Constipation - Santa Rosa Family Medicine Residency

A Smooth Approach
IM Team
• Common
– Up to 20% of population; 2-3% chronic (some
surveys more like 1/3 of population, subsets
up to 75% in institutional elderly)
• Costly
– $725 million is spent on laxative products
each year in the U.S
• Confusing
• Frequency: OPTIMAL vs. NORMAL
– Normal: 3 BM’s QD to 3 BM’s Q week
– Optimal: 1-3 a day
(gives an idea of transit time)
• Form: excessively hard stools
• Effort: Straining and unproductive urges
• Feeling: incomplete evacuation, toxic,
creates worsening of other sx.
Bristol Stool Scale
• Constipation:
– 2 y/o boy, hard stools, force for 1 year
– 53 y/o male with severe GERD, got worse
with antacids
• Painful Menses:
– 29 y/o woman with severe pain on menses
• BPH:
– 60 y/o man BPH, up 7 times a night
• Back Pain:
– 38 y/o on methadone with mod depression
Thought there are a lot of CAUSES
of Initial TREATMENT are the SAME.
Causes Pathophysiology
• Passenger: (hard or large or irritating)
– too little (water or fiber)
– too much (irritants, large proteins, bacteria)
• Powers: Peristalsis impaired (slow transit)
– dilated colon, meds, toxins-irritants-bacteria
• Passage: inflamed, irritated, weak,
uncoordinated, dilated (pelvic floor dysfct)
– inhibits peristalsis
– pelvic muscles weak,
– dilated colon does not work well.
Other Causes
Take a Good History
Stool: Quality/Frequency/Effort/Associated Sx
Foods and Fluids: Fiber and White Food
Fast paced: esp. Calls Answered
Flacid: Daily Movement, (o+) 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
• PE:
– Abdomen: R and LLQ can you feel stool
– Rectal: External-DRE-(+/-Anoscope)
• hemorrhoids, fissures, anal wink
• sphincter tone, hard stool, wide open space,
hemmocult for blood,
– Exam specific for any Other Sx
• GERD, Urinary Retention, Fatigue, malaise,
depression, abdominal pain
• Blood Work: most guidelines say optional
– TSH, BG, CBC if concern of CA
• Consider
– BE or Sigmo in more serious cases
– Radiology: Bowel Score (most say not
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)
• Powers
– Peristaltic irritants – stimulants (dulcolax/senna)
• “make it go faster”
– Others: prokinetic, prosecretors (probiotics)
• Passage: exercises, position, biofeedback
4 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!
– 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
• Flacid: get more movement
2. Clear OUT Bowel
• From Above
– Mild: Magnesium, Vitamin C and Oils
– Moderate: Senna or Smooth Move
– Severe: Sorbitol, Lactulose or Miralax
• From Below
– Enema (Fleets, Oil, Milk, etc)
– Suppository (glycerine, dulcolax)
3. Restore Normal Function
• Remove Causes
– done above-consider further elimination diet
• Special Exercises
– peristalsis/pelvic strength
– Position (raise feet)
• Digestive Enzymes and Betaine HCL
– improves digestion especially in high protein
• Probiotics: (peristalsis)
• Biofeedback (dysynergy)
4. Wean Down
• Dairy/other Elimination
– Dairy: 22% tolerated at 6 months vs 88% after a
• 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, some question re:
all. Largely unknown. (compared to what?)
Clinic Patient: Tx
4 Steps
1.Treat Cause: stop dairy, drink fluids,
increase fiber (metamucil or flax)
2.Clear out Bowel: Magnesium/Vit 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
Hospitalized Pt: TX
4 Steps
1.Treat Cause (activity or may not be able)
2.Clear out Bowel: Bisacodyl 10mg PO or
use PR, MOM (Mg Hydroxide) 5-15mL
QID or Mg 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
Severe = Impaction: TX
• Main focus is on step 2 (clear out bowels)
– Disimpact (manually)
– Mineral oil enema then…
– Fleets x 3 days +/- Polyethelene Glycol until
colon clear
– Then: Lactulose, Sorbitol, PEG …
– IF no BM in 2 daysBisacodyl or Glycerin
• Then focus on steps 1 (cause) and 3
When to Refer
• Not getting better with good trial of
• If they have had it since birth
• If you find a serious pathology…Duh?
• Red Flags…Duh?
• Constipation:
– 2 y/o boy, hard stools, force for 1 year
– 53 y/o male with severe GERD, got worse
with antacids
• Painful Menses:
– 29 y/o woman with severe pain on menses
• BPH:
– 60 y/o man BPH, up 7 times a night
• Back Pain:
– 38 y/o on methadone with mod depression
Data and Detail on Treatment
• 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
– Defecate when urge arises
• Deep Breathing on toilet (relaxation)
Caffeinated coffee stimulates colonic motor
•Its magnitude is similar to a 1000 kcal meal
•60% stronger than water
•23% stronger than decaffeinated coffee.
•N = 12
Coffee 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
Peds: Milk Allergy
27 children who did not respond to 2 month
laxative therapy
No dairy products for a 1 month period
then re-challenge over 2 wk.
(responders n=21) and non-responders
That is 78% that responded to dairy elim.
Cow's milk allergy related pediatric constipation: appropriate time of milk
tolerance. - El-Hodhod MA - Pediatr Allergy Immunol - 01-MAR-2010; 21(2 Pt 2):
Fiber and Elimination Diet
• 60 children
• aged 2 to 12 years
• a special diet
– daily intake of raw bran and high-fiber foods
– exclusion of milk and other constipating foods
• Within six weeks, the problem resolved in
all 60 patients.
Chronic constipation in children: can it be managed by diet alone? Olness K - Postgrad Med - 01-OCT-1982; 72(4): 149-54
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
• Dosing: start 1 tsp, titrate to effect
• 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.
• 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
Nature Reviews Gastroent and Hep 2011; 8: 306-307
Bowes & Church’s Food Values of Portions Commonly Used, 17th Ed.
High dose 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.
Life Extension Foundation Accessed 9/24/11
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
• In children
– some organisms showed a beneficial
• 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 UpToDate
or the American College Gastroenterology Chronic Constipation
– Psyllium is superior to docusate sodium for treatment of chronic
Aliment Pharmacol Ther. 1998;12:491–7
J Pain Symptom Manage. 2000;19:130–6.
Am J Gastro 2005
Hyperosmolar Laxatives
• Reduce water absorption from colon. Stools soft, still
• Saline Laxatives (Generally Safe)
• Milk of Magnesia (1-3 tsp QID) (caution with renal failure)
• Mag Citrate (Short Term Use) 120-300mL x 1 or 2
• Fleets Phospho-soda
• Non-Saline
• Can cause cramping, nausea, fluid loss and electrolyte imbalances
(Na, K).
• Lactulose (undigested sugar, Rx)
• Sorbitol – several studies show equivalent efficacy as lactulose,
plus it’s cheaper.
• Miralax (Polyethylene Glycol)- 17-34g QD; less bloating
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)
• Enemas
– Fleets
– Mineral Oil
– Milk
• Suppositories
– Glycerin
• Commonly used in children. Digital stimulation may be actual
– Bisacodyl/Dulcolax
• Stimulant laxative
Other TX
• Biofeedback
– Extremely (75%) effective for Pelvic-Floor
Dysfunction and outlet-inertia.
• Massage
– small number trials positive
– Baby massage
• Herbs (lots)
Still More Tx
Botulinum Toxin Injection
– Chloride chanel activator
– Placebo controlled trials +; no head to head
• Zelnorm (is back) 5HT4
• Surgery
More Info
• Integrative Approaches to Childhood Constipation and
Encopresis Pediatric Clinics of North America - Volume
54, Issue 6 (December 2007)

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