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Case 8
by
Chitchai
Pumchandh
Medical History
 Female
90 kg.
 Complained
of abdominal pain and
constipation after their town fiesta
where she consumed mostly met
viands.
1 How do you manage constipation ?
2 What are the different group of laxatives ?
3 Give the mechanism of action and
therapeutic indication ?
The presentation will cover the following topics :

General survey of constipation.
– Sign and symptoms.
– Causes
– Risk factors



Treatment (for the answer of question no.1).
Different group of laxative (for the answer of
question no.2).
Mechanism of action and therapeutic indication
(for the answer of question no.3).
Constipation
 Constipation
is defined as having a
bowel movement fewer than three times
per week.
 With
constipation, stools are usually
hard, dry, small in size, and difficult to
eliminate.
 Some
people who are constipated find it
painful to have a bowel movement and
often experience straining, bloating, and
the sensation of a full bowel.
Signs and symptoms
Not having a bowel movement every day doesn't
necessarily mean you are constipated.
 You are likely constipated, however, if you :

–Pass a hard stool fewer than three times a week
–Strain frequently during bowel movements
–Have abdominal bloating or discomfort
Causes

Normally, the waste products
of digestion are propelled
through your intestines by
muscle contractions.

In the large intestine, most of
the water and salt in this
mixture is reabsorbed because
they are essential for many of
your body's functions.

If too much water is absorbed
or if the waste moves too
slowly, you may become
constipated.
Risk factors
Common causes of constipation are :











not enough fiber in the diet
lack of physical activity (especially in the elderly)
medications
irritable bowel syndrome
changes in life or routine such as pregnancy, aging, and travel
abuse of laxatives
ignoring the urge to have a bowel movement
dehydration
specific diseases or conditions, such as stroke (most common)
problems with the colon and rectum
problems with intestinal function (chronic idiopathic
constipation)
Medications
Some medications can cause constipation, including
 pain
medications (especially narcotics)
 antacids that contain aluminum and calcium
 blood pressure medications (calcium channel
blockers)
 antiparkinson drugs
 antispasmodics
 antidepressants
 iron supplements
 diuretics
 anticonvulsants
Specific Diseases
 Diseases
that cause constipation include
neurological disorders, metabolic and
endocrine disorders, and systemic
conditions that affect organ systems.
 These
disorders can slow the movement
of stool through the colon, rectum, or
anus.
Conditions that can cause constipation are found below :

Neurological
disorders
– multiple sclerosis
– Parkinson's disease
– chronic idiopathic
intestinal pseudoobstruction
– stroke
– spinal cord injuries

Metabolic and
endocrine conditions
–
–
–
–
–
diabetes
uremia
hypercalcemia
poor glycemic control
hypothyroidism
• Systemic disorders
- amyloidosis
- lupus
- scleroderma
How do you manage
constipation ?
Treatment

From the medical history and physical
examination, it can be concluded that :
– This lady is overweight and obese due to the
eating- oriented habit.
– The abdominal pain and a subsequent constipation
are apparently originated from the diet, that
contains less fiber. That results in the impaction of
the waste material in the intestine and the rectum.
– In reality, the obese individuals are prone to have
the bowel movement problem more than the
normal one.
– Since the patient manifests the abdominal pain, an
immediate administration of medication would be
needed in order to relieve the pain.
Treatment (Cont’)
– For immediate effect, a kind of laxative or stool softener, such
as mineral oil can be prescribed by mouth and enema to soften
the fecal impaction.
– Or another alternative is to prescribed a stimulant laxative like
Dulcolax, Correctol, which will induce the bowel movement.
This is a short-term management.
– Never use stool softeners on a regular basis because they can
cause other problem. Mineral oil may interfere with the
absorption of the fat-soluble vitamins and can cause a serious
from the pneumonia if it is accidentally inhaled into your lung.
– For long-term treatment, the patient should try to eat lots of
high-fiber foods, such as fruits, vegetables and whole grains.
– Drink plenty of fluid and get as much exercise as you can,
swimming and walking are good choices.
What are the different group of
laxatives ?
Laxative may be classified by their major
mechanism of action :
1.
2.
Bulk-forming laxatives.
–
Indigestible, hydrophilic colloids that absorb water,
foaming a bulky emollient gel that distend the colon and
promote peristalsis.
–
Natural plant products : Psyllium, Methyl cellulose, bran
synthetic fiber : Polycarbophil.
Stool softeners.
–
these agents soften stool material, permitting water and
lipid to penetrate, they may be administrated orally or
rectally.
–
For example :- Docusate ( oral or enema )
- Glycerine (suppository)
- Mineral oil ( lubricating the fecal
material, retarding water
absorption from the
stool.)
3. Osmosis laxatives.
–
–
Osmotic laxatives are soluble but no absorbable
compounds that result in increase stool liquidity
due to an obligate increase in fecal fluid.
For example :
- Magnesium oxide ( or milk of
magnesia)
- Sorbitol and lactulose
- Magnesium citrate
- Sodium phosphate
- Polyethylene glycol
4. Stimulant laxatives.
–
–
Stimulant laxatives (Cathartic) induce bowel
movement
For example : - Anthraquinone dervatives.
in
from
Ex. Aloe, Senna, Cassara ( all natural
plants).
- Diphenylmethane derivatives.
Ex. Phenolphalein ( recently removed
the market)
- Oastol oil.
Give the mechanism of action and
therapeutic indication.
Bulk-forming laxative
 Mechanism of action
– These agents are polysaccharide polymers that are
not broken down by the normal processes of
digestion in the upper part of the gastrointestinal tract.
– They have capacity to retain water in the gut lumen
and so increase the softness and promote peristalsis.
– They take several days to work but there is no serious
undesirable effect.
 Therapeutic indications
- Bulk-forming laxatives are considered the safest for
long-term use, but they can interfere with the absorption
of some medicines.
Bulk-forming laxative (Cont’)
– These agents must be taken with excessive water or they
can cause the obstruction.
– Bacterial digestion of plant fibers within the colon may lead
to increasing bloating and flatus.
– Brand names include Metamucil, Fiberall, Citrucel, Konsyl
and Serutan.
Stool softeners
 Mechanism of action :
– Stool softener or Docusate sodium is a surface-active
compound that acts in the gastrointestinal tract in a manner
similar to a detergent and produced soft fecal material. It is
also a weak stimulant laxative.
– They will moisten the stool and prevent the stool from
dehydration.
 Therapeutic indication :
– These laxatives are often recommended for people who
should avoid straining in order to pass a bowel movement.
Stool softeners (Cont’)
 They are also recommended to patients who are recovering
from abdominal, pelvic or rectal surgery, childbirth, a heartattack and patients with severe high blood pressure or
abdominal hernias.
 The prolonged use of this class of drug may result in an
electrolyte imbalance.
 Brand names include Colace, Surfak.
Osmotic laxatives
 Mechanism of action :
– There osmotic laxatives maintain an increased
volume of fluid in the lumen of the bowel by
osmosis, which accelerates the transfer of the gut
contents thought the small intestine and results in
an abnormally large volume entering the colon.
– This leads to distension and purgation about an
hour later.
Osmotic laxatives (Cont’)
 Therapeutic indication :
– This class of drugs is useful for people with idiopathic
constipation.
– People with diabetes should be monitored for electrolyte
imbalances.
– The main salts in use are magnesium sulfate and
magnesium hydroxide. The amount of magnesium absorbed
after an oral dose is usually too small to have adverse
systemic effects, but there salts should be avoid in small
children and in patients with poor renal function in whom
they can cause heart block, neuromuscular block or CNS
depression.
– Brand name include Cephulac, Sorbitol, Miralax.
Stimulant laxatives
 Mechanism of action :
– Stimulant laxative are also known as cathartics.
– They influence a direct stimulation of the enteric
nervous system and colonic electrolyte and fluid
secretion.
– They cause also rhythmic contraction in the
intestines
Stimulant laxatives (Cont’)
 Therapeutic indication
– There has been concern that long-term use of
cathartics could lead to dependency and
destruction of the myenteric plexus, resulting in
colonic atony and dilation.
– More recent research suggests that long-term use
of these agents probably is safe in most patients,
especially for those who are neurologically impaired
and in bed-ridden patient in long-term care facilities.
Stimulant laxatives (Cont’)
 The food and drug administration has proposed
a ban on all over-the-counter products
containing phenolphthaein due to a possible
also of cancer, they were recently removed
from the market.
 Brand name include Dulcolax, Purge and
Senokot
Points to Remember
 Constipation affects almost everyone at one time or another.
 Many people think they are constipated when, in fact, their
bowel movements are regular.
 The most common causes of constipation are poor diet and
lack of exercise.
 Other causes of constipation include medications, irritable
bowel syndrome, abuse of laxatives, and specific diseases.
 A medical history and physical exam may be the only
diagnostic tests needed before the doctor suggests treatment.
 In most cases, following these simple tips will help relieve
symptoms and prevent recurrence of constipation:
– Eat a well-balanced, high-fiber diet that includes beans,
bran, whole grains, fresh fruits, and vegetables.
– Drink plenty of liquids.
– Exercise regularly.
– Set aside time after breakfast or dinner for undisturbed
visits to the toilet.
– Do not ignore the urge to have a bowel movement.
– Understand that normal bowel habits vary.
– Whenever a significant or prolonged change in bowel
habits occurs, check with a doctor.
 Most people with mild constipation do not need laxatives.
However, a doctor may recommend laxatives for a limited
time for people with chronic constipation.