This document discusses chronic constipation, flatulence, and their causes, diagnosis, and treatment. It provides details on: - Common causes of flatulence including swallowed air, certain foods, and medical conditions. - Diagnosis involving a food diary and eliminating suspected trigger foods. - Treatments for flatulence including simethicone to reduce gas bubbles and activated charcoal to absorb gas. - Definitions, etiologies like slow transit or medication side effects, and treatments for constipation including lifestyle changes, fiber, fluids, probiotics, and various classes of laxatives.

1. Chronic Constipation

2. Flatulence
 Passing gas is normal, and every human being
does it at least 14 times a day, consciously or
unconsciously.
 Most cases of flatulence are related to factors
that can be controlled. This is because intestinal
gas usually comes from two sources — 1)
swallowed air or 2) the work of intestinal bacteria
on undigested food.
 People swallow air in many different ways:
 Unconsciously gulping air as they talk, especially
when they are upset, excited or nervous
 Eating or drinking in a hurry
 Chewing gum
 Smoking
 Drinking carbonated beverages.

3. Etiologies
 Foods that tend to cause gas include:
 Foods rich in fiber
 Foods containing fructose
 Vegetables containing raffinose (cruciferous
vegetables (cabbage, Brussels sprouts,
broccoli, cauliflower) and in beans
 Sorbitol
 Dairy products containing lactose, a sugar
found in milk
 Certain medications, especially
Cholestyramine, used to treat high
cholesterol, or the diet drug Orlistat.
 Irritable bowel syndrome
 Giardiasis

4. Diagnosis
 Do you often gulp your food on the run?
 Do you drink many carbonated beverages or eat a lot of high-fiber fruits
and vegetables, dairy products, and sugar-free or diet foods? Keep a diary
to record what you eat and drink and the severity of your symptoms
 Are any prescription and nonprescription medications you take, including
any diet drinks or diet meals, causing your flatulence? If you suspect that
your problem is medication related, don't stop taking your medicine. Call
your doctor for advice.
 Are you lactose intolerant? Consider stopping all milk-based products for
two weeks

5. Prevention
 Eat and drink slowly, in a calm environment. Chew your food thoroughly
before you swallow
 For a few days, avoid the foods that most commonly cause flatulence, such
as beans, high-fiber foods, cruciferous vegetables, carbonated beverages
and sugar-free products containing sorbitol. Then gradually add them to
your diet again, one by one, while keeping track of your symptoms. This
should let you determine which foods trigger flatulence for you. Then you
can avoid them
 If you need to add more fiber to your diet, increase your fiber slowly over a
period of days or weeks. A sudden increase in dietary fiber often triggers
flatulence, but a gradual increase may not

6. Treatment
 Preventive steps
 Anti-gas medications
 Lactose intolerance 1) the enzyme lactase 2) Lactose free dairy products

7. Simethicone
 A silicone compound that functions as a non-systemic surfactant,
decreasing the surface tension of gas bubbles in the GI tract
 This action results in coalescence and dispersion of the gas bubbles
allowing their removal from the GI tract as flatulence or belching
 Simethicone does not have any serious side effects
 Simethicone is not absorbed systemically, so it is safe in pregnancy and
breastfeeding

8. Activated charcoal
 The extra spaces in the charcoal trap gas molecules, reducing the gas that
causes bloating
 Activated charcoal is not absorbed systemically
 Black stools is a common side effect
 May reduce absorption of some drugs

9. Constipation
Definition
 There are many subjective definitions for constipation
 The Rome IV Consensus Criteria define constipation as a condition
where at least two of the following symptoms have occurred for the
last 3 months with symptom onset 6 months prior to diagnosis:
 • Straining during at least 25% of defecations
 • Lumpy or hard stools in at least 25% of defecations
 (Bristol stool form type 1 and type 2)
 • Sensation of incomplete evacuation for at least 25% of
 defecations
 • Sensation of anorectal obstruction/blockage for at least
 25% of defecations
 • Manual maneuvers to facilitate at least 25% of defecations (e.g.,
digital evacuation, support of the pelvic
 floor)
 • Fewer than three defecations per week

10. Etiologies
 One of the most common gastrointestinal complaints
 Can result from any of several different distinct causes and can be
categorized as A) idiopathic or B) secondary
 A) Slow-transit constipation due to lack of propulsion through the
colon (idiopathic)
 Pelvic floor dysfunction causes 1) slowed colonic transit 2) storage of
fecal contents in the rectum for long periods of time
 Irritable bowel syndrome
 B) Secondary constipation
 Obstruction (rectal outlet obstruction, fecal impaction, adhesions,
presence of a tumor)
 Scleroderma, amyloidosis
 Neurological diseases such as multiple sclerosis or Parkinson’s
disease
 Can be a side effect of many different classes of medications
 Anticholinergic drugs, Analgesics (i.e., opiates), Antidepressants (i.e.,
amitriptyline), Diuretics, Antihistamines and nonsteroidal anti-
inflammatory drugs
 Over-the counter medications such as iron, calcium, and other
nutrient supplements

11. Treatment
 Life style changes including diet and activity
 Biofeedback
 Laxatives

12. Nutrition Interventions
 Ensuring adequate fiber and fluid intake has
been the foundation for nutrition therapy in
constipation treatment
 25 to 38 g of dietary fiber are recommended
for adults each day (14 g of dietary fiber per
1000 kcal)
 This should begin slowly with adding one to
two high-fiber foods each day
 The clinician should also emphasize adequate
fluid intake. Adults should ingest a minimum
of 2000 mL/day (approximately 8–10
cups/day)
 Probiotics and prebiotics has been shown to
soften feces and to assist in relieving
constipation

13. Figs
Prune
Kiwi
Grapes
Damask rose
purslane

14. Medications
 Accelerate the motility of the bowel,
soften the stool, and increase the
frequency of bowel movements
 Classified on the basis of their
mechanism of action
 increase the potential for loss of
pharmacologic effect of poorly
absorbed, delayed-acting, and
extended-release oral preparations by
accelerating their transit through the
intestines.
 They may also cause electrolyte
imbalances when used chronically.
 Many of these drugs have a risk of
dependency for the user

15.  Cholinomimetic drugs (e.g. neostigmine) increase motility and
may cause colic and diarrhea. They are very occasionally used
in the treatment of paralytic ileus.
 Motility stimulants (Metoclopramide, Domperidone) facilitate
acetylcholine release from the myenteric plexus and are used
in the treatment of esophageal reflux and gastric stasis
 Nonpharmacological treatments for constipation include
exercising, laughing (because it massages the intestines and
thus encourages peristalsis), increasing dietary fiber, drinking
more fluids, decreasing consumption of dairy products, and
drinking warmed prune juice
 1) Bulk laxatives
 2) Irritants and stimulants
 3) Saline and osmotic laxatives
 4) Stool softeners (emollient laxatives or surfactant&)
 5) Lubricant laxatives
 6) Chloride channel activators

16.  1) Bulk laxatives
 They form gels in the large intestine, causing
water retention and intestinal distension, thereby
increasing peristaltic activity
 Methylcellulose, psyllium seeds, and bran
(cellulose)
 Should be used cautiously in patients who are
immobile because of their potential for causing
intestinal obstruction
 Psyllium can reduce the absorption of other oral
drugs, and administration of other agents should
be separated from psyllium by at least 2 hours
 Prunes and bran have the same effects
 Are the best laxatives to take during pregnancy
and if needed on a routine basis
 Usually Take 12 hours to 3 days to work

17.  2) Irritants and stimulants
 Increase motility by acting on the mucosa or nerve plexuses, which
may be damaged by prolonged drug use. They often cause
abdominal cramp
 Typically effective within 6 to 8 hours
 Side effects include: cramping, diarrhea, flatulence, and nausea
 Chronic use can lead to decreased peristalsis and cathartic colon
 Senna, aloe, and cascara sagrada discolor urine
 Senna
 A widely used stimulant laxative
 Stimulate the myenteric plexus
 Taken orally, senna causes evacuation of the bowels within 6 to 12
hours. It also causes water and electrolyte secretion into the bowel
 In combination products with a docusate containing stool softener, it
is useful in treating opioid-induced constipation
 Bisacodyl
 Is a potent stimulant of the colon. It acts directly on nerve fibers in
the mucosa of the colon

18. o Castor oil
o Broken down in the small intestine to ricinoleic acid, which is very irritating
to the stomach and promptly increases peristalsis.
o Pregnant patients should avoid castor oil because it may stimulate uterine
contractions and premature labor or during lactation because it may cause
diarrhea in the infant
o Not recommended due to poor palatability and potential for GI adverse
effects

19.  3) Saline and osmotic laxatives
 Nonabsorbable salts such as magnesium hydroxide (anions and cations) that hold water in the
intestine by osmosis. This distends the bowel, increasing intestinal activity and producing
defecation in a few hours
 Electrolyte solutions containing polyethylene glycol(PEG) are used as colonic lavage solutions to
prepare the gut for radiologic or endoscopic procedures.
 Evacuation of stool, sometimes in the form of diarrhea, within 15 to 60 minutes.
 Are contraindicated in patients with hypertension, edema, or congestive heart failure because of
the stress on the cardiovascular system caused by this rapid action
 PEG powder for solution without electrolytes is also used as a laxative and has been shown to
cause less cramping and gas than other laxatives
 Lactulose
 Semisynthetic disaccharide sugar that acts as an osmotic laxative by retaining water
 Cannot be hydrolyzed by Gl enzymes
 Degraded by colonic bacteria into lactic, formic, and acetic acids. This increases osmotic pressure,
causing fluid accumulation, colon distension, soft stools, and defecation
 Also used for the treatment of hepatic encephalopathy, due to its ability to reduce ammonia levels
 Milk of Magnesia
 Mild osmotic laxative sometimes called a saline laxative and usually works within 2 to 12 hours
 A safe option for patients with hypertension, edema, or congestive heart failure

20.  4) Stool softeners (emollient laxatives or surfactant&)
 Docusate sodium and Docusate calcium and Arachis oil
 Surface active agents that become emulsified with the stool produce softer
feces and ease passage of stool
 Used routinely in patients with limited mobility resulting from injury or
chronic illness
 May take days to become effective and are often used for prophylaxis
rather than acute treatment
 Should not be taken concomitantly with mineral oil because of the
potential for absorption of the mineral oil

21.  5) Lubricant laxatives
 Lubricant laxatives are typically oily
 Mineral oil and Glycerin suppositories
 Act by facilitating the passage of hard stools by lubricating the intestinal
mucosa
 Mineral oil should be taken orally in an upright position to avoid its
aspiration and potential for lipid or lipoid pneumonia
 They take 6 to 8 hours to work

22.  6) Chloride channel activators
 Lubiprostone
 Works by activating chloride channels to increase fluid secretion in the
intestinal lumen
 Eases the passage of stools and causes little change in electrolyte balance
 Used in the treatment of chronic constipation and irritable bowel
syndrome with constipation (IBS-C), particularly because tolerance or
dependency has not been associated with this drug
 Drug-drug interactions are minimal because metabolism occurs quickly in
the stomach and jejunum

23.  References:
 Lippincott Illustrated Reviews: Pharmacology
 Nutrition Therapy and Pathophysiology
 Medical Pharmacology at a Glance
 Pharmacology Clear and Simple_ A Guide to Drug Classifications and
Dosage Calculations
 Williams' Basic Nutrition & Diet Therapy
 Netter's Illustrated Pharmacology
 www.drugs.com