Cons%pa%on means having infrequent or hard bowel movements, some6mes with Primary vs.

Secondary:
straining or a feeling that you haven't emp6ed your bowels completely. It's considered • primary (no iden6fiable cause)
chronic if these problems last for three months or more. • secondary (caused by drugs, lifestyle, or medical condi6ons).

Common Causes:
Cons%pa%on • Low fiber diet.
Defini6on of cons6pa6on used in clinical studies: • Inadequate fluid intake.
A Less than 3 stools per week for women and 5 stools per week for men despite a • Decreased physical ac6vity.
high-residue diet, or a period of more than 3 days without a bowel movement; • Use of cons6pa6ng drugs (especially opioids).
B straining at stool greater than 25% of the 6me and/or 2 or fewer stools per week;
or
C straining at defeca6on and less than 1 stool daily with minimal effort.
Disease/Condi%on-Related Causes:
• Gastrointes%nal (GI) Disorders: IBS, diver6culi6s, GI tract diseases, hemorrhoids,
Cons%pa%on anal fissures, tumors, etc.
⁃ is a commonly encountered medical condi6on in for which many pa6ents
ini6ate self-treatment. • Metabolic/Endocrine Disorders: Diabetes mellitus with neuropathy,
⁃ is lack of adequate dietary fiber hypothyroidism, hypercalcemia, etc.
⁃ people have misconcep6ons about normal bowel func6on, and think that daily • Pregnancy.
bowel movements are required for health and well being- lack of daily bowel • Cardiac disorders (e.g., heart failure).
movement = accumula6on of toxic substances/associated with various soma6c
complaints • Neurogenic Cons%pa%on: Head trauma, CNS tumors, spinal cord injury,
⁃ inappropriate use of laxa6ves Parkinson's disease, etc.

Defini6on-Several difficult-to-quan6fy variables: • Psychogenic Causes: Ignoring the urge to defecate, psychiatric diseases.
⁃ Bowel movement frequency-most oRen used to describe cons6pa6on but this is
not well established
⁃ Stool size or consistency
Drug-Induced Cons%pa%on:
⁃ Symptoms as the sensa6on of incomplete defeca6on • Opioid deriva6ves are a significant cause.
• The majority of cases of drug-induced cons6pa6on are caused by opiates, various
agents with an%cholinergic proper%es, and antacids containing aluminum or
calcium.
An interna6onal commiTee defined and classified cons6pa6on on the basis of stool
frequency, consistency, and difficulty of defeca6on.
Opiates – muscle relaxa6on
Func%onal cons%pa%on is defined as two or more of the following complaints present - loperamide – can cause cons6pa6on
for at least 12 months in the absence of laxa6ve use:
⁃ have effects on all segments of the bowel, but effects are most pronounced on
a) straining at least 25% of the 6me;
the colon.
b) lumpy or hard stools at least 25% of the 6me;
⁃ The major mechanism by which opiates produce cons6pa6on has been proposed
c) a feeling of incomplete evacua6on at least 25% of the 6me; or
to be prolonga6on of intes6nal transit 6me by causing spas6c, nonpropulsive
d) two or fewer bowel movements in a week.
contrac6ons.
Rectal outlet delay is defined as anal blockage more than 25% of the 6me and ⁃ An addi6onal contributory mechanism may be an increase in electrolyte
prolonged defeca6on or manual disimpac6on when necessary. absorp6on.
⁃ All opiate deriva6ves are associated with cons6pa6on, but the degree of
intes6nal inhibitory effects seems to differ between agents.
⁃ Orally administered opiates appear to have greater inhibitory effects than
parenterally administered products. Orally administered enkephalins
(endogenous opiate-like polypep6des) are recognized to have an6mo6lity
proper6es.
PATHOPHYSIOLOGY

Pathophysiology
⁃ Cons6pa6on is not a disease, but a symptom of an underlying disease or
problem.
⁃ Treatment: determine its cause
⁃ Disorders of the Gl tract: irritable bowel syndrome or diver6culi6s
⁃ Metabolic disorders: DM
⁃ Endocrine Disorders: Hypothyroidism
⁃ Diet low in fiber or from use of cons6pa6ng drugs such as opiates
⁃ Some6mes be psychogenic in origin
⁃ Problem in elderly:
⁃ Improper diet (§fiber and Iliquids)
⁃ Diminished abdominal wall muscular strength
⁃ Diminished physical ac6vity
 TREATMENT
DESIRED OUTCOME
• A major goal for treatment of cons6pa6on is preven6on of cons6pa6on by altera6on of
lifestyle (par6cularly diet) to prevent further episodes of cons6pa6on. For acute
cons6pa6on, the goal is to relieve symptoms and restore normal bowel func6on.

GENERAL APPROACH
• Comprehensive Pa%ent History:
o Gather informa6on on bowel movement frequency, symptom dura6on,
diet, and current laxa6ve use.

• Address Underlying Causes:

o Treat any iden6fied underlying diseases (e.g., surgical removal of GI
malignancies, correc6on of endocrine/metabolic imbalances).

• Medica%on Review:
o If medica6ons are contribu6ng to cons6pa6on, consider:
§ Alterna6ve medica6ons.
§ Lowering the dosage.
§ If the medica6on can not be changed, focus on preventa6ve
measures.

• Combined Therapy:
o Effec6ve cons6pa6on management involves a combina6on of
nonpharmacologic and pharmacologic approaches.

Drug-Induced Cons%pa%on:
• Iden6fy poten6al drug causes.
• Consider non-cons6pa6ng alterna6ves when available (e.g., for antacids).
• If no alterna6ves exist, consider lowering the dose.
• If the cons6pa6ng medica6on must con6nue, emphasize preventa6ve measures
(dietary modifica6on, bulk-forming agents).

Surgical Interven%on:
• Surgery is necessary in a small percentage of cons6pa6on cases.
• Commonly required for colonic malignancies and GI obstruc6ons.

NONPHARMACOLOGIC THERAPY

Dietary Fiber Increase:

• The cornerstone of therapy is increasing fiber intake.
• Aim for 20-30 grams of fiber daily.| Aim for at least 10g of crude fiber daily.
• Achieve this through dietary changes (fruits, vegetables, cereals) or fiber
supplements.

Trial Period:
• Con6nue dietary modifica6ons for at least one month.
• Expect no6ceable effects on bowel func6on within 3-5 days.

Poten%al Side Effects:

• Abdominal disten6on and flatus may occur, especially in the ini6al weeks,
par6cularly with high bran consump6on.

PHARMACOLOGIC THERAPY

Laxa%ve Classifica%ons (by onset of ac%on):

• 1-3 Days (Fecal SoVening):
o Bulk-forming laxa6ves.
o Docusates.
o Low-dose polyethylene glycol (PEG), sorbitol, and lactulose.

• 6-12 Hours (SoV/Semifluid Stool):

o Bisacodyl.
o Senna.
o Magnesium sulfate.

• 1-6 Hours (Watery Evacua%on):

o Magnesium salts.
o Rectal bisacodyl.
o PEG-electrolyte lavage solu6on.

Other Agents:
• Lubiprostone (calcium channel ac6vator).
• Linaclo6de (guanylate cyclase C agonist).
• Naldemedine.
 RECOMENDATIONS o Most oral or rectal laxa6ves are acceptable.
o For prompt relief:
§ Tap-water enemas.
§ Glycerin suppositories.
§ Milk of magnesia.

DRUGS

•The approach to the treatment of cons6pa6on in infants and children should consider
neurologic, metabolic, or anatomic abnormali%es when cons6pa6on is a persistent
problem. When not related to an underlying disease, the approach to cons6pa6on is
similar to that in an adult. High-fiber diet should be emphasized.

EMOLLIENT LAXATIVES (DOCUSATES)

• Mechanism of Ac%on:
o Surfactant agents that facilitate the mixing of water and fats in the
intes6nes.
o May increase water and electrolyte secre6on.

• Onset of Ac%on:
o Stool soRening occurs within 1-3 days.
Diagnosis and Evalua%on:
• Start with diagnosis: Confirm cons6pa6on is the issue.
• Primary Use:
• Review history and medica%ons: Iden6fy poten6al causes or contribu6ng
o More effec6ve for preven6ng cons6pa6on than trea6ng it.
factors.
o Useful in situa6ons where straining should be avoided (e.g., post-
myocardial infarc6on, perianal disease, rectal surgery).
Ini%al Management:
• Treat underlying causes: Address any iden6fied medical condi6ons contribu6ng
• Limita%ons:
to cons6pa6on.
o Not effec6ve if major underlying causes of cons6pa6on are not
• Dietary changes: Increase fiber intake and consider bulk-forming supplements.
addressed (e.g., opiate use, uncorrected pathology, low fiber intake).
Cons%pa%on Types and Treatments:
• Opioid-induced cons%pa%on: (If cons6pa6on is caused by opioids and lasts over
4 weeks)
o First-line: Osmo6c or s6mulant laxa6ves.
o If no relief: Lubiprostone or opioid receptor antagonists (e.g.,
methylnaltrexone, naloxegol, naldemedine).
• Acute cons%pa%on (less than 3-6 months):
LUBRICANTS (MINERAL OIL)
o Ini%al: Dietary changes (fiber, bulk-forming agents).
Mechanism of Ac%on:
o If no relief: Add osmo6c laxa6ve (e.g., PEG) for 2-4 weeks.
• Coats stool for easier passage.
• Chronic cons%pa%on (more than 6 months):
• Inhibits colonic water absorp6on, increasing stool weight and decreasing transit
o Ini%al: Dietary changes (fiber, bulk-forming agents).
6me.
o If no bowel movement (BM) in 2 days or no relief: Add s6mulant laxa6ve
(e.g., bisacodyl).
Onset of Ac%on:
o If no relief: Trial of intes6nal secretagogue (e.g., lubiprostone,
• Effects typically seen aRer 2-3 days of use.
linaclo6de, plecana6de).
Uses:
• Similar to docusates: to maintain soR stools and avoid straining for short periods
First-Line Therapy:
(a few days to 2 weeks).
• Osmo%c laxa%ves are the preferred ini6al treatment.
• Combine with increased dietary fiber or fiber supplements.
Adverse Effects:
• Systemic absorp6on can cause foreign-body reac6ons in lymphoid 6ssue.
Osmo%c laxa%ves - helps relieve cons6pa6on by increasing the amount of water in your
• Aspira6on risk in debilitated or recumbent pa6ents, leading to lipoid pneumonia.
intes6nes.

This soRens the stool and makes it easier to pass.

Addi%onal Lifestyle Measures:

• Encourage increased daily fluid intake.
• Promote regular physical ac6vity.
• Advise pa6ents to respond promptly to the urge to defecate.
LACTULOSE:
• Mechanism: Disaccharide that creates an osmo6c effect, retaining water in the
Founda%on:
colon.
• Bulk-forming agents combined with dietary modifica6ons to increase fiber intake
• Use: Treats cons6pa6on, but not typically a first-line agent.
are the primary approach.
• Advantages: Can be useful for acute cons6pa6on and elderly pa6ents.
• Disadvantages:
Acute Cons%pa%on (Nonhospitalized):
o Costly.
• Occasional use of laxa6ves is acceptable (less than every few weeks).
o May cause flatulence, cramps, diarrhea, and electrolyte imbalances.
• Start with simple measures:
o Tap-water enemas.
o Glycerin suppositories.
• If simple measures fail, consider:
SORBITOL:
o Oral sorbitol.
• Mechanism: Monosaccharide that also creates an osmo6c effect.
o Low-dose bisacodyl or senna.
• Use: Recommended as a primary agent for func6onal cons6pa6on in cogni6vely
o Saline laxa6ves (e.g., milk of magnesia).
intact pa6ents.
• Advantages:
o As effec6ve as lactulose.
o Much less expensive.

• Prolonged Laxa%ve Use:

o If laxa6ve use is needed for more than one week, a physician should be
consulted to rule out underlying medical causes.
SALINE CATHARTICS
• Chronic Cons%pa%on (Bedridden/Geriatric):
Mechanism:
o Bulk-forming laxa6ves are generally first-line, but more potent laxa6ves
• Contain poorly absorbed ions (magnesium, sulfate, phosphate, citrate).
may be frequently required.
• Work by osmo6c ac6on, retaining fluid in the GI tract.
o Op6ons include milk of magnesia and lactulose.
Administra%on:
• Hospitalized Pa%ents (Non-GI Disease):
• Oral or rectal.
o Cons6pa6on is oRen due to general anesthesia and/or opiates.
Onset of Ac%on:
• Oral: Bowel movement within a few hours. how to give sup
• Rectal: Bowel movement within 1 hour or less.
First, wash your hands thoroughly. Then, posi6on the person comfortably: on their side
Uses: with knees bent for rectal inser6on, or on their back with knees bent for vaginal inser6on.
• Acute bowel evacua6on (before diagnos6c exams, aRer poisonings, with Unwrap the suppository and lubricate the 6p with a water-soluble lubricant if needed.
anthelmin6cs). Gently insert the suppository into the rectum or vagina, pointed end first, to the
• Occasional use (every few weeks) for cons6pa6on in healthy adults (e.g., milk of appropriate depth. Hold the buTocks together briefly for rectal administra6on, or remain
magnesia). s6ll for vaginal administra6on, to prevent it from coming out. Finally, wash your hands
• Fecal impac6ons (enema formula6ons). again.

Limita%ons:
• Not for rou6ne cons6pa6on treatment.

CASTER OIL
Mechanism:
• Metabolized to ricinoleic acid in the GI tract.
• Ricinoleic acid s6mulates secretory processes.
• Decreases glucose absorp6on.
• Promotes intes6nal mo6lity, primarily in the small intes6ne.

Onset of Ac%on:
• Bowel movement within 1 to 3 hours.

Use:
• Not for rou6ne cons6pa6on treatment due to its strong purga6ve effect.

GLYCERIN
- sup for baby
Administra%on:
o Usually a 3-g suppository.
• Mechanism:
o Osmo6c ac6on in the rectum.

• Onset of Ac%on:
o Less than 30 minutes.

• Safety:
o Considered a safe laxa6ve.
o May occasionally cause rectal irrita6on.1

• Use:
o IntermiTent basis for cons6pa6on.
o Par6cularly acceptable for use in children.

POLYETHYLENE GLYCOL-ELECTROLYTE LAVAGE SOLUTION

Use:
• Whole-bowel irriga6on for colon cleansing before diagnos6c procedures or
colorectal opera6ons.
Administra%on:
• Four liters administered over 3 hours.
Effect:
• Complete evacua6on of the GI tract.
Limita%ons:
• Not recommended for rou6ne cons6pa6on treatment.
• Should be avoided in pa6ents with intes6nal obstruc6on.

LUBIPROSTONE:
• Mechanism: Chloride channel ac6vator, acts locally on the gut.
• Effects: Accelerates GI transit 6me, delays gastric emptying.
• Use: Chronic idiopathic cons6pa6on in adults.
• Dosage: 24 mg capsule twice daily with food.
• Side Effects: Headache, diarrhea, nausea.

Other Agents:
• Tap-Water Enemas:
o Use: Simple cons6pa6on.
o Administra6on: 200 mL water by enema (adults).
o Onset: Bowel movement within 1.5 hours.

• Soapsuds Enemas:
o Not recommended.
o May cause proc66s or coli6s.