This document discusses constipation and provides information about its causes, symptoms, and treatments. It defines constipation as a decrease in stool frequency and discusses normal ranges. Common causes include inadequate water/fiber intake, disruption of diet/routine, lack of exercise, stress, loss of bowel function, and laxative overuse. Symptoms are abdominal bloating, hard stool, headache, and rectal fullness. The document also covers hemorrhoids, provides guidelines for when to see a doctor, and discusses appropriate lifestyle modifications and treatment options for constipation.

1. Constipation
&
Hemorrhoids

3. Question no.1
I am 30 years old and my stool
frequency decreased from three
times per day to once every two
days,
Am I constipated?
What are the major symptoms
of constipation?

4. Constipation
Decrease in frequency of fecal
elimination.
Hard, dry and sometimes painful.
Normal stool frequency range
( 3 times / day : 3 times / week )

5. Causes
Inadequate water intake.
Inadequate fiber in the diet.
A disruption of regular diet or routine; traveling.
Inadequate exercise or immobility.
Stress and overuse of laxatives.
Loss of defecatory mechanism .

6. Symptoms
Abdominal Bloating.
Headache. Hard stool.
Low back pain ± rectal fullness.
Straining.
Vomiting may occur.

7. Question no.2
Constipation may be a sign for
many serious health problems,
( When to refer to a physician? )

8. 1. Constipation + abdominal pain + nausea / vomiting
( Appendicitis )
2. Constipation + rectal bleeding or sudden change
in bowel habbits (2 weeks )
( Cancer )
3. Constipation following recent abdominal surgery
( Ileus = Lack of peristalsis )
4. Colostomy or ileostomy.

10. Colostomy

11. Ileostomy

12. Question no.3
My mother suffers from abdominal
discomfort as a result of constipation
but she refuses taking laxatives,
Could you tell me the appropriate life
style modifications for her to follow?

14. Question no.4
What are the factors
predisposing both elderly people
and pregnant women to
constipation?

15. Elderly
Lifelong laxative abuse,
Immobility,
Chronic illness and medication use,
Poor nutrition,
Reduce fluid intake.

16. Pregnancy
*High progesterone level,
*Uterus may compress the intestine,
*Decrease exercises,
*Iron and calcium intake .

17. Question no.5
Mention health problems that
may lead to constipation?

18. **Pain
**Parkinsonism
Abnormal gut motility
Rigid abdominal muscle
Progressive general immobility
**Diabetes
High blood glucose level
nerve damage
**Carcinoma
-Constipation + discomfort
anorexia
weight loss Colorectal Carcinoma
tenesmus
blood in the stool
-Tumors
**Inert colon
**IBS
**Chronic renal failure

19. Question no.6
Is there a relationship between
anal disorders as abscesses and
constipation?

20. Anal disorders
Anal fissures
Anal fistula
Perianal abscesses
Hemorrhoids

21. Question no.7
I heard that is a medical condition
called "Colonic Inertia“,
What it is?
What are its causes?
How is it treated ?
How diet can affect colonic motility ?

23. Colonic inertia
Is referred to a motility disorder.
It is an abnormal passage of waste through
the digestive system .
Stool may remain stored in portions of the
colon and not progress adequately to the
part of the colon (Rectosigmoid) responsible
for the propulsion and transfer of stool out
of the body.

24. Symptoms of colonic inertia
•Constipation.
*Individuals with colonic inertia often do not pass
a stool for 7–10 days at a time.
*Sometimes colonic inertia is accompanied by
abnormalities in motility of the upper intestine
including delayed emptying of the stomach and
small intestinal pseudo-obstruction (a disorder
that causes symptoms of blockage, but no actual
blockage).

25. •Diarrhea
•Abdominal pain
•Bloating
•Nausea
•Vomiting
•Bloody discharge
Symptoms of colonic inertia (cont.)

26. Causes
•Nerve or Muscle damage.
•Hypothyroidism.
•Diabetes.
•Some rheumatologic conditions may also
decrease the function of the nerves and
muscles within the colon and produce
severe constipation.

27. •Not enough water in a person's diet.
•Eating too much diary products.
•Frequent use of antacids and laxatives.
•Strong pain killers and other medication.
•Thyroid conditions.
Causes (cont.)

28. Diagnosis of colonic inertia
Transit time measurement test to
determine the speed at which the body
moves food through the digestive system.
This test may, in fact, point towards
causes that are not even related to colonic
inertia, such as low thyroid hormone levels.

29. Treatment
•Eating foods high in fiber.
•Motility enhance by carbohydrates and
limiting proteins.
•Drinking plenty of water.
•Avoiding dairy products.
•Avoiding fatty foods.

30. Surgical treatment
Surgically shortening the colon (large
intestine) corrects a slow colon.
Most of the colon is removed (80 %), and
the small intestine is attached directly to
the rectum.
The technical term for the operation is
“Total abdominal colectomy and ileorectal
anastomosis".

32. Question no.8
I am taking Heama caps® for anemia ,
could that be the cause for constipation I
am suffering from,
What can I do to alleviate this side effect?
Can you recommend me other iron
formulations from the market that wouldn’t
cause this problem?
What are other drugs that can cause
constipation ?

34. Each capsule contains:
Ferrous fumarate...............350 mg
Folic acid..............................2 mg
Vitamin C...........................50 mg
Vitamin B12......................7.5 mcg
Vitamin E acetate.................5 mg
Copper..............................2.5 mg
Manganese........................2.5 mg
Vitamin B1..........................15 mg
Vitamin B2............................2 mg
Vitamin B6..........................10 mg
Vitamin D..........................400 i.u.
Calcium gluconate................75 mg
Linoleic acid.......................200 mg
Linolenic acid.......................45 mg
Taurine...............................15 mg

36. *Most of iron preparations may induce
GIT disorders;
Abdominal pain.
Bloating.
Constipation.
Dark in stool.
due to there absorption problem.

37. To alleviate this side effect try to :
Take after meals .
Take absorption enhancers like;
•Vitamin C is a powerful enhancer of
absorption of non-heme iron.
•Animal proteins: meat, fish, or poultry
Taken other iron formulations .

38. Oral Iron formulations;
•Elemental iron .
•Iron salts (ferrous , ferric ) ;
Sulfate Succinate
Fumarate Gluconate
•Iron complexes :
Amino acid chelates,
Disaccharides,
Polysaccharides

39. 1) Carbonyl iron ;
Dissolve in gastric secretion.
Convert to hydrochloric salts prior to
absorption in the stomach.
Absorption rate is slow, which permits
continued release of iron for 1 to 2 days.

40. 2) Ferrous glycine sulphate complex;
An iron-amino acid chelate relatively high
bioavailability.
The conjugation of ferrous iron with amino
acid prevents the iron from forming insoluble
ferric hydroxide in the small intestine.

41. May be less likely to cause GI intolerance
than ferrous sulfate.
e.g. Ferrosanol duodenal®
Ferric with EDTA acting as sustain
release formulation of low absorption
rate
e.g. Sytron®
2) Ferrous glycine sulphate complex;

42. 3) Iron poly saccharides;
e.g. Ferric hydroxide poly maltose
Haemojet®

43. E.g. Iron hydroxide poly maltose
Hydroferrin
Promoted to cause less GI irritation .
Similar bioavailability as ferrous sulfate.
Ferric iron is complexed to hydrolyzed
starch, making it tasteless and odorless.

44. Drugs that cause constipation:
Narcotic analgesics.
Diuretics.
Anticonvulsants.
Sympathomimetics or Anti_cholinergics.
Antihistaminic.
Antacids (containing Calcium, Aluminium).
H2 blocker.
TCA.
Nonprescription medication as Iron
supplement.

45. Question no.9
I have constipation and want to
know the different classes of
drugs that I can use for treatment.
Enumerate with examples.

46. Classes of laxatives ;
Bulk forming laxatives.
Emollient laxatives.
Lubricant laxatives.
Stimulant laxatives.
Osmotic laxatives.

47. Bulk forming laxative :
Poly saccharides derivatives
Types
Natural
Synthetic

48. 1) Natural
Psyllium Bran
Regumucil® sachets Bran® tablets

49. N.B.
Delay gastric emptying and depress
appetite in some patients.
In addition, esophageal and intestinal
obstruction and asthmatic reactions from
psyllium have been reported.
Fermentation occurs by intestinal bacteria
resulting in gas production and flatulence.

50. 2) Synthetic
Methyl cellulose
Citrucel®
Calcium polycarbophile
Evak® tablets
Evaculaxe® capsules

51. N.B.
Calcium may impair absorption of
tetracycline if taken concurrently.
Metabolically inert and resistant to
bacterial fermentation.

52. 2) Emollient laxative :
They act as surfactants by allowing
absorption of water into the stool makes
the softened stool easier to pass.
They are salts of Docusate.
Another names ( DSS, Aerosol OT ,
Dioctyl sodium sulfosuccinate).

54. 3) Lubricant laxative
They work at the colon to
increase water retention.
They coat stool.
They prevent water removal
from stool.
Mineral oils ( Liquid paraffin)

55. 4) Stimulant laxative:
They work in small and large intestine.
They stimulate bowel motility.
They increase secretion of fluids into
the bowel through nerve stimulation.
Stimulate prestaltic movement .

56. Examples
1) Anthraquinone laxative
as senna
Warning:
may discolor the urine with (pink to red or
brown to black).

57. Examples ;
2) bisacodyl :
It is diphenylmethane derivatives.
Bisadyl® tablets and suppositories.

58. Examples ;
3) Castor oil

59. 5) Osmotic laxative:
They are substances that work by
creating osmotic gradient to pull water
to small and large intestine,
Increase stool volume resulting in
distention of the intestinal lumen,
Causing increase peristalsis and bowel
mobility.

60. Examples
1) Glycerin:
Irritating the rectum .
The drug of choice for pediatrics and
geriatrics patients.

61. Examples ;
2) Enema :
Locally acting,
Rapid,
Less toxic.

62. Examples ;
3) Lactulose ;
Duphlac® syp. Lactulose® syp.
Used for hepatic failure patients .

63. Examples ;
4) Sorbitol :
It is non absorbable sugar,
Similar efficacy to lactulose.
Administrated
Orally 70% solution.
Rectally 25% solution..

64. Examples ;
5)poly ethylene glycol 3350:
FDA switched it to relief of occasional
constipation .

65. Examples ;
6) Saline laxative
•Magnesium citrate •Sodium phosphate.
•Magnesium sulphate.

67. Question no.10
My wife is pregnant she is complaining of
constipation if you don’t mind
Recommend her the appropriate
medication illustrating How it work onset
of action?
How to use it properly demonstrating
ToWhich class it belongs giving examples
and subtypes?

68. Class: Bulk laxative (category B)
Sub type : Natural (psyllium)
MOA: natural polysaccharide derivative
that absorb water to soften the stool
increase bulk which stimulate perstalisis.

69. Drug interaction:
Bulk laxative may reduce the effect of
some medication.
Make dose spacing
not less than 2 hours.
Contraindication:
GIT blockage & Appendicitis

70. Onset of action
Slow onset (12-24) hr.
How to use:
Dose:1*1
Must given with cup of water
to prevent obstruction.

71. Question no.11
My grand father is taking many medications
for his CHF and rheumatic pain,
Can he take Regumcil® sachets and Epsom
salt for constipation?

72. Regumucil® : bulk laxative.
It may reduce the effectiveness of
digitalis and warfarin.
Dose spacing is essential.

74. Epsom salt: ( magnesium sulfate)
Class: saline laxative (osmotic)
MOA:
It drawn the water to the colon by osmosis
Soften the stool and make easy to pass.
Contraindication:
Appendicitis GIT blockage Kidney disease
High level of Mg Low level of Na

75. Patient counselling:
Drink a lot of water with Epsom® salt to
prevent dehydration
Not used for long time
Should make dose spacing not less than 2
hours between other medication as it
affect absorption of medication.

76. Epsom salt is contraindicated in the case
of your grand father,
It may elevate level of Mg serum;
Hypocalcemia.
Arrythmia.
Bradycardia.
Ca blocker.

77. Question no.12
My grandmother is constipated
but, cannot swallow oral tablet,
What other dosage forms are
available?

78. Other dosage form :
Sachet : Regumucil®

79. SUPPOSITORY: Glycerin

80. Syrup : Lactulose®

81. Enema

82. Question no.13
My baby is usually straining during
defecation,
What is the best OTC medication for his
condition? How it works?
Administration guidelines, adverse
effects and contraindications if any?

83. •Stool softeners :
Glycerin suppositories.
•Mechanism of action :
Stimulates net secretion of water,
sodium, chloride, and potassium and inhibits
net absorption of glucose and bicarbonate in
the jejunum.
•Adverse effects :
local irritant effects.

84. Question no.14
My friend suggests me enema as rapid
treatment for constipation,
What do they contain?
What are their advantage and
disadvantages?

85. •Enema contain :
Sodium biphosphate + sodium phosphate.
•Advantage:
Treatment of constipation.
Clean the bowel before colon surgery&
endoscopy examination.

86. Disadvantages:
Cramps in stomach.
Irritation in rectal area.
Vomiting & severe diarrhea.
Reduce muscle tone in anal sphincter.
Dependence.

87. N.B.
Enema Shouldn't be used more
than one time in 24 hours.
Using too much of this medicines
can cause rare but life
threatening side effects on your
and heart electrolyte balance.

88. Question no.15
My grandfather suffers from hepatic
encephalopathy, I heard some laxatives
are used for treatment of this condition .
Is that true?
and if so what's their mechanism of action
and their precaution concerning it is use?

89. What is the hepatic encephalopathy?
Senna increase the risk.
Lactulose.
Colonic acidification.

90. Precaution:
If you have stomach pain, vomiting, muscle
cramps, dizziness or weakness, stop taking the
lactulose and call your doctor right away.
If you should experience any signs of an allergic
reaction like difficulty breathing, swelling of your
face, lips, tongue or throat seek emergency
medical help.

91. If you are having more bowel
movements, you may be dehydrating
yourself, and taking more lactulose than
you need. Finding the right dose of the
lactulose.
•Lactulose can be used long-term to
reduce the risk of having Hepatic
Encephalopathy recurrences.

92. Question no.16
My brother suffer from chronic
constipation he starts talking ( Purgation® )
tablet on regular basis first the condition
improved but now the case is worse,
What do you think?

93. •Purgaton®
natural glycosides as sennosides A&B
•MOA of Purgaton®:
-Stimulant laxative.
-It increases the motility of intestine using
more than 2 weeks cause lazy bowel syndrome.

94. Uses of Senna:
-Mildest of the stimulant laxatives
-Less pronounced laxative effect than the
violent purgation produced by castor oil.

95. Disadvantages :
Chronic use or over dosage of laxatives
may produce persistent diarrhea,
hypokalemia, loss of essential nutritional
factors, and dehydration.
Chronic constipation, and loss of normal
bowel function may occur during long-term
use

96. Electrolyte disturbances
(hypokalemia, hypocalcemia, metabolic
acidosis or alkalosis).
Abdominal pain, diarrhea, mal absorption,
weight loss, and protein-losing enteropathy
may occur.
Disadvantages : (cont.)

97. Question no.17
I heard that some commercially available
herbal teas that I can use for my
constipation , contain some laxative herbs
safer than Drugs?
Do they have any drug interactions (senna)
or side effect?

98. Answer
• No , they aren’t safer than drugs &
should be used with caution.
• Their drug interaction:-
Digoxin ( Lanoxine)
Warfarin ( Coumadin )
Water pills ( Diuretics )

99. * Their side effect :-
1- Stomach cramps.
2- Diarrhea.
3- Lax colon.

100. Question no.18
Abilaxine® ( bisacodyl ) tablets are
effective in relieving constipation .
Comment on their administration
immediately after meals or with
Epicogel® suspension .

101. Answer
1- According to meals :-
It should be taken on empty stomach or at
bed time .
It should be taken with full glass of water .
It is enteric coated tablet .
You should avoid drinking milk or taking
antacid within 1 hour after using it.

102. 2- According to Epicogel® :-
- It’s active ingredient is Aluminium
hydroxide .
- It alters the effect of bisacodyl.
- So , they should be separated at least 1
hour.

103. Question no.19
My sister is pregnant ;
Can she take castor oil or Minalax®
tablets for constipation?
What is docusate?
Could it be misused?
Mention it’s medical applications and
other synonyms .

105. Answer
1- NO , she can’t take castor oil,
it hastens delivery and
can cause amniotic fluid embolism.
2- Minalax® tablets can be used for
pregnancy category C .
3- She can take Sobo Cusate.

106. 4-Docusate is stool softener . It makes
bowel movement easier .
5- Medical applications of docusate :
- treatment of constipation.
- reduce rectal damage.
- wax softener in otic preparation.

107. Synonyms of docusate
Docusate Calcium.
Docusate Sodium.
Correctol soft gel extra gentle.
Doculase .
DSS.
Aerosol OT.
Dioctyl Sodium Sulfosuccinate.

108. Question no.20
My friend recommended me liquid
paraffin as laxative,
What’s your advice?
How about using it concomitantly with
Minalax® tablets in severe
constipation?

109. - Liquid paraffin not recommended as it
has side effects like :-
- Anal seepage or irritation.
- Granulomatous reactions.
- Pneumonia if accidentally inhaled.
- It may interact with fat soluble
vitamins as vitamin K , E , D , A.
- Shouldn’t be taken at bed time.
Answer

110. In severe constipation:-
Only Minalax® ;
-Liquid paraffin is not recommended.
-Hepatotoxicity may occur up on using
together.

112. I am suffering from chronic constipation and usually
strain during defecation , can this lead to lead to
hemorrhoids ? And are there any other causes?
Define hemorrhoids and mention its etiology and
epidemiology

115. Other Causes of hemorrhoid :
•Pregnancy
•Over-weight
•Medical condition
•Heart & liver disease
•Work staring ) heavy lifting )
•Itching

116. Hemorrhoid
are condition which veins
around the anus or lower
rectum are swollen and
inflamed

117. External hemorrhoid

118. Epidemiology
the incidence rate is 4.4%
with an age distribution that
show a prevalence between
45 – 65 years old.

119. I am feeling discomfort in the anal
area, a friend suggested I am suffering
from hemorrhoids; I want to know if
my symptoms can be caused by any
other condition and what are the other
symptoms of hemorrhoids?

120. 1
2
3
4
5
Anal fistula or Anal fissure
Anorectal abscess
Colon polyp
Inflammatory bowel disease , partically crohn’s disease
Rectal prolpse
6
7
Colorectal cancer
Staphylococcus infection
Other conditions

121. 1
2
3
4
5
6
Skin irritation due to large hemorrhoid
symptoms
Rectal pain
Thrombosed or clotted, hemorrhoid
Itching
Bleeding during bowel movements
Bright red streaks of blood

122. I know that hemorrhoids can be
classified into different types; please
tell me these types and how each
type is treated?

123. 2
Internal
hemorrhoids
External
hemorrhoids

125. 1
First degree
2
Second degree
3
Third degree
4
Fourth degree
Classification of Internal hemorrhoids
Dose not
descend
during
straining in
defecation
,painless
and
bleeding
Descend
during
defecation but
return with
relaxation ,
mild bleeding
and pain
Need manual
replacement
into rectum,
pain, bleeding
and mucous
discharge
Permanent
prolapsed
“descend” and
can not be
manipulated
manually
1
First degree
Dose not
descend
during
straining in
defecation
,painless
and
bleeding

134. Question no.23
I know that hemorrhoids can be
classified into different types;
Please tell me these types,
How each type is treated.

135. Internal hemorrhoids:
Veins can swell inside the anal canal.
External hemorrhoids:
Veins can swell near the opening of the
anus.

136. *Most hemorrhoids can be treated
with simple changes to diet and bowel
habits.
*Most do not require surgery or other
treatment unless the hemorrhoids are
very large and painful.

137. Internal hemorrhoids:
Fixative procedures include tying off
the hemorrhoids with a rubber band
(rubber band ligation) or using heat,
lasers, or electric current to create
scar tissue.
(Coagulation therapy)

138. *Surgical removal of hemorrhoids
(Hemorrhoidectomy)
*can be used for large internal
hemorrhoids,
*When several small hemorrhoids are
present, or when other treatments have not
controlled bleeding.

139. Sometimes a combination of treatments
Fixative procedure + Hemorrhoidectomy
The most effective ttt

140. External hemorrhoids:
Can only be removed surgically, if
needed.
If a blood clot develops in the external
hemorrhoid, the clot may need to be
removed to relieve pain.

141. Question no.24
My brother suffers from hemorrhoid;
He relies on self-treatment, but could
you tell me,
When should he consult a physician.

142. He should consult a physician if:
Moderate rectal pain lasts longer than 1
week after home treatment.
Pain or swelling is severe.
A lump inside the anus becomes bigger or
more painful.

143. Tissue from inside the body bulges from
the anus and does not return to normal
after 3 to 7 days of home treatment.
Rectal bleeding becomes heavy or changes
color (such as from bright red to dark red),
or if stools change size, shape, or color
(from brown to maroon or black).

144. Question no.25
There are many dosage forms available
for relieving hemorrhoids;
What are they?
Also what is the best one?

145. 1) Ointments that protect the skin,
ex; Zinc oxide or Petroleum jelly
Best nonprescription ttt
-They
can prevent further injury.
reduce itching by forming a barrier
over hemorrhoids.

146. 2) Use suppositories,
(formerly Anusol).
( 7 - 10 ) days.
to relieve irritation,
to lubricate the anal canal during bowel
movements.
*Some of these products contain
substances that can harm anal tissues if
they are used for too long.

147. 3) An ointment 1% hydrocortisone
-A type of steroid medicine.
-May relieve inflammation and itching..
-They should not be used for more than 2
weeks ( thin the skin )

148. 5) Apply products that contain medicine to
numb an area (local anesthetic).
These products help some people,
especially those who have painful external
hemorrhoids,
Some people become allergic to them.
Ask your doctor before using these
products

149. Question no.26
I heard there are a variety of medications
that can be used for hemorrhoids and can
be present in one formulation.
What are possible classes they belong to?
Giving example from the Egyptian market.

150. 1-local anesthetics:
Used for relief pain, itching, and burning
in the perianal region or lower anal canal.
Not in the rectum as rectum has no
sensory pain receptor.
Ex: lidocaine & cinchocaine
Not be applied to abraded skin as lead to
systemic absorption.
Not to be used for more than 7 days.

151. 2-Vasoconstriction:
They decrease mucosal perfusion by
constriction the blood vessels in the
anorectal area.
Vasoconstriction are not approved for
minor bleeding.
EX: ephedrine sulfate & phenylephrine HCL
Care should be taken to patient with
cardiovascular diseases, high blood pressure.

152. 3-Protectant:
Provide a physical barrier, forming a
protective coating over skin or mucous
membranes.
They prevent irritation of anorectal
tissues and prevent water loss from the
stratum corneum.
Ex: shark liver oil & cod liver oil

153. 4-Astringent
-Protect underlying tissue through
protein coagulation; provide temporary
relief of itching, discomfort.
Ex:
Calamine
Witch hazel (external use only)

154. 5-Keratolytics
Cause desquamation of the surface cells
of the epidermis.
Provide temporary relief of discomfort
and itching.
For external use only ( Resorcinol )
-Resorcinol should not be used on open
wound due to potential hypersensitivity.

155. 6-Analgesics
These agents should not be used to
treat internal hemorrhoids.
Ex:
Menthol & Camphor

156. 7-Antibacterial
-Protect hemorrhoids or fissures against
microbial infection. ( Framycetine )
EXAMPLES:
1- Proctosedyl
(Hydrocortisone+Cinchocaine+Framycetine+Esculin)
2-Anusol
(zing oxide- bismuth subgallate-bismuth oxide-
balsam Peru)

157. Question no.27
My friend usually feels pain during
defecation as he suffers from
hemorrhoids,
He started to use Lignocaine® cream
as a pain reliever, Please tell me
How to use it properly?

158. Wash your hands well before and
after using lignocaine® cream.
Wash the affected area with mild
soap and warm water.
Gently dry anorectal area.
Apply thin layer of cream to the area.

159. Gently rub the cream until it is
distributed.
-Lignocaine® cream comes with rectal
pipes which allow patient to insert the
cream directly to the rectal.
-To use the pipes, attach it to the tube,
Gently inserts the pipe into the rectum,
squeeze the tube to deliver the medicine.
-Do not insert any part of the tube into
the rectum.

160. Question no.28
My brother defects bloody stool,
can he take H-Formula®cream for his
condition?
What is the role of shark liver oil in
this product?

161. H-Formula® cream
-Shark liver oil 3%
-Phenylephrine 25%
-Dibucaine 1%

162. -Use:
*Reduce inflammation in blood vessels.
-Role of shark liver oil:
Prevent irritation of anorectal tissue.
Prevent water loss from stratum corneum.