Constipation

Faculty of Pharmacy - Alexandria University
(Egypt)

Question №. 1
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?

(Egypt)

What is Constipation?
 Decrease in the frequency in of fecal elimination.
 Passage of hard, dry, sometimes painful stool.

Normal Range
 From 3 times daily
to 3 times per week.
* So the patient is not constipated
(Egypt)

Etiology

Patient Counseling
 Life Style causes of constipation:

1. Diet:
a) Inadequate fluid intake
 Should drink at least 8 glasses of
non-caffeinated fluids daily.

(Egypt)

Etiology

Patient Counseling
b) Inadequate dietary fibers
 Diets include a good quantity of fibers are less likely
to suffer from constipation.
 Fiber retains water, softening stool & ease
evacuation.
 Foods low in fiber  high fat food.
 Foods rich in fiber  fruits, veg. and whole grain.
 Normal daily fiber intake 10 ̴ 25 g.■
(Egypt)

Etiology

Patient Counseling
c) Inadequate exercises
 Walking help prevent constipation by promoting
bowel motility.

d) Loss of defecatory reflex
 If you ignore the urge to have
a bowel movement.
 The urge can gradually go away.
 The longer can you delay it,
the drier and harder stool will become.
(Egypt)

Headache

Sense of
rectal
Symptoms of Abdominal
bloating
fullness constipation

Low back
pain

(Egypt)

Question №. 2
1. My grandmother usually feels discomfort
from chronic constipation:

 What are reasons for
this problem?
 What are your advice?

(Egypt)

Epidemiology

Risk factors of
constipation

Age Gender

• Constipation is common in • Females are three times more
elderly people ( > 65 y.) likely to suffer from constipation
• Laxative abuse than males
•  gut motility
• Medication use
• Poor nutrition
(Egypt)

Your advice
1. Laxative abuse:
 Lead to cathartic colon (loss of tone of
intestinal muscles) cause poor bowel function.

2. Increase intake fluids & fibers.
3. Increase exercise (  bowel tone).

(Egypt)

Question №. 3
3. My wife is pregnant she is worried about
constipation, I would like to know:

 What is the factors that
predispose pregnant to
constipation?

(Egypt)

Factors which constipate pregnant
 Progesterone
• Bowel hypo-motility
level
Uterus compress • Slowing down the passage
the intestine of food

Less exercise • Reduce bowel activity

Vitamins intake • Can be constipated
(Fe2+ , Ca2+ )
(Egypt)

Question №. 4
4. Is there a relationship between
anal disorders as abscesses
and constipation?

(Egypt)

Abscess
 It is a collection of pus (dead neutrophils)
that has accumulated in a cavity formed by
the tissue.
 Usually caused by bacteria or parasites
infection.

(Egypt)

Perianal abscesses
• Passage of hard stool
 Found in patients with inflammatory
1 • Cause an internal wound

bowel disease (Crohn's disease) or the rectal
• The wound infected because of presence of feces in
diabetes.
2 area.

• Abscess is developed
3

• It presents as a lump of tissue near the anus
4

• By the time, it becomes larger and more painful
5
(Egypt)

Question №. 5
5. I heard that there is a medical condition
called “Colonic inertia”:

 What is it?
 How diet can affect colonic
motility?

(Egypt)

Colonic Inertia
Prolonged colon transit time

• The average time of passage through the GIT is 4 days.

 Colonic dysfunction

 Prolong colon transit of the
fecal polus

 More water absorption

 Increase in its hardness
(Egypt)

Diet & Colonic motility
 Motility may be stimulated by boosting
carbohydrates intake while limiting
protein.

(Egypt)

Question №. 6
6. Is it true that some health problems
may lead to constipation?

 Explain your answer.

(Egypt)

Pain
 During defecation  avoidance  constipation.

Causes
1. Passage of hard stool.
2. Anal fissures and abscess.
3. Hemorrhoids.

(Egypt)

Health problems may lead to
constipation
1. Carcinoma
2. Irritable bowel syndrome (IBS)
common cause in younger people
3. Diabetes
60% of diabetics patient
4. Renal failure
due to electrolyte & fluid disturbance
(Egypt)

Health problems may lead to
constipation
5. Parkinsonism
up normal gut motility & rigid muscles
6. Colonic inertia
7. Pregnancy

(Egypt)

Question №. 7
7. I am taking Hæma-Caps for anemia: ®

 Is that related to constipation
I am suffering these days?

 What are the others drugs
that can cause constipation?

(Egypt)

Iron vs. Constipation
 Iron slow down the digestive system &
slowing of normal bowel movement.
 This may be because iron is a metal in its
basic form.
 Metals carry a charge that can affecting
muscles and nerves in the bowel

(Egypt)

Drugs cause constipation
1. Narcotic analgesics
2. Diuretics
3. Anticonvulsants
4. Sympathomimetics or anticholinergic
5. Antihistaminic
6. Antacids (containing Ca2+,Al3+)

(Egypt)

Question №. 8
8. My brother suffers from chronic constipation.
®
He starts taking Purgaton tablets on
regular basis. First the condition improved
but now the case is worse.

 What do you think?

(Egypt)

®
Purgaton tablet
Contain senna glycosides (anthraquinone)

 With extended use cause lazy bowel
syndrome (atonic colon)
 Bowel unable to move without chemical
stimulation.■

(Egypt)

Question №. 9
 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 ?

(Egypt)

Life style modifications
 increased intake of water, and fiber (either
dietary or as supplements).

 The routine use of laxatives is discouraged,
as having bowel movements may come to
be dependent upon their use.

(Egypt)

Life style modifications
 Enemas can be used to provide a form of
mechanical stimulation. However, enemas
are generally
 useful only for stool in the rectum, not in
the intestinal tract.

(Egypt)

Question №. 10
 Constipation may be a sign for many
serious health problems .
 Is that true? Explain

(Egypt)

General precautions

(Egypt)

Question №. 11
 I have constipation and want to know the
different classes of drugs that I can use for
treatment?

(Egypt)

Types of laxative
1. Bulk laxative
 Natural or synthetic polysaccharide
derivatives that absorb water to soften
stool.
 Slow onset of action (12-24 hr).
 E.g. Psyllium & malt soup extract (natural)
Methyl cellulose (Synthetic)

(Egypt)

Types of laxative
1. Bulk laxative
 Shouldn't used with patient have an
obstructing bowel legion.
 Used for protection from constipation.
 Used for pregnant.

(Egypt)

Types of laxative
2. Stimulant laxative
 Work on small and large intestine to
simulate bowel motility.
 Onset of action 6-12 hr orally
 Shouldn’t used more than 1 week.
 Should avoid in pregnancy

(Egypt)

Types of laxative
2. Stimulant laxative
 E.g.
 Senna glycoside (Anthraquinone)
 Castor oil
 Strong cathartic effect
 Lead to dehydration

(Egypt)

Types of laxative
Bisacodyl
 Diphenyl derivative
 Enteric coated
 Avoided with H2 blocker

(Egypt)

Types of laxative
3. Emollient laxative

 Stool softeners
 Slow onset 24 – 72 hr.
 Used for prevention than treatment.

(Egypt)

Types of laxative
4. Lubricant laxatives
 Mineral oil (as liquid paraffin)
 Increase water retention in colon
 Onset 6 – 8 hr orally
 5 – 15 min rectally
 Cause anal seepage results in etching
 Decrease absorption of fat-soluble vit.
(Egypt)

Types of laxative
4. Lubricant laxatives
 Should take on empty stomach
 Shouldn’t take at bed time
 Shouldn’t given to children < 6 years

(Egypt)

Question №. 12
 My wife is pregnant and she is
complaining of constipation . If you don't
mind recommend her the appropriate
medication illustrating how it works.
 And how to use it properly ?

(Egypt)

Bulk forming laxative
 Natural or synthetic polysaccharide
derivative that absorb H2O to soften the
stool and increase bulk.
 Onset of action of these agents is slow
(12-24 hr and up to hr), which is why they
are the best used to prevent constipation
rather than to treat severe acute
constipation.
(Egypt)

How to use?

(Egypt)

Question №. 13
 My grandmother is constipated but cannot
swallow oral tablets. What other dosage
form are available?

(Egypt)

Dosage form
 Syrup
as Duphalac®
 Suppositories
as Glycerin ®, Bisadyl ®
 Oral drops
as Picolax ®
 Enema
as Enemax ® ■
(Egypt)

Question №. 14
 My grandfather is taking many medication
for his CHF and rheumatic pain but the
condition is not improving also can he
takes Regumucil® sachets and Epsom salt
for constipation?

(Egypt)

Answer
 Dose spacing is essential with digitalis for
(CHF) and salicylates as the laxative may
reduce the effectiveness of the medication.

(Egypt)

Question №. 15
 My baby is usually straining during
defecation.
What is the best OTC medication for his
condition?

(Egypt)

Answer
 The first question to ask: Is my child really
constipated if he is constipated so glycerin
pediatric suppositories is considered.

(Egypt)

Question №. 16
 My friend suggest me enemas as rapid
treatment for constipation, what do they
contain? and what they advantage?

(Egypt)

Enemas
 Di-Na Phosphate and Mono-Na Ph.
 They are highly hygroscopic and water
soluble.

(Egypt)

Advantages
 Rapid & effortless
 evacuation of the bowel
Used in cases of:
1. Cardiac patients
2. Glaucoma
3. Ophthalmic surgery
4. Post operative
(Egypt)

Question №. 17
My grandfather suffer from hepatic encephalopathy, is
there is any laxative that can help in his condition ?

What are the precaution concerning its use?
(Counseling and interactions)

(Egypt)

A) Is there is any laxative that can help in
his condition?

 Lactulose®

1. Duphalak syrup.
2. Lactulose syrup.

(Egypt)

B) What are the precautions concerning its use?
(Counseling and interactions)

1-It may take from (1-3)days to act so useful in
treatment of chronic constipation in adults

2-It shouldn’t be taken concomitantly with locally
acting aminoglycoside antibiotics.

3-It should be taken with fruit juice, water or milk
to increase its palatability.
(Egypt)

Question №. 18
My brother abuse taking Mucinum cascara®
tablets for constipation,
what is your advice?
A: Mucinum cascara® tablets shouldn’t be used for
more than 1 week.

B: Chronic use of this stimulant laxative leads to
cathartic colon resulting in a poorly functioning
colon .

(Egypt)

C: It may show the symptoms of ulcerative colitis.
Also, it may discolor the urine with pink to red or
brown to black.

(Egypt)

Question №. 19
 Abilaxine® tab are effective in reliving
constipation . Comment on their
administration immediately after meals or
with Epicogel® suspension.

(Egypt)

Bisacodyl
 Abilaxine ® is containing Bisacodyl formed
as an enteric coated tablet .
 All biscodyl containing product shouldn't
be taken within an hour of ingesting food
or antacid (as epicogel) or milk.
 Should be avoided in patient tacking H2
blocker.

(Egypt)

Question №. 20
My sister is pregnant; can she take castor oil
or Minalax® tablets for constipation?
What is docusate?
Mention its medicinal syndromes.

 Can she take castor oil or Minalax® tablets
for constipation?
 No she cannot take castor oil because of its danger

(Egypt)

What is the danger of Castor oil in this case?
1. Premature labor due to premature
uterine contractions.

2. Death due to amniotic air
embolism.

3. Impaired health of the infant.

(Egypt)

But, she can take Minalax
tablets because :-

1- It is emollient laxative (stool
softener) which is safe.

2- It acts as surfactant by allowing
absorption of water into the
stool so;
It makes the softened stool easier
to pass.
(Egypt)

B) What is docusate?

1. It is emollient laxative (stool softener).

2. They act as surfactant by allowing absorption of
water into the stool so; it makes the softened stool
easier to pass).

(Egypt)

C) Mention its medicinal syndromes?
1. For patients who must avoid straining to pass
hard stools. as those recently have a myocardial
infarction or rectal surgery.
2. Safe for pregnant.

(Egypt)

Question №. 21
I prefer taking paraffin as laxative.
What is your advice?

How about using it concomitantly
with Minalax® tablets in severe
constipation?

(Egypt)

A:- My advice:-
1. It should be taken on an empty stomach.
(Because of its possible aspiration into the
lungs, lipid pneumonitis may occur).

2. Patients shouldn’t take it at bed time or
recline after administration.

(Egypt)

B) How about using it concomitantly with
Minalax® tablets in severe constipation?

 Minalax® may increase the systemic absorption of
paraffin leading to hepatotoxicity.

(Egypt)

Question №. 22
I am suffering from chronic constipation and
usually strain during defecation. Can this lead to
hemorrhoids? And are there are any other causes?
(Define hemorrhoids and mention its etiology and
epidemiology).

A) Can this lead to hemorrhoids?
- Yes, hemorrhoids will occur.

(Egypt)

B) Define hemorrhoids
 Hemorrhoids refers to a condition in
which the veins around the anus or
lower rectum are swollen, inflamed
and abnormally large.

 Simply, hemorrhoids represent
downward displacement of anal
cushions that contain arteriovenous
anastomoses.

(Egypt)

B. Etiology

1- Hereditary.

2-Acquired factors:

 Straining during defecation push
the hemorrhoid veins downward
with increased venous pressure,
they dilate and become engorged.

(Egypt)

 Over time the fibers that anchor the hemorrhoidal veins
to their underlying muscular coats stretch which result
in prolapsed.

 Occupations that require heavy lifting can transform
asymptomatic hemorrhoids into a problem.

(Egypt)

C) Epidemiology
 The risk of developing hemorrhoids increases with
advanced age and pregnancy.■

(Egypt)

• Is a condition in which the veins around the anus or lower
rectum are swollen and inflamed
• Risk of developing hemorrhoid increase with advanced
age and pregnancy.
• It may internal or external or mixed.

Question №. 23
 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?

(Egypt)

Other conditions
1. A similar knife-like pain can be caused by
herpes simplex virus.
2. aching discomfort made worse by
defecation could be due to piles.
3. A throbbing pain, worsening over a few
days, and bad enough to disturb your
sleep.

(Egypt)

Other conditions
1. An occasional, severe, cramp-like pain
deep in the anal canal.
2. A continuous aching pain in the anus
needs to be sorted out by your doctor..

(Egypt)

Symptoms of Hemorrhoid
 Bleeding during bowel movements, itching, and rectal
pain are the most common hemorrhoid symptoms.

1. Internal hemorrhoids
 Rectal bleeding, Itching , skin irritation and pain.

2. External hemorrhoids
 Rectal pain occurs mainly.
 Blood may pool under the skin, forming a hard,
painful lump.
 This is called a thrombosed, or clotted.
(Egypt)

Question №. 24
 I know that hemorrhoids can be classified
into different types.
 Please tell me these types and how each
type is treated?

(Egypt)

1. External Hemorrhoids
 occurs outside of the anal canal.
 very painful
 It’s very common for these type of
hemorrhoids to bleed.
 Blood can often be found on the stool or
toilet paper.

(Egypt)

2. Internal Hemorrhoids
 Occur inside the anal canal.
 Internal hemorrhoids don’t usually cause
as much pain as external.
 Internal hemorrhoids come about when
there is too much pressure on the veins
inside the anal canal.

(Egypt)

Other classification
1. First degree :
painless bleeding is present
2. Second degree :
descend with defecation but returns
spontaneously with relaxation.
3. Third degree :
requires manual replacement into rectum after
prolapse. pain ,bleeding are present
4. Fourth degree :
can't be manipulated manually . thrombosis often
occur

(Egypt)

Treatment
 For external hemorrhoids which are still not
bleeding and have not yet thrombosed, this
could be treated with a hemorrhoid cream,
ointment, warm baths, witch hazel.

 Mild internal hemorrhoids could also be cured
with suppositories of hemorrhoid cream, witch
hazel, and possibly by using a supplement.

(Egypt)

Treatment
 when your hemorrhoids have thrombosed,
prolapsed more intensive treatment may be
recommended.
 Some of the options include hemorrhoid surgery,
and laser coagulation.
 Higher degree of internal hemorrhoids:
 Hemorrhoid banding
 is a procedure in which the physician puts a tight
band around the hemorrhoid to control bleeding

(Egypt)

Treatment
 Infrared photocoagulation:
infrared light is focused at the base of
hemorrhoids
 Sclerotherapy:
injection of aseclerosing agent into the
hemorrhoids
 Cryotherapy:
freezing the hemorrhoids
(Egypt)

Question №. 25
My brother suffer hemorrhoid he relies on
self treatment, but could you tell me
when should he consult doctor?

 IF these products don't improve
symptoms within seven days , if severe
bleeding ,pain happen, if patient below 12
years old.
 So you should consult your doctors to seek
the medical attention immediately
(Egypt)

Question №. 26
 There are many dosage forms available
for relieving hemorrhoid what they also
what is the best one?

 Ointment ,cream , suppositories, sprays
but Cream ,oint., is superiors to suppositories, it
may be bypass the affected area.
 Area must be washed by soap and dry before
applied product.
(Egypt)

Question №. 27
 I heard that there are varieties of OTC
drugs used for ttt of hemorrhoid what are
the possible class they belongs to ?giving
Ex from Egypt markets.

(Egypt)

Trade name Dosage form Active ingredient

Anusol Supp,ont Zno ,bisthmus subgallate balsam
peru,bisthmus oxide

bisthmus oxide, balsam peru
bisthmus subgallate: :is demulcent
are astringent

(Egypt)

Faktu® Supp,oint. Policresulen,
cinchocaine
Policresulen is Cinchocaine is
atopical an amide local
haemostatic anesthetic
and antiseptic

(Egypt)

Procto-4® Supp,cream Framycetine,es
culin,hydrocorti
sone, bisthmus
oxide
Framycetine: Esculin:
is antibacterial vasoprotective
to protect ,have capillary
against bacterial astengthening
infection action

(Egypt)

proctoglyvenol Supp,cream Tribenoids,lidoc
aine
Tribenoids is
vasoprotective

(Egypt)

Question №. 28
 My friend usually feel pain during
defecation as he suffers from hemorrhoids
he start to use Lignocaine® cream as pain
relievers ,please tell me how to use it
properly ?

(Egypt)

 It is local anesthetics used for pain , itching
,burning in the perianal region or lower
anal canal (not in rectum ) as no sensory
pain receptors .
 Must not to be applied to abraded skin as
this will increase absorption systemically.
 Not to be used for more than seven days.

(Egypt)

Question №. 29
 My brothers defecation bloody ,can he take H-
formula cream for his condition ,what is the
role of shark liver oil in this product?

(Egypt)

 Yes, he can take it until he have normal
blood pressure ,no cardiac problems ,no
thyroid gland problems.
 As H-formula contain phenyl ephedrine
which is vasoconstrictors.

(Egypt)

Shark liver oil
 Shark liver oil is natural source of vitamin
A which is promotes wound healing and
tissues repair ,relieves symptoms
accompanying .
 It act as emollient and protectant that
provides physical barriers to irritation by
forming protective layers over mucos
membrane and anal region by preventing
excessive water loss from tissue .
(Egypt)

Question №. 30
 I am suffering from sever irritation and
inflammation in the preanal area which
is the best form my condition .
Anusol® , or Anusol-HC® Oint. ?

(Egypt)

 Anusol-HC® is best . because it have
hydrocortisone which ttt sever irritation
and inflammation but it mask fungal ,
bacterial infection.■

(Egypt)

the

END
(Egypt)

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