Transcript 9-7 Denver_CONSTIPATION

Chronic
Constipation
Barbara P. Yawn, MD MSc FAAFP
Olmsted Medical Center
Rochester, MN
[email protected]
Thank you to Louis Kuritzky, M.D. for some of the slides.
1
AFP/FPM Live learning objectives
• Discuss the etiologies of chronic constipation
• Identify treatment options for chronic constipation
• Explain the importance and details of behavioral
therapy for chronic constipation
• Describe treatment options for constipationpredominant irritable bowel syndrome
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Our discussion today
• What is constipation?
• How common is it?
• Different types
– Primary
– Secondary
• Treatment
– OTC
– Prescriptions
– Unusual
– What to avoid
3
“No true definition exists for
Constipation.”
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002, Rakel,
Bope, eds. WB Saunders (Philadelphia)
4
What is constipation?
• Unsatisfactory defecation
– Infrequent stool
– Difficult stool passage
– Both
– ? <3 stools/week
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
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Chronic Constipation: Rome criteria
•
•
•
•
•
•
For past 3 months, with onset > 6 months prior, 2 or more
of the following:
straining > 25% of time
lumpy or hard > 25% of time
sensation of incomplete evacuation > 25% of the time
sensation of obstruction/blockage > 25% of the time
manual maneuvers > 25% of time
< 3 defecations/week
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
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Practical Clinical Definition
Any noteworthy departure from established
• persistent  stool frequency
•  stool hardness
•  straining at stool.
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How common is it?
•
•
•
•
2.5 million annual US physician visits
> $500 million annual US laxative sales
Overall annual cost of $29 billion
30% seen by family physicians
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
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Constipation: Geriatrics
• Survey: persons > 65 yrs, Olmsted County,
Minnesota (n=328)
• Constipation = 23% [def: straining, hard stools,
< 3 stools/week ]
• 23.7% required digital self-facilitation
Ehrenpreis ED “Definitions and epidemiology of constipation” Constipation Etiology
Evaluation & Management. Wexner SD, Bartolo DCC, eds (Butterworth-Heinemann
Ltd , Oxford) 1995:3-8
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Secondary constipation
Causes
– Endocrine and metabolic disorders (Diabetes,
hypothyroidism, hypercalcemia)
– Neurological disorders (Neuropathies, multiple
sclerosis)
– Collagen-vascular diseases (Progressive systemic
sclerosis)
– Medications
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Secondary constipation
Causes (continued)
• Medications
– Metals: aluminum, barium or iron
– Analgesics-NSAIDs, opiods
– Anti-cholinergic: anti-Parkinsons, anti-depressants,
atropine
– Anticonvulsants
– Antihistamines
– Anti-hypertensives
– Chemotherapy: vinca alkaloids
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Secondary constipation: Causes
Hirschsprung disease
Chagas disease
Intestinal pseudo-obstruction
Autonomic neuropathy
Neurofibromatosis
MS
Cord Lesions
Parkinsons
Nervi Erigentes Trauma
Stroke
DM
Hypothyroidism
Ca++
Pregnancy
Hypopituitarism
Systemic Sclerosis
Amyloidosis
Dermatomyositis
Myotonic dystrophy
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
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Extra-colonic Causes You Will See
• Diabetes
– ± 20%; probably autonomic neuropathy
• Hypothyroidism:
– May be 1st indicator; Rx restores normal function
• Medications:
– CCB: verapamil = 7.5%
– NSAIDS: ibuprofen, naproxen = 3%, sulindac = 9%
– Opioids
• Chronic stimulant (e.g. anthraquinone, bisacodyl) use
• Pregnancy
– Often starts long before uterus enlarges
Castro DD, Cherry DA”Extracolonic causes of constipation” Constipation Etiology Evaluation &
Management. Wexner SD, Bartolo DCC, eds (Butterworth-Heinemann Ltd , Oxford) 1995:23-30
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Primary constipation
• Normal transit constipation
– 59% of all, often perception not reality
• Dyssynergic defecation
– 25%, failure of pelvic floor to relax
• Slow-transit constipation
– 13% of all, delayed emptying of proximal colon
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
14
Mrs. J is 64 year old woman with multiple
problems for which she takes 6 medications
daily. She comes in complaining of
constipation.
Which of the following do you want to know by
week’s end?
– A. History of stooling
– B. Types of medications
– C. Whether she has seen blood in stools
– D. The results of her barium enema.
– E. All of the above.
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Delayed Transit = Colonic Inertia
Slowed Colonic Emptying
 Fluid Absorption
 Hard, Dry Stool
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Delayed Transit = Colonic Inertia
Slowed Colonic Emptying
 Rectal Stool Volume Delivery
Insufficient Stool to Trigger
Rectal Evacuation Mechanism
 Stool Interval
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Active
absorption
1000 mL fluid presented
to colon daily
NaCl
Osmotic
Effect
ClFollows
Electrical Gradient
Na+
Electrical
gradient
900 mL fluid absorption
Guyton AC, Hall JE. Digestion and absorption in the GI tract. In: Textbook of Medical
Physiology. 10th ed. Philadelphia, PA: WB Saunders Co 2000;754-763
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Dyssynergic Defecation (Anismus)
• Failure to coordinate pelvic floor  anal sphincter
• Aberrant manometry patterns on insertion of probe:
–  rectal pressure + paradoxic  anal sphincter pressure
– no  rectal pressure + paradoxic anal contraction
– Rectal pressure + incomplete/no anal sphincter relaxation
Jancin B. “Biofeedback Often Effective in Chronic Constipation” Report on a presentation at
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the ACG by SSC Rao, Fam Pract News 2001; page 17
Medical history
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•
•
•
•
•
Patient’s definition
Describe onset
Severity
Duration
Relationship to “normal”
Usual behaviors
–
–
–
–
Fluid and diet intake
Activity
Cognitive abilities
Medications—OCT and prescribed
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7..
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Bristol scale
•
•
•
•
•
•
•
1= hard lumps like nuts
2=sausage but not lumpy
3=sausage like with “cracks”
4=smooth, snake-like
5=soft blobs
6=fluffy pieces
7=watery, no form
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7..
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Physical examination
• Digital rectal exam
– Anal strictures
– Masses
– Sphincter tone
– Puborectalis tenderness or spasm
• Abdominal exam
• Pelvic exam for women
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
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Digital rectal examination should evaluate
• Resting tone of the sphincter segment, and its
augmentation by a squeezing effort.
• The voluntary external anal sphincter will be tightened
by squeezing; the internal sphincter will not.
– Puborectalis muscle (above internal spincter)
• Palpate during squeeze and compress between the
examining finger and the thumb. Acute localized pain
along the border of the muscle is a feature of the
puborectalis spasm syndrome.
– Ability to integrate the expulsionary forces by
requesting that she/he "expel my finger".
• http://www.guidelines.gov/summary/summary.aspx?doc_id=3061
&nbr=002287&string=Constipation
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At the conclusion of initial evaluation, you
can tentatively diagnose …
• Irritable bowel syndrome when pain and the other
features of irritable bowel syndrome are present;
• Slow-transit constipation;
• Rectal outlet obstruction;
• A combination of slow-transit constipation and rectal
outlet obstruction;
• Organic constipation (mechanical obstruction or drug
side effect)
• Constipation due to systemic disease. (Level B)
– http://www.guidelines.gov/summary/summary.aspx?doc_id=3061&nbr=00228
7&string=Constipation
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Laboratory, imaging and other tests
Not unless alarming signs
– No evaluation
– Try 2-4 weeks of empiric therapy
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
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Alarming signs
• Fever, nausea, vomiting, wt loss > 10 pounds
• Blood in stool, anemia
• Family history
– Inflammatory bowel disease
– Colon cancer
• Onset after age 50
• Acute changes in “elderly” (age 60 and over)
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
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ASGE guideline on using endoscopy in
managing constipation
Colonoscopy is indicated in selected patients to exclude
obstruction from cancer, stricture, and extrinsic
compression. Patients with constipation should undergo
colonoscopy if they have rectal bleeding, heme-positive
stool, iron deficiency anemia, weight loss, obstructive
symptoms, recent onset of constipation, rectal prolapse,
or change in stool caliber. Colonoscopy should also be
done before surgery for constipation. (Level C)
http://www.guidelines.gov/summary/summary.aspx?doc_id=7780&nbr=004485
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Older patients may need colonoscopy
Patients older than 50 who have not had colorectal
cancer screening should undergo colonoscopy.
Chronic constipation associated with  risk of colon cancer in two
US population-based, retrospective studies (odds ratio 2.36: 95%
CI 1.4, 3.93; relative risk 4.4 for severe constipation: 95% CI 2.1,
8.9) but not in a prospective study of women nurses. A retrospective
study from Australia also reported increased cancer risk in patients
with constipation, and a retrospective study from Japan found
increased risk in frequent laxative users. (Level B)
http://www.guidelines.gov/summary/summary.aspx?doc_id=7780&nbr=004485
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What you might see on Barium Enema
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•
•
•
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Obstructing neoplasm
Strictures
Hirschsprung’s (megacolon)
Spasm (suggests laxative abuse)
Absent haustral markings (seen in chronic
laxative use, atonic megacolon)
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
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Diagnostic Studies
3 day colonic transit study (radio-opaque marker):
presence > 70 hours = colonic inertia
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
30
Mrs. J has long history of 2 stools per week. Since she
added the NSAIDs and occasional opoids for her PHN to
her medication for hypothyroidism, antihypertensive,
statin, daily baby aspirin and calcium tablets, she is
having much more straining at stool, sees occasional
blood on tissue and has only 1 stool per week with
manual help.
You decide that …
A. This is acute onset constipation.
B. This is probably aggravation of existing constipation.
C. This sounds like primary constipation.
D. This sounds like secondary constipation.
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Is it Constipation?
Secondary?
Evaluate,
Diagnose,
Treat
Idiopathic?
•
•
•
•
Provisional Rxs 2-4 weeks:
Stool Hygiene
Fiber/Hydration
Osmotic Laxatives (PEG)
Emollient
Inadequate Response?
?Referral
Saline Laxative
Stimulant
Alarm/Alerts?
Late onset
Sudden onset
Blood
Obstructive Sx
Weight loss
Fever
Mass
Further evaluation
BE, endoscopy
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Clinical:Scientific Discordance
We don’t approach this commonplace and
burdensome malady with the same scientific
intellectual base that is accorded essentially all
other equally consequential health issues.
We do a rudimentary (read fair to poor) job of
constipation management.
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Patient with multiple morbidities
OA
DM
DYSLIPDEMIA
OBESITY
HTN
CONSTIPATION
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Our Prioritization
DYSLIPDEMIA
DM
HTN
OA
CONSTIPATION
OBESITY
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Which is the patient’s top priority?
A.
B.
C.
D.
E.
Diabetes
Hyperlipidemia
Obesity
Constipation
Pleasing you
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Patient Priorities
CONSTIPATION
OA
DM
OBESITY
HTN
DYSLIPDEMIA
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Constipation: Typical Scenario
Pt (at end of visit, after HTN, DM, Obesity, yada
yada, have been dealt with): “… and Doc, I have
been having a bit of constipation lately.”
MD: “More fiber and water.”
Pt: OK Doc, we’ll give it a try.
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Treatment types
• Laxative: slower onset of action (1-3 days), lesser
degree of bowel evacuation
• Cathartic: more rapid onset of action (6-12 hours),
greater degree of bowel evacuation
Locke GR 3rd, Pemberton JH, Phillips SE. AGA technical review on constipation
Gastroenterology. 2000;119:1766-1778
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Primary constipation:
• Normal transit constipation
– 59% of all, often perception, not reality
• Dyssynergic defecation
– 25%, failure of pelvic floor to relax
• Slow-transit constipation
– 13% of all, delayed emptying of proximal colon
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
40
Secondary constipation
Causes
– Endocrine and metabolic disorders (Diabetes,
hypothyroidism, hypercalcemia)
– Neurological disorders (Neuropathies, multiple
sclerosis)
– Collagen-vascular diseases (Progressive systemic
sclerosis)
– Medications
41
Secondary constipation
Causes (continued)
• Medications
– Metals: aluminum, barium or iron
– Analgesics-NSAIDs, opiods
– Anti-cholinergic: anti-Parkinsons, anti-depressants,
atropine
– Anticonvulsants
– Antihistamines
– Anti-hypertensives
– Chemotherapy: vinca alkaloids
42
Rx Approach
“After exclusion or appropriate Rx of medical
problems, the therapy of constipation is empiric.”
Jensen JE “Medical treatment of constipation” in Constipation Etiology Evaluation &
Management. Wexner SD, Bartolo DCC, eds (Butterworth-Heinemann Ltd , Oxford)
1995:137-153.
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Steps in therapy
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Correct misconceptions
Reassure
Identify neurotic preoccupation
Modify medication regimen
Behavioral Rx
Laxatives
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
44
Step 1
•
•
•
•
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Education
High Fiber Diet
Fiber Supplementation
Exercise
Evacuation Posture
Dedicated Time for Evacuation
Avoidance of Stimulant Laxatives
Adapted from Jensen JE “Medical treatment of constipation” in Constipation Etiology
Evaluation & Management. Wexner SD, Bartolo DCC, eds (Butterworth-Heinemann Ltd ,
Oxford) 1995:137-153.
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Step 2
•
•
•
•
Stool softeners
Hyperosmolar agents
Glycerin suppositories
Enemas
– Tap water
– Avoid soap suds
• Intermittent sparing use of stimulants
Adapted from Jensen JE “Medical treatment of constipation” in Constipation Etiology
Evaluation & Management. Wexner SD, Bartolo DCC, eds (Butterworth-Heinemann Ltd ,
Oxford) 1995:137-153.
46
Behavioral therapy
• Regular daily routine for BM
• Preferred time = 5-10 minutes PP (uses
gastrocolic reflex)
• May initially induce timed stool
– Enema (lukewarm tap water preferred)
– Suppository (bisacodyl preferred)
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
47
Laxatives: Basic Issues
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•
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Mechanisms poorly understood
Potential for toxicity often underestimated
Few head-to-head comparative data
Rx choice most often motivated by personal
preference rather than objective efficacy data
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
48
Laxatives: Classification
(> 700 brands in US)
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•
•
•
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Bulk-forming
Emollient
Saline
Stimulant
Osmotic
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
49
Bulk-forming Laxatives
• Components: natural polysaccharides,
synthetic polysaccharides, or cellulose
derivatives
• Best effects with increased fluid intake (use
with caution in CHF)
• Multiple formats: powder, biscuit, tablet
• GI adverse effects
• Tolerance
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
50
Bulk Forming Laxatives: Mechanisms
• Water Absorption
•  Fecal Mass
• Metabolism by colonic flora osmotically
active metabolites
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
51
Bulk Forming Laxatives: Use
• Examples: Konsyl, Effersyllium, Perdiem,
Metamucil, FiberCon
• Initial use may cause bloating, but  over time
• May cause obstruction if strictures, atonic
colon
• Mean impact = 1.4 stools/week 
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
52
Emollient Laxatives
• Mineral oil
– Can cause decreased vitamin A, D, E, K absorption
– Administer between meals
– Avoid if aspiration risk (can cause lipid pneumonia)
• Docusate sodium (Colace)
– Decreases stool surface tension, which increases
aqueous/fat mixtures, thereby increasing water
penetration into stool and producing softer stool
– Increases colonic fluid and electrolyte secretion
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
53
Saline Laxatives
• Examples: Milk of Magnesia, Fleets Phosphosoda
• Mg++ or Na+ salts
• Mechanisms:
– Poorly absorbed  hyperosmolar solution  water
entry into colonic lumen
– Stimulate cholecsytokinin release
• Adverse effects: hypermagnesemia, hypocalcemia
(PO4 OD), Na+ overload)
• Avoid in renal disease or CHF
• Not for chronic use
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
54
Osmotic Laxatives: Lactulose
• Unmetabolizable semisynthetic disaccharide
–  osmotic effect of undigested sugar
– conversion by colonic bacteria organic acids
 altered electrolyte transport  colonic
motility
– 24-48 hrs to achieve effect
Cheskin LJ. “Constipation and Diarrhea” in Principles of Ambulatory Medicine 5th Edition,
1999; Barker LR, Burton HR, Zieve PD, Eds Williams & Wilkins (Baltimore)
55
Hyperosmolar Agents:
PEG, lactulose, sorbitol
• Can be used chronically
• May use PEG-ELS (e.g, GoLytely,
NuLytely) reduced dose daily: 250-500 mL
• PEG (Miralax)
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
56
Stimulant Laxatives
• Examples:
– cascara sagrada (Peri-Colase)
– bisacodyl (Dulcolax)
– senna (Senokot, ExLax)
• Mechanism:
–  altered mucosal electrolyte transport 
colonic motor activity
– Chronic use can  dependency
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
57
Stimulant Laxatives: side effects
• Phenolphthalein  severe allergic
dermatitis, Stevens-Johnson syndrome
• Anthraquinones (e.g., Senna, cascara,
danthron): chronic use can  myenteric
plexus damage  impaired bowel motility
Etzkorn KP, Rodriguez L. “Constipation” in Conn’s Current Therapy 2002. Rakel, Bope,
eds. WB Saunders (Philadelphia).
58
Serotonin Modulation: Tegaserod
• Study: Randomized, double-blind, controlled trial
(n=1,348) adults with chronic idiopathic
constipation
• Rx: tegaserod 2mg b.i.d. (n=450), tegaserod 6 mg
b.i.d. (n=451), or placebo (n=447)
• Primary outcome:
–  ≥ 1 BM/week during weeks 1-4
• Secondary outcome:
–  ≥ 1 BM/week during weeks 1-12
Johanson JF, Wald A, Tougas G, et al. “Effect of tegaserod in chronic contstipation: a
randomized, double-blind, controlled trial.” Clin Gastroenterol Hepatol. 2004;2:706-805.
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Tegaserod status
• Removed from market March 30, 20071
• Can be used in new drug (IND) protocol to treat irritable
bowel syndrome with constipation (IBS-C) and chronic
idiopathic constipation (CIC) in women younger than 55
who meet specific guidelines2
• Increased risk of cardiovascular events
– 13 events in 11,614 on Tegaserod (0.11%)
– 1 event in 7,031 on placebo (0.01%)
• Talk to your physician
• Seek immediate care if symptoms
• Transition to other meds
1. Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
2. www.FDA.gov/bbs/topics/NEWS/2007/NEW01673.html.
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Refractory Constipation: Misoprostol
• STUDY: 9 pts severe chronic constipation
• Rx: misoprostol 1200 mcg/d vs placebo X 3 wks
• RESULTS:
– misoprostol  #BM / week ( 2.2  6.2)
– Abdominal pain: Rx = placebo
– Contra-indicated in pregnancy
Soffer, EE Misoprostol is effective treatment for patients with severe chronic constipation. Dig
Dis Sci 1994.39:929-933.
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Chronic Constipation: Biofeedback
•
•
•
•
May help with functional obstruction
First long-term trial (1 yr)
STUDY: chronic constipation (n=80)
INTERVENTION: diaphragmatic breathing
exercises, then biofeedback Q wk
• RESULTS (at 6 wks, 6 months, &1 year):
stool frequency 4.2/wk 7.2/wk
Lembo A. Chronic constipation. N Eng J Med. 2003:349:1360-1368
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Colchicine
•
•
•
•
Diarrhea is known side effect
Increases stool frequency
Reduces need for laxative in 10% of CC
Uncommon treatment due to side effects
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
63
Lubiprostone
•
•
•
•
•
•
Bicyclic fatty acid
Locally activates CL channels in membranes
Increases intestinal fluid secretions
Improved stool frequency
Decreased straining at stool
Side effects
–
–
–
–
31% nausea
13% diarrhea
13% headache
13% abdominal distention
Cash BD et al. J Fam Pract. 2007; June supplement:S1-S7.
64
Summary
•
•
•
•
Common but commonly mislabeled
Must rule out secondary constipation
Ask about patient’s priorities
Primary constipation treated empirically first
– Assessment of life style and self therapy
– Fluid, diet and activity
– Better toileting habits
– Laxatives
• Bulk
• Stimulants
• Unusual types
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