Ms. C.J. is a 71-year-old woman who presents with hard, dry stools for weeks despite trying fiber and increased fluids. Her medical history includes hypertension, chronic renal insufficiency, and a stroke one year ago. Differential diagnoses include medication-induced constipation, colon cancer, or inadequate food intake. Treatment goals are to investigate the cause, educate the patient, and restore normal bowel movements. The treatment plan includes lifestyle modifications, probiotics, bulk laxatives, and osmotic laxatives if needed. She is prescribed PEG 17g daily for one week and asked to follow up if constipation is not resolved.

1. CONSTIPATION:
CASE STUDY

2. PATIENT INTRODUCTION
 Ms. C.J. is a 71year old woman who presents for follow-up. She complains of hard , dry
stools over the past weeks. She tried using fiber and increase her fluid intake with no
positive results.
 Past medical history: hypertension, chronic renal insufficiency. Had a stroke one year
ago with little or no residual.
 Meds: Verapamil SR 240 mg daily
Lisinopril 10 mg P.O daily
Calcium carbonate 1,250 mg P.O. twice a day
Aspirin 325 mg P.O daily
Diagnosis: Constipation
(Arcangelo, Peterson, Wilbur, & Reinhold, 2017, p. 494)

3. DIFFERENTIAL DIAGNOSES
 Autoimmune disease – Hypothyroidism / Diabetes
 Medication induced constipation
 Colon cancer
 Inadequate food intake
 Irritable Bowel Syndrome (IBS) – unlikely at her age
(Arcangelo et al., 2017; Rao, 2017)

4. PATHOPHYSIOLOGY OF THE
DISEASE
According to Basson (2017), constipation is very common condition which is rather a
symptom then a disease itself. Constipation can dramatically affect quality of life and
can be a symptom of a bigger problem. Hard stools as a result inadequate fluid
intake and poor dietary intake are one of the common cause for constipation, the
other one caused by slow colonic transit due to laxative abuse, drug induced or
endocrine disease. Although not very common, but acute constipation can be a
consequence of a bowel obstruction as a result of tumor, volvulus and
intussusception. Bad habits of decrease response to the “urge to go” due to fear of
pain (fissure), or other reasons can escalate the problem and worsen constipation
(Arcangelo et al.,2017)
.

5. PATHOPHYSIOLOGY OF THE DISEASE
CONT.
constipatio
n
Normal Transit (functional)
• Low fiber diet
• Inadequate fluid
• Low physical activity
• Suppression of urge (lesions
of anus/ pain)
Slow transit
• Neurogenic disorders/ trauma
• Endocrine disorders
• Drugs (opioids, alcohol,
Calcium)
• IBS
• Pregnancy
• Aging
No transit/Obstruction
• Cancer
• Ileus
• intussusception
(McCane & Huether, 2014, p.1424)

6. TREATMENT GOALS
 Investigate the cause for constipation :
* look into her medications
* rule out cancer and other underlying disease
(possible endoscopy)
* rule out anal fissures haemorrhoids that cause
pain
 Patient education regarding probable cause, treatment options
and prognoses.
 Correct constipation and restore normal (patient specific) bowel
regime.
 Diet counseling.

7. AVAILABLE TREATMENT OPTIONS
 Non pharmacologic:
o Life style modification - exercise
o Diet modification – high fiber, plenty of water
o Establish regular pattern of bowel movement – same time of the day,
usually two hours after breakfast and exercise
o Take enough time in the bathroom – no rush and no destructions
o Prune juice
o Probiotics (Dimidi et. Al.,2014)
o Biofeedback – has been effective for patients with pelvic floor
dysfunction
(Rao,2017)

8. AVAILABLE TREATMENT OPTIONS
CONT.
 Pharmacological: Laxatives to help restore normal bowel
movement.
 First line therapy
Bulk-
forming
Stool
softener
Glycerin Linaclotide,
Lubiprostone
Naloxegol,
Lubiproston
e
Indication For all types
of
constipation
Hard, dry
stool or
when
straining
should be
avoided
Safest due to
no sys.
effects.
Recommende
d
In infants.
Chronic
Idiopathic
Constipation
Opioid
induced
(Arcangelo et al.,2017)

9. AVAILABLE TREATMENT OPTIONS
CONT.
 Second line:
 Third line : Stimulant laxatives – use with caution as they
associated with many side effects
Magnesium Hydroxide Osmotic Laxative
Comments Avoid in patient with renal
impairment and elderly
Use with caution in
patients with diabetes
(Arcangelo et al.,2017)

10. PATIENT SPECIFIC TREATMENT
 Take a good history and preform physical exam
 Order comprehensive metabolic panel, CBC, thyroid function
 Rule out any underlying conditions
 See if can modify medication (calcium supplements, and CCB)
 Life style modification – add exercise
 Advise use of probiotics

11. PATIENT SPECIFIC TREATMENT
CONT.
 Bulk Laxatives – psyllium 25-30g a day in divided doses till
constipation resolves, maintenance dose 20g a day
 Osmotic laxative – low dose PEG 17g a day
 Teaching regarding proper lifestyle and use caution with overuse
of laxatives
(Rao, 2017)

12. INITIATING THERAPY
 Start with lifestyle modification
 Probiotics with breakfast
 Psyllium 30g a day – with plenty of water, once constipation
resolved can decrease to 21g a day (OTC)
 Prune juice before bed
 If no positive effect in 3 days start PEG 17g a day
 Come see practitioner if constipation persist in a week

13. SIDE EFFECTS
 First line therapy laxatives associated with very few minor side effects
o Abdominal bloating
o Stomach upset
o Flatulence
 Second line:
o GI upset
o Diarrhea
 Third line should be used with caution and should be avoided in long-
term use
(Arcangelo et al.,2017)

14. DRUG-DRUG AND FOOD-DRUG
INTERACTIONS
The laxatives have very few drug interactions:
 Bulk-forming laxatives can interfere with effectiveness of
quinolone and tetracycline, it is advised to take those meds
separately.
 Magnesium containing laxatives also interfere absorption of
quinolone and tetracycline – take 2 hours before or after
 Milk of Magnesia will increase gastric PH, don’t take with any
drugs that require low PH (Iron, Azoles)
 (Arcangelo et al.,2017)

15. DRUG-DRUG AND FOOD-DRUG
INTERACTIONS CONT.
 Don’t administer Docusate with mineral oil, as this combination
can be liver toxic.
 Mineral oil can decrease absorption of fat-soluble vitamins,
therefore people who taking Warfarin may be affected.
 Overall patients should increase their fluid intake when using
laxatives, as it improves their efficacy and reduce side effects.
(Arcangelo et al.,2017)

16. PATIENT SPECIFIC RISK FACTORS
 Women - 2.2 female to 1 male
 Age – increases with age
 Calcium supplements
 CCB’s
 Stroke

17. EPIDEMIOLOGY
Constipation found in 15% of the population in North America
 Women
 Pregnant women –due to low bowel motility
 Children – between 0.7% to 29% (equal between sexes)
 Elderly – most common in females (26% men and 34% women)
 Low education level
 Low socioeconomic level
 Opioid users – affect motility
(Rao, 2017)

18. Patient name: C.J.
Patient Address: 125 Main st. Kelowna, BC v1w 4t4
Date of Birth: Jan 01, 1946
Rx: PEG 17 g
Mitte: PO once daily
Sig: Mix with fluids according to instructions on the box
Diagnosis : For constipation
Number of refils: 1 come to see practitioner in a week if not resolved
Substitutions: yes
Signature: ____Zinaida Roitman__
Zinaida Roitman FNP
Licence Number : 1234567
Zinaida Roitman FNP
123 Main st,
Kelowna, BC
v1w4t4
250-333-4444
Date: Mar 11,
2017 Serial# 0001

19. REFERENCE
 Arcangelo, V. P., Peterson, A. M., Wilbur, V. & Reinhold, J.A.
(2017). Pharmacotherapeutics for advanced practice: A practical
approach (4th ed.). Philadelphia: Wolters Kluwer.
 Basson, M., (2017). Constipation. Medscape. Retrived from
http://emedicine.medscape.com/article/184704-
overview?pa=gPc2PS9JP%2FBfEjlxhwk7uSE9bkW0Y3g6YLCoih
yhEbXg5MWhAeKIBfHWdzV7zq%2B2GiCyUDk2GmFMmHAZTu
%2FWx3Ba6qMPn9v9%2B17kWmU%2BiQA%3D#a3
 Dimidi, E., Chritodoulides, S., Fragkos, K., Scott, M., Whelan, K.
(2014). The effect of probiotics on functional constipation in
adults: a systematic review and meta-analysis of randomized
controlled trials. The American Journal of Clinical Nutrition,100:
1075-84.
 McCance, K. L. & Huether, S. E. (2014). Pathophysiology: The
biologic basis for disease in adults and children (7th ed.). St.
Louise: Elsevier Mosby.

20. REFERENCE CONT.
 Rao, S. (2017). Constipation in Older Adult. UptoDate. Retrieved
from https://www.uptodate.com/contents/constipation-in-the-older-
adult?source=search_result&search=constipation%20in%20elderl
y&selectedTitle=1~150
 Rome Foundation. (2016). Appendix A: Rome III Diagnostic
Criteria for Functional Gastrointestinal Disorders. Retrieved from
http://www.romecriteria.org/assets/pdf/19_RomeIII_apA_885-
898.pdf