treatments for constipation

Treatments for Treatments for constipationconstipation

CJ LauCJ Lau

26 Aug 200926 Aug 2009

OutlineOutline

Definition of constipationDefinition of constipation Etiology and pathophysiology of Etiology and pathophysiology of

constipationconstipation Rationale for drug useRationale for drug use Pharmacological and non Pharmacological and non

pharmacological treatmentspharmacological treatments Patient education/counsellingPatient education/counselling

DefinitionDefinition Constipation has varied meaning for Constipation has varied meaning for

different peopledifferent people Rome II criteria define constipation as Rome II criteria define constipation as

>2 of the following in a 12 weeks >2 of the following in a 12 weeks period:period:

1.1. Straining at defecation at least a Straining at defecation at least a quarter of the timequarter of the time

2.2. Lumpy or hard stools at least a Lumpy or hard stools at least a quarter of the timequarter of the time

3.3. Sensation of incomplete evacuation at Sensation of incomplete evacuation at least a quarter of the timeleast a quarter of the time

4.4. 3 or fewer bowel movements/week3 or fewer bowel movements/week

Types of constipationTypes of constipation

Acute constipationAcute constipation1.1. Use suppositories or enema to clear Use suppositories or enema to clear

the rectum and followed by simple non the rectum and followed by simple non drug measuredrug measure

2.2. Use lactulose or sorbitol if dietary Use lactulose or sorbitol if dietary fibre cannot be adequately increasedfibre cannot be adequately increased

Fecal impactionFecal impaction1.1. Occurs when dry hard stool become Occurs when dry hard stool become

compacted into large hard stool which compacted into large hard stool which cannot be expelled from rectumcannot be expelled from rectum

Fecal impaction Fecal impaction continues..continues..

2.2. Should initially be disimpacted by Should initially be disimpacted by manual disimpactionmanual disimpaction

3.3. An enema with mineral oil can then An enema with mineral oil can then be used to soften the stoolbe used to soften the stool

4.4. Sometimes impacted fecal must be Sometimes impacted fecal must be accomplished using sigmoidoscopy accomplished using sigmoidoscopy with instrumentationwith instrumentation

5.5. Regular laxative use in addition to Regular laxative use in addition to lifestyle and diet changes lifestyle and diet changes

Types of constipationTypes of constipation

Chronic constipationChronic constipation

1.1. Normal colonic transit- exhibit Normal colonic transit- exhibit psychosocial distresspsychosocial distress

2.2. Colonic inertia/slow colonic transit- have Colonic inertia/slow colonic transit- have delayed passage of radiopaque markers delayed passage of radiopaque markers through proximal colon, have little or no through proximal colon, have little or no increase in motor activity following a mealincrease in motor activity following a meal

3.3. Dyssynergic defecation- inappropriate Dyssynergic defecation- inappropriate contraction of pelvic floor muscle, can be contraction of pelvic floor muscle, can be only diagnosed with anorectal manometryonly diagnosed with anorectal manometry

EtiologyEtiology The slowing of colonic transit may be The slowing of colonic transit may be

idiopathic or due to motor disorders idiopathic or due to motor disorders associated with many diseasesassociated with many diseases

Due to side effects of many drugs- Due to side effects of many drugs- opiods, calcium supplements, verapamil, opiods, calcium supplements, verapamil, anticholinergics, aluminium antacidsanticholinergics, aluminium antacids

Medical conditions (secondary causes)- Medical conditions (secondary causes)- hypothyroidism, pregnancy, irritable hypothyroidism, pregnancy, irritable bowel syndrome, Parkinson disease, bowel syndrome, Parkinson disease, colon cancer & colon cancer & Hirschprung’s diseaseHirschprung’s disease

PathophysiologyPathophysiology

Defecation involves the coordinated relaxation Defecation involves the coordinated relaxation of puborectalis and external anal sphincter of puborectalis and external anal sphincter muscles, together with increased in muscles, together with increased in intraabdominal pressure and inhibition of intraabdominal pressure and inhibition of colonic segmenting activity.colonic segmenting activity.

Slow transit constipation- possibly related to Slow transit constipation- possibly related to decreased numbers of high-amplitude decreased numbers of high-amplitude propagated contractionspropagated contractions

Pelvic floor dysfunction- features normal or Pelvic floor dysfunction- features normal or slightly slowed colonic transit, leads to slightly slowed colonic transit, leads to inability to evacuate adequately the content inability to evacuate adequately the content from the rectum. from the rectum.

Hirschsprung’s diseaseHirschsprung’s disease

Incidence of 1 in 5000 patients, commonly due to Incidence of 1 in 5000 patients, commonly due to trisomy 21trisomy 21

A rare cause of intractable constipation in toddler A rare cause of intractable constipation in toddler and childrenand children

Absence of ganglion cells in the myenteric & Absence of ganglion cells in the myenteric & subcutaneous plexures of the distal colon subcutaneous plexures of the distal colon resulting sustained contraction of the aganglionic resulting sustained contraction of the aganglionic segment.segment.

Bowel above the constricted area dilates Bowel above the constricted area dilates (megacolon) due to stool trapping (megacolon) due to stool trapping

Commonly occurs near rectum regionCommonly occurs near rectum region May require surgery to remove the aganglion May require surgery to remove the aganglion

segmentsegment

Evaluation/diagnosisEvaluation/diagnosis

Careful history taking- defining the Careful history taking- defining the nature and duration of constipation nature and duration of constipation and identify secondary causes and identify secondary causes

Physical examination- rectal Physical examination- rectal examination may be helpful. It can examination may be helpful. It can identify fissures and heamorrhoidsidentify fissures and heamorrhoids

Endoscopy/colonoscopyEndoscopy/colonoscopy Radiography/imagingRadiography/imaging

Dietary and lifestyle Dietary and lifestyle changeschanges

Is the mainstay treatment for constipation, Is the mainstay treatment for constipation, it should be continued even when it should be continued even when laxatives are usedlaxatives are used

Ensure adequate dietary fibre intake (25-Ensure adequate dietary fibre intake (25-30g/daily). Increase intake gradually to 30g/daily). Increase intake gradually to avoid bloating & flatulenceavoid bloating & flatulence

Ensure adequate fluid intakeEnsure adequate fluid intake Increase exercise, avoid sedentary Increase exercise, avoid sedentary

lifestylelifestyle Behaviour changes- do not hold urge to Behaviour changes- do not hold urge to

defecatedefecate

When to start treatmentWhen to start treatment

Symptoms do not resolve after Symptoms do not resolve after treating reversible causes (eg. treating reversible causes (eg. Hypothyroidism, depression etc)Hypothyroidism, depression etc)

Dietary changes are ineffectiveDietary changes are ineffective Fecal impactionFecal impaction When starting on opioid analgesiaWhen starting on opioid analgesia

Onset of effect of Onset of effect of laxativeslaxativesGroup of Group of

laxativeslaxatives ExamplesExamples Onset of Onset of

actionaction

Bulking Bulking agentsagents

pyslliumpysllium Oral: 48-Oral: 48-72hours72hours

Osmotic Osmotic laxativeslaxatives

Glycerol, Glycerol, lactulose, lactulose, sorbitolsorbitol

Oral: 24-Oral: 24-72hours72hours

Rectal: 5-Rectal: 5-30min30min

Polyethylene Polyethylene glycol, saline glycol, saline laxativeslaxatives

Oral: 0.5-Oral: 0.5-3hours3hours


Stool Stool softenersoftener

Docusate, Docusate, liquid liquid paraffinparaffin



Stimulant Stimulant laxativeslaxatives

Senna, Senna, bisacodylbisacodyl



Bulking agent (eg. Bulking agent (eg. psyllium)psyllium)

Useful for mild constipation,small hard Useful for mild constipation,small hard stool and long term controlstool and long term control

Not to be used in acute constipationNot to be used in acute constipation Absorb water into colon to increase fecal Absorb water into colon to increase fecal

bulk which stimulates peristaltic activitybulk which stimulates peristaltic activity Ensure adequate fluid intake to avoid Ensure adequate fluid intake to avoid

intestinal obstructionintestinal obstruction Pregnancy risk factor B & excretion in Pregnancy risk factor B & excretion in

breast milk unknownbreast milk unknown S/E: flatulence, bloating, abdominal S/E: flatulence, bloating, abdominal

discomfortdiscomfort

Osmotic laxativesOsmotic laxatives GlycerolGlycerol (suppository)- can be used for acute relief of (suppository)- can be used for acute relief of

constipation, onset of action (5-30minutes)constipation, onset of action (5-30minutes)1.1. Ravin enema (List C item) is available in hospital, Ravin enema (List C item) is available in hospital,

contains glycerin 25% and NaCl 15% contains glycerin 25% and NaCl 15% Lactulose Lactulose (List B item, available as 3.35g/5ml in (List B item, available as 3.35g/5ml in

hospital)hospital)1.1. not suitable for acute relief (onset of action-1 to 3 not suitable for acute relief (onset of action-1 to 3

days), need to be taken regularlydays), need to be taken regularly2.2. Poorly absorbed, metabolised by colonic bacteria, Poorly absorbed, metabolised by colonic bacteria,

exert osmotic effect on colonexert osmotic effect on colon3.3. CI- lactose and galactose intoleranceCI- lactose and galactose intolerance4.4. Dose- adult: 15-30ml/day, increase to 60ml/day in 1-2 Dose- adult: 15-30ml/day, increase to 60ml/day in 1-2

divided dose, paed: 0.5ml/kg 12-24hourlydivided dose, paed: 0.5ml/kg 12-24hourly5.5. Pregnancy risk factor B and excretion in breast milk Pregnancy risk factor B and excretion in breast milk

unknownunknown6.6. Can be mixed with water, fruit juice or milk for better Can be mixed with water, fruit juice or milk for better

tastetaste

Osmotic laxativesOsmotic laxatives

Sorbitol 70%Sorbitol 70%

1.1. non absorbable sugar, produce osmotic non absorbable sugar, produce osmotic effect at the coloneffect at the colon

2.2. Dose: 2-11yo – 2ml/kg , >12yo- 30-150mlDose: 2-11yo – 2ml/kg , >12yo- 30-150ml

3.3. Precaution- use with caution with patients Precaution- use with caution with patients with severe cardiopulmonary or renal with severe cardiopulmonary or renal impairment, large volume may cause fluid impairment, large volume may cause fluid overload or electrolytes imbalanceoverload or electrolytes imbalance

4.4. S/E: oedema, abdominal discomfort, S/E: oedema, abdominal discomfort, diarrhea, fluid and electrolytes disturbancesdiarrhea, fluid and electrolytes disturbances

Osmotic laxativesOsmotic laxatives Polyethylene glycolPolyethylene glycol1.1. Used for bowel cleansing prior to GI Used for bowel cleansing prior to GI

examination or occasional treatment of examination or occasional treatment of constipationconstipation

2.2. Dose for constipation: adult- 17g of Dose for constipation: adult- 17g of powder dissolves in 8oz(240ml) of water powder dissolves in 8oz(240ml) of water for Miralax, not to be used for > 2 weeksfor Miralax, not to be used for > 2 weeks

3.3. Do not add flavouring agent to the Do not add flavouring agent to the solution, chilled solution is more palatablesolution, chilled solution is more palatable

4.4. Many commercial dosage forms available, Many commercial dosage forms available, dose depends on each product (eg. dose depends on each product (eg. Movicol, Movicol half, Colonlytelly)Movicol, Movicol half, Colonlytelly)

Osmotic laxativesOsmotic laxatives Saline laxativesSaline laxatives1.1. Contains poorly absorbed irons eg Contains poorly absorbed irons eg

magnesium sulfate, phosphate, and citrate magnesium sulfate, phosphate, and citrate which retain water in colon by osmotic which retain water in colon by osmotic effect and stimulates peristalsiseffect and stimulates peristalsis

2.2. Onset of action- 30min to 3hoursOnset of action- 30min to 3hours3.3. Sodium phosphate laxatives are CI in heart Sodium phosphate laxatives are CI in heart

failure and renal impairmentfailure and renal impairment4.4. Dosage- depending on each productDosage- depending on each product5.5. S/E: nausea, bloating, electrolyte imbalanceS/E: nausea, bloating, electrolyte imbalance6.6. Eg- Fleet Ready-to-use Enema®, Eg- Fleet Ready-to-use Enema®,

Micolette®, Microlax®, Micolette®, Microlax®,

Stool softenerStool softener Have little value used as single agent in Have little value used as single agent in

chronic constipation or opiod induced chronic constipation or opiod induced constipationconstipation

Liquid paraffinLiquid paraffin (List C item) (List C item)

1.1. Lubricates fecal material to facilitate passageLubricates fecal material to facilitate passage

2.2. CI in children <3yo, pregnancy, bed ridden CI in children <3yo, pregnancy, bed ridden patientspatients

3.3. Dose- 10-30ml in adults, 1ml/kg dailyDose- 10-30ml in adults, 1ml/kg daily

4.4. S/E: rectal leakage and anal irritationS/E: rectal leakage and anal irritation

5.5. Do not take a dose immediately before lying Do not take a dose immediately before lying down to prevent aspirationdown to prevent aspiration

Stool softenerStool softener DocusateDocusate1.1. Used for constipation associated with dry hard Used for constipation associated with dry hard

stools and for avoiding strainingstools and for avoiding straining2.2. Facilitate admixture of fat and water to soften Facilitate admixture of fat and water to soften

stoolstool3.3. Onset of action- 24-72hoursOnset of action- 24-72hours4.4. Dosage (oral): Dosage (oral):

-children 3-6 yo, 10-40mg/day in 1-4 divided -children 3-6 yo, 10-40mg/day in 1-4 divided dosedose-children 6-12yo, 40-150mg/day in 1-4 divided -children 6-12yo, 40-150mg/day in 1-4 divided dosedose-adults, 50-500mg/day in 1-4 divided dose-adults, 50-500mg/day in 1-4 divided dose

5.5. Available in capsule, syrup, enema formAvailable in capsule, syrup, enema form

Stimulant laxativesStimulant laxatives Act by direct stimulation at nerve ending in Act by direct stimulation at nerve ending in

colonic mucosa to increase intestinal motilitycolonic mucosa to increase intestinal motility CI in intestinal obstruction or inflammatory bowel CI in intestinal obstruction or inflammatory bowel

syndrome as it often causes abdominal crampsyndrome as it often causes abdominal cramp S/E: abdominal discomfort, cramp, nausea, S/E: abdominal discomfort, cramp, nausea,

diarrhoea, fluid & electrolyte imbalance with diarrhoea, fluid & electrolyte imbalance with prolonged useprolonged use

May be use in long term for constipation May be use in long term for constipation associated with spinal damage, chronic associated with spinal damage, chronic neuromuscular disease and in people taking neuromuscular disease and in people taking opioidopioid

Stimulant laxativesStimulant laxatives BisacodylBisacodyl1.1. Available in hospital as 5mg tablet and 5mg & 10mg Available in hospital as 5mg tablet and 5mg & 10mg

suppositorysuppository2.2. Onset of action- 15min to 1 hr (suppository), 6 to Onset of action- 15min to 1 hr (suppository), 6 to

12hr (oral)12hr (oral)3.3. Dose (Oral): >10yo, 10mg at nightDose (Oral): >10yo, 10mg at night

children 4-10yo, 5mg at nightchildren 4-10yo, 5mg at night4.4. Dose (supp): <10yo, 5mg morningDose (supp): <10yo, 5mg morning

>10yo, 10mg morning>10yo, 10mg morning SennaSenna1.1. Onset of action- 6-12hrOnset of action- 6-12hr2.2. S/E: discolouration of urine to yellowish brown or S/E: discolouration of urine to yellowish brown or

red.red.3.3. Dose: 7.5-30mg at bedtime for adultsDose: 7.5-30mg at bedtime for adults4.4. Available in market as tablet, granule Available in market as tablet, granule

Non pharmacological Non pharmacological treatmenttreatment

BiofeedbackBiofeedback1.1. Behavioral approach that is used to Behavioral approach that is used to

correct inappropriate contraction of the correct inappropriate contraction of the pelvic floor muscles and external anal pelvic floor muscles and external anal sphincter during defecation sphincter during defecation

2.2. Train patients to relax pelvic floor Train patients to relax pelvic floor muscles during straining and to correlate muscles during straining and to correlate relaxation and pushing during defecationrelaxation and pushing during defecation

3.3. Does not appear to benefit patients with Does not appear to benefit patients with slow transit constipationslow transit constipation

4.4. Evidence quality is moderateEvidence quality is moderate

Overall ManagementOverall Management

Normal or slow transit constipation- Normal or slow transit constipation- patient education, dietary changes, patient education, dietary changes, drug therapy, behavioral therapydrug therapy, behavioral therapy

Severe intractable slow transit Severe intractable slow transit constipation- surgery in extreme constipation- surgery in extreme conditioncondition

Dyssynergic defecation- biofeedbackDyssynergic defecation- biofeedback

ReferencesReferences Tramonte, SM, Brand, MB, Mulrow, CD, et al. The Tramonte, SM, Brand, MB, Mulrow, CD, et al. The

treatment of chronic constipation in adults. A systematic treatment of chronic constipation in adults. A systematic review. J Gen Intern Med 1997; 12:15. review. J Gen Intern Med 1997; 12:15.

Floch, MH, Wald, A. Clinical evaluation and treatment of Floch, MH, Wald, A. Clinical evaluation and treatment of constipation. Gastroenterologist 1994; 2:50 constipation. Gastroenterologist 1994; 2:50

Longstreth, GF, Thompson, G, Chey, WD, et al. Longstreth, GF, Thompson, G, Chey, WD, et al. Functional bowel disorders Gastroenterology 2006; Functional bowel disorders Gastroenterology 2006; 130:1480 130:1480

An Evidence-Based Approach to the Management of An Evidence-Based Approach to the Management of Chronic Constipation in North America. Am J Chronic Constipation in North America. Am J Gastroenterol 2005; 100:S1 Gastroenterol 2005; 100:S1

Chiarioni, G, Whitehead, WE, Pezza, V, et al. Biofeedback Chiarioni, G, Whitehead, WE, Pezza, V, et al. Biofeedback is superior to laxatives for normal transit constipation is superior to laxatives for normal transit constipation due to pelvic floor dyssynergia. Gastroenterology 2006; due to pelvic floor dyssynergia. Gastroenterology 2006; 130:657. 130:657.

Lexi-comps drug information handbook 13Lexi-comps drug information handbook 13thth ed ed Australian medicine handbook 2008Australian medicine handbook 2008 BNF and BNF for children onlineBNF and BNF for children online Frank Shann 14Frank Shann 14thth ed ed

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