constipation, definition, management , lifestyle modification, high risk factors, diet and lifestyle modifications, diet, pharmacotherapy, medications, opiods, surgical corrections,laxatives, bulk forming agents, lactulose,

1. CONSTIPATION
 DR BHAVIN MANDOWARA


2. MANAGEMENT
Lifestyle modification
Diet and fiber
Laxatives
- Bulk forming laxatives
- Osmotic laxatives
- Stimulant laxatives
Stool softeners, suppositories, and
enemas
Other therapies for chronic
constipation
- Colonic secretagogues
- Opioid antagonists
- 5HT(4) receptor agonists

3. APPROACH CONSIDERATIONS
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Manual disimpaction of stool should be considered only after
critical illness asocaited constipation has been ruled out
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Medical care should focus on dietary change and exercise .
Correctionof dietary deficiency and aerobic exercise
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Surigcal care is generally restricted to evaluation of underlying
causes or management of acute complication of
constipation.
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4. HIGH RISK FACTORS
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UNCERTAIN DIAGNOSIS
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EVIDENCE OF INTRA-ABDOMINAL CATASTROPHE
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SEVERE ABDOMINAL PAIN
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FEVER , CHILLS
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LOWER GI BLEED
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INSTABILITY OF VITAL SIGNS
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ABSENCE OF BOWEL SOUNDS
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ACUTE RECENT CHANGE IN BOWEL SOUNDS
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5. DIETARY AND LIFESTYLE MEASURES
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FIBER : NATURAL -->FRUITS , VEGETABLES , AND CEREALS
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FIBER SUPPLEMENT : WHEAT , PSYLLIUM OR METHYLCELLULOSE
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DAILY FIBER OF ABOUT 20-25G/DAY IS RECOMMENDED
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FIBERS ARE GOOD FOR LONG TERM USE AS COMPARED TO
STOOL SOFTNERS IN WHICH TACHYPHYLAXIS DEVELOPS .
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FIBRES SHOULD BE GRADUALLY TITRATED UP AS TO PREVENT SIDE
EFFECTS OF FLATULENCE AND BLOATING
●
PATIENT MUST BE EXPLAINED THAT IT HAS TO BE TAKEN DAILY AS
ONSET OF ACTION MAY TAKE WEEKS .
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INCREASE FLUID INTAKE OF ATLEAST 8 GLASSES PER DAY ,
DECREASE MILK , TEA , COFFE , ALCOHOL
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6. PHARMACOLOGIC THERAPY
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BULK FORMING AGENTS/LAXATIVES – includes psyllium
,methylcellulose , wheat dextran, act by absorbing water
and increasing fecal mass , best , least expensive but has
to be used for long term
●
EMOLLIENT STOOL SOFTNERS - eg include docusate which acts
as a surfactant . It is easier to use but lose effectiveness with
long term administeration and hence are reserved for short
term setting like post op narcotic prescription
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RAPIDLY ACTING LUBRICANTS – includes PEG(polyethylene
glycol , bisacodyl and sodium picosulfate v , long term term
riskof habituationor toxicity is there
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PROKINETICS – cisapride , tegaserod are 5HT4 antagonist ,
increase colonic motility and decrease transit time . They
have been withdrawn
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7. LAXATIVES
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Laxative usage in the older adults should be individualizedkeeping in
mind the patient's history (cardiac and renal comorbidities),drug
interactions, cost, and side effects
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OSMOTIC LAXATIVES : USED IN PATIENTS NOT RESPONDING TO BULK
LAXATIVES
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PEG: Low-dose polyethylene glycol (PEG) (17 g/day) has been
demonstrated to be efficacious and well tolerated in older
patients . However,high-dose PEG (34 g/day) is associated with
abdominal bloating, cramping,and flatulence, and older adults
may be more susceptible to these side effects
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LACTULOSE increases stool frequency, decreases the severity of
constipation symptoms, and reduces the need for other laxatives
in older adult patients
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SORBITOL : less expensive and better tolerated
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8. LAXATIVES
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Saline laxatives such as magnesium hydroxide have not been
examined in older adults, and should be used with caution
because of the risk of hypermagnesemia.
●
Stimulant laxatives — Stimulant laxatives affect electrolyte
transport across the intestinal mucosa and enhance
colonic transport and motility.

9. OSMOTIC AGENTS/COLONIC
SECRETAGOGUES
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Lubiprostone is an oral bicyclic fatty acid that activates the
type 2 chloride channels on the intestinal epithelial
cells,thus secreting chloride and water into the gut
lumen .It is best reserved for patients with severe
constipation in whom other approaches have been
unsuccessful.
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IT HAS BEEN APPROVED BY FDA FOR CHRONIC IDIOPATHIC
CONSTIPATION , IBS-C , OPIOD INDUCED CONSTIPATION
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ADVERSE EFFECTS INCLUDE FLATULENCE , NAUSEA AND
DIARRHOEA
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other agent Linaclotide is a guanylate cyclase C receptor
agonist that stimulates intestinal fluid secretion and
transit . Approved by the FDA for use in the treatment of
chronicidiopathic constipation, the long-term risks and
benefits of linaclotide,especially in older adults, remain to
be determined

10. OPIOD ANTAGONIST
●
Opioid antagonists — Two peripherally acting mu opioid
receptor antagonists, alvimopan and methylnaltrexone ,
may have a role in treatment of narcotic-induced
constipation and paralytic ileus, but data are lacking
among older adults. As these opioid receptor antagonists
act peripherally and do not cross the blood brain barrier,
they do not impair the analgesic effects of opioids.

11. SURGICAL CORRECTION OF
CAUSE AND COMPLICATIONS
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FOR EVALUATION OF UNDERLYING CAUSE -LARGE BOWEL
OBSTRUCTION , VOLVULUS ,INTRABDOMINAL
INFECTION/ISCHEMIA , HEMORRHOIDAL THROMBUS
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RECTAL OUTLET OBSTRUCTION , RECTOCELE , RECTAL
PROLAPSE , RECTAL INTUSSUSCEPTION
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HYPOMOTILE COLON REFRACTORY TO MEDICAL THERAPY.
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12. MANAGEEMNT IN SPECIAL
PATIENTS
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PREGNANCY :
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CAUSE : DIETARY CHANGES ,
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ANATOMIC IMPINGEMENT BECAUSE OF LARGE UTERUS
PRESSING ON RECTOSIGMOID
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HEMORRHOIDS BECAUSE OF VENOUS CONGESTION
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TREATMENT : FIBRE , WATER , GENTLE EXERCISE , OCCASIONAL
LACTULOSE
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IF HEMORRHOIDS ARE THERE THEN SUPPOSITOERY AND SITZ
BATH WILL BE REQUIRED

13. MANAGEMENT IN SPECIAL
PATIENTS
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ELDERLY : MEDICATIONS ARE TO BE ESPECIALLY ASKED WHICH
CAUSE CONSTIPATION AND ALSO SELF REPORTED
CONSTIPATION IS HIGH
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TREAMENT INCLUDIING DIET AND EXERCISE IS USUALLY
INSUFFICIENT AND CHRONIC LAXATIVE USE IS OFTEN
REQUIRED .
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MENTALLY INCAPACITATED INDIVIDUALS THERE IS PATTERN OF
BOWEL RETENTION IN WHICH SHORT TERM USE OF LAXATIVE
OR STOOL SOFTENERS IS REQUIRED
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14. MANAGEMENT IN SPECIAL
PATIENTS
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OPIOD INDUCED CONSTIPATION(OIC)
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40-80% EXPERIENCE CONSTIPATION
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SOME HAVE SEVERE ENOUGH TO STOP OPIODS ALSO
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MECHANISM: OPIOD BINDS TO PERIPHERAL OPIOD RECEPTOR
AND DECREASES GI TRACT FLUID
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TREATMENT : LUBIPROSTONE- ADULTS WITH OIC WITH NON
CANCER PAIN INHIBITS CIC-2 CL- CHANNEL
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OTHER AGENTS INCLUDE NALOXEGOL AND
METHYLNALTREXONE

15. SURGICAL CONSULTATION
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LARGE BOWEL OBSTRUCTION
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COLONIC ILEUS SECONDARY TO INTRABDOMINAL PROCESS
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ANORECTAL COMPLICATIONS
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HEMORRHOIDS , FISSURE
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ACUTE HEMORRHOIDAL THROMBOSIS
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CHRONIC NON HEALING FIISURE
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PERIRECTAL ABSCESS AND FISTULA