This document discusses a 84-year-old female patient with a history of chronic constipation managed for 10 years with laxatives including Colace, senna, and glycerine suppositories. It reviews the potential for laxative abuse, defined as repeated misuse or overuse leading to dependency and decreased bowel function. Key signs of abuse include dosing too frequently, overdosing, or using multiple types together. Complications can include electrolyte disturbances, metabolic disturbances, and bowel and kidney issues. The role of dietitians in assessing laxative use patterns and monitoring for abuse or disordered eating is discussed. It is unclear if this patient's laxative use represents abuse or is appropriate management of

1. Chronic Constipation and
Laxative Abuse
LAURA HUTCHINSON
DIETETIC INTERN
BENEDICTINE UNIVERSITY

2. Patient Profile
 Age: 84
 Gender: Female
 Race: Caucasian
 Height: 4’11
 Weight: 95 lb
 Changes in Weight: 5# weight loss in previous 2 months.
 BMI: 19.1 (WNL)
 Social hx: Married, Jewish, retired, lives at home.
 Current medical diagnoses: Small bowel obstruction d/t
adhesions, chronic renal insufficiency, chronic
constipation/obstipation

3. Patient Hx
 Past dx: B12 deficiency anemia, pure
hypercholesterolemia, chronic kidney disease stage
III, gastric ulcer, osteoporosis, depression, closed
Colles’ fx of right arm, hiatal hernia, breast cancer,
endometrial cancer, hypertension
 Nutrition hx: Follows Kosher diet. Severe, chronic
constipation x 10 years.

4. Interrelationships of Medical Dx
Hypertension  CKD Stage III


Anemia

Osteoporosis



Increased Age Fluid Restriction Small Stature Mobility

Depression



Chronic Constipation

Laxative Abuse?

5. Nutrition Diagnoses
 Altered GI Function related to Chronic
Constipation/Obstipation as evidenced by
patient need to supplement with Colace,
Senna, and Glycerine suppositories to have a
normal bowel movement.
 Inadequate oral intake related to poor appetite secondary to abdominal
distension and chronic constipation as evidenced by 25-50% intake at
meals per patient and dietitian.
 Altered GI Function related to Small Bowel Obstruction as evidenced
by CT scan of pelvis/abdomen.

6. Back to this Nutrition Dx..
 Altered GI function related to chronic
constipation/obstipation as evidenced by
patient needs to supplement with Colace,
senna, and glycerine suppositories to have a
normal bowel movement.
Is this normal laxative use?

7. What is Laxative Abuse?
 Laxative abuse is the repeated misuse and overuse of
laxatives involving





Dosing too frequently
Overdosing
Using laxatives for non-intended reasons (such as weight loss)
Using multiple types of laxatives at once
Using the wrong type of laxative (such as a purgative laxative
when a stool softener would have been appropriate)
 Overuse can lead to dependency and a decrease in
bowel function
(Fruit Eze)

8. Types of Laxatives
 Bulk-Forming Laxatives
 Saline Laxatives
 Osmotic Laxatives
 Surfactant Laxatives 
 Lubricants
 Stimulant Laxatives
 Diphenylmethane derivatives
 Anthraquinone derivatives
(Roerig)

9. Profile of a Laxative Abuser
 Eating Disorder patients





Histrionic personality traits
Lower self-esteem
Lower “self-liking”
Weight and shape concerns
Depression
 Middle aged or older adults

Perceived poor physical health
 Athletes in sports with
weight limits
 Factitious disorder patients
 Comorbidities
(Roerig, Steffen, Pryor, Harari, Surgenor, Weltzin)

10. A Vicious Cycle
–with
dehydration, the
reninangiotensin
system kicks in,
following by
rehydration and
water weight
gain
Complications
(Roerig)

11. Electrolyte
Disturbances
Metabolic
Disturbances
Bowel
Disturbances 
Kidney
Disturbances
Complications
(Roerig, Cummings, Copeland)

12. Diagnosis
 Practitioner’s suspicion
 Melanosis Coli
 GI symptoms
 Serum hypokalemia
 Fecal electrolytes
 Stool osmotic gap : 290 – 2* (Stool Na + Stool K)
(Roerig)

13. Role of the Registered Dietitian
 Identify patient’s bowel
patterns.
 Identify type and frequency of
laxative use.

Be specific – patients will not always
willingly offer this information.
 Check labs, electrolytes, and
fluid status.
 Monitor for disordered eating
patterns or disordered bowel
regimens.

14. Treatment/Monitoring
 Education
 Appropriate treatment for eating disorders
 Risks?
 Goals of treatment:
 Stop laxative abuse
 Maintain healthy GI Function
 Weight trends
 Labs and other nutritional parameters

15. Is this patient abusing laxatives?
YES. But, is it an eating disorder, or is she just
an older adult with constipation?
 Anxiety/depression issues
 Rigid bowel regimen
 Renal failure
 Aging
 Poor appetite

16. References
Copeland PM. Renal failure associated with laxative abuse. Psychother
Psychosom. 1994;62:200-202.
Cummings JH, Sladen GE, James OF et al. Laxative-induced diarrhoea: a
continuing clinical problem. BMJ. 1974;23:537-541.
Escott-Stump S. Nutrition and Diagnosis Related Care Seventh Edition.
2012. Baltimore: Lippincott, Williams, and Wilkins.
Fruit-Eze. Laxative Abuse and the Laxative Habit. 2003. Retrieved on May
7, 2013 from http://web.pdx.edu/~sujata/FruitEzeWeb/education/
laxative/habit.html
Harari D, Gurwitz JH, Avor J et al. Constipation: assessment and
management in an institutionalized elderly population. J Am
Geriatric Soc. 1994;42:947-952.
Mahan LK, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition
Care Process Thirteenth Edition. 2010. St. Louis: Elsevier Saunders.
Mikrut R, Groetsma C et al. Clinical Dietetic Reference Pocket Guide. 2010.
Hines: Edward Hines Jr. Hospital Department of Veterans Affairs
Pagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference
Tenth Edition. 2011. St. Louis: Elsevier Mosby.

17. References
Pronsky ZM, Crowe JP. Food Medication Interactions Seventeenth Edition.
2012. Birchrunville: Food Medication Interactions.
Pryor T, Widerman MW, McGilly B. Laxative Abuse Among Women With
Eating Disorders: An Indication of Pathophysiology? Int J Eat Disord.
1996;20(1):13-18.
Roerig JL, Steffen KJ, Mitchell JE, Zunker C. Laxative Abuse: Epidemiology,
Diagnosis, and Management. Drugs. 2010;70(12):1487-1503.
Steffen KJ, Mitchell JE, Roerig JL. The eating disorders medicine cabinet
revisited: a clinician’s guide to ipecac and laxatives. Int J Eat Disord
2007;40:360-368.
Surgenor LJ, Maguire S, Russel J, et al. Self-liking and aself-competence:
relationship to symptoms of anorexia nervosa. Eur Eat Disord Rev.
2007;15:139-145.
Weltzin TE, Bulik CM, McConaha CW et al. Laxative withdrawal and anxiety in
bulimia nervosa. Int J Eat Disord. 1995;17:141-146.
Wilson BA, Shannon MT, Shields KM. Pearson Nurse’s Drug Guide. 2013.
Upper Saddle River: Pearson Education.