constipation (management)

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CONSTIPATION

CONSTIPATION

DR BHAVIN MANDOWARA

MANAGEMENT

Lifestyle modification Diet and fiber Laxatives - Bulk forming laxatives - Osmotic laxatives - Stimulant laxatives Stool softeners, suppositories, and enemas Other therapies for chronic constipation - Colonic secretagogues - Opioid antagonists - 5HT(4) receptor agonists

APPROACH CONSIDERATIONS

Manual disimpaction of stool should be considered only after critical illness asocaited constipation has been ruled out

Medical care should focus on dietary change and exercise . Correctionof dietary deficiency and aerobic exercise

Surigcal care is generally restricted to evaluation of underlying causes or management of acute complication of constipation.

HIGH RISK FACTORS

UNCERTAIN DIAGNOSIS

EVIDENCE OF INTRA-ABDOMINAL CATASTROPHE

SEVERE ABDOMINAL PAIN

FEVER , CHILLS

LOWER GI BLEED

INSTABILITY OF VITAL SIGNS

ABSENCE OF BOWEL SOUNDS

ACUTE RECENT CHANGE IN BOWEL SOUNDS

DIETARY AND LIFESTYLE MEASURES

FIBER : NATURAL -->FRUITS , VEGETABLES , AND CEREALS

FIBER SUPPLEMENT : WHEAT , PSYLLIUM OR METHYLCELLULOSE

DAILY FIBER OF ABOUT 20-25G/DAY IS RECOMMENDED

FIBERS ARE GOOD FOR LONG TERM USE AS COMPARED TO STOOL SOFTNERS IN WHICH TACHYPHYLAXIS DEVELOPS .

FIBRES SHOULD BE GRADUALLY TITRATED UP AS TO PREVENT SIDE EFFECTS OF FLATULENCE AND BLOATING

PATIENT MUST BE EXPLAINED THAT IT HAS TO BE TAKEN DAILY AS ONSET OF ACTION MAY TAKE WEEKS .

INCREASE FLUID INTAKE OF ATLEAST 8 GLASSES PER DAY , DECREASE MILK , TEA , COFFE , ALCOHOL

PHARMACOLOGIC THERAPY

BULK FORMING AGENTS/LAXATIVES includes psyllium ,methylcellulose , wheat dextran, act by absorbing water and increasing fecal mass , best , least expensive but has to be used for long term

EMOLLIENT STOOL SOFTNERS - eg include docusate which acts as a surfactant . It is easier to use but lose effectiveness with long term administeration and hence are reserved for short term setting like post op narcotic prescription

RAPIDLY ACTING LUBRICANTS includes PEG(polyethylene glycol , bisacodyl and sodium picosulfate v , long term term riskof habituationor toxicity is there

PROKINETICS cisapride , tegaserod are 5HT4 antagonist , increase colonic motility and decrease transit time . They have been withdrawn

LAXATIVES

Laxative usage in the older adults should be individualizedkeeping in mind the patient's history (cardiac and renal comorbidities),drug interactions, cost, and side effects

OSMOTIC LAXATIVES : USED IN PATIENTS NOT RESPONDING TO BULK LAXATIVES

PEG: Low-dose polyethylene glycol (PEG) (17 g/day) has been demonstrated to be efficacious and well tolerated in older patients . However,high-dose PEG (34 g/day) is associated with abdominal bloating, cramping,and flatulence, and older adults may be more susceptible to these side effects

LACTULOSE increases stool frequency, decreases the severity of constipation symptoms, and reduces the need for other laxatives in older adult patients

SORBITOL : less expensive and better tolerated

LAXATIVES

Saline laxatives such as magnesium hydroxide have not been examined in older adults, and should be used with caution because of the risk of hypermagnesemia.

Stimulant laxatives Stimulant laxatives affect electrolyte transport across the intestinal mucosa and enhance colonic transport and motility.

OSMOTIC AGENTS/COLONIC SECRETAGOGUES

Lubiprostone is an oral bicyclic fatty acid that activates the type 2 chloride channels on the intestinal epithelial cells,thus secreting chloride and water into the gut lumen .It is best reserved for patients with severe constipation in whom other approaches have been unsuccessful.

IT HAS BEEN APPROVED BY FDA FOR CHRONIC IDIOPATHIC CONSTIPATION , IBS-C , OPIOD INDUCED CONSTIPATION

ADVERSE EFFECTS INCLUDE FLATULENCE , NAUSEA AND DIARRHOEA

other agent Linaclotide is a guanylate cyclase C receptor agonist that stimulates intestinal fluid secretion and transit . Approved by the FDA for use in the treatment of chronicidiopathic constipation, the long-term risks and benefits of linaclotide,especially in older adults, remain to be determined

OPIOD ANTAGONIST

Opioid antagonists Two peripherally acting mu opioid receptor antagonists, alvimopan and methylnaltrexone , may have a role in treatment of narcotic-induced constipation and paralytic ileus, but data are lacking among older adults. As these opioid receptor antagonists act peripherally and do not cross the blood brain barrier, they do not impair the analgesic effects of opioids.

SURGICAL CORRECTION OF CAUSE AND COMPLICATIONS

FOR EVALUATION OF UNDERLYING CAUSE -LARGE BOWEL OBSTRUCTION , VOLVULUS ,INTRABDOMINAL INFECTION/ISCHEMIA , HEMORRHOIDAL THROMBUS

RECTAL OUTLET OBSTRUCTION , RECTOCELE , RECTAL PROLAPSE , RECTAL INTUSSUSCEPTION

HYPOMOTILE COLON REFRACTORY TO MEDICAL THERAPY.

MANAGEEMNT IN SPECIAL PATIENTS

PREGNANCY :

CAUSE : DIETARY CHANGES ,

ANATOMIC IMPINGEMENT BECAUSE OF LARGE UTERUS PRESSING ON RECTOSIGMOID

HEMORRHOIDS BECAUSE OF VENOUS CONGESTION

TREATMENT : FIBRE , WATER , GENTLE EXERCISE , OCCASIONAL LACTULOSE

IF HEMORRHOIDS ARE THERE THEN SUPPOSITOERY AND SITZ BATH WILL BE REQUIRED

MANAGEMENT IN SPECIAL PATIENTS

ELDERLY : MEDICATIONS ARE TO BE ESPECIALLY ASKED WHICH CAUSE CONSTIPATION AND ALSO SELF REPORTED CONSTIPATION IS HIGH

TREAMENT INCLUDIING DIET AND EXERCISE IS USUALLY INSUFFICIENT AND CHRONIC LAXATIVE USE IS OFTEN REQUIRED .

MENTALLY INCAPACITATED INDIVIDUALS THERE IS PATTERN OF BOWEL RETENTION IN WHICH SHORT TERM USE OF LAXATIVE OR STOOL SOFTENERS IS REQUIRED

MANAGEMENT IN SPECIAL PATIENTS

OPIOD INDUCED CONSTIPATION(OIC)

40-80% EXPERIENCE CONSTIPATION

SOME HAVE SEVERE ENOUGH TO STOP OPIODS ALSO

MECHANISM: OPIOD BINDS TO PERIPHERAL OPIOD RECEPTOR AND DECREASES GI TRACT FLUID

TREATMENT : LUBIPROSTONE- ADULTS WITH OIC WITH NON CANCER PAIN INHIBITS CIC-2 CL- CHANNEL

OTHER AGENTS INCLUDE NALOXEGOL AND METHYLNALTREXONE

SURGICAL CONSULTATION

LARGE BOWEL OBSTRUCTION

COLONIC ILEUS SECONDARY TO INTRABDOMINAL PROCESS

ANORECTAL COMPLICATIONS

HEMORRHOIDS , FISSURE

ACUTE HEMORRHOIDAL THROMBOSIS

CHRONIC NON HEALING FIISURE

PERIRECTAL ABSCESS AND FISTULA

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