Untitled Quiz

Constipation: A New View for the 2020s

• Prevalence: 2-28% of the US population; women are 3x more likely than men to experience constipation
• Consequences: 2.5 million physician visits/year; $1.4 billion in combined sales of enemas and laxatives

Constipation: Symptoms

• Straining to have a bowel movement
• Hard, dry stools
• Small stools
• Feeling as though bowel evacuation is incomplete (tenesmus)
• Decreased stool frequency

Causes of Constipation

• Medications: antihistamines, anticholinergic drugs, antidepressants, calcium channel blockers, calcium supplements and antacids, diuretics, iron supplements, opioids.
  • Opioid-induced Constipation: First-line therapy: stimulant laxative (senna/bisacodyl) ± docusate or polyethylene glycol (PEG) 3350 scheduled daily. Bulk-forming laxatives are NOT used due to the risk of fecal impaction.
• Conditions: dementia, depression, diabetes, irritable bowel syndrome, multiple sclerosis, neurologic disorders, Parkinsonism, stroke, thyroid disorders.
• Lifestyle: low calorie or low fiber diet, dehydration, inactivity, urge avoidance.
• Special Populations: postpartum patients, older adults, patients with colostomies, irritable bowel syndrome, or diverticular disease

Complications of Constipation

• Hemorrhoids
• Anal fissures
• Rectal prolapse
• Fecal impaction

Self-Treatment Exclusion

• Conditions: prolonged constipation, marked abdominal pain, distention, cramping, or flatulence, fever, nausea/vomiting, blood in stool or dark, tarry stool, sudden change in character of stool, weight loss.
• Special Populations: diabetics, children, pregnant women

SCHOLAR-MAC: A Mnemonic for History Taking

• Symptoms
• Characteristics
• History
• Onset
• Location
• Aggravating Factors
• Remitting Factors
• Medications
• Allergies
• Conditions

Treatment Goals

• Relieve: Relieve symptoms and reestablish normal bowel function.
• Establish: Establish dietary and exercise habits to prevent recurrence.
• Promote: Promote safe and effective use of laxatives, if indicated.

Non-Pharmacologic Therapy

• Hydrate: 64 fl oz (~ 1.9 liters) per day
• Increase fiber intake: 25 g for females and 38 g for males, gradually increase over 1-2 weeks to avoid abdominal discomfort.
• Increase physical activity.
• Behavioral modifications: bowel training and toileting positioning.
• Juice: plum or prune juice (3-4 g fiber per serving), sorbitol-containing juices (prune, apple, and pear).

Pharmacotherapy

• Bulk-forming agents: Considered first-line treatment as they closely approximate the physiological process.
  • Mechanism of action: swell in the presence of intestinal fluid to facilitate defecation.
  • Options: methylcellulose (Citrucel®), calcium polycarbophil (Fibercon®), psyllium (Metamucil®, Konsyl®), wheat dextrin (Benefiber®).
• PEG 3350: Use if bulk-forming agents are ineffective or faster onset is desired.
• Stimulant laxatives: Use if PEG 3350 is ineffective.
• Referral: Refer to a healthcare professional if no improvement after 7 days of self-treatment.

Medications Classes

• Bulk-forming laxatives: Increase stool bulk by swelling in water to form an emollient gel or viscous solution, promoting peristalsis (e.g., methylcellulose, psyllium).
• Hyperosmotic laxatives: Increase water content in the intestines, stimulating bowel movement (e.g., polyethylene glycol, magnesium hydroxide).
• Mineral oil: Softens fecal contents, but not recommended due to potential for aspiration pneumonia and adverse events.
• Stimulant laxatives: Stimulate the muscles in the intestines, increasing bowel movement (e.g., senna, bisacodyl).
• Stool softeners: Soften stool by decreasing water absorption in the intestines (e.g., docusate).