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Constipation & Diarrhoea

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Constipation affects twice as many women as

men.

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.

The following factors can increase a person’s likelihood of becoming constipated; however, these do not need to be present for constipation to occur:

Female gender - Pregnancy

Over 65 years of age

Low caloric intake (eating less food)

Greater number of medications used

Sedentary lifestyle (lack of exercise)

Ignoring the urge to defecate

Smoking – Tobacco addiction

• 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

Two approaches to consider:

Non-drug Approach

Drug Approach

A) Acute – functional Constipation

B) Chronic – Organic Constipation

A) Acute – functional Constipation

- -Dehydration

- -Acute illness

- -Sedentary Life style

- -Lack of dietary fibers

- -Acute intestinal Obstruction

B) Chronic – Organic Constipation

Endocrine disorder

Psychiatric disorder

Drug Induces

Anorectal disorder

Pelvic disorder

Metabolic disorder

Drug Measures:

Purgatives / Cathartics / Aperients / Evacuant /

Laxatives

Laxatives / Aperients – milder in action, elimination of

soft & formed stool.

Purgatives / Cathartics -Stronger in action,

evacuation of more fluids.

Many drugs act in low concentration as laxatives &

in high concentration as purgatives.

There are many different types of drugs that can

be used for constipation:

1) Bulk-forming Agents

2) Stool Softeners

3) Osmotics

4) Stimulants

1) Bulk-Forming Agents:

Are the drug of choice for prevention; not for

immediate relief.

Dietary fibers

Bran

Ispaghula husk (seeds of Plantago ovata)

Methyl cellulose

2) Stool Softeners

Docusate (DOSS) – Di Octyl Sodium

Sulfosuccinate

Liquid Paraffin

Eg – Cremmafin (Liq Paraffin + Mag

sulphate)

3) Osmotics:Magnesium salts (Hydroxide & Sulphate)

Sodium salts (Sulphate & Phospahte)

Sod. Pot. Tartrate

Lactulose

Eg - Milk of Magnesia

4) Stimulants:

A) Diphenyl Methanes

Phenolphthalin

Bisacodyl

Sod. Picosulfate

B) Anthraquinones (glycosides)

Seena (Cassia)

Cascara sargada

C) 5-HT4 agonist – Tegaserod

D) Fixed oil – Castor Oil emulsion

-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).

Constipation is very common in the elderly

and nursing home residents.

There are many causes of constipation; it

should be considered a symptom, not a

disease.

There are many options for prevention and

treatment. The choice should be tailored to

each individual person.

Talk to your health care provider if you have

any concerns or if constipation lasts for

longer than one week.

-Increase in frequency, size or loosening of

bowel movements.

-Differentiate from fecal incontinence or

functional bowel disease- normal stool weight

Increased active anion secretion

Decreased absorption of water and

electrolytes

Transmissible agents

Noninfectious - abnormal mucosa

Inflammatory Bowel disease

Celiac disease, microscopic colitis, eosinophilic

and allergic gastroenteritis, radiation enteritis

Noninfectious - normal mucosa

Osmotic diarrhea

Mal-absorption

Mostly feco-oral route

Bacterial

Viral

Parasitic

Watery

Enterotoxigenic-

Vibrio cholera

Enterotoxigenic E.coli

Food borne toxins-

Bacillus cereus

Clostridium perfringens

Mycobacterium avium-intracellular complex

Bloody

Invasive

Campylobacter jejuni

Destructive

Shigella

Enteropathogenic E.coli

Clostridium difficile

Rotavirus Children less than 2 years

Most common cause of diarrhea in children all over the world

Norwalk Older children and adults

These viruses injure the small intestinal mucosa

Watery diarrhea

CMV Immunocompromised

Protozoa Giardia lamblia

Entamoeba histolytica

Cryptosporidium

Helminths Ascaris lumbricoides

Ancylostoma

Strongyloides stercoralis

Trichinella spiralis

Capillaria philippensis

Is it truly diarrhea?

Duration-

acute <3 weeks

Chronic >4 weeks

Texture

Frequency

Blood?

Chronic diarrhea Malnutrition

Weight loss

Muscle wasting

Tetany

Oral and skin lesions

Peripheral neuropathy

Ataxia

Edema

Stool culture

Positive in only 40 to 60%

Stool for ova and parasites

Stool for Clostridium difficile toxin

Stool Sudan test for fat

Stool Electrolytes-differentiates secretory

diarrhea from osmotic diarrhea

Stool pH-<7 indicates carbohydrate

malabsorption

Fluid therapy Persons with moderate to severe diarrhea lose large

amounts of Na, CL, K, HCO3 & H20

Pre renal azotemia, hypokalemia, metabolic acidosis

ORS

IV Fluids

Saline solution (water plus Na+) by mouth

- no beneficial effect

Na+ absorption is impaired in the diarrhoeal

state

if the Na+ is not absorbed water cannot be

absorbed.

Excess Na+ in the lumen of the intestine causes

increased secretion of water and the diarrhoea

worsens.

Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism. This occurs in a 1:1 ratio, one molecule of glucose co-transporting one sodium ion (Na+).

Starch –

metabolized in the intestine to glucose and

therefore it has the same properties of

enhancing sodium absorption

less osmotic effect in the lumen of the intestine.

Citrate, a base precursor, corrects acidosis

and enhances the absorption of water and

electrolytes

First developed in the early 1950’s and was formulated to mirror ions lost in stool.

In the early 1960’s the mechanism by which ORT works, the coupled transport of sodium and glucose, was discovered.6

In 1971, the efficacy of ORT demonstrated during an epidemic of cholera in a refugee camp in Bangladesh. ORT reduced the death rate from more than

50% to only 5%.7 By the early 1970’s a consensus was reached about the effectiveness of ORT.

Sodium Chloride - 2.6gm -3.5

gm

Potassium Chloride- 1.5 gm -1.5gm

Tri Sod Citrate- 2.9 gm -2.9gm

Glucose 13.5 gm -

20gm

Must contain Potassium and a base

Ringer’s lactate

Zn and Magnesium replacement

Should be avoided

Concern for promoting bacterial invasion or

prolonging the infection

Thank You!