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Copyright (c) 2014 James E. Rose, MD | Peak Gastroenterology Associates, PC

S

Constipation“I wish being famous prevented me from being

constipated”- Marvin Gaye

“Besides death, constipation is the big fear in hospitals”

- Robert McCrumm

-

James Rose, MDPeak Gastroenterology Associates, P.C.

CME Credit: 1.0


Question

- Which patient has constipation?- A) 32yo woman who describes with every BM the need to strain and has hard

pebble-like movement- B) 46yo man with less than 3 BMs per week- C) 25yo man who requires a laxative every day in order to have a BM- D) 88yo women that says in order to have a BM, she will press her peri-anal area

to stimulate a BM- E) All of the above- F) None of the above


Definition:

Rome 3

- Symptoms lasting >6months and

- Must include at least 2 of the following:

(1)At least 25% of bowel movements associated with- Straining

- Lumpy or hard stools

- Incomplete bowel evacuation

- Anorectal obstruction

- Need for manual manoeuvres

- < 3 bowel movements per week

(2)Loose stools rarely present without the use of laxatives

(3)Insufficient criteria for IBS

Patient Definition:• Hard Stools

• Infrequent stools (<3 per

week)

• Excessive straining

• Sense of incomplete bowel

emptying

• Excessive, unsuccessful

time spent on toilet


Used in Clinical Trials

Correlates with symptoms of straining and difficult evacuation

Also correlates with colonic transit (Type 1 or Type 7 stool is correlated with slow or rapid colonic transit Degen LP, Phillips SF. How well does stool form reflect

colonic transit? Gut 1996;39:109-113.)

Majority of “constipated”patients have stools that are Type 1-3

University of Bristol, Scand J Gastroenterol, 1997


Other Symptoms and Consequences of Constipation

Nausea +/- vomiting

Abdominal and Rectal

pain

Flatulence

Loss of appetite

Lethargy

Depression

Nausea and reduced appetite - weight

loss

Behavioral disturbances in dementia -

increased use of psychotropic medications

Extra staff time needed for increased

toileting needs

Overall increased number of medications

in the regime


Epidemiology

- Medline 2010 literature search of 58 articles- North American prevalence 2 – 27% with mean of 16% (overall)- 33% in adults aged 60-101

- Using Rome 2, about 63 million Americans with chronic constipation

- Risks- Women (F:M=1.5:1), non-whites, >60’s, low income, little exercise, poor

education, institutionalized

- >65 years of age 26% men, 34% women


Quality of Life (QOL)

- Impact as severe as Diabetes, IHD, Rheumatoid Arthritis

- Social and mental health particularly affected

- Estimates that > 13 million work days lost to constipation in USA/year

Systematic review: impact of constipation on quality of life in adults Belsey et al Alim, Ther & Pharm 2010


Economic Costs

- UK National study- 2 x number of GP visits for pts between 65 – 74 yrs, 5 x number of visits for pts

> 75

- About 2.5 million Americans undergo Iaxatives for Constipation annually at a cost of $2700/pt (based on 1994 paper!)…85% of those pts will be prescribed long term laxatives

- In 1994, In US, about 90,000 pt hospitalized for constipation

- In 2004 (Levy et al), $660 million OTC Laxatives sold (US)


Principles

CONSTIPATION SIMPLIFIED

There are a lot of CAUSES

the PATHOLOGY and the PRINCIPLES

of TREATMENT are the SAME.


Things to Ask

- Feces: Quality/Frequency/Effort/Associated Sx

- Foods and Fluids: Fiber and White Food

- Fast paced: esp. Calls Answered

- Flaccid: Daily Movement, Childbirth trauma

- Medical: Laxative Use, other Meds, Thyroid Sx

- RED FLAGS: rectal bleeding, abrupt weight loss, change in bowel habits, FHx of colon CA,IBS

- Tools: Bowel Diary (see Symptom Diary on web),

Transit time trial ... corn, beets, or other identifiable food


- Passenger: (hard or large or irritating)- too little (water or fiber) - too much (irritants, large proteins, bacteria)

- Push: Peristalsis impaired (slow transit)- dilated colon, meds, toxins-irritants-bacteria

- Passage: inflamed, irritated, weak, uncoordinated, dilated (pelvic floor dysfunction)- inhibits peristalsis- pelvic muscles weak- dilated colon does not work well


Causes


Labs

- Blood Work: most guidelines say optional- TSH, BG, CBC if concern of CA

- Consider- Barium Enema or Flexible Sigmoidoscopy in more serious

cases- Radiology: Bowel Score (most say not needed)


Categories of Treatment

- Passenger:- Bulk/hydrophilic agents – fiber

- “make it bigger” - Surfactants/Emollients – stool softeners

- “make it slippery” (colace, some psyllium-bulk)- Osmotic laxatives – not absorbed

- “don’t let the water leave” (Mg/lactose/sorbitol/PEG)

- Push- Peristaltic irritants

- stimulants (dulcolax/senna)- “make it go faster”

- Others: prokinetic, prosecretors (probiotics)

- Passage- exercises, position, biofeedback


Steps of Treatment

1.Treat Cause

2.Clear out Bowel

3.Restore Normal Function

4.Then Wean down or off of therapies…


1. Treat Causes

- Food: Insufficient Fiber (?too much White Stuff)- Trial of no dairy products!- Psyllium Husks/prunes-prune juice/other

- Fluids: not enough- Especially warm relaxing drink in the morning- Water (minimum= ½ oz per # of Body Wt/QD)

- Fast Paced: - Chew Food 20-30x (stimulates peristalsis)- Cut out or decrease Caffeine, ETOH- Answer “Call of the Bowels”- Discuss relaxation- Treat Anxiety, Depression, OCD-tendencies

- Flaccid: get more movement


2. Clear out the Bowel

- From Above- Mild: Magnesium, Vitamin C and Oils- Moderate: Senna or MOM- Severe: Sorbitol, Lactulose or Miralax

- From Below- Enema (Fleets, Oil, Milk, etc)- Suppository (glycerine, dulcolax)


3. Restore Normal Function

- Remove Causes - consider further elimination diet

- Special Exercises - peristalsis/pelvic strength- Position (raise feet)

- Digestive Enzymes and Betaine HCL- improves digestion especially in high protein diets/elderly

- Probiotics: (peristalsis)

- Biofeedback (dysynergy)


4. Wean Down

- Elimination - Dairy: 22% tolerated at 6 months vs 88% after a year

- Use Clear Out only prn - Senna, Sorbitol, Lactulose or Miralax- Dulcolax/Enemas

- What if they need long term stool softeners- No proven down side to most- Largely unknown.


Treatment in Outpatient Setting

4 Steps

1. Treat Cause: stop dairy, drink fluids, increase fiber (metamucil or flax)

2. Clear out Bowel: Magnesium products/Vitamin C

3. Restore Normal Function: teach exercises/digestive enzymes

4. Then Wean down or off of therapies…see if they can stop Mg or Vit C or PEG, then metamucil or flax


Treatment in Hospitalized Patient

4 Steps

1. Treat Cause (activity or may not be able)

2. Clear out Bowel: Bisacodyl 10mg PO or use PR, MOM (Mag-Hydroxide) 5-15mL QID or Mag Citrate, if hard stool then Colace

3. Restore Normal Function (may not be as much a focus for now)

4. Then wean down or off of therapies…(later)


Severe (Impaction Treatment)

- Main focus is on step 2 (clear out bowels)- Disimpact (manually or with enemas)- Mineral oil enema then…

- Fleets x 3 days +/- Polyethelene Glycol until colon clear- Then: Lactulose, Sorbitol, PEG …

- IF no BM in 2 daysBisacodyl or Glycerin suppository

- Then focus on steps 1 (cause) and 3 (restore)


Lifestyle Changes

- Aerobic Exercise 30 minutes, 3-5/week- sedentary folks are three times more likely to report constipation- need to increase fluids

- Retraining: - Sit on toilet at same time every day (ie. After eating breakfast, upon rising,

after every meal)- Defecate when urge arises

- Deep Breathing on toilet (relaxation)


COFFEE

Caffeinated coffee stimulates colonic motor activity.- Its magnitude is similar to a 1000 kcal meal- 60% stronger than water - 23% stronger than decaffeinated coffee.- N = 12Coffee increases rectosigmoid motor activity within 4 min after ingestion

in some people.

Scand J Gastroenterol Suppl. 1999;230:35-9. Eur J Gastroenterol Hepatol. 1998 Feb;10(2):113-8. Gut. 1990 Apr;31(4):450-3


Other Dietary Supplements

- Prunes- High fiber, 6 gm fiber/10 prunes

• sorbitol • neochlorogenic acid

- How much: 50 grams bid in one study: 14 prunes (but 281 kcals!)• Slightly more BMs/week cp to psyllium

- Antioxidant benefit, ORAC value = 6463- Tamarindo – tambien possible ayuda

- Vitamin C- Dose: 1000 mg vitamin C tid before meals- Often rec to take to “bowel tolerance”- Or rec w/ Chitosan

- Fiber composed of chitin, a component of the shell of shellfish. - Six 500-milligram (mg) capsules of chitosan- Vit C helps transform chitosan in the stomach and intestine into a fat-absorbing gel.

Nature Reviews Gastroent and Hep 2011; 8: 306-307Bowes & Church’s Food Values of Portions Commonly Used, 17th Ed.

http://www.lef.org/protocols/gastrointestinal/constipation_01.htm

Life Extension Foundation Accessed 9/24/11




Classes of Treatment

- Causes water evacuation in 1 – 6 hours- Saline cathartics, PEG solutions, Castor Oil

- Causes soft/semisoft stools in 6 – 8 hours- Bisacodyl

- Causes softening of stool in 1 – 3 days- Docusate, Psyllium, Lactulose, Mineral Oil


Bulk Forming Agents/Fiber

- “Just add water”: Swell in intestines, lubricate and soften stool. - Note: Water necessary, or risk choking/obstruction!

- Best Evidence- mucilage from Ispaghula seeds (Plantago ovata, aka Psyllium, aka Metamucil)

- Dosing: start 1 tsp, titrate to effect (~1T).

- If Flatulence, consider…- Methyl-Cellulose (Citrucel)- Calcium polycarbophil (FiberCon; Fiber-Lax)- Wheat dextrin (Benefiber®), - Chia seeds, flax, others

Aliment Pharmacol Ther 1998, J Am Geriatr Soc 1995, J Am Geriatr Soc 1995;43:666–9.10, Curr Med Res Opin 1998.

https://vpn.ucsf.edu/online/content/,DanaInfo=www.uptodateonline.com+topic.do?topicKey=drug_l_z/30358&drug=true


Probiotic Supplements

- Five RCTs : 377 subjects - adults (three RCTs, n = 266) - children (two RCTs, n = 111)

- In adults, - some organisms favorable effect on defecation frequency and stool

consistency.

- In children- some organisms showed a beneficial effect.

Systematic review of randomised controlled trials: probiotics for functional constipation. - Chmielewska A - World J Gastroenterol - 7-JAN-2010; 16(1): 69-75 (MEDLINE® is the source for the citation and abstract of this record )Children: L. casei rhamnosus Lcr35, but not L. rhamnosus GG, Adults: Bifidobacterium lactis DN-173 010, Lactobacillus casei Shirota, and Escherichia coli Nissle 1917


Magnesium

- HIGH Efficacy (used as bowel prep!) – only caution is renal failure (risk of mag toxicity) generally above 3 grams a day.

- Milk of magnesia (1-3 tsp QID)- Antacid activity in low doses: all OH- entering the stomach used to

neutralize stomach acid. - Laxative effect at high doses: OH- moves past stomach to intestines

attract and retain water, thereby increasing intestinal movement (peristalsis) and inducing the urge to defecate

- Mag Citrate (Short Term Use) 120-300mL x 1 or 2

- Mag oxide/citrate pills 400-500mg QD


Stool Softeners

- Docusate (Colace) 250 BID – oral use may take 1-3 days to cause effect, enema works within 20-60 min

- Emulsifier/emollient: Lowers surface tension of stool (also used as a pesticide and as oil dispersing agent in oil spills…)

- However…- Less effective than psyllium- Likely ineffective in chronically ill elderly - Not recommended for long-term use/chronic constipation by Up-To-Date or the American

College Gastroenterology Chronic Constipation Taskforce- Psyllium is superior to docusate sodium for treatment of chronic constipation.

Aliment Pharmacol Ther. 1998;12:491–7 J Pain Symptom Manage. 2000;19:130–6. Am J Gastro 2005


Stimulant Laxatives

- Increase peristalsis by irritating colon- Bisacodyl (Correctol®, Dulcolax®)- Senna (Senokot®, ex-lax)

- Long Term Use can lead to - dependency “lazy bowel”- electrolyte disorders (hypo K, Hyper Na)


Per Rectum Medications

- Enemas- Fleets- Mineral Oil- Milk

- Suppositories- Glycerin

- Commonly used in children. Digital stimulation may be actual mechanism.

- Bisacodyl/Dulcolax - Stimulant laxative


Other Treatments

- Biofeedback- Extremely (75%) effective for

Pelvic-Floor Dysfunction and outlet-inertia.

- Massage- small number trials positive- Baby massage

- Herbs (lots)

- Colchicine

- Misoprostol

- Botulinum Toxin Injection

- Zelnorm (is back) 5HT4

- Surgery


Intestinal Secreatogues

- Lubiprostone (Amitiza)- Bicyclic fatty acid derivative- Works on CIC2 Chloride channel activating prostaglandin receptors and CFTR to

increase intestinal fluid- Dosages

- 24micrograms BID for chronic constipation and 8micrograms BID for IBS-C in women

- Linaclotide (Linzess)- 14-amino acid peptide homolog to heat-stable endotoxin- Acts on Guanylyl cyclase C which acts on CFTR to increase intestinal fluid secretion- Dosages

- 145-micrograms daily in chronic constipation and 290-micrograms daily in IBS-C


- Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship

- Buddha

- “The best and most beautiful things in the world cannot be seen nor touched – they must be felt in the heart” - Helen Keller


Questions?

James E. Rose, MDPeak Gastroenterology Associates, P.C.

www.peakgastro.com719.636.1201

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