Management of Constipation in Family Medicine

Meera Kaur, PhD, RD, CDE Assistant Professor, Family Medicine

University of Manitoba, Canada

http://home.cc.umanitoba.ca/~kaur/

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76 year old female with PMHx of HTN & DM-2, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation?- A. Lactulose- B. Senna- C. Docusate- D. Weekly tap water enemas

Case

• Is a symptom, not a disease

• Is a condition in which a person has fewer than three bowel movements a week or has bowel movements with stools that are hard, dry, and small, making them painful or difficult to pass

• Has varied meanings for different individuals, patients and care givers

It is best when the stools are soft and passed at an hour customary to the patients when in health

Hippocrates2

What is constipation?

• Patients’ Definition– Straining 52%, hard stools 44%, infrequent Straining 52%, hard stools 44%, infrequent stool stool

32%32%

• MisconceptionMisconception – 62% believe that daily defecation is necessary to 62% believe that daily defecation is necessary to

good digestive healthgood digestive health

Ala, 20063

Patients definition & concept about Patients definition & concept about constipationconstipation

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• Rome III criteria: 2 of the below defines 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

Rome III Criteria

• Good history is enough for most cases– Duration, frequency, Consistency, blood in the stool,

weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs

• Basic laboratory test – CBC, Electrolytes, BS, BUN, Cr, TSH

• Structural

– Barium enema

– Sigmoidoscopy

– Colonoscopy

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Diagnosis

• Primary cause – Primary Colorectal dysfunction

– Slow Transit

– Dyssnerygic Defecation

– Irritable Bowel Syndrome

• Secondary cause –Endocrine/Metabolic

–Neurologic

–Myogenic Disorders

–Medications

–Obstruction

• Chronic Idiopathic Constipation (CIC))6

Causes

• Initial Management of chronic functional constipation

–Lifestyle changes • Exercise

• Establishing regular bowel regimen pattern

• Early rising from bed

–Diet • High fibre (20-35 g/day including both soluble and

insoluble components)

• ↑ Fluid intake

• ↓ soft drinks, caffeinated drink

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Management…

• Bulk forming agent – Metamucil

– Citrucel

– Konsyl

– Serutan

• Osmotic agent – Milk of Magnesia– Fleet Phospho-Soda– Sorbitol– Cephulac– Miralax

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Management…Medication…

• Stool Softener– Colace

– Docusate

– Surfak

• Lubricants

– Fleet– Zymenol

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Management…Medication…

•Stimulant– Correctol

– Dulcolax

– Purge

– Senokot

•Chloride Channel Blockers – Lubiprostone (Amitiza)

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Management…Medication…

• Surgery

• Biofeedback

• Alternative and Complementary Medicine– Yoga

– Warm water + Honey

– Herbal preparation

– Homeopathic and Ayurvedic treatment

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Management

• Hemorrhoid

• Anal Fissures

• Rectal Prolapse

• Fecal Impaction

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Complication

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References

• Books

• Journal articles published during 1990-2012

• International, National and Provincial governments’ relevant websites

• Regulatory organizations’ websites and reports

• Other relevant organizations’ publications/reports

• Guidelines, and

References are available on request

Thank you

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

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

Therapy includes: Diet/lifestyle Stimulant Laxatives Osmotic Laxatives Bulk Forming agents Other therapy

Summary

Questions?

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