15. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  16. 16. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  17. 17. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  18. 18. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  19. 19. Categories of Treatment S Passenger: S Bulk/hydrophilic agents – fiber S “make it bigger” S Surfactants/Emollients – stool softeners S “make it slippery” (colace, some psyllium-bulk) S Osmotic laxatives – not absorbed S “don’t let the water leave” (Mg/lactose/sorbitol/PEG) S Push S Peristaltic irritants S S stimulants (dulcolax/senna) “make it go faster” S Others: prokinetic, prosecretors (probiotics) S Passage S exercises, position, biofeedback Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  20. 20. 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
  21. 21. 1. Treat Causes S Food: Insufficient Fiber (?too much White Stuff) S Trial of no dairy products! S Psyllium Husks/prunes-prune juice/other S Fluids: not enough S Especially warm relaxing drink in the morning S Water (minimum= ½ oz per # of Body Wt/QD) S Fast Paced: S Chew Food 20-30x (stimulates peristalsis) S Cut out or decrease Caffeine, ETOH S Answer “Call of the Bowels” S Discuss relaxation S Treat Anxiety, Depression, OCD-tendencies S Flaccid: get more movement Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  22. 22. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  23. 23. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  24. 24. 2. Clear out the Bowel S From Above S Mild: Magnesium, Vitamin C and Oils S Moderate: Senna or MOM S Severe: Sorbitol, Lactulose or Miralax S From Below S Enema (Fleets, Oil, Milk, etc) S Suppository (glycerine, dulcolax) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  25. 25. 3. Restore Normal Function S Remove Causes S consider further elimination diet S Special Exercises S peristalsis/pelvic strength S Position (raise feet) S Digestive Enzymes and Betaine HCL S improves digestion especially in high protein diets/elderly S Probiotics: (peristalsis) S Biofeedback (dysynergy) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  26. 26. 4. Wean Down S Elimination S Dairy: 22% tolerated at 6 months vs 88% after a year S Use Clear Out only prn S Senna, Sorbitol, Lactulose or Miralax S Dulcolax/Enemas S What if they need long term stool softeners S No proven down side to most S Largely unknown. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  27. 27. 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
  28. 28. 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
  29. 29. Severe (Impaction Treatment) S Main focus is on step 2 (clear out bowels) S Disimpact (manually or with enemas) S Mineral oil enema then… S Fleets x 3 days +/- Polyethelene Glycol until colon clear S Then: Lactulose, Sorbitol, PEG … S IF no BM in 2 daysBisacodyl or Glycerin suppository S Then focus on steps 1 (cause) and 3 (restore) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  30. 30. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  31. 31. Lifestyle Changes S Aerobic Exercise 30 minutes, 3-5/week S sedentary folks are three times more likely to report constipation S need to increase fluids S Retraining: S Sit on toilet at same time every day (ie. After eating breakfast, upon rising, after every meal) S Defecate when urge arises S Deep Breathing on toilet (relaxation) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  32. 32. COFFEE Caffeinated coffee stimulates colonic motor activity. S Its magnitude is similar to a 1000 kcal meal S 60% stronger than water S 23% stronger than decaffeinated coffee. S N = 12 Coffee 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
  33. 33. Other Dietary Supplements S Prunes S High fiber, 6 gm fiber/10 prunes • sorbitol • neochlorogenic acid S How much: 50 grams bid in one study: 14 prunes (but 281 kcals!) • Slightly more BMs/week cp to psyllium S Antioxidant benefit, ORAC value = 6463 S Tamarindo – tambien possible ayuda S Vitamin C S Dose: 1000 mg vitamin C tid before meals S Often rec to take to “bowel tolerance” S Or rec w/ Chitosan http://www.lef.org/protocols/gastrointestinal/constipation_01. htm Life Extension Foundation Accessed 9/24/11 S Fiber composed of chitin, a component of the shell of shellfish. S Six 500-milligram (mg) capsules of chitosan S Vit C helps transform chitosan in the stomach and intestine into a fat-absorbing gel. Nature Reviews Gastroent and Hep 2011; 8: 306-307 Bowes & Church’s Food Values of Portions Commonly Used, 17th Ed. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  34. 34. Classes of Treatment S Causes water evacuation in 1 – 6 hours S Saline cathartics, PEG solutions, Castor Oil S Causes soft/semisoft stools in 6 – 8 hours S Bisacodyl S Causes softening of stool in 1 – 3 days S Docusate, Psyllium, Lactulose, Mineral Oil Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  35. 35. Bulk Forming Agents/Fiber S “Just add water”: Swell in intestines, lubricate and soften stool. S Note: Water necessary, or risk choking/obstruction! S Best Evidence S mucilage from Ispaghula seeds (Plantago ovata, aka Psyllium, aka Metamucil) S Dosing: start 1 tsp, titrate to effect (~1T). S If Flatulence, consider… S S S S 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
  36. 36. Probiotic Supplements S Five RCTs : 377 subjects S adults (three RCTs, n = 266) S children (two RCTs, n = 111) S In adults, S some organisms favorable effect on defecation frequency and stool consistency. S In children S 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 Copyright (c) 2014 James E. Rose, MD | Peak Nissle 1917 Gastroenterology Associates, PC
  37. 37. Magnesium S HIGH Efficacy (used as bowel prep!) – only caution is renal failure (risk of mag toxicity) generally above 3 grams a day. S Milk of magnesia (1-3 tsp QID) S Antacid activity in low doses: all OH- entering the stomach used to neutralize stomach acid. S 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 S Mag Citrate (Short Term Use) 120-300mL x 1 or 2 S Mag oxide/citrate pills 400-500mg QD Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  38. 38. Stool Softeners S Docusate (Colace) 250 BID – oral use may take 1-3 days to cause effect, enema works within 20-60 min S Emulsifier/emollient: Lowers surface tension of stool (also used as a pesticide and as oil dispersing agent in oil spills…) S However… S Less effective than psyllium S Likely ineffective in chronically ill elderly S Not recommended for long-term use/chronic constipation by Up-To-Date or the American College Gastroenterology Chronic Constipation Taskforce S 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
  39. 39. Stimulant Laxatives S Increase peristalsis by irritating colon S Bisacodyl (Correctol®, Dulcolax®) S Senna (Senokot®, ex-lax) S Long Term Use can lead to S dependency “lazy bowel” S electrolyte disorders (hypo K, Hyper Na) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  40. 40. Per Rectum Medications S Enemas S Fleets S Mineral Oil S Milk S Suppositories S Glycerin S Commonly used in children. Digital stimulation may be actual mechanism. S Bisacodyl/Dulcolax S Stimulant laxative Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  41. 41. Other Treatments S Biofeedback S Colchicine S Misoprostol S Botulinum Toxin Injection S small number trials positive S Zelnorm (is back) 5HT4 S Baby massage S Surgery S Extremely (75%) effective for Pelvic- Floor Dysfunction and outlet-inertia. S Massage S Herbs (lots) Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  42. 42. Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  43. 43. Intestinal Secreatogues S Lubiprostone (Amitiza) S Bicyclic fatty acid derivative S Works on CIC2 Chloride channel activating prostaglandin receptors and CFTR to increase intestinal fluid S Dosages S 24micrograms BID for chronic constipation and 8micrograms BID for IBS-C in women S Linaclotide (Linzess) S 14-amino acid peptide homolog to heat-stable endotoxin S Acts on Guanylyl cyclase C which acts on CFTR to increase intestinal fluid secretion S Dosages S 145-micrograms daily in chronic constipation and 290-micrograms daily in IBS-C Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  44. 44. S Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship - Buddha S “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
  45. 45. Questions? James E. Rose, MD Peak Gastroenterology Associates, P.C. www.peakgastro.com 719.636.1201 Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×