Constipation

&

Hemorrhoids

Question no.1

I am 30 years old and my stool frequency decreased from three times per day to once every two days,

Am I constipated? What are the major symptoms

of constipation?

Constipation

Decrease in frequency of fecal elimination. Hard, dry and sometimes painful.

Normal stool frequency range ( 3 times / day : 3 times / week )

Causes

Inadequate water intake.

Inadequate fiber in the diet.

A disruption of regular diet or routine; traveling.

Inadequate exercise or immobility.

Stress and overuse of laxatives. 

Loss of defecatory mechanism .

Symptoms

Abdominal Bloating.

Headache. Hard stool.

Low back pain ± rectal fullness.

Straining.

Vomiting may occur.

Question no.2

Constipation may be a sign for many serious health problems,

( When to refer to a physician? )

1. Constipation + abdominal pain + nausea / vomiting

( Appendicitis )

2. Constipation + rectal bleeding or sudden change in bowel habbits (2 weeks )

( Cancer )

3. Constipation following recent abdominal surgery

( Ileus = Lack of peristalsis )

4. Colostomy or ileostomy.

Colostomy

Ileostomy

Question no.3

My mother suffers from abdominal discomfort as a result of constipation but she refuses taking laxatives,

Could you tell me the appropriate life style modifications for her to

follow?

Question no.4

What are the factors predisposing both elderly people and pregnant women to constipation?

Elderly

Lifelong laxative abuse,

Immobility,

Chronic illness and medication use,

Poor nutrition,

Reduce fluid intake.

Pregnancy

*High progesterone level,

*Uterus may compress the intestine,

*Decrease exercises,

*Iron and calcium intake .

Question no.5

Mention health problems that may lead to constipation?

**Pain

**Parkinsonism

Abnormal gut motility

Rigid abdominal muscle

Progressive general immobility

**Diabetes High blood glucose level

nerve damage

**Carcinoma -Constipation + discomfort anorexia weight loss Colorectal Carcinoma tenesmus blood in the stool -Tumors

**Inert colon

**IBS

**Chronic renal failure

Question no.6

Is there a relationship between anal disorders as abscesses and constipation?

Anal disorders

Anal fissures

Anal fistula

Perianal abscesses

Hemorrhoids

Question no.7

I heard that is a medical condition called "Colonic Inertia“,

What it is? What are its causes?

How is it treated ? How diet can affect colonic motility ?

Colonic inertia Is referred to a motility disorder. It is an abnormal passage of waste through the digestive system . Stool may remain stored in portions of the colon and not progress adequately to the part of the colon (Rectosigmoid) responsible for the propulsion and transfer of stool out of the body.

Symptoms of colonic inertia

•Constipation.

*Individuals with colonic inertia often do not pass a stool for 7–10 days at a time.

*Sometimes colonic inertia is accompanied by abnormalities in motility of the upper intestine including delayed emptying of the stomach and small intestinal pseudo-obstruction (a disorder that causes symptoms of blockage, but no actual blockage).

•Diarrhea

•Abdominal pain

•Bloating

•Nausea

•Vomiting

•Bloody discharge

Symptoms of colonic inertia (cont.)

Causes

•Nerve or Muscle damage.

•Hypothyroidism.

•Diabetes.

•Some rheumatologic conditions may also decrease the function of the nerves and muscles within the colon and produce severe constipation.

•Not enough water in a person's diet.

•Eating too much diary products.

•Frequent use of antacids and laxatives.

•Strong pain killers and other medication.

•Thyroid conditions.

Causes (cont.)

Diagnosis of colonic inertia

Transit time measurement test to determine the speed at which the body moves food through the digestive system.

This test may, in fact, point towards causes that are not even related to colonic inertia, such as low thyroid hormone levels.

Treatment

•Eating foods high in fiber.

•Motility enhance by carbohydrates and limiting proteins.

•Drinking plenty of water.

•Avoiding dairy products.

•Avoiding fatty foods.

Surgical treatment

Surgically shortening the colon (large intestine) corrects a slow colon.

Most of the colon is removed (80 %), and the small intestine is attached directly to the rectum. The technical term for the operation is “Total abdominal colectomy and ileorectal anastomosis".

Question no.8

I am taking Heama caps® for anemia , could that be the cause for constipation I am suffering from,

What can I do to alleviate this side effect?Can you recommend me other iron formulations from the market that wouldn’t cause this problem?

What are other drugs that can cause constipation ?

Each capsule contains:

Ferrous fumarate...............350 mg Folic acid..............................2 mgVitamin C...........................50 mg Vitamin B12......................7.5 mcgVitamin E acetate.................5 mgCopper..............................2.5 mgManganese........................2.5 mgVitamin B1..........................15 mgVitamin B2............................2 mgVitamin B6..........................10 mgVitamin D..........................400 i.u.Calcium gluconate................75 mgLinoleic acid.......................200 mgLinolenic acid.......................45 mgTaurine...............................15 mg

*Most of iron preparations may induce GIT disorders;

Abdominal pain.

Bloating.

Constipation.

Dark in stool. due to there absorption problem.

To alleviate this side effect try to :

Take after meals .

Take absorption enhancers like;

•Vitamin C is a powerful enhancer of absorption of non-heme iron.

•Animal proteins: meat, fish, or poultry Taken other iron formulations .

Oral Iron formulations;

•Elemental iron .

•Iron salts (ferrous , ferric ) ; Sulfate Succinate Fumarate Gluconate

•Iron complexes :Amino acid chelates,

Disaccharides,Polysaccharides

1) Carbonyl iron ;

Dissolve in gastric secretion.

Convert to hydrochloric salts prior to absorption in the stomach.

Absorption rate is slow, which permits continued release of iron for 1 to 2

days.

2) Ferrous glycine sulphate complex;

An iron-amino acid chelate relatively high bioavailability.

The conjugation of ferrous iron with amino acid prevents the iron from forming insoluble ferric hydroxide in the small intestine.

May be less likely to cause GI intolerance than ferrous sulfate.

e.g. Ferrosanol duodenal®

Ferric with EDTA acting as sustain release formulation of low absorption rate e.g. Sytron®

2) Ferrous glycine sulphate complex;

3) Iron poly saccharides;

e.g. Ferric hydroxide poly maltose

Haemojet®

E.g. Iron hydroxide poly maltose

Hydroferrin

Promoted to cause less GI irritation .

Similar bioavailability as ferrous sulfate.

Ferric iron is complexed to hydrolyzed starch, making it tasteless and odorless.

Drugs that cause constipation: Narcotic analgesics. Diuretics. Anticonvulsants. Sympathomimetics or Anti_cholinergics. Antihistaminic. Antacids (containing Calcium, Aluminium). H2 blocker. TCA. Nonprescription medication as Iron supplement.

Question no.9

I have constipation and want to know the different classes of drugs that I can use for treatment.

Enumerate with examples.

Classes of laxatives ;

Bulk forming laxatives.

Emollient laxatives.

Lubricant laxatives.

Stimulant laxatives.

Osmotic laxatives.

Bulk forming laxative : Poly saccharides derivatives

Types

Natural

Synthetic

1) Natural

Psyllium Bran

Regumucil® sachets Bran® tablets

N.B. Delay gastric emptying and depress appetite in some patients.

In addition, esophageal and intestinal obstruction and asthmatic reactions from psyllium have been reported.

Fermentation occurs by intestinal bacteria resulting in gas production and flatulence.

2) Synthetic

Methyl cellulose

Citrucel®

Calcium polycarbophile

Evak® tablets Evaculaxe® capsules

N.B.

Calcium may impair absorption of tetracycline if taken concurrently.

Metabolically inert and resistant to bacterial fermentation.

2) Emollient laxative :

They act as surfactants by allowing absorption of water into the stool makes the softened stool easier to pass.

They are salts of Docusate.

Another names ( DSS, Aerosol OT ,Dioctyl sodium sulfosuccinate).

3) Lubricant laxative

They work at the colon to increase water retention.

They coat stool. They prevent water removal from stool.

Mineral oils ( Liquid paraffin)

4) Stimulant laxative:

They work in small and large intestine.

They stimulate bowel motility. They increase secretion of fluids into the bowel through nerve stimulation.

Stimulate prestaltic movement .

Examples

1)Anthraquinone laxative as senna

Warning: may discolor the urine with (pink to red or brown to black).

Examples ;

2) bisacodyl :

It is diphenylmethane derivatives. Bisadyl® tablets and suppositories.

Examples ;

3) Castor oil

5) Osmotic laxative:

They are substances that work by creating osmotic gradient to pull water to small and large intestine,

Increase stool volume resulting in distention of the intestinal lumen,

Causing increase peristalsis and bowel mobility.

Examples

1) Glycerin:

Irritating the rectum . The drug of choice for pediatrics and geriatrics patients.

Examples ;

2) Enema : Locally acting, Rapid, Less toxic.

Examples ;3) Lactulose ;

Duphlac® syp. Lactulose® syp. Used for hepatic failure patients .

Examples ;4) Sorbitol :

It is non absorbable sugar, Similar efficacy to lactulose.

Administrated

Orally 70% solution. Rectally 25% solution..

Examples ;

5)poly ethylene glycol 3350:

FDA switched it to relief of occasional constipation .

Examples ;

6) Saline laxative •Magnesium citrate •Sodium phosphate.

•Magnesium sulphate.

Question no.10

My wife is pregnant she is complaining of constipation if you don’t mind

Recommend her the appropriate medication illustrating How it work onset of action? How to use it properly demonstrating ToWhich class it belongs giving examples and subtypes?

Class: Bulk laxative (category B)Sub type : Natural (psyllium)

MOA: natural polysaccharide derivative that absorb water to soften the stoolincrease bulk which stimulate perstalisis.

Drug interaction: Bulk laxative may reduce the effect of some medication. Make dose spacing not less than 2 hours.

Contraindication:

GIT blockage & Appendicitis

Onset of action Slow onset (12-24) hr.

How to use:

Dose:1*1 Must given with cup of water to prevent obstruction.

Question no.11

My grand father is taking many medications for his CHF and rheumatic pain,

Can he take Regumcil® sachets and Epsom salt for constipation?

Regumucil® : bulk laxative. It may reduce the effectiveness of digitalis and warfarin.

Dose spacing is essential.

Epsom salt: ( magnesium sulfate)Class: saline laxative (osmotic)

MOA: It drawn the water to the colon by osmosis Soften the stool and make easy to pass. Contraindication: Appendicitis GIT blockage Kidney disease

High level of Mg Low level of Na

Patient counselling:

Drink a lot of water with Epsom® salt to prevent dehydration

Not used for long time Should make dose spacing not less than 2 hours between other medication as it affect absorption of medication.

Epsom salt is contraindicated in the case of your grand father,

It may elevate level of Mg serum; Hypocalcemia. Arrythmia. Bradycardia. Ca blocker.

Question no.12

My grandmother is constipatedbut, cannot swallow oral tablet,

What other dosage forms are available?

Other dosage form :Sachet : Regumucil®

SUPPOSITORY: Glycerin

Syrup : Lactulose®

Enema

Question no.13

My baby is usually straining during defecation, What is the best OTC medication for his condition? How it works? Administration guidelines, adverse effects and contraindications if any?

•Stool softeners : Glycerin suppositories.

•Mechanism of action : Stimulates net secretion of water, sodium, chloride, and potassium and inhibits net absorption of glucose and bicarbonate in the jejunum.

•Adverse effects : local irritant effects.

Question no.14

My friend suggests me enema as rapid treatment for constipation,

What do they contain?

What are their advantage and disadvantages?

•Enema contain : Sodium biphosphate + sodium phosphate.

•Advantage:

Treatment of constipation.

Clean the bowel before colon surgery& endoscopy examination.

Disadvantages:

Cramps in stomach.

Irritation in rectal area.

Vomiting & severe diarrhea.

Reduce muscle tone in anal sphincter.

Dependence.

N.B.

Enema Shouldn't be used more than one time in 24 hours.

Using too much of this medicines can cause rare but life threatening side effects on your and heart electrolyte balance.

Question no.15

My grandfather suffers from hepatic encephalopathy, I heard some laxatives are used for treatment of this condition .

Is that true?and if so what's their mechanism of action and their precaution concerning it is use?

What is the hepatic encephalopathy?

Senna increase the risk.

Lactulose.

Colonic acidification.

Precaution:

If you have stomach pain, vomiting, muscle cramps, dizziness or weakness, stop taking the lactulose and call your doctor right away.

If you should experience any signs of an allergic reaction like difficulty breathing, swelling of your face, lips, tongue or throat seek emergency medical help.

If you are having more bowel movements, you may be dehydrating yourself, and taking more lactulose than you need. Finding the right dose of the lactulose.

•Lactulose can be used long-term to reduce the risk of having Hepatic Encephalopathy recurrences.

Question no.16

My brother suffer from chronic constipation he starts talking ( Purgation® ) tablet on regular basis first the condition improved but now the case is worse,

What do you think?

•Purgaton® natural glycosides as sennosides A&B

•MOA of Purgaton®:

-Stimulant laxative.

-It increases the motility of intestine using more than 2 weeks cause lazy bowel syndrome.

Uses of Senna:

-Mildest of the stimulant laxatives

-Less pronounced laxative effect than the violent purgation produced by castor oil.

Disadvantages :

Chronic use or over dosage of laxatives may produce persistent diarrhea, hypokalemia, loss of essential nutritional factors, and dehydration.

Chronic constipation, and loss of normal bowel function may occur during long-term use

Electrolyte disturbances (hypokalemia, hypocalcemia, metabolic acidosis or alkalosis).

Abdominal pain, diarrhea, mal absorption, weight loss, and protein-losing enteropathy may occur.

Disadvantages : (cont.)

Question no.17 I heard that some commercially

available herbal teas that I can use for my constipation , contain some laxative herbs safer than Drugs?

Do they have any drug interactions

(senna) or side effect?

Answer

• No , they aren’t safer than drugs & should be used with caution.

• Their drug interaction:- Digoxin ( Lanoxine) Warfarin ( Coumadin ) Water pills ( Diuretics )

* Their side effect :-

1- Stomach cramps.

2- Diarrhea.

3- Lax colon.

Question no.18

Abilaxine® ( bisacodyl ) tablets are effective in relieving constipation .

Comment on their administration immediately after meals or with Epicogel® suspension .

Answer

1- According to meals :-

It should be taken on empty stomach or at bed time .

It should be taken with full glass of water .

It is enteric coated tablet . You should avoid drinking milk or taking

antacid within 1 hour after using it.

2- According to Epicogel® :-

- It’s active ingredient is Aluminium hydroxide .

- It alters the effect of bisacodyl.

- So , they should be separated at least 1 hour.

Question no.19

My sister is pregnant ; Can she take castor oil or Minalax®

tablets for constipation?

What is docusate? Could it be misused? Mention it’s medical applications and

other synonyms .

Answer

1- NO , she can’t take castor oil, it hastens delivery and can cause amniotic fluid embolism.

2- Minalax® tablets can be used for pregnancy category C .

3- She can take Sobo Cusate.

4-Docusate is stool softener . It makes bowel movement easier .

5- Medical applications of docusate : - treatment of constipation. - reduce rectal damage. - wax softener in otic preparation.

Synonyms of docusate

Docusate Calcium. Docusate Sodium. Correctol soft gel extra gentle. Doculase . DSS. Aerosol OT. Dioctyl Sodium Sulfosuccinate.

Question no.20

My friend recommended me liquid paraffin as laxative,

What’s your advice?

How about using it concomitantly with Minalax® tablets in severe constipation?

- Liquid paraffin not recommended as it has side effects like :-

- Anal seepage or irritation. - Granulomatous reactions. - Pneumonia if accidentally inhaled. - It may interact with fat soluble

vitamins as vitamin K , E , D , A. - Shouldn’t be taken at bed time.

Answer

In severe constipation:-

Only Minalax® ; -Liquid paraffin is not recommended.

-Hepatotoxicity may occur up on using together.

I am suffering from chronic constipation and usually strain during defecation , can this lead to lead to hemorrhoids ? And are there any other causes?

Define hemorrhoids and mention its etiology and epidemiology

•This is common

problem can be

painful, but it’s

usually not serious

….

If you strain or sit on

the toilet a long time to

move stool, the

increased pressure cause

the veins in this tissue

to swell and stretch.

This can cause

hemorrhoids

Other Causes of hemorrhoid :•Pregnancy •Over-weight •Medical condition •Heart & liver disease •Work staring ) heavy lifting )•Itching

Hemorrhoid

are condition which veins around the anus or lower rectum are swollen and inflamed

External hemorrhoid

Epidemiology the incidence rate is 4.4% with an age distribution that show a prevalence between 45 – 65 years old.

I am feeling discomfort in the anal area, a friend suggested I am suffering from hemorrhoids; I want to know if my symptoms can be caused by any other condition and what are the other symptoms of hemorrhoids?

1

2

3

4

5

Anal fistula or Anal fissure

Anorectal abscess

Colon polyp

Inflammatory bowel disease , partically crohn’s disease

Rectal prolpse

6

7

Colorectal cancer

Staphylococcus infection

Other conditions

1

2

3

4

5

6Skin irritation due to large hemorrhoid

symptoms

Rectal pain

Thrombosed or clotted, hemorrhoid

Itching

Bleeding during bowel movements

Bright red streaks of blood

I know that hemorrhoids can be classified into different types; please tell me these types and how each type is treated?

Types of hemorrhoids

1

2

Internal hemorrhoids

External hemorrhoids

1

First degree

2

Second degree

3

Third degree

4

Fourth degree

Classification of Internal hemorrhoids

Dose not descend during

straining in defecation ,painless and

bleeding

Descend during

defecation but return with relaxation ,

mild bleeding and pain

Need manual replacement into rectum,

pain, bleeding and mucous discharge

Permanent prolapsed

“descend” and can not be

manipulated manually

1

First degree

Dose not descend during

straining in defecation ,painless and

bleeding

Treatment

of

hemorrhoids

Question no.23

I know that hemorrhoids can be classified into different types;

Please tell me these types, How each type is treated.

Internal hemorrhoids: Veins can swell inside the anal canal.

External hemorrhoids: Veins can swell near the opening of the anus.

*Most hemorrhoids can be treated with simple changes to diet and bowel habits.

*Most do not require surgery or other treatment unless the hemorrhoids are very large and painful.

Internal hemorrhoids:

Fixative procedures include tying off the hemorrhoids with a rubber band (rubber band ligation) or using heat, lasers, or electric current to create scar tissue.

(Coagulation therapy)

*Surgical removal of hemorrhoids (Hemorrhoidectomy) *can be used for large internal hemorrhoids, *When several small hemorrhoids are present, or when other treatments have not controlled bleeding.

Sometimes a combination of treatments

Fixative procedure + Hemorrhoidectomy

The most effective ttt

External hemorrhoids:

Can only be removed surgically, if needed. If a blood clot develops in the external hemorrhoid, the clot may need to be removed to relieve pain.

Question no.24

My brother suffers from hemorrhoid; He relies on self-treatment, but could you tell me,

When should he consult a physician.

He should consult a physician if:

Moderate rectal pain lasts longer than 1 week after home treatment.

Pain or swelling is severe.

A lump inside the anus becomes bigger or more painful.

Tissue from inside the body bulges from the anus and does not return to normal after 3 to 7 days of home treatment.

Rectal bleeding becomes heavy or changes color (such as from bright red to dark red), or if stools change size, shape, or color (from brown to maroon or black).

Question no.25

There are many dosage forms available for relieving hemorrhoids;

What are they? Also what is the best one?

1) Ointments that protect the skin,

ex; Zinc oxide or Petroleum jelly

Best nonprescription ttt -They can prevent further injury. reduce itching by forming a

barrier over hemorrhoids.

2) Use suppositories, (formerly Anusol). ( 7 - 10 ) days. to relieve irritation, to lubricate the anal canal during bowel movements.

*Some of these products contain substances that can harm anal tissues if they are used for too long.

3) An ointment 1% hydrocortisone

-A type of steroid medicine.

-May relieve inflammation and itching..

-They should not be used for more than 2 weeks ( thin the skin )

5) Apply products that contain medicine to numb an area (local anesthetic).

These products help some people, especially those who have painful external hemorrhoids,

Some people become allergic to them.

Ask your doctor before using these products

Question no.26 I heard there are a variety of medications that can be used for hemorrhoids and can be present in one formulation.

What are possible classes they belong to? Giving example from the Egyptian market.

1-local anesthetics:

Used for relief pain, itching, and burning in the perianal region or lower anal canal.

Not in the rectum as rectum has no sensory pain receptor.Ex: lidocaine & cinchocaine

Not be applied to abraded skin as lead to systemic absorption. Not to be used for more than 7 days.

2-Vasoconstriction:

They decrease mucosal perfusion by constriction the blood vessels in the anorectal area.

Vasoconstriction are not approved for minor bleeding.EX: ephedrine sulfate & phenylephrine HCL

Care should be taken to patient with cardiovascular diseases, high blood pressure.

3-Protectant:

Provide a physical barrier, forming a protective coating over skin or mucous membranes.

They prevent irritation of anorectal tissues and prevent water loss from the stratum corneum.

Ex: shark liver oil & cod liver oil

4-Astringent

-Protect underlying tissue through protein coagulation; provide temporary relief of itching, discomfort.

Ex: Calamine Witch hazel (external use only)

5-Keratolytics

Cause desquamation of the surface cells of the epidermis.

Provide temporary relief of discomfort and itching.

For external use only ( Resorcinol )

-Resorcinol should not be used on open wound due to potential hypersensitivity.

6-Analgesics

These agents should not be used to treat internal hemorrhoids.

Ex: Menthol & Camphor

7-Antibacterial

-Protect hemorrhoids or fissures against microbial infection. ( Framycetine )

EXAMPLES:

1- Proctosedyl (Hydrocortisone+Cinchocaine+Framycetine+Esculin)

2-Anusol (zing oxide- bismuth subgallate-bismuth oxide-balsam Peru)

Question no.27

My friend usually feels pain during defecation as he suffers from hemorrhoids,

He started to use Lignocaine® cream as a pain reliever, Please tell me

How to use it properly?

Wash your hands well before and after using lignocaine® cream.

Wash the affected area with mild soap and warm water.

Gently dry anorectal area.

Apply thin layer of cream to the area.

Gently rub the cream until it is distributed.

-Lignocaine® cream comes with rectal pipes which allow patient to insert the cream directly to the rectal.

-To use the pipes, attach it to the tube, Gently inserts the pipe into the rectum, squeeze the tube to deliver the medicine.

-Do not insert any part of the tube into the rectum.

Question no.28

My brother defects bloody stool, can he take H-Formula®cream for his condition?

What is the role of shark liver oil in this product?

H-Formula® cream

-Shark liver oil 3%

-Phenylephrine 25%

-Dibucaine 1%

-Use:

*Reduce inflammation in blood vessels.

-Role of shark liver oil:

Prevent irritation of anorectal tissue. Prevent water loss from stratum corneum.