Management of Management of Constipation in Constipation in

AdultsAdultsStephen Aglubat, MDStephen Aglubat, MD

May 2012May 2012

ObjectivesObjectives

Define ConstipationDefine Constipation Treatment options for constipationTreatment options for constipation

CaseCase 76 year old female with PMHx of HTN, DMII, 76 year old female with PMHx of HTN, DMII,

HLD, presents to the clinic. She’s complaining of HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling having stools only twice a week, and feeling “full.” She’s eating more vegetables, started “full.” She’s eating more vegetables, started drinking more water, and she recently included drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to year ago was clean. She comes to your office to be evaluated for her constipation. What would be evaluated for her constipation. What would you offer her for the constipation?you offer her for the constipation?

A. LactuloseA. Lactulose B. SennaB. Senna C. DocusateC. Docusate D. Weekly tap water enemasD. Weekly tap water enemas

DefinitionDefinition

Rome III criteria: 2 of the below Rome III criteria: 2 of the below defines constipationdefines constipation StrainingStraining Lumpy Hard StoolsLumpy Hard Stools Incomplete EvacuationIncomplete Evacuation Use of Digital Rectal ManeuversUse of Digital Rectal Maneuvers Sensation of Anorectal BlockageSensation of Anorectal Blockage < 3 Bowel Movements per week< 3 Bowel Movements per week

Pathophysiology IPathophysiology I

Constipation is caused by:Constipation is caused by: Primary Colorectal dysfunctionPrimary Colorectal dysfunction

Slow TransitSlow Transit Dyssnerygic DefacationDyssnerygic Defacation Irritable Bowel SyndromeIrritable Bowel Syndrome

Pathophysiology IIPathophysiology II

Constipation is caused by:Constipation is caused by: Secondary CausesSecondary Causes

Endocrine/MetabolicEndocrine/Metabolic NeurologicNeurologic Myogenic DisordersMyogenic Disorders MedicationsMedications ObstructionObstruction

Chronic Idiopathic Constipation (CIC)Chronic Idiopathic Constipation (CIC)

ManagementManagement

Initial treatment of Chronic Initial treatment of Chronic Functional ConstipationFunctional Constipation Lifestyle modificationLifestyle modification Diet and fiberDiet and fiber

Lifestyle ModificationsLifestyle Modifications

Increased fluid intakeIncreased fluid intake ExerciseExercise Establish regular bowel regimen Establish regular bowel regimen

patternpattern

Diet and fiberDiet and fiber

Fiber increases bulk/distensionFiber increases bulk/distension Distention causes stool propulsion.Distention causes stool propulsion.

>25 g of fiber/day>25 g of fiber/day Effect may take weeks.Effect may take weeks. Adverse effects: Bloating, flatulenceAdverse effects: Bloating, flatulence

Laxatives ILaxatives I

Stimulant LaxativesStimulant Laxatives SennaSenna BisacodylBisacodyl

Laxatives IILaxatives II

Bulk forming laxativesBulk forming laxatives Psyllium (Metamucil)Psyllium (Metamucil) Methylcellulose (Citrucel)Methylcellulose (Citrucel) Polycarbophil (FiberCon)Polycarbophil (FiberCon) Dextran (Benefiber)Dextran (Benefiber)

Laxatives IIILaxatives III

Osmotic LaxativesOsmotic Laxatives Polyethylene glycolPolyethylene glycol LactuloseLactulose SorbitolSorbitol Magnesium HydroxideMagnesium Hydroxide

Other therapiesOther therapies

Colonic secretagoguesColonic secretagogues LubipristoneLubipristone

SummarySummary

Constipation in the older adult may Constipation in the older adult may be due to chronic constipation, be due to chronic constipation, secondary etiologic factorssecondary etiologic factors

A thorough history must be obtained A thorough history must be obtained to rule out secondary causes.to rule out secondary causes.

Therapy includes:Therapy includes: Diet/lifestyleDiet/lifestyle Stimulant LaxativesStimulant Laxatives Osmotic LaxativesOsmotic Laxatives

CaseCase 76 year old female with PMHx of HTN, DMII, 76 year old female with PMHx of HTN, DMII,

HLD, presents to the clinic. She’s complaining of HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling having stools only twice a week, and feeling “full.” She’s eating more vegetables, started “full.” She’s eating more vegetables, started drinking more water, and she recently included drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to year ago was clean. She comes to your office to be evaluated for her constipation. What would be evaluated for her constipation. What would you offer her for the constipation?you offer her for the constipation?

A. LactuloseA. Lactulose B. SennaB. Senna C. DocusateC. Docusate D. Weekly tap water enemasD. Weekly tap water enemas

CaseCase 76 year old female with PMHx of HTN, DMII, 76 year old female with PMHx of HTN, DMII,

HLD, presents to the clinic. She’s complaining of HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling having stools only twice a week, and feeling “full.” She’s eating more vegetables, started “full.” She’s eating more vegetables, started drinking more water, and she recently included drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to year ago was clean. She comes to your office to be evaluated for her constipation. What would be evaluated for her constipation. What would you offer her for the constipation?you offer her for the constipation?

A. LactuloseA. Lactulose B. SennaB. Senna C. DocusateC. Docusate D. Weekly tap water enemasD. Weekly tap water enemas

ReferencesReferences

1. Management of chronic 1. Management of chronic constipation in older adults. Wald, constipation in older adults. Wald, Arthur. Uptodate.com. March 2012 Arthur. Uptodate.com. March 2012