03- Constipation.pdf

Constipation Prof. Ibrahim Al-Adham Has been taken from Handbook of Nonprescription Drugs > Chapter 15. 1  Constipation: Introduction Constipation is a common gastrointestinal (GI) comp...

Constipation Prof. Ibrahim Al-Adham Has been taken from Handbook of Nonprescription Drugs > Chapter 15. 1  Constipation: Introduction Constipation is a common gastrointestinal (GI) complaint. Generally, it is defined as having fewer than 3 bowel movements per week that are characterized by straining and the difficult passage of hard, dry stools. Patients may describe constipation as (1) straining to have a bowel movement; (2) passing hard, dry stools; (3) passing small stools; (4) feeling as though bowel evacuation is not complete; or (5) experiencing decreased stool frequency. Constipation usually results from the abnormally slow movement of feces through the colon, resulting in accumulation in the descending colon. 2 3  Etiology Causes of constipation include Various medical conditions and medications; Psychological and physiologic conditions (e.g., menopause and dehydration); Lifestyle characteristics. Constipation can stem from either primary or secondary causes. Primary constipation is often characterized by Slower than normal movement of fecal matter through the GI tract (slow transit time) or Defecatory disorders (e.g., pelvic floor dysfunction, anal sphincter abnormalities,rectal prolapse, etc.). Secondary causes of constipation include systemic, neurological, or psychological disorders, as well as structural abnormalities that result in obstruction. 4 Diet related constipation: Dietary fiber dissolves or swells in the intestinal fluid, which increases the bulk of fecal mass and, in turn, aids in stimulating peristalsis and eliminating stools. A diet that is low in calories, carbohydrates, or fiber may contribute to diet related constipation. Inadequate intake of fluids may also promote constipation in patients who are dehydrated. Intestinal fluids are essential for eliminating stools and therefore must be replenished. 5  Lifestyle characteristics Gravity and good abdominal muscle tone also aid in proper bowel function. Exercise increases muscle tone and promotes bowel motility. Avoiding the urge to empty the bowel can eventually lead to constipation. When the urge is ignored or suppressed, rectal muscles can lose tonicity and become less effective in eliminating stool. Nerve pathways may degenerate and stop sending the signal to defecate. In these cases, bowel retraining often is necessary to establish a pattern of regular bowel movements. 6  Medications contribute to constipation. Constipation is of particular concern in patients taking multiple medications and in those who also have conditions that can induce constipation. Opioid induced constipation is a common reason for self care laxative use. Selected Drugs That May Induce Constipation: − Analgesics (including nonsteroidal anti-inflammatory drugs) − Gastrointestinal antispasmodics (e.g., dicyclomine, hyoscyamine) − Antacids (e.g., calcium and aluminum compounds, bismuth) − Hematinics (especially iron) − Anticholinergics (e.g., benztropine, glycopyrrolate) − Hyperlipidemia agents (e.g., cholestyramine, pravastatin, simvastatin) − Anticonvulsants (e.g., carbamazepine, divalproate) − Hypotensives (e.g., angiotensinconverting − Antidepressants (specifically tricyclics such as amitriptyline) − enzyme inhibitors, betablockers) − Antihistamines (e.g., diphenhydramine, loratadine) − Memantine − Antimotility (e.g., diphenoxylate, loperamide) − Muscle relaxants (e.g., cyclobenzaprine, metaxalone) − Antimuscarinics (e.g., oxybutynin, tolterodine) − Opiates (e.g., morphine, codeine) − Barium sulfate − Parasympatholytics (e.g., atropine) − Benzodiazepines (especially alprazolam and estazolam) − Parkinsonism agents (e.g., bromocriptine) − Calcium channel blockers (e.g., verapamil, diltiazem) − Polystyrene sodium sulfonate − Calcium supplements (e.g., calcium carbonate) − Psychotherapeutic drugs (e.g., phenothiazines, butyrophenones) − Clonidine − Sedative hypnotics (e.g., zolpidem, benzodiazepines, phenobarbital) 7 − Diuretics (e.g., hydrochlorothiazide, furosemide) − Sucralfate  Sine and symptom: Decreased frequency or difficulty passing stools, other presenting symptoms may include anorexia, dull headache, lassitude, low back pain, abdominal discomfort, bloating, flatulence, and psychosocial distress. Constipation continuing over several weeks to months is considered to be chronic and may require more sustained and aggressive therapy directed by a health care provider. 8  Complications Straining to pass hard stool can lead to hemorrhoids, anal fissures with rectal bleeding, or rectal prolapse. If hard stool is packed very tightly in the rectum or intestine, fecal impaction or rectal ulcers may occur. Because defecation has been found to alter hemodynamics, straining to defecate may result in blood pressure surges or cardiac rhythm disturbances. 9  Treatment of Constipation The primary goals of treatment are to (1) Relieve constipation and reestablish normal bowel function, (2) Establish dietary and exercise habits that aid in preventing recurrences, (3) Promote the safe and effective use of laxative products. 10  Non-pharmacological treatment Adjusting the diet to include foods high in fiber, increasing fluid intake, and engaging in some form of exercise. Lifestyle modifications if more immediate relief is desired. Nonprescription products limits patients to short term (