Constipation

Prince Sattam Bin AbdulAziz University College Of Pharmacy

Pharmaco-therapeutics 2

Case 1Mr Johnson is a middle-aged man who occasionally

visits your pharmacy.Today he complains of constipation, which he has

had for several weeks. He has been having a bowel movement every few days; normally they are every day or every other day. His motions are hard and painful to pass.

He has not tried any medicines as he thought the problem would go of its own accord. He has never had problems with constipation in the past.

• He has been taking atenolol tablets 50 mg once a day, for over 1 year.

• He does not have any other symptoms, except a slight feeling of abdominal discomfort.

• You ask him about his diet; he tells you that since he was made redundant from his job at a local factory 3 months ago, he has tended to eat less than usual; his dietary intake sounds as if it is low in fiber.

• He tells you that he has been applying for jobs, with no success so far. He says he feels really down and is starting to think that he may never get another job.

Define constipation ?

• Reduction in frequency of bowel movements relative to a patient’s normal frequency .

• characterized by difficulty with or incomplete evacuation, straining, or presence of hard, dry stools.

• Abdominal pain and distention may occur, as well as low back pain and anorexia.

Bowel habit ?

• Normal range for the bowel habit?

Vary from three movements in 1 day to three in 1 week.

Therefore an important health education role for the pharmacistis in reassuring patients that their frequency of bowel movement is normal

Patients who are constipated will usually complain of hard stools which are difficult to pass and less frequent than usual.

A sudden change, which has lasted for 2 weeks or longer, would be an indication for referral

Associated symptoms ?

obstruction or blockage that’s caused by constipation

causing colicky abdominal pain, abdominal distension and vomiting.

Most probably

urgent referral is necessary as hospital admission is the usual course of action

There are other causes of obstruction. Othercauses such as bowel tumours or twisted bowels (volvulus) requireurgent surgical intervention

Associated symptoms ?

Blood in the stool

Alarming but not necessarily serious

(haemorrhoids) (anal fissure)cause less bleeding but much more severe pain on defaecation

Blood mixed in with the stool has usually originated higher in the GI tract

Fresh bright red blood usually comes from low down in the GI tract (Examples include fissures and haemorrhoids)

Medical referral is advisable

Diet ?

I. Insufficient dietary fiber …………….> is a common cause of constipation.

wholemeal cereals, bread, fresh fruit and vegetables.

II. Changes in diet and lifestyle, e.g. following a job change, loss of work, retirement or travel, may result in constipation.

III. Inadequate fluid intake may result in constipation.

The recommended daily amount of fluid is 1500-2000 ml.

Medication ?

Continuous use, especially of stimulant laxatives, can result in a vicious circle where the contents of the gut are expelled, causing a subsequent cessation of bowel actions for 1 or 2 days.

This then leads to the false conclusion that constipation has recurred andmore laxatives are taken and so on.

Medication ?

Chronic overuse of stimulant laxatives can result in loss of muscularactivity in the bowel wall (an atonic colon) and thus further constipation.

• When to refer a patient with constipation ?

Referral for further evaluation may be required for some patient populations.a. Symptoms for more than 1–2 weeks despite treatmentb. Considerable pain or crampingc. Pregnancyd. Presence of fevere. Blood in the stoole. Reduction in stool caliberf. Weight lossg. Paraplegia, quadriplegia

Management

• Removal or treatment of underlying cause(s) if possible

Nonpharmacologic interventions Pharmacologic interventions

I. Increase fluid intake to 6–8 glasses of water per day if possible.

II. Increase dietary fiber to 20–30 g/day.

III. Incorporate or increase exercise to 3–5 days/week.

Management

• Removal or treatment of underlying cause(s) if possible

Nonpharmacologic interventions Pharmacologic interventions

A- Choose drug therapy on the basis of desired onset of action, patient preference, presenceof potential contraindications, and use in special populations.B- . Provide patient education on alternative dose forms (enema, suppository).

Case 1Mr Johnson is a middle-aged man who occasionally

visits your pharmacy.Today he complains of constipation, which he has

had for several weeks. He has been having a bowel movement every few days; normally they are every day or every other day. His motions are hard and painful to pass.

He has not tried any medicines as he thought the problem would go of its own accord. He has never had problems with constipation in the past.

• He has been taking atenolol tablets 50 mg once a day, for over 1 year.

• He does not have any other symptoms, except a slight feeling of abdominal discomfort.

• You ask him about his diet; he tells you that since he was made redundant from his job at a local factory 3 months ago, he has tended to eat less than usual; his dietary intake sounds as if it is low in fiber.

• He tells you that he has been applying for jobs, with no success so far. He says he feels really down and is starting to think that he may never get another job.

• The pharmacist’s viewMr Johnson’s symptoms are almost certainly due to the change in his lifestyle and eating pattern ( the loss of his Job)

To address the dietary problems, he could be advised to start the daywith a wholegrain cereal and to eat at least four slices of wholemealbread each day ( increase fiber )I. Increase fluid intake to 6–8 glasses (2.5 litres each

day) of water per day if possible.II. Increase dietary fiber to 20–30 g/day.III. Incorporate or increase exercise to 3–5 days/week

To provide relief from the discomfort, a suppository of glycerinor bisacodyl could be recommended to produce a bowel evacuationquickly

• The pharmacist’s view

Mr Johnson’s symptoms are almost certainly due to the change in his lifestyle and eating pattern

To address the dietary problems, he could be advised to start the daywith a wholegrain cereal and to eat at least four slices of whole mealbread each day ( increase fiber )I. Increase fluid intake to 6–8 glasses (2.5 litres each

day) of water per day if possible.II. Increase dietary fiber to 20–30 g/day.III. Incorporate or increase exercise to 3–5 days/week

The longer term, dietary changes provide the key.

• The pharmacist’s view

Can beta blocker be the problem ?

beta-blockers can sometimes cause constipation, he has been taking the drug for over 1 year with no previous problems.

When should the patient see the doctor ?the doctor if the suppository does not produce an effect; if it worksbut the dietary changes have not been effective after 2 weeks,

• Write about essential question about bowel habit when identifying the cause of constipation ?

• What’s the appropriate action when a petient have on bowel obstruction causing colicky abdominal pain, abdominal distension and vomiting ?

• Mention some causes of blood in the stool?

• What’s the appropriate action when the Blood mixed in with the stool ?

• Questioning a constpitated patient regarding his diet is important !what would you ask him regarding his diet and what diet changes may cause constipation?

• What’s the common cause of constipation in relation with the DIET ?

• Referral for further evaluation may be required for some patient populations , mention four conditions?

LogBook Questions

• CCB (calcium channel blockers) can be a cause for constipation ? (T/F)

• When a patient have Symptoms of constipation for more than 1–2 weeks despite treatment you’d treat him with senna (T/F)

• Nonpharmacoligical treatment of constipation include ( 1-……….. 2-………….. 3-……………)

• Onset of action Glycerine suppository?• Onset of action of lactulose and side effect ?• Onset of action of PEG and safety regarding

pregnancy ?• Drugs used to prevent opiod induced constipaion?• …………………. (drug) preffered in chronic liver disease • ……………………..(drug) used for Preoperative or

preprocedure bowl preparation

Answer the following Questions

References • Symptoms in the Pharmacy: A Guide to the Management of

Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton and J. Blenkinsopp © 2009 Alison Blenkinsopp

• American College of Gastroenterology Chronic Constipation Task Force. An evidence-based approach to the management of chronic constipation in North America. Am J Gastroenterol 2005;100:S1–S22.

• AGA Technical Review on Constipation. Gastroenterology 2000;119:1768–78.

• American Gastroenterological Association Medical Position Statement: guidelines on constipation. Gastroenterology 2000;119:1761–78.