Constipati

on
By:

Dr. Shahram Ala

(Pharm.D, BCPS)

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

Patients definition &

concept about constipation
can be different

Patients definition:
Straining 52%, hard stools 44%,
infrequent
stool 32%

Misconception:
62% believe that daily defecation
is necessary to good digestive health

What is the right number

of daily or weekly bowel
movements?!

Clinical definition
Any of two of following symptoms for at
least 3 month (not necessarily
consecutive) in a year

Straining
Hard or lumpy stool
Sensation of incomplete evacuation
Fewer than 3 defecation per week

Causes of constipation

fiber :(most common)

liquid ( 8 glasses/d is needed for
constipated)
Exercise : bedridden, coma
Ignoring urge to defecate
Systemic: Hypothyroidism, DM, Uremia,
pregnancy, hypercalcemia, Hypokalemia
Neurological: Stroke, Parkinsonism,
Multiple sclerosis

Causes of constipation
(Cont.)

GI-related: IBS, Hemorrhoid, Anal fissure, Anorectal & Colorectal

carcinoma ,obstruction

Medication: Opiate, Anticholinergics, Al(OH)3

Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics),
relaxants, chronic use of laxatives, Antiepileptics, progestron

Uncertain: idiopathic chronic constipation

Rate of empting:
carbohydrate>protein>Lipid

Fear, Pain Inhibit and exitation stimulate

Clinical manifestation:
Pale- Icteric-Anorexia-HeadacheAbdominal pain,

Diagnosis

Good history is enough for most cases

(Duration, frequency, Consistency, blood in the
stool, weight loss, Diet, Exercise, Toilet habits,
Laxative use (what), other drugs)

Basic laboratory tests:

CBC, Electrolytes, BS, BUN, Cr, TSH

Structural:
Barium enema, Sigmoidoscopy, Colonoscopy

Treatment

Treatment of underlying disease

(Malignancies, Hypothyroidism,)

Alteration of lifestyle (Diet, Exercise,

Liquids)

Laxatives

Acute constipation

Glycerin suppository
Sorbitol powder
Bisacodyl
Anthraquinones ( C-lax)
Saline laxative (MOM)
Tap-water enema
If laxative treatment is required for
> 1 week, refer to a physician

Chronic constipation
Most common in bedridden or
geriatrics

Choice: Psyllium (with enough

liquids)

Low doses of other laxatives:

C-lax, MOM, Sorbitol, Lactulose

Constipation in hospitalized
patients
May be related to general anesthesia
or opiates

Glycerin suppository
Milk of magnesium
Tap water enema

Constipation in infants &

children
If constipation is a persistent
problem:
Consider neurological, metabolic or
anatomical abnormalities

If No:
Approach as adults

Drug classes

Those causing water evacuation in 1-6 hr

Caster oil, Saline cathartics, PEG lavage
solutions

Those causing soft or semi fluid stool in 6-8 hr

C-lax, Bisacodyl
Those causing softening of stool in 1-3 days
Psyllium, Lactulose, Mineral oil, Decussate

Bulks

Psyllium, musillium
Increase Volume of intestine
Stimulate natural intestine
peristaltic
Anti Diarrhea & constipation
Lasts 12-24 h (even 3 days)
Drink freely water unless
obstruction

Emullients

Docusate Na cap: 500mg

Anionic surfactants
Decrease stool surface tension,
increase Fluide secration into
intestine
Lasts 1-3 days
SE: GI cramp

Lubricants
Liquid Parafine
Inhibition of fluide reabsorbtion from colon,
Softener of stool, stimulate peristaltic
Post MI, Post surgery
lasts 6-8 h
15-45 ml PO, or rectal

SE: Aspiration (neonate, Geriatrics, before sleep),

malabsorbtion (lipid soluble Vit.), Anal pruritis,
staining

Stimulant laxatives

Bisacodyl
Stimulates mucosal nerve plexus of the
colon (myentric)
Intermittent use for constipation
Oral: 6-8hr Supp: 15-60min
Interactions: Milk, Antacids (EC)
SE: Cramp, fluid and electrolyte imbalance,
Contraindication: pregnancy, lactation,
appendicitis

Caster oil
Usually for bowel preparation
Active metabolite: Ricinoleic acid
Onset: 1-3 hr

Saline

MOM, mgso4
Indications: Antacid (5-15 ml PRN),
Laxatives
(30-60 ml HS)
Mg: Osmotic, Release cholecystokinin
Onset: 3-6 hr
Interactions: Quinolones, Tetracycline,
Fe,
EC drugs (bisacodyl, sulfasalazine)
Breast-feeding: can be used
CRF?

Hyperosmotics

Glycerin, Lactulose, mannitol,

Sorbitol
Lactulose: Acetic acid, Formic acid,
Lactic acid
Encephalopathy ( lasts :24-48 h)
SE: flatulence, abdominal cramp,
diarrhea, electrolyte imbalance

Glycerin
Is very safe and acceptable for
intermittent basis particularly in
infants

Supp: 1g, 3g
Onset: less than 30 min

Mannitol

Tap-water enema

200 ml results in a bowel

movement within 0.5hr

Soapsuds are no longer

recommended (proctitis, colitis)

Drugs for chronic idiopathic

constipation

Cisapride (also for Parkinson's

disease)

Erythromycin

Summary

Underlying causes of constipation should

be considered
Foundation of treatment is diet and
psyllium
Acute constipation may be treated with
tap-water enema or glycerin suppository,
if needed, oral sorbitol, low dose bisacodyl
or C-Lax
Approach for chronic constipation is use
of psyllium and if needed, intermittent
low-doses of other drugs