1. The document defines constipation as infrequent and/or unsatisfactory bowel movements of less than 3 times per week. Constipation is a symptom rather than a disease and can be caused by slow colonic transit time, pelvic floor dysfunction, or functional issues. 2. Most cases of primary constipation are caused by slow colonic transit time. Risk factors include low fiber diet, low fluid intake, inactivity, ignoring the urge to defecate, and certain medications. Diagnosis involves history and physical; testing may include bloodwork and imaging if red flags are present. 3. Treatment involves non-drug approaches like diet, exercise and toilet habits or drug approaches including bulk-forming agents, osmot

1. Constipation & Diarrhea
Dr Gaurav Gupta

3. BRISTOL STOOL CHART

4. Am College of Gastroenterology …
Unsatisfactory defecation, characterized
by infrequent stools and/or difficult stool
passage
Brandt 2005
4
DEFINE CONSTIPATION

5. What is constipation?
• Constipation is generally defined as infrequent
and/or unsatisfactory defecation fewer than 3 times
per week.
• Patients may define constipation as passing hard
stools or straining, incomplete or painful defecation.
• Constipation is a symptom,
NOT a disease.
• Constipation has many causes
and may be a sign of undiagnosed
disease.

6. Normal Colonic Transit Time
• A meal reaches the ileo-cecal valve in 4 hours
…the sigmoid colon 12hours later
… then slows to the anus.
• Plastic pellets with a meal → 70% recovered
in 3 days; remainder in a week!
6

7. Most with primary constipation suffer
from which one of the following?
1. Slow colonic transit time
2. Pelvic floor/anal sphincter dysfunction
3. Functional – normal transit time and
sphincter function
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8. Most with primary constipation suffer
from which one of the following?
1. Slow colonic transit time
2. Pelvic floor/anal sphincter dysfunction
3. Functional – normal transit time and
sphincter function
8

9. Secondary Constipation
• Endocrine dysfunction (DM, hypothyroid)
• Metabolic disorder (↑ Ca,↓ K)
• Mechanical (obstruction, rectocele)
• Pregnancy
• Neurologic disorders (Hirschsprung’s,
multiple sclerosis, spinal cord injuries)
9

10. At risk of constipation
• ↓ fiber :(most common)
• ↓ liquid ( 8 glasses/d is needed for constipated)
• ↓ Exercise : bedridden, coma
• Ignoring urge to defecate
• Systemic: Hypothyroidism, DM, Uremia,
pregnancy, hypercalcemia, Hypokalemia
• Neurological: Stroke, Parkinsonism, Multiple
sclerosis
10

11. Medicines causing of constipation
Opiate,
Anticholinergics,
Al(OH)3
Iron,
cholestyramine,
Antihypertensive drugs (CCBs, diuretics),
relaxants,
chronic use of laxatives,
Antiepileptics,
progestrone
11

12. Prevention of constipation
• High fibre diet
• Minimum fluid consumption of 1500mL daily
• Regular, private toilet routine
• Heed the urge to defecate
• Use of a laxative if using constipating medication
or in presence of diseases associated with
constipation

13. Diagnosis
• Good history is enough for most cases
(Duration, frequency, Consistency, blood in
the stool, weight loss, Diet, Exercise, Toilet
habits, Laxative use (what), other drugs)
Am Gastroenterological Assn (AGA) guidelines:
• CBC, Glucose, TSH, calcium, creatinine
• Sigmoid/colonoscopy if red flags are present.
13

14. I’m constipated, now what?
• Two approaches to consider:
•Non-drug Approach
•Drug Approach

15. Treatment – Behavioral
• Toileting program to take advantage of
natural reflexes
• Obey the urge
– Gastro-colic
– Defecation reflex
15

16. I’m constipated, now what?
• Non-Drug Measures:
– Have a regular bowel regimen: patients should attempt to have a
bowel movement at the same time each day especially after
breakfast since colonic activity is highest at that time.
– Don’t spend prolonged periods of time at the toilet. Placing a
footstool in front of the toilet helps elevate the thighs, thus placing
the pelvis in the optimum position for defecation.
– Consume a high fibre diet: the target is 25-28g of fibre daily
– Eat more fruits: apples, pears, and prunes contain the natural
laxative sorbitol
– Exercise: inactivity is associated with constipation
– Weight loss: want BMI to be between 18.5-24.9

17. I’m constipated, now what?
• Drug Measures:
– There are many different types of drugs that can be used
for constipation:
• Bulk-forming Agents
• Emollients/Stool Softeners
• Osmotics
• Stimulants

18. I’m constipated, now what?
• Bulk-Forming Agents:
– Examples: Metamucil, Benefiber, FiberSure
– Are considered the safest agents and are suitable for long-
term use
– Each dose of a bulk-forming laxative should be administered
with a full glass of water or juice
– Do not use if patient is dehydrated or fluid restricted
– Are the drug of choice for prevention; not for immediate relief

19. I’m constipated, now what?
• Emollients/Stool Softeners
– Example: Docusate
– Used for prevention; not for immediate relief
– Used very often but lack of data showing it actually works
– Company says that this product “makes it easier to go”

20. I’m constipated, now what?
• Osmotics:
– Examples: Glycerin Suppositories, Lactulose Syrup, Lax-a-Day
(PEG 3350), Milk of Magnesia
– PEG produces the loosest stool and overall greatest efficacy
compared to other members in this class. Daily use of PEG is safe
and does not have significant side effects. May take 2-4 days to see
an effect. This is the drug of choice in almost all situations!
– Lactulose is very safe to use long term. May see increase in gas
and bloating compared to other options. Takes 1-2 days to work.
– Glycerin suppositories have a quicker onset of action (usually 30-
60 minutes). They are less effective if the stool is dry and hard.

21. I’m constipated, now what?
• Stimulants:
– Examples: Senokot, Dulcolax (bisacodyl)
– This group produces rhythmic muscle contractions in the
intestines and may be recommended if osmotic laxatives fail
or are not tolerated.
– Are usually given at bedtime and they usually provide
overnight relief (work within 8-12 hours).

22. Practical management of Constipation

23. Address Immediate Concerns
• Bloating/discomfort/straining
– Osmotic agent like PEG
• Post-op, childbirth, hemorrhoids, fissures
– Stool softener to make defecation easier
• Stimulants and suppositories acutely
• Manual disimpaction as needed
then approach the chronic condition….
23

24. Start with Lifestyle Changes …
• Exercise, increase fluids and fiber to 25
grams/day over a period of 6 weeks.*
– Fiber must be accompanied by sufficient fluid
– Initial approach – fruits and vegetables
– Add commercial bulking agents
• Obey the ‘Urge’!
• For children trial of rice vs cow’s milk
* Uncontrolled studies support fiber for normal transient
constipation. Am J Gastroenterol. 1999; G Nutr 4/2010 24

25. If No Improvement…
• Add osmotic laxative
– adjust dose slowly until stools are soft
– take several days to work
– caution if CHF or renal insufficiency
• Add stimulant laxatives
25

26. Diarrhea

27. What is Diarrhea?

28. Classification as per duration

29. Causes of Acute Diarrhea

37. Desired outcome
37

41. Antimicrobial agents
Type of diarrhea Antimicrobial agent
Cholera Tetracycline,
Doxycycline,
Ciprofloxacine
Shigellosis Pivmecillinam
(Selexid), Nalidixic
acid, Ciprofloxacin,
Ceftriaxone
Amebiasis Metronidazole
41

42. Chronic diarrhea
• Lasts longer than 4 weeks
• Reasons can be: stress, food intolerance (e.g.
lactose intolerance), disorders of
pancreas/liver/gallbladder, chronic intestinal
infections (Morbus Crohn, Colitis ulcerosa),
bowel cancer
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46. Complications
• Loss of water: dehydration (dizzyness,
unconsciousness)
• Loss of electrolytes: cramps
• In severe cases both can lead to death
46

47. Quiz

48. Quiz
What are the 4 types of diarrhea?

49. Quiz
What are the 4 types of diarrhea?
• Secretory,
• osmotic,
• exudative (inflammatory),
• and altered intestinal transit (Dysmotile)

50. What are the characteristics of Secretory
Diarrhea?

51. What are the characteristics of Secretory
Diarrhea?
Watery, large volume outputs,
that are typically painless,
persist with fasting,

52. Causes of Secretory diarrhea?
• Stimulant laxatives;
• bowel resection, disease, or fistula,
• hormone-producing tumors (carcinoid,
pancreatic, medullary cancer of the thyroid),
• Addison's dx

53. • How to clinically differentiate osmotic /
secretory diarrhea?

54. How to clinically differentiate osmotic /
secretory diarrhea?
• Fasting

55. Some agents that cause osmotic diarrhea?

56. Some agents that cause osmotic diarrhea?
• Osmotic laxatives (Mg2+);
• lactase deficiencies;
• nonabsorbable carbohydrates (sorbitol, lactulose,
polyethylene glycol);
• intraluminal maldigestion (pancreatic exocrine
insufficiency, bariatric surgery, liver disease);
• mucosal mal-absorption (celiac sprue, ischemia
of colon, whipple's disease)

57. • What symptoms accompanies exudative
(inflammatory diarrhea)?

58. What symptoms accompanies exudative
(inflammatory diarrhea)?
• pain, fever, bleeding, or other manifestations
of inflammation

59. What are characteristics of dysmotile diarrhea?

60. What are characteristics of dysmotile diarrhea?
• Diarrheal pattern is rapid, small, coupling
burst of waves, see this a lot with IBS.

61. What are some causative agents of dysmotile
diarrhea?

62. What are some causative agents of dysmotile
diarrhea?
• IBS;
• Hyperthyroidism;
• Intestinal resection, bypass surgery;
• Prokinetic agents such as metoclopramide or
prostaglandins;
• Diabetic diarrhea (may be accompanied by
peripheral and generalized autonomic
neuropathies)

63. How does the American Gastroenterology
Association (AGA) defines functional
constipation?

64. How does the American Gastroenterology
Association (AGA) defines functional
constipation?
• difficult, infrequent, or seemingly incomplete
defecation

65. Complications of constipation?

66. Complications of constipation?
• Hemorrhoids
• anal fissures
• rectal prolapse
• fecal impaction