Transcription

1

2

3 Constipationn By Dr. Shahram Ala (Pharm.D, BCPS)

4 Constipation is a symptom, not a disease e Some causes IBS, Diabetes Mellitus, Hypothyroidism

5 Patients definition & concept constipation can be different about Patients definition S training 52 %, hard stools 44 4%, s tool 32 % infrequent Misconception 62 % believe that daily to good digestive health h defecation is necessary

6 What is the right number of daily or weekly bowel movements?!

7 Clinical definition n A ny of two of following symptoms for at least 3 month (not necessarily consecutive) in a year Strainin g Hard or lumpy stoo l Sensation of incomplete evacuatio n F ewer F than 3 defecation per wee k

8 Causes of constipation n fiber ( most common ) liqui d ( 8 glasses/d is needed for constipated ) Exercise b edridden, com a Ignoring urge to defecat e S ystemic S H ypothyroidism, DM, Uremia, pregnancy, hypercalcemia, Hypokalemia a N eurological N S troke, sclerosiss Parkinsonism, Multiple

9 Causes of constipation (Cont.) GI G - r elated I BS, Hemorrhoid, Anal fissure, A norectal & Colorectal carcinoma,obstructio n M edication M O piate, A nticholinergics, Al(OH ) 3 I ron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of l axatives, Antiepileptics, progestro n U ncertain idiopathic chronic constipatio n

10 Rate of empting carbohydrate>protein>lipi d F ear, Pain Inhibit and e xitatio n stimulat e C linical manifestatio n C Pale - I cteri c- A norexi a- H eadach e- Abdominal pain,

11 Diagnosiss Good history is enough for most case s (Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs) B asic laboratory test s B CBC, Electrolytes, BS, BUN, Cr, TSH Structural Barium enema, Sigmoidoscopy, Colonoscopy

12 Treatmentt Treatment of underlying disease (Malignancies, Hypothyroidism, ) A lteration of lifestyle ( Diet, Exercise, Liquids ) Laxative s

13 Acute constipation n Glycerin suppositor y Sorbitol powde r Bisacody l A nthraquinones ( C Saline laxative (MOM ) T a p- water enem a I f laxative treatment is A - lax ) I required for > 1 week, refer to a physician

14 Chronic constipation n Most common in bedridden or geriatrics Choice Psyllium (with enough liquids) Low doses of other laxatives C- lax, MOM, Sorbitol, Lactulos e

15 Constipation in hospitalized patients May be related to general anesthesia or opiates Glycerin suppositor y Milk of magnesiu m Tap water enem a

16 Constipation in infants & children If constipation is I a persistent problem Consider neurological, metabolic or anatomical abnormalities If No Approach as adults

17 Drug classes s T hose Caster causing water evacuation in 1-6 hr oil, Saline cathartics, PEG lavage solutions s T hose causing soft or semi fluid stool in C- lax, Bisacody l 6-8 hr T hose T causing softening of stool in 1-3 day s Psyllium, Lactulose, Mineral oil, Decussate e

18 Bulks P syllium, musilliu m Increase Volume of intestin e Stimulate natural intestine peristalti c Anti Diarrhea & constipatio n L asts L h (even 3 days ) Drink freely water unless obstructio n

19

20

21 Emullients D ocusat e N a cap 5 0 0mg Anionic surfactant s D ecrease secration L asts L 1-3 day s SE GI cram p stool surface into intestin e tension, increase Fluid e

22

23 L iquid I nhibition Softener Parafin e of of Lubricants f luid e stool, Post MI, Post surger y l asts 6-8 h r eabsorbtio n stimulate ml PO, or recta l peristaltic from colon, SE Aspiration (neonate, Geriatrics, before sleep), m alabsorbtion ( lipid soluble V i t. ), Anal p ruriti s, stainin g

24 Stimulant laxatives Bisacody l Stimulates (myentric) Intermittent O ral mucosal use for nerve plexus constipation O 6-8 h r Supp mi n I nteraction s Milk, Antacids of (EC) the colon SE Cramp, fluid and electrolyte imbalanc e, Contraindication appendicitis pregnancy, lactation,

25

26

27 Caster oil Usually for bowel preparation A ctive metabolite O nset 1-3 hr R icinolei c aci d

28 Saline M OM, mgs o M 4 I ndications I A ntacid ( ml PRN), Laxatives ( ml HS ) M g O nset O smotic, Release 3-6 hr I nteractions B reas t Q uinolone s, cholecystokini n Tetracycline, Fe, E C drugs ( b isacody l, s ulfasalazin e) B - f eeding CRF? can be use d

29 Hyperosmoticss Glycerin, Lactulose, mannitol, Sorbito l L actulos e Acetic acid, Formic acid, Lactic aci d E ncephalopathy ( lasts E h) SE flatulence, abdominal electrolyte imbalance cramp, diarrhea,

30 Glycerin Is very basis safe and acceptable for particularly in infants intermittent S upp S 1 g, 3g O nset l ess than 3 0 mi n

31

32 Mannitol

33 Tap - water enem a ml results in a bowel movement within 0.5hr Soapsuds are no longer recommended ( p roctiti s, colitis )

34 Drugs for chronic idiopathic constipation n Cisaprid e (also for Parkinson's disease) Erythromyci n

35

36

37 Summary Underlying consideredd F oundation of causes of treatment constipation is diet should be and psylliu m A cute constipation may be treated with ta p A - water enema or glycerin suppository, if needed, o ral s orbito l, low dose b isacody l o r C- La x Approach for chronic constipation is use of psyllium a nd if needed, intermittent lo w- doses of other drugs

38