Management of Constipation in Adults Stephen Aglubat, MD May 2012

Objectives Define Constipation Define Constipation Treatment options for constipation Treatment options for constipation

Case 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? A. Lactulose A. Lactulose B. Senna B. Senna C. Docusate C. Docusate D. Weekly tap water enemas D. Weekly tap water enemas

Definition Rome III criteria: 2 of the below defines constipation Rome III criteria: 2 of the below defines constipation Straining Straining Lumpy Hard Stools Lumpy Hard Stools Incomplete Evacuation Incomplete Evacuation Use of Digital Rectal Maneuvers Use of Digital Rectal Maneuvers Sensation of Anorectal Blockage Sensation of Anorectal Blockage < 3 Bowel Movements per week < 3 Bowel Movements per week

Pathophysiology I Constipation is caused by: Constipation is caused by: Primary Colorectal dysfunction Primary Colorectal dysfunction Slow Transit Slow Transit Dyssnerygic Defacation Dyssnerygic Defacation Irritable Bowel Syndrome Irritable Bowel Syndrome

Pathophysiology II Constipation is caused by: Constipation is caused by: Secondary Causes Secondary Causes Endocrine/Metabolic Endocrine/Metabolic Neurologic Neurologic Myogenic Disorders Myogenic Disorders Medications Medications Obstruction Obstruction Chronic Idiopathic Constipation (CIC) Chronic Idiopathic Constipation (CIC)

Management Initial treatment of Chronic Functional Constipation Initial treatment of Chronic Functional Constipation Lifestyle modification Lifestyle modification Diet and fiber Diet and fiber

Lifestyle Modifications Increased fluid intake Increased fluid intake Exercise Exercise Establish regular bowel regimen pattern Establish regular bowel regimen pattern

Diet and fiber Fiber increases bulk/distension Fiber increases bulk/distension Distention causes stool propulsion. Distention causes stool propulsion. >25 g of fiber/day >25 g of fiber/day Effect may take weeks. Effect may take weeks. Adverse effects: Bloating, flatulence Adverse effects: Bloating, flatulence

Laxatives I Stimulant Laxatives Stimulant Laxatives Senna Senna Bisacodyl Bisacodyl

Laxatives II Bulk forming laxatives Bulk forming laxatives Psyllium (Metamucil) Psyllium (Metamucil) Methylcellulose (Citrucel) Methylcellulose (Citrucel) Polycarbophil (FiberCon) Polycarbophil (FiberCon) Dextran (Benefiber) Dextran (Benefiber)

Laxatives III Osmotic Laxatives Osmotic Laxatives Polyethylene glycol Polyethylene glycol Lactulose Lactulose Sorbitol Sorbitol Magnesium Hydroxide Magnesium Hydroxide

Other therapies Colonic secretagogues Colonic secretagogues Lubipristone Lubipristone

Summary Constipation in the older adult may be due to chronic constipation, secondary etiologic factors Constipation in the older adult may be due to chronic constipation, secondary etiologic factors A thorough history must be obtained to rule out secondary causes. A thorough history must be obtained to rule out secondary causes. Therapy includes: Therapy includes: Diet/lifestyle Diet/lifestyle Stimulant Laxatives Stimulant Laxatives Osmotic Laxatives Osmotic Laxatives

Case 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? A. Lactulose A. Lactulose B. Senna B. Senna C. Docusate C. Docusate D. Weekly tap water enemas D. Weekly tap water enemas

Case 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? 76 year old female with PMHx of HTN, DMII, HLD, presents to the clinic. She’s complaining of having stools only twice a week, and feeling “full.” She’s eating more vegetables, started drinking more water, and she recently included Metamucil to her diet. Her last colonoscopy one year ago was clean. She comes to your office to be evaluated for her constipation. What would you offer her for the constipation? A. Lactulose A. Lactulose B. Senna B. Senna C. Docusate C. Docusate D. Weekly tap water enemas D. Weekly tap water enemas

References 1. Management of chronic constipation in older adults. Wald, Arthur. Uptodate.com. March Management of chronic constipation in older adults. Wald, Arthur. Uptodate.com. March 2012