Constipation & Diarrhea

Dr Gaurav Gupta

BRISTOL STOOL CHART

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Am College of Gastroenterology …

Unsatisfactory defecation, characterized by infrequent stools and/or difficult stool passage

Brandt 2005

DEFINE CONSTIPATION

What is constipation?• Constipation is generally defined as infrequent

and/or unsatisfactory defecation fewer than 3 times per week.

• Patients may define constipation as passing hard stools or straining, incomplete or painful defecation.

• Constipation is a symptom, NOT a disease.

• Constipation has many causes and may be a sign of undiagnosed disease.

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Normal Colonic Transit Time

• A meal reaches the ileo-cecal valve in 4 hours…the sigmoid colon 12hours later… then slows to the anus.

• Plastic pellets with a meal → 70% recovered in 3 days; remainder in a week!

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Most with primary constipation suffer from which one of the following?

1. Slow colonic transit time2. Pelvic floor/anal sphincter dysfunction3. Functional – normal transit time and

sphincter function

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Most with primary constipation suffer from which one of the following?

1. Slow colonic transit time2. Pelvic floor/anal sphincter dysfunction3. Functional – normal transit time and

sphincter function

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Secondary Constipation

• Endocrine dysfunction (DM, hypothyroid)• Metabolic disorder (↑ Ca,↓ K)• Mechanical (obstruction, rectocele)• Pregnancy• Neurologic disorders (Hirschsprung’s,

multiple sclerosis, spinal cord injuries)

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At risk of constipation

• ↓ fiber :(most common)• ↓ liquid ( 8 glasses/d is needed for constipated)• ↓ Exercise : bedridden, coma• Ignoring urge to defecate• Systemic: Hypothyroidism, DM, Uremia,

pregnancy, hypercalcemia, Hypokalemia• Neurological: Stroke, Parkinsonism, Multiple

sclerosis

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Medicines causing of constipation

Opiate, Anticholinergics, Al(OH)3 Iron, cholestyramine, Antihypertensive drugs (CCBs, diuretics), relaxants, chronic use of laxatives, Antiepileptics, progestrone

Prevention of constipation

• High fibre diet • Minimum fluid consumption of 1500mL daily• Regular, private toilet routine• Heed the urge to defecate• Use of a laxative if using constipating medication

or in presence of diseases associated with constipation

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Diagnosis• Good history is enough for most cases

(Duration, frequency, Consistency, blood in the stool, weight loss, Diet, Exercise, Toilet habits, Laxative use (what), other drugs)

Am Gastroenterological Assn (AGA) guidelines:• CBC, Glucose, TSH, calcium, creatinine• Sigmoid/colonoscopy if red flags are present.

I’m constipated, now what?

• Two approaches to consider:

• Non-drug Approach• Drug Approach

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Treatment – Behavioral • Toileting program to take advantage of

natural reflexes• Obey the urge

– Gastro-colic– Defecation reflex

I’m constipated, now what?

• Non-Drug Measures:

– Have a regular bowel regimen: patients should attempt to have a bowel movement at the same time each day especially after breakfast since colonic activity is highest at that time.

– Don’t spend prolonged periods of time at the toilet. Placing a footstool in front of the toilet helps elevate the thighs, thus placing the pelvis in the optimum position for defecation.

– Consume a high fibre diet: the target is 25-28g of fibre daily – Eat more fruits: apples, pears, and prunes contain the natural

laxative sorbitol– Exercise: inactivity is associated with constipation– Weight loss: want BMI to be between 18.5-24.9

I’m constipated, now what?

• Drug Measures:

– There are many different types of drugs that can be used for constipation:

• Bulk-forming Agents• Emollients/Stool Softeners• Osmotics• Stimulants

I’m constipated, now what?

• Bulk-Forming Agents:– Examples: Metamucil, Benefiber, FiberSure– Are considered the safest agents and are suitable for long-

term use– Each dose of a bulk-forming laxative should be administered

with a full glass of water or juice– Do not use if patient is dehydrated or fluid restricted– Are the drug of choice for prevention; not for immediate relief

I’m constipated, now what?

• Emollients/Stool Softeners– Example: Docusate– Used for prevention; not for immediate relief– Used very often but lack of data showing it actually works– Company says that this product “makes it easier to go”

I’m constipated, now what?• Osmotics:

– Examples: Glycerin Suppositories, Lactulose Syrup, Lax-a-Day (PEG 3350), Milk of Magnesia

– PEG produces the loosest stool and overall greatest efficacy compared to other members in this class. Daily use of PEG is safe and does not have significant side effects. May take 2-4 days to see an effect. This is the drug of choice in almost all situations!

– Lactulose is very safe to use long term. May see increase in gas and bloating compared to other options. Takes 1-2 days to work.

– Glycerin suppositories have a quicker onset of action (usually 30-60 minutes). They are less effective if the stool is dry and hard.

I’m constipated, now what?

• Stimulants:– Examples: Senokot, Dulcolax (bisacodyl)– This group produces rhythmic muscle contractions in the

intestines and may be recommended if osmotic laxatives fail or are not tolerated.

– Are usually given at bedtime and they usually provide overnight relief (work within 8-12 hours).

Practical management of Constipation

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Address Immediate Concerns

• Bloating/discomfort/straining – Osmotic agent like PEG

• Post-op, childbirth, hemorrhoids, fissures– Stool softener to make defecation easier

• Stimulants and suppositories acutely• Manual disimpaction as needed

then approach the chronic condition….

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Start with Lifestyle Changes …• Exercise, increase fluids and fiber to 25

grams/day over a period of 6 weeks.* – Fiber must be accompanied by sufficient fluid– Initial approach – fruits and vegetables– Add commercial bulking agents

• Obey the ‘Urge’!• For children trial of rice vs cow’s milk

* Uncontrolled studies support fiber for normal transient constipation. Am J Gastroenterol. 1999; G Nutr 4/2010

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If No Improvement…

• Add osmotic laxative – adjust dose slowly until stools are soft – take several days to work– caution if CHF or renal insufficiency

• Add stimulant laxatives

Diarrhea

What is Diarrhea?

Classification as per duration

Causes of Acute Diarrhea

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Desired outcome

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Antimicrobial agentsType of diarrhea Antimicrobial agentCholera Tetracycline,

Doxycycline,Ciprofloxacine

Shigellosis Pivmecillinam(Selexid), Nalidixicacid, Ciprofloxacin,Ceftriaxone

Amebiasis Metronidazole

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Chronic diarrhea

• Lasts longer than 4 weeks • Reasons can be: stress, food intolerance (e.g.

lactose intolerance), disorders of pancreas/liver/gallbladder, chronic intestinal infections (Morbus Crohn, Colitis ulcerosa), bowel cancer

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Complications

• Loss of water: dehydration (dizzyness, unconsciousness)

• Loss of electrolytes: cramps• In severe cases both can lead to death

Quiz

Quiz

What are the 4 types of diarrhea?

Quiz

What are the 4 types of diarrhea?• Secretory, • osmotic, • exudative (inflammatory), • and altered intestinal transit (Dysmotile)

What are the characteristics of Secretory Diarrhea?

What are the characteristics of Secretory Diarrhea?Watery, large volume outputs, that are typically painless, persist with fasting,

Causes of Secretory diarrhea?• Stimulant laxatives; • bowel resection, disease, or fistula, • hormone-producing tumors (carcinoid,

pancreatic, medullary cancer of the thyroid),• Addison's dx

• How to clinically differentiate osmotic / secretory diarrhea?

How to clinically differentiate osmotic / secretory diarrhea?• Fasting

Some agents that cause osmotic diarrhea?

Some agents that cause osmotic diarrhea?• Osmotic laxatives (Mg2+); • lactase deficiencies; • nonabsorbable carbohydrates (sorbitol, lactulose,

polyethylene glycol); • intraluminal maldigestion (pancreatic exocrine

insufficiency, bariatric surgery, liver disease);• mucosal mal-absorption (celiac sprue, ischemia of

colon, whipple's disease)

• What symptoms accompanies exudative (inflammatory diarrhea)?

What symptoms accompanies exudative (inflammatory diarrhea)?• pain, fever, bleeding, or other manifestations

of inflammation

What are characteristics of dysmotile diarrhea?

What are characteristics of dysmotile diarrhea?• Diarrheal pattern is rapid, small, coupling

burst of waves, see this a lot with IBS.

What are some causative agents of dysmotile diarrhea?

What are some causative agents of dysmotile diarrhea?• IBS; • Hyperthyroidism; • Intestinal resection, bypass surgery;• Prokinetic agents such as metoclopramide or

prostaglandins; • Diabetic diarrhea (may be accompanied by

peripheral and generalized autonomic neuropathies)

How does the American Gastroenterology Association (AGA) defines functional constipation?

How does the American Gastroenterology Association (AGA) defines functional constipation?• difficult, infrequent, or seemingly incomplete

defecation

Complications of constipation?

Complications of constipation?• Hemorrhoids• anal fissures• rectal prolapse• fecal impaction