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Constipation
“I wish being famous prevented me from being constipated”
- Marvin Gaye

“Besides death, constipation is the big fear in hospitals”
-

Robert McCrumm

-

James Rose, MD
Peak Gastroenterology Associates, P.C.

CME Credit: 1.0

S

Copyright (c) 2014 James E. Rose, MD | Peak
Gastroenterology Associates, PC

Question

S Which patient has constipation?
S A) 32yo woman who describes with every BM the need to strain and has hard pebble-like
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S
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movement
B) 46yo man with less than 3 BMs per week
C) 25yo man who requires a laxative every day in order to have a BM
D) 88yo women that says in order to have a BM, she will press her peri-anal area to
stimulate a BM
E) All of the above
F) None of the above

Definition:
Rome 3
S Symptoms lasting >6months and

Patient Definition:

S Must include at least 2 of the following:

•

Hard Stools

(1) At least 25% of bowel movements associated with

•

Infrequent stools (<3 per

S
S

Lumpy or hard stools

S

Incomplete bowel evacuation

S

Anorectal obstruction

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Need for manual manoeuvres

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< 3 bowel movements per week

week)

Straining

(2) Loose stools rarely present without the use of

laxatives
(3) Insufficient criteria for IBS

•

Excessive straining

•

Sense of incomplete bowel
emptying

•

Excessive, unsuccessful time
spent on toilet

Used in Clinical Trials
Correlates with symptoms of straining and difficult evacuation
Also correlates with colonic transit
(Type 1 or Type 7 stool is correlated with slow or rapid colonic
transit Degen LP, Phillips SF. How well does stool form reflect
colonic transit? Gut 1996;39:109-113.)
Majority of “constipated”
patients have stools that are Type 1-3

University of Bristol, Scand J Gastroenterol, 1997


Other Symptoms and Consequences of
Constipation
Nausea +/- vomiting

Nausea and reduced appetite

Abdominal and Rectal pain

Behavioral disturbances in dementia

Flatulence
Loss of appetite
Lethargy
Depression

weight loss

increased use of psychotropic medications
Extra staff time needed for increased
toileting needs
Overall increased number of medications in
the regime

Epidemiology
S Medline 2010 literature search of 58 articles
S North American prevalence 2 – 27% with mean of 16% (overall)
S 33% in adults aged 60-101

S Using Rome 2, about 63 million Americans with chronic constipation
S Risks
S Women (F:M=1.5:1), non-whites, >60’s, low income, little exercise, poor education,

institutionalized

S >65 years of age 26% men, 34% women

Quality of Life (QOL)
S Impact as severe as Diabetes, IHD,

Rheumatoid Arthritis
S Social and mental health particularly

affected
S Estimates that > 13 million work

days lost to constipation in
USA/year
Systematic review: impact of constipation on quality
of life in adults
Belsey et al Alim, Ther & Pharm 2010

Economic Costs
S UK National study
S 2 x number of GP visits for pts between 65 – 74 yrs, 5 x number of visits for pts > 75
S About 2.5 million Americans undergo Iaxatives for Constipation annually at a cost of

$2700/pt (based on 1994 paper!)…85% of those pts will be prescribed long term
laxatives

S In 1994, In US, about 90,000 pt hospitalized for constipation

S In 2004 (Levy et al), $660 million OTC Laxatives sold (US)


Principles

CONSTIPATION SIMPLIFIED

There are a lot of CAUSES
the PATHOLOGY and the PRINCIPLES

of TREATMENT are the SAME.


Things to Ask
S

Feces: Quality/Frequency/Effort/Associated Sx

S

Foods and Fluids: Fiber and White Food

S

Fast paced: esp. Calls Answered

S

Flaccid: Daily Movement, Childbirth trauma

S

Medical: Laxative Use, other Meds, Thyroid Sx

S

RED FLAGS: rectal bleeding, abrupt weight loss, change in bowel habits, FHx of colon CA,IBS

S

Tools: Bowel Diary (see Symptom Diary on web),
Transit time trial ... corn, beets, or other identifiable food


S Passenger: (hard or large or irritating)
S too little (water or fiber)
S too much (irritants, large proteins, bacteria)
S Push: Peristalsis impaired (slow transit)
S dilated colon, meds, toxins-irritants-bacteria
S Passage: inflamed, irritated, weak, uncoordinated, dilated (pelvic floor dysfunction)
S inhibits peristalsis
S pelvic muscles weak
S dilated colon does not work well

Causes


Labs

S Blood Work: most guidelines say optional

S TSH, BG, CBC if concern of CA

S Consider

S Barium Enema or Flexible Sigmoidoscopy in more serious cases
S Radiology: Bowel Score (most say not needed)

Categories of Treatment
S Passenger:
S Bulk/hydrophilic agents – fiber
S

“make it bigger”

S Surfactants/Emollients – stool softeners
S “make it slippery” (colace, some psyllium-bulk)
S Osmotic laxatives – not absorbed
S “don’t let the water leave” (Mg/lactose/sorbitol/PEG)

S Push
S Peristaltic irritants
S
S

stimulants (dulcolax/senna)
“make it go faster”

S Others: prokinetic, prosecretors (probiotics)

S Passage
S exercises, position, biofeedback


Steps of Treatment

1.Treat Cause

2.Clear out Bowel
3.Restore Normal Function

4.Then Wean down or off of therapies…

1. Treat Causes
S Food: Insufficient Fiber (?too much White Stuff)
S Trial of no dairy products!
S Psyllium Husks/prunes-prune juice/other
S Fluids: not enough
S Especially warm relaxing drink in the morning
S Water (minimum= ½ oz per # of Body Wt/QD)
S Fast Paced:
S Chew Food 20-30x (stimulates peristalsis)
S Cut out or decrease Caffeine, ETOH
S Answer “Call of the Bowels”
S Discuss relaxation
S Treat Anxiety, Depression, OCD-tendencies
S Flaccid: get more movement


2. Clear out the Bowel
S From Above
S Mild: Magnesium, Vitamin C and Oils

S Moderate: Senna or MOM
S Severe: Sorbitol, Lactulose or Miralax

S From Below
S Enema (Fleets, Oil, Milk, etc)
S Suppository (glycerine, dulcolax)

3. Restore Normal Function
S Remove Causes
S consider further elimination diet
S Special Exercises
S peristalsis/pelvic strength
S Position (raise feet)
S Digestive Enzymes and Betaine HCL
S improves digestion especially in high protein diets/elderly
S Probiotics: (peristalsis)
S Biofeedback (dysynergy)

4. Wean Down
S Elimination
S Dairy: 22% tolerated at 6 months vs 88% after a year

S Use Clear Out only prn
S Senna, Sorbitol, Lactulose or Miralax
S Dulcolax/Enemas

S What if they need long term stool softeners
S No proven down side to most
S Largely unknown.


Treatment in Outpatient Setting

4 Steps
1. Treat Cause: stop dairy, drink fluids, increase fiber (metamucil or flax)
2. Clear out Bowel: Magnesium products/Vitamin C
3. Restore Normal Function: teach exercises/digestive enzymes
4. Then Wean down or off of therapies…see if they can stop Mg or Vit C or

PEG, then metamucil or flax

Treatment in Hospitalized Patient

4 Steps
1. Treat Cause (activity or may not be able)
2. Clear out Bowel: Bisacodyl 10mg PO or use PR, MOM (Mag-Hydroxide) 5-

15mL QID or Mag Citrate, if hard stool then Colace
3. Restore Normal Function (may not be as much a focus for now)
4. Then wean down or off of therapies…(later)

Severe (Impaction Treatment)
S Main focus is on step 2 (clear out bowels)
S Disimpact (manually or with enemas)
S Mineral oil enema then…
S Fleets x 3 days +/- Polyethelene Glycol until colon clear
S Then: Lactulose, Sorbitol, PEG …
S IF no BM in 2 daysBisacodyl or Glycerin suppository
S Then focus on steps 1 (cause) and 3 (restore)

Lifestyle Changes
S Aerobic Exercise 30 minutes, 3-5/week
S sedentary folks are three times more likely to report constipation
S need to increase fluids
S Retraining:
S Sit on toilet at same time every day (ie. After eating breakfast, upon rising, after every
meal)
S Defecate when urge arises
S Deep Breathing on toilet (relaxation)

COFFEE

Caffeinated coffee stimulates colonic motor activity.
S Its magnitude is similar to a 1000 kcal meal
S 60% stronger than water
S 23% stronger than decaffeinated coffee.
S N = 12
Coffee increases rectosigmoid motor activity within 4 min after ingestion in some
people.
Scand J Gastroenterol Suppl. 1999;230:35-9. Eur J Gastroenterol Hepatol. 1998 Feb;10(2):113-8. Gut. 1990
Apr;31(4):450-3

Other Dietary Supplements
S

Prunes
S High fiber, 6 gm fiber/10 prunes
•
sorbitol
•
neochlorogenic acid
S How much: 50 grams bid in one study: 14 prunes (but 281 kcals!)
•
Slightly more BMs/week cp to psyllium
S Antioxidant benefit, ORAC value = 6463
S Tamarindo – tambien possible ayuda

S

Vitamin C
S

Dose: 1000 mg vitamin C tid before meals

S

Often rec to take to “bowel tolerance”

S

Or rec w/ Chitosan

http://www.lef.org/protocols/gastrointestinal/constipation_01.
htm
Life Extension Foundation Accessed 9/24/11

S

Fiber composed of chitin, a component of the shell of shellfish.

S

Six 500-milligram (mg) capsules of chitosan

S

Vit C helps transform chitosan in the stomach and intestine into a fat-absorbing gel.

Nature Reviews Gastroent and Hep 2011; 8: 306-307
Bowes & Church’s Food Values of Portions Commonly Used, 17th Ed.


Classes of Treatment
S Causes water evacuation in 1 – 6 hours
S Saline cathartics, PEG solutions, Castor Oil

S Causes soft/semisoft stools in 6 – 8 hours
S Bisacodyl

S Causes softening of stool in 1 – 3 days
S Docusate, Psyllium, Lactulose, Mineral Oil

Bulk Forming Agents/Fiber
S “Just add water”: Swell in intestines, lubricate and soften stool.
S Note: Water necessary, or risk choking/obstruction!

S Best Evidence
S mucilage from Ispaghula seeds (Plantago ovata, aka Psyllium, aka Metamucil)
S Dosing: start 1 tsp, titrate to effect (~1T).

S If Flatulence, consider…
S
S
S
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Methyl-Cellulose (Citrucel)
Calcium polycarbophil (FiberCon; Fiber-Lax)
Wheat dextrin (Benefiber®),
Chia seeds, flax, others
Aliment Pharmacol Ther 1998, J Am Geriatr Soc 1995, J Am Geriatr Soc 1995;43:666–9.10, Curr Med Res Opin 1998.


Probiotic Supplements
S Five RCTs : 377 subjects
S adults (three RCTs, n = 266)

S children (two RCTs, n = 111)

S In adults,
S some organisms favorable effect on defecation frequency and stool consistency.

S In children
S

some organisms showed a beneficial effect.

Systematic review of randomised controlled trials: probiotics for functional constipation. - Chmielewska A - World J Gastroenterol - 7-JAN-2010; 16(1):
69-75 (MEDLINE® is the source for the citation and abstract of this record )
Children: L. casei rhamnosus Lcr35, but not L. rhamnosus GG, Adults: Bifidobacterium lactis DN-173 010, Lactobacillus casei Shirota, and Escherichia coli
Nissle 1917

Magnesium
S HIGH Efficacy (used as bowel prep!) – only caution is renal failure (risk of mag

toxicity) generally above 3 grams a day.
S Milk of magnesia (1-3 tsp QID)
S Antacid activity in low doses: all OH- entering the stomach used to neutralize

stomach acid.
S Laxative effect at high doses: OH- moves past stomach to intestines  attract and
retain water, thereby increasing intestinal movement (peristalsis) and inducing the
urge to defecate
S Mag Citrate (Short Term Use) 120-300mL x 1 or 2
S Mag oxide/citrate pills 400-500mg QD

Stool Softeners
S Docusate (Colace) 250 BID – oral use may take 1-3 days to cause effect, enema works

within 20-60 min
S Emulsifier/emollient: Lowers surface tension of stool (also used as a pesticide and as

oil dispersing agent in oil spills…)

S However…
S Less effective than psyllium
S Likely ineffective in chronically ill elderly
S Not recommended for long-term use/chronic constipation by Up-To-Date or the American College
Gastroenterology Chronic Constipation Taskforce
S Psyllium is superior to docusate sodium for treatment of chronic constipation.
Aliment Pharmacol Ther. 1998;12:491–7

J Pain Symptom Manage. 2000;19:130–6.

Am J Gastro 2005

Stimulant Laxatives
S Increase peristalsis by irritating colon

S Bisacodyl (Correctol®, Dulcolax®)
S Senna (Senokot®, ex-lax)
S Long Term Use can lead to
S dependency “lazy bowel”
S electrolyte disorders (hypo K, Hyper Na)

Per Rectum Medications
S Enemas
S Fleets
S Mineral Oil
S Milk
S Suppositories
S Glycerin
S Commonly used in children. Digital stimulation may be actual mechanism.

S Bisacodyl/Dulcolax
S Stimulant laxative

Other Treatments

S Biofeedback
S

Colchicine

S

Misoprostol

S

Botulinum Toxin Injection

S small number trials positive

S

Zelnorm (is back) 5HT4

S Baby massage

S

Surgery

S Extremely (75%) effective for Pelvic-

Floor Dysfunction and outlet-inertia.
S Massage

S Herbs (lots)

Intestinal Secreatogues
S Lubiprostone (Amitiza)
S Bicyclic fatty acid derivative
S Works on CIC2 Chloride channel activating prostaglandin receptors and CFTR to increase
intestinal fluid
S Dosages
S

24micrograms BID for chronic constipation and 8micrograms BID for IBS-C in women

S Linaclotide (Linzess)
S 14-amino acid peptide homolog to heat-stable endotoxin
S Acts on Guanylyl cyclase C which acts on CFTR to increase intestinal fluid secretion
S Dosages
S

145-micrograms daily in chronic constipation and 290-micrograms daily in IBS-C

S Health is the greatest gift, contentment the greatest wealth, faithfulness the best

relationship
- Buddha

S “The best and most beautiful things in the world cannot be seen nor touched – they

must be felt in the heart”
- Helen Keller


Questions?

James E. Rose, MD

Peak Gastroenterology Associates, P.C.
www.peakgastro.com
719.636.1201


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