constipiation

1. ConstipationConstipation
Dr Atakan YeşilDr Atakan Yeşil
Gastroenterology DepartmentGastroenterology Department
Yeditepe UniversityYeditepe University

2. ConstipationConstipation
 Epidemiology of ConstipationEpidemiology of Constipation
 Objectives of self-treatmentObjectives of self-treatment
 Nondrug MeasuresNondrug Measures
 OTC medications for the relief of constipationOTC medications for the relief of constipation

3. ConstipationConstipation
 Signs and Symptoms include:Signs and Symptoms include:
 A decrease in the frequency of fecal eliminationA decrease in the frequency of fecal elimination
 Difficult passage of dry hard stoolsDifficult passage of dry hard stools
 Straining to have stoolStraining to have stool

4. ConstipationConstipation
Common medications that can induceCommon medications that can induce constipationconstipation
are:are:
 Narcotic analgesicsNarcotic analgesics
 Calcium-or aluminum containing antacidsCalcium-or aluminum containing antacids
 Drugs with anticholinergic activityDrugs with anticholinergic activity
 Tricyclic antidepressantsTricyclic antidepressants
 Certain calcium channel blockers: ex. VerapamilCertain calcium channel blockers: ex. Verapamil

5. ConstipationConstipation
Can be induced by one of the followingCan be induced by one of the following
diseases:diseases:
 HypothHypothyyroidismroidism
 MegacolonMegacolon
 StrictureStricture
 Diabetes MellitusDiabetes Mellitus
 Irritable Bowel SyndromeIrritable Bowel Syndrome

6. A.Ş.K. Ağrı Şişkinlik Kabızlık

7. Irritable bowel syndrome (IBS)Irritable bowel syndrome (IBS)
 IBS is a functional bowel disorder in which abdominalIBS is a functional bowel disorder in which abdominal
pain or discomfort is associated with defecation or apain or discomfort is associated with defecation or a
change in bowel habit, and with features of disorderedchange in bowel habit, and with features of disordered
defecationdefecation
 10-20% adults in world, female predominant10-20% adults in world, female predominant
 Come and go over time, overlap with other FGIDCome and go over time, overlap with other FGID
 Poor QoL, high heath care costsPoor QoL, high heath care costs
Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

12. Enteric nervous system (ENS)Enteric nervous system (ENS)

13. IBS in femalesIBS in females
VS

14. Sex hormones or genderSex hormones or gender
impacts on brain-gut axisimpacts on brain-gut axis
 AnimalsAnimals
 Low threshold for visceromotor response in rat proestrusLow threshold for visceromotor response in rat proestrus vsvs
estrus phaseestrus phase
 ⇑⇑ potency of opiates topotency of opiates to ⇓⇓ visceromotor response in male ratsvisceromotor response in male rats
 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: malesDifferent areas of brain activation: males vsvs femalesfemales
 Different polymorphism of 5-HT transporter promoter:Different polymorphism of 5-HT transporter promoter:
malesmales vsvs femalesfemales
Ouyang A, et al. Am J Gastroenterol 2006;101:S602-9.

15. Diagnostic criteria for IBS, C1Diagnostic criteria for IBS, C1
 Recurrent abdominal pain or discomfort at least 3 daysRecurrent abdominal pain or discomfort at least 3 days
per month in the last 3 months associated with 2 or moreper month in the last 3 months associated with 2 or more
of the following:of the following:
 ImprovementImprovement with defecationwith 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) of stoolOnset associated with a change in form (appearance) of stool
 Criteria fulfilled for the last 3 months with symptom onset at least 6Criteria fulfilled for the last 3 months with symptom onset at least 6
months prior to diagnosismonths prior to diagnosis
 Discomfort: uncomfortable sensation not described as painDiscomfort: uncomfortable sensation not described as pain
Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

16. Diagnostic criteria for IBSDiagnostic criteria for IBS
 Organik sebepleri dışlaOrganik sebepleri dışla
 Roma II criteriaRoma II criteria
 Son 12 ayda en az ≥12 hafta olan abdominal ağrı ve huzursuzluk veSon 12 ayda en az ≥12 hafta olan abdominal ağrı ve huzursuzluk ve
dışkılama alışkanlığında değişiklik olacakdışkılama alışkanlığında 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 kadarAşağıdaki semptomların bulunması şart değildir, fakat bunlardan ne kadar
çoğu mevcutsa, tanı o kadar kesinleşirçoğu mevcutsa, tanı o kadar kesinleşir::
 AAnormalnormal dışkılama sıklığıdışkılama sıklığı (>3/(>3/güngün veyaveya <3/<3/haftahafta))
 AAnormalnormal dışkı şeklidışkı şekli
 AAnormalnormal dışkı pasajıdışkı pasajı
 Mukus pasajıMukus pasajı
 ŞŞişkinlikişkinlik veyaveya abdominal distansiyonabdominal distansiyon hissihissi

17. Sub-typing IBS bySub-typing IBS by
predominant stool patternpredominant stool pattern
 SubtypeSubtype ((absent use of antidiarrheals or laxativesabsent use of antidiarrheals or laxatives))
 IBS-C (IBS with constipation):IBS-C (IBS with constipation): hard or lumpy stoolshard or lumpy stools >>25% and loose25% and loose
(mushy) or watery stools <25% of BMs(mushy) or watery stools <25% of BMs
 IBS-D (IBS with diarrhea):IBS-D (IBS with diarrhea): loose (mushy) or watery stoolsloose (mushy) or watery stools >>25% and25% and
hard or lumpy stool <25% of BMshard or lumpy stool <25% of BMs
 IBS-M (mixed IBS):IBS-M (mixed IBS): hard or lump stools >25% and loose (mushy) orhard or lump stools >25% and loose (mushy) or
watery stools > 25% of BMswatery stools > 25% of BMs
 IBS-U (unsubtyped IBS):IBS-U (unsubtyped IBS): insufficient abnormality of stool consistency toinsufficient abnormality of stool consistency to
meet criteria for IBS-C, D, or Mmeet criteria for IBS-C, D, or M
 StoolStool form:form: BristolBristol scalescale
Longstreth GF, et al. Gastroenterology 2006;130:1480-91.

20. Alarm symptoms in IBS diagnosisAlarm symptoms in IBS diagnosis
 Age of onset over 50 yrsAge of onset over 50 yrs
 Progressive or very severe non-fluctuating symptomsProgressive or very severe non-fluctuating 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.

22. Patient AssessmentPatient Assessment
 Obtain lifestyle and medical history beforeObtain lifestyle and medical history before
making any recommendationsmaking any recommendations
 Determine the reason for use of a laxativeDetermine the reason for use of a laxative
productproduct
1. To relieve constipation1. To relieve constipation
2. To evacuate the bowel prior to an upcoming2. To evacuate the bowel prior to an upcoming
radiologic or endoscopic examinationradiologic or endoscopic examination
 Inquire about the patient’s current and pastInquire about the patient’s current and past
use of laxative productsuse of laxative products

23. Refer When……Refer When……
 Symptoms have persisted for more than 2 weeksSymptoms have persisted for more than 2 weeks
 Have recurred after previous dietary or lifestyleHave recurred after previous dietary or lifestyle
changes or laxative usechanges or laxative use
 Patients who admit to blood in the stoolPatients who admit to blood in the stool

24. Objectives for Self TreatmentObjectives for Self Treatment
To relieve constipation and restore “normal”To relieve constipation and restore “normal”
bowel functioning using:bowel functioning using:
 Dietary and Lifestyle measuresDietary and Lifestyle measures
 Using OTC medications for the relief ofUsing OTC medications for the relief of
constipationconstipation

25. Nondrug MeasuresNondrug Measures
includeinclude
 High fiber diet: foods high in wheat grains, oats,High fiber diet: foods high in wheat grains, oats,
or fruits & vegetablesor fruits & vegetables
 Adequate fluid intakeAdequate fluid intake
 ExerciseExercise
 Avoid foods that cause constipation: processedAvoid foods that cause constipation: processed
cheeses & concentrated sweetscheeses & concentrated sweets

26. Non Prescription MedicationsNon Prescription Medications
Types of laxativesTypes of laxatives::
 Bulk Forming LaxativesBulk Forming Laxatives
 EmollientEmollient
 LubricantLubricant
 SalineSaline
 HyperosmoticHyperosmotic
 StimulantStimulant

27. Bulk Forming LaxativesBulk Forming Laxatives
 Derived from agar, or psyllium seedDerived from agar, or psyllium seed
 Synthetic examples used today areSynthetic examples used today are
methylcellulose & carboxymethyl cellulosemethylcellulose & carboxymethyl cellulose
sodiumsodium
 Dissolve in the intestinal fluid, thus creatingDissolve in the intestinal fluid, thus creating
emollient gels that increase passage of theemollient gels that increase passage of the
intestinal contentsintestinal contents
 Stimulate peristalsisStimulate peristalsis
 No systemic absorptionNo systemic absorption

28. Bulk Forming LaxativesBulk Forming Laxatives
 Onset of action is 12-24hrsOnset of action is 12-24hrs
 Resemble the physiologic mechanism inResemble the physiologic mechanism in
promoting evacuationpromoting evacuation
 Are the FIRST choice of therapy forAre the FIRST choice of therapy for
constipationconstipation
 Examples are: Citrucel powder, Metamucil,Examples are: Citrucel powder, Metamucil,
Mitrolan Chewable TabletsMitrolan Chewable Tablets

29. Bulk Forming LaxativesBulk Forming Laxatives
 Use caution in patients that are younger than 6Use caution in patients that are younger than 6
yrs of ageyrs of age
 Avoid in pts with intestinal ulcerations, stenosisAvoid in pts with intestinal ulcerations, stenosis
 Interact with anticoagulants, digitalis glycosides,Interact with anticoagulants, digitalis glycosides,
and salisylatesand salisylates
 Not used for a fast clearing effect before aNot used for a fast clearing effect before a
diagnostic procedurediagnostic procedure

30. Emollient LaxativesEmollient Laxatives
 Are anionic surfactants that eventually lead to theAre anionic surfactants that eventually lead to the
softening of the stoolsoftening 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 preventMajor use is as a stool softener, & to prevent
constipation and maintain regularityconstipation and maintain regularity
 Example : Docusate sodiumExample : Docusate sodium
 Avoid in pts with who have nausea, vomiting, orAvoid in pts with who have nausea, vomiting, or
undetermined abdominal painundetermined abdominal pain

31. Lubricant LaxativesLubricant Laxatives
 Prevent colonic absorption of fecal water, thus softenPrevent colonic absorption of fecal water, thus soften
the stoolthe stool
 Are minimally absorbedAre minimally absorbed
 Onset of action (oral) 6-8 hrs, (rectal) 5-15 minOnset of action (oral) 6-8 hrs, (rectal) 5-15 min
 Avoid prolonged useAvoid prolonged use
 Can cause malabsorption of fat-soluble vitaminsCan cause malabsorption of fat-soluble vitamins
 Example: Mineral oil ( only)Example: Mineral oil ( only)

32. Saline LaxativesSaline Laxatives
 Nonabsorbable cations & anions that draw water intoNonabsorbable cations & anions that draw water into
intestine causing an increase in intraluminal pressure,intestine causing an increase in intraluminal pressure,
which stimulates intestinal motilitywhich stimulates intestinal motility
 Are systemically absorbedAre systemically absorbed
 Onset of action (oral)30min-3 hrs,(rectal) 2-5minOnset of action (oral)30min-3 hrs,(rectal) 2-5min
 Used ONLY when fast clearance of the bowel isUsed ONLY when fast clearance of the bowel is
requiredrequired
 Ex:Citroma, Fleet Ready-to-Use EnemaEx:Citroma, Fleet Ready-to-Use Enema
 Avoid in pts with CHF, ileostomy, renal functionAvoid in pts with CHF, ileostomy, renal function
impairment, or younger than 6 yrs oldimpairment, or younger than 6 yrs old

33. Hyperosmotic LaxativesHyperosmotic Laxatives
 Combine an osmotic effect with local effect ofCombine an osmotic effect with local effect of
sodium sterate, which draws water intosodium sterate, which draws water into
rectumrectum⇒⇒bowel 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 (only)Example: Glycerin suppositories (only)
 Avoid in pts with rectal irritationAvoid in pts with rectal irritation

34. Stimulant LaxativesStimulant Laxatives
 Come from 2 classes: anthraquinone (ex:senna) &Come from 2 classes: anthraquinone (ex:senna) &
diphenylmethane ( bisacodyl)diphenylmethane ( bisacodyl)
 Increase the propulsive peristaltic activity of theIncrease the propulsive peristaltic activity of the
intestine by local irritation of the mucosa which leads tointestine by local irritation of the mucosa which leads to
increased motilityincreased motility
 Onset of action senna (PO) 8-12 hrsOnset 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 bowel priorMajor use: for thorough evacuation of the bowel prior
to GI surgery or examinationto GI surgery or examination

35. Stimulant LaxativesStimulant Laxatives
 Examples: Sennakot, Sennakot S (with sodiumExamples: Sennakot, Sennakot S (with sodium
docusate), Exlax, Dulcolaxdocusate), Exlax, Dulcolax
 Interact with H1 blockers, antacids if administeredInteract with H1 blockers, antacids if administered
within 1 hrwithin 1 hr
 Avoid in pregnancyAvoid in pregnancy
 Pts who are breast feeding & taking senna laxative havePts who are breast feeding & taking senna laxative have
reported a brown discoloration of breast milkreported a brown discoloration of breast milk
 Adverse effects with regular use are severe cramping,Adverse effects with regular use are severe cramping,
electrolyte & fluid deficiencies, metabolicelectrolyte & fluid deficiencies, metabolic
acidosis/alkalosis, and othersacidosis/alkalosis, and others

36. Patient CounselingPatient Counseling
 Laxative use to treat constipation should be onlyLaxative use to treat constipation should be only
on a temporary measureon a temporary measure
 If laxatives are not effective after 1 week, aIf laxatives are not effective after 1 week, a
physician should be consultedphysician should be consulted