Transcript Causes of Constipation

Constipation
Karol L. Gordon, DO, CAQG, CMD
Edward Warren, MD, CAQG, CMD January 2012
GOAL
To understand constipation, its causes
and management in patients.
Learning Objectives
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List the impacts of constipation. (slide 5)
Define constipation. (slide 6)
State normal stool frequency. (slide 7)
State the cause of diarrhea in constipation. (slide 8)
List the relationships of diet, activity, and pregnancy to
constipation. (slide 9)
List the steps in the vicious cycle of laxative abuse. (slide 9)
List systemic medical conditions causing constipation. (slide
10)
List colon lesions causing constipation. (slide 11)
Learning Objectives
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List GI medical conditions causing constipation. (slide 12)
List anal conditions causing constipation. (slide 13)
List medications causing constipation. (slide 14)
List red flags indicating something more serious is going on as
well. (slide 17)
List common risk factors for constipation. (slide 18)
State the steps in the proper workup for constipation. (slides 19 –
20)
List the various treatments for constipation. (slides 21 – 24)
Define and characterize impaction. (slide 25)
OMM techniques are in an accompanying Power Point.
Constipation
• Common in children and older age
• About 2% of the population suffers
from chronic constipation.
• The number of physician visits for
constipation increases after age 65
• Associated with anxiety, depression,
and poor health perception.
PRUNES
Are 3 enough?...
5 too many?
Constipation - Definition
• infrequent bowel movements
• typically <3 times per wk
• difficulty during defecation (straining during
more than 25% of bowel movements or a
subjective sensation of hard stools)
• the sensation of incomplete bowel
evacuation.
Hmmm…
wonder
what’s the normal # ?
ANSWER: “NORMAL” ranges from
3 - 4 BM’s/day
to 1 every 3 - 4 days!
Constipation
Constipation can also cause diarrhea confusing the
diagnosis
• The liquid stool is able to come around the solid
stool presenting as diarrhea.
• This is easily misdiagnosed!!!!
• Physical exam is key:
• Abdomen soft with good to hyper bowel sounds?
• Not likely constipation
• Abdomen firm to hard with decreased bowel sounds?
• Likely constipation
Constipation
• Various conditions can cause constipation:
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Poor diet
Inactivity
Pregnancy
Irritable bowel syndrome
• Various medications can cause constipation:
– Overuse of laxatives, a vicious circle
• more use causes more need
– Opioids
– Anticholinergics

Causes of Constipation
• Various medical conditions:
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Hypothyroidism
Multiple sclerosis
Lupus
Parkinson's disease
Stroke
Spinal cord injuries
Spinal cord disorder
Diabetes
Thyroid diseases
Uremia
Amyloidosis
Scleroderma
Causes of Constipation
– Colon polyp
– Colon tumor
– Colon cancer
Causes of Constipation
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Intestinal obstruction
Intestinal adhesions
Diverticulosis
Intestine tumors
Colorectal stricture
Hirschsprung's disease
Chronic idiopathic constipation (type of Constipation)
Vitamin B deficiency - causing colon muscles to
have dysfunction.
Causes of Constipation
• Anorectal conditions
– Anorectal dysfunction
– Anismus (pelvic floor spasms)
– Rectal prolapse
• Painful defecation - any cause of painful
defecation, may cause patients to hold back a
bowel movement leading to constipation.
– Hemorrhoids
– Anal fissure
Causes of ConstipationMedications
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Laxative overuse *
Opioids
Antacids with aluminum
Antispasmodics
Antidepressants
Calcium supplements
Diuretics
Anticonvulsants (some) - esp. for epilepsy
Calcium channel blockers
Beta blockers
Cholestyramine
Certain tranquilizers
SIDE NOTE
• Aluminum that causes constipation is mixed with
magnesium that causes diarrhea in products like
Mylanta for an antacid that does not cause such
side effects.
• Cholestyramine that causes constipation is most
commonly used for treatment of chronic diarrhea.
It is seldom used for hyperlipidemia.
Joke break
Q. Well, did you hear about the constipated accountant?
A. He couldn't budget.
Q. Did you hear about the constipated composer?
A. He couldn't finish the last movement.
Red Flags
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Bleeding, unless hemorrhoids present
Fever
Weight loss
Persistent severe pain
Malnutrition.
New Onset Constipation =
Colon cancer
until proven
otherwise!
Constipation- Risk Factors
• Low fluid intake
• Low level of activity
• Medications
– Especially opioids
• Poor diet
Constipation Work Up
Laboratory Studies
 TSH - to rule out hypothyroidism
 Basic metabolic profile - to assess electrolyte
imbalance
 Fecal occult blood - to assess an obstructing
neoplasm of the colon.
 CBC - helps to give an indication that the
constipation is related to blood loss.
Constipation Work Up
• In the acute situation with a patient at low risk who usually
is not constipated, no further evaluation is necessary.
• Consider sigmoidoscopy, colonoscopy, or barium enema
for colorectal cancer screening in patients older than 50
years.
• Counsel the patient regarding the appropriate dietary
prophylaxis with follow-up visits on an outpatient basis.
• If the patient experiences further episodes of constipation,
a more detailed evaluation may then become appropriate.
Constipation
Treatment
• Diet
– Increase fiber
– Increase fluid intake
– Increase activity
– Decrease intake of milk, coffee, tea, and alcohol
Constipation Treatment
• Bulk-forming agents (fibers)
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Fiber is the best medication for long-term treatment
Metamucil- 15-60 g/d PO with at least 8 glasses of water
Citrocel- 15-60 g/d fiber PO with at least 8 glasses of water
• Emollient stool softeners
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Docusate sodium- 50-360 mg/d PO
• Osmotic laxatives
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Magnesium hydroxide- 2.4-4.8 g/day PO qd or divided
Magnesium citrate- 11-18 g/day PO qd or divided
Magnesium sulfate- 10-30 g/day PO qd or divided
Lactulose- 20-30 g (30-45 mL) PO q1-2h; adjust dose slowly to
produce 2-3 soft stools daily in liver failure
Polyethylene glycol (Miralax)- 17 g/d PO in 8 oz of water
Constipation Treatment
• Lubricant laxatives
• Mineral oil - 15-45 mL PO as 1-time dose or qd or as
retention enemas
• Stimulant laxatives
• Senna- 0.12-0.25 g/d PO
• Bisacodyl (Bisac-Evac, Bisco-Lax, Dulcolax,
Dacodyl)- 5-15 mg PO as single dose
10 mg PR as single dose
• Lubiprostone (Amitiza)- 24 mcg PO bid with food
• Opioid reversal
• Methylnaltrexone – 0.15 mg/kg sq qod prn
Constipation Treatment
• Stimulant laxatives
• Senna- 0.12-0.25 g/d PO
• Bisacodyl (Bisac-Evac, Bisco-Lax,
Dulcolax, Dacodyl) 5-15 mg PO as single
dose
10 mg PR as single dose
Fecal Impaction
Impaction of hard stool in the bowel
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Requires manual disimpaction (removal)
May be high in the colon
Serious complication
May result in bowel
perforation!
References
• Foundations for Osteopathic Medicine, 2nd edition,pp.400407,1052-1055, copyright 2003
• Arch Surg,2003;138:206-214
• Clinics in Family Practice - Volume 6, Issue 3 (September
2004)
• http://emedicine.medscape.com/article/184704-treatment
• American Family Physician
Volume 67 • Number 10 • May 15, 2000
Copyright © 2003 American Academy of Family Physicians
• Brocklehurst’s Textbook of Geriatric Medicine and
Gerontology 6th edition