LAURA HUTCHINSONDIETETIC INTERN

BENEDICTINE UNIVERSITY

Chronic Constipation and Laxative Abuse

Patient Profile

Age: 84Gender: FemaleRace: CaucasianHeight: 4’11Weight: 95 lbChanges in Weight: 5# weight loss in previous 2

months.BMI: 19.1 (WNL)Social hx: Married, Jewish, retired, lives at home.Current medical diagnoses: Small bowel obstruction

d/t adhesions, chronic renal insufficiency, chronic constipation/obstipation

Patient Hx

Past dx: B12 deficiency anemia, pure hypercholesterolemia, chronic kidney disease stage III, gastric ulcer, osteoporosis, depression, closed Colles’ fx of right arm, hiatal hernia, breast cancer, endometrial cancer, hypertension

Nutrition hx: Follows Kosher diet. Severe, chronic constipation x 10 years.

Interrelationships of Medical Dx

Hypertension CKD Stage III Anemia Osteoporosis Increased Age Fluid Restriction Small Stature Mobility

Depression Chronic Constipation Laxative Abuse?

Nutrition Diagnoses

Altered GI Function related to Chronic Constipation/Obstipation as evidenced by patient need to supplement with Colace, Senna, and Glycerine suppositories to have a normal bowel movement.

Inadequate oral intake related to poor appetite secondary to abdominal distension and chronic constipation as evidenced by 25-50% intake at meals per patient and dietitian.

Altered GI Function related to Small Bowel Obstruction as evidenced by CT scan of pelvis/abdomen.

Back to this Nutrition Dx..

Altered GI function related to chronic constipation/obstipation as evidenced by patient needs to supplement with Colace, senna, and glycerine suppositories to have a normal bowel movement.

Is this normal laxative use?

What is Laxative Abuse?

Laxative abuse is the repeated misuse and overuse of laxatives involving Dosing too frequently Overdosing Using laxatives for non-intended reasons (such as weight

loss) Using multiple types of laxatives at once Using the wrong type of laxative (such as a purgative

laxative when a stool softener would have been appropriate)

Overuse can lead to dependency and a decrease in bowel function

(Fruit Eze)

Types of Laxatives

Bulk-Forming LaxativesSaline LaxativesOsmotic LaxativesSurfactant Laxatives LubricantsStimulant Laxatives

Diphenylmethane derivatives Anthraquinone derivatives

(Roerig)

Profile of a Laxative Abuser

Eating Disorder patients Histrionic personality traits Lower self-esteem Lower “self-liking” Weight and shape concerns Depression

Middle aged or older adults Perceived poor physical health

Athletes in sports with weight limits

Factitious disorder patientsComorbidities

(Roerig, Steffen, Pryor, Harari, Surgenor, Weltzin)

Complications

A Vicious Cycle –with dehydration, the renin-angiotensin system kicks in, following by rehydration and water weight gain

(Roerig)

Complications

Electrolyte Disturbances

Metabolic Disturbances

Bowel Disturbances

Kidney Disturbances

(Roerig, Cummings, Copeland)

Diagnosis

Practitioner’s suspicionMelanosis ColiGI symptomsSerum hypokalemiaFecal electrolytes

Stool osmotic gap : 290 – 2* (Stool Na + Stool K)

(Roerig)

Role of the Registered Dietitian

Identify patient’s bowel patterns.

Identify type and frequency of laxative use. Be specific – patients will not

always willingly offer this information.

Check labs, electrolytes, and fluid status.

Monitor for disordered eating patterns or disordered bowel regimens.

Treatment/Monitoring

EducationAppropriate treatment for eating disordersRisks?Goals of treatment:

Stop laxative abuse Maintain healthy GI Function

Weight trendsLabs and other nutritional parameters

Is this patient abusing laxatives?

YES. But, is it an eating disorder, or is she just an older adult with constipation?

Anxiety/depression issuesRigid bowel regimenRenal failureAgingPoor appetite

References

Copeland PM. Renal failure associated with laxative abuse. Psychother Psychosom. 1994;62:200-202.Cummings JH, Sladen GE, James OF et al. Laxative-induced diarrhoea: a

continuing clinical problem. BMJ. 1974;23:537-541.Escott-Stump S. Nutrition and Diagnosis Related Care Seventh Edition.

2012. Baltimore: Lippincott, Williams, and Wilkins.Fruit-Eze. Laxative Abuse and the Laxative Habit. 2003. Retrieved on May

7, 2013 from http://web.pdx.edu/~sujata/FruitEzeWeb/education/laxative/habit.htmlHarari D, Gurwitz JH, Avor J et al. Constipation: assessment and management in an institutionalized elderly population. J Am Geriatric Soc. 1994;42:947-952.Mahan LK, Escott-Stump S, Raymond J. Krause’s Food and the Nutrition Care Process Thirteenth Edition. 2010. St. Louis: Elsevier Saunders.Mikrut R, Groetsma C et al. Clinical Dietetic Reference Pocket Guide. 2010. Hines: Edward Hines Jr. Hospital Department of Veterans AffairsPagana KD, Pagana TJ. Mosby’s Diagnostic and Laboratory Test Reference

Tenth Edition. 2011. St. Louis: Elsevier Mosby.

References

Pronsky ZM, Crowe JP. Food Medication Interactions Seventeenth Edition. 2012. Birchrunville: Food Medication Interactions.

Pryor T, Widerman MW, McGilly B. Laxative Abuse Among Women With Eating Disorders: An Indication of Pathophysiology? Int J Eat Disord. 1996;20(1):13-18.Roerig JL, Steffen KJ, Mitchell JE, Zunker C. Laxative Abuse: Epidemiology,

Diagnosis, and Management. Drugs. 2010;70(12):1487-1503.Steffen KJ, Mitchell JE, Roerig JL. The eating disorders medicine cabinet

revisited: a clinician’s guide to ipecac and laxatives. Int J Eat Disord 2007;40:360-368.

Surgenor LJ, Maguire S, Russel J, et al. Self-liking and aself-competence: relationship to symptoms of anorexia nervosa. Eur Eat Disord Rev. 2007;15:139-145.

Weltzin TE, Bulik CM, McConaha CW et al. Laxative withdrawal and anxiety in bulimia nervosa. Int J Eat Disord. 1995;17:141-146.Wilson BA, Shannon MT, Shields KM. Pearson Nurse’s Drug Guide. 2013.

Upper Saddle River: Pearson Education.