Management of Management of Constipation in Constipation in

AdultsAdultsStephen Aglubat, MDStephen Aglubat, MD

May 2012May 2012

ObjectivesObjectives Define ConstipationDefine Constipation Treatment options for constipationTreatment options for constipation

CaseCase 76 year old female with PMHx of HTN, DMII, HLD, 76 year old female with PMHx of HTN, DMII, HLD,

presents to the clinic. She’s complaining of having presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more eating more vegetables, started drinking more water, and she recently included Metamucil to her water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her She comes to your office to be evaluated for her constipation. What would you offer her for the constipation. What would you offer her for the constipation?constipation?

A. LactuloseA. Lactulose B. SennaB. Senna C. DocusateC. Docusate D. Weekly tap water enemasD. Weekly tap water enemas

DefinitionDefinition Rome III criteria: 2 of the below Rome III criteria: 2 of the below

defines constipationdefines 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

Pathophysiology IPathophysiology I Constipation is caused by:Constipation is caused by:

Primary Colorectal dysfunctionPrimary Colorectal dysfunction Slow TransitSlow Transit Dyssnerygic DefacationDyssnerygic Defacation Irritable Bowel SyndromeIrritable Bowel Syndrome

Pathophysiology IIPathophysiology II Constipation is caused by:Constipation is caused by:

Secondary CausesSecondary Causes Endocrine/MetabolicEndocrine/Metabolic NeurologicNeurologic Myogenic DisordersMyogenic Disorders MedicationsMedications ObstructionObstruction

Chronic Idiopathic Constipation (CIC)Chronic Idiopathic Constipation (CIC)

ManagementManagement Initial treatment of Chronic Initial treatment of Chronic

Functional ConstipationFunctional Constipation Lifestyle modificationLifestyle modification Diet and fiberDiet and fiber

Lifestyle ModificationsLifestyle Modifications Increased fluid intakeIncreased fluid intake ExerciseExercise Establish regular bowel regimen Establish regular bowel regimen

patternpattern

Diet and fiberDiet and fiber Fiber increases bulk/distensionFiber increases bulk/distension

Distention causes stool propulsion.Distention causes stool propulsion. >25 g of fiber/day>25 g of fiber/day

Effect may take weeks.Effect may take weeks. Adverse effects: Bloating, flatulenceAdverse effects: Bloating, flatulence

Laxatives ILaxatives I Stimulant LaxativesStimulant Laxatives

SennaSenna BisacodylBisacodyl

Laxatives IILaxatives II Bulk forming laxativesBulk forming laxatives

Psyllium (Metamucil)Psyllium (Metamucil) Methylcellulose (Citrucel)Methylcellulose (Citrucel) Polycarbophil (FiberCon)Polycarbophil (FiberCon) Dextran (Benefiber)Dextran (Benefiber)

Laxatives IIILaxatives III Osmotic LaxativesOsmotic Laxatives

Polyethylene glycolPolyethylene glycol LactuloseLactulose SorbitolSorbitol Magnesium HydroxideMagnesium Hydroxide

Other therapiesOther therapies Colonic secretagoguesColonic secretagogues

LubipristoneLubipristone

SummarySummary Constipation in the older adult may be Constipation in the older adult may be

due to chronic constipation, secondary due to chronic constipation, secondary etiologic factorsetiologic factors

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

Therapy includes:Therapy includes: Diet/lifestyleDiet/lifestyle Stimulant LaxativesStimulant Laxatives Osmotic LaxativesOsmotic Laxatives

CaseCase 76 year old female with PMHx of HTN, DMII, HLD, 76 year old female with PMHx of HTN, DMII, HLD,

presents to the clinic. She’s complaining of having presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more eating more vegetables, started drinking more water, and she recently included Metamucil to her water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her She comes to your office to be evaluated for her constipation. What would you offer her for the constipation. What would you offer her for the constipation?constipation?

A. LactuloseA. Lactulose B. SennaB. Senna C. DocusateC. Docusate D. Weekly tap water enemasD. Weekly tap water enemas

CaseCase 76 year old female with PMHx of HTN, DMII, HLD, 76 year old female with PMHx of HTN, DMII, HLD,

presents to the clinic. She’s complaining of having presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more eating more vegetables, started drinking more water, and she recently included Metamucil to her water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her She comes to your office to be evaluated for her constipation. What would you offer her for the constipation. What would you offer her for the constipation?constipation?

A. LactuloseA. Lactulose B. SennaB. Senna C. DocusateC. Docusate D. Weekly tap water enemasD. Weekly tap water enemas

ReferencesReferences 1. Management of chronic 1. Management of chronic

constipation in older adults. Wald, constipation in older adults. Wald, Arthur. Uptodate.com. March 2012 Arthur. Uptodate.com. March 2012