Because laxative products are both widely used and abused, clinicians can provide a valuable service by educating patients about the appropriate use of laxatives. Proper education about laxative products and wise advice on product selection and use are particularly crucial for children and older patients. Before recommending a laxative product, the clinician should first discuss the nondrug measures for treating constipation. Pregnant women and children, especially, should be counseled on proper diet, ade- quate fluid intake, and reasonable exercise. Individuals may not understand the importance of these factors in the development of constipation and how simple lifestyle changes can restore relatively normal bowel function without laxative use. If a laxative is needed, the health care provider should explain why a particular type of laxative is appropriate for the present situation, how to use the laxative, when to expect to see results, what adverse effects could occur, and what precautions to take. The box Patient Education for Constipation lists specific information to provide patients. Patient  Read more [...]

Laxative products are available in a wide array of dosage forms, most of them for oral use. This variety probably yields the most benefits for pediatric and geriatric patients. Many of the dosage forms enhance patient acceptability and perhaps make laxative use more pleasant. However, laxatives available as chewing gum, wafers, effervescent granules, and chocolate tablets may not be thought of as drug products; therefore, they are more likely to be misused and abused. Enemas and suppositories are popular nonoral dosage forms used for laxative administration. Routine use oflaxative enemas includes preparing patients for surgery, child delivery, and gastrointestinal radiologic or endoscopic examinations, as well as for treating certain cases of constipation. The enema fluid determines the mechanism by which evacuation is produced. Tap water and normal saline create hulk through an osmotic volume effect; vegetable oils lubricate, soften, and facilitate the passage of hardened fecal matter: and the irritant action of soapsuds produces defecation. However, prolonged rectal irritation may occur after Read more [...]

Children A number of factors can alter a child's bowel habits, including unavailable toilet facilities; emotional distress; febrile illness: chronic medical conditions (e.g., cystic fibrosis and hypothyroidism); family conflict: dietary changes (e.g.. switching from human to cow's milk); or a change in daily routine or environment. Some children are poor or picky eaters, which may contribute to the development of constipation due to inadequate bulk and fluids in the diet. Constipation associated with an organic or pathologic etiology is uncommon in children." Bowel movement patterns vary widely in children; therefore constipation can be a complex problem that is often difficult to detect and manage. Selected Laxative Products Trade Name Primary Ingredients Bulk-Forming Laxatives Citrucel Powder Methylcellulose 2 g/tsp Citrucel Sugar Free Powder Methylcellulose 2 g/tsp FiberCon Tablets Calcium polycarbophil 625 mg Maltsupex Liquid Barley malt extract 750 mg/tsp Metamucil Fiber Wafer Psyllium hydrophilic mucilloid 3.4 g/2 wafers Metamucil Read more [...]

The ideal laxative would (1) be nonirritating and nontoxic, (2) act on only the descending and sigmoid colon, and (3) produce a normally formed stool within a few hours, after which its action would cease and normal bowel activity would resume. Because no currently available laxative precisely meets these criteria, proper selection of a laxative depends on the etiology of the constipation. Agents used to treat constipation have been classified according to their chemical structure and site, intensity, or mechanism of action. The most meaningful classification is by mechanism of action, including bulk-forming, emollient, lubricant, saline, hyperosmotic and stimulant agents. None of these laxative agents should be taken for more than 1 week without consulting a primary care provider. Bulk-Forming Agents Most bulk-forming laxatives are derived from natural sources such as agar. plantago (psyllium) seed, kelp (alginates) and plant gums (e.g.. tragacanth, chondrus, karaya [Sterculia]). Guar gum is a natural product found in the bean cluster plant (Cyamopsis tetragonolobus); it is most useful today Read more [...]

The patient should attempt nondrug measures initially to relieve constipation and help prevent recurrences. Constipation associated with an underlying medical condition or use of medications should be referred to a primary care provider to evaluate the need for further medical treatment or to adjust therapy of constipating medications. At a minimum, successful therapy for constipation should return the patient to the preconstipation frequency, consistency, and quantity of stool. Pharmacotherapy should restore usual function using the lowest effective dosage without producing adverse effects. Treatment Goals The primary goals of treatment are to (1) relieve constipation and reestablish normal bowel function, (2) establish dietary and exercise habits that aid in preventing recurrences, (3) promote the safe and effective use of laxative products, and (4) avoid the overuse of laxative products. General Treatment Approach In general, constipation should be initially managed by adjusting the diet to include foods high in fiber and increasing fluid intake, accompanied by some form of exercise. Pharmacologic Read more [...]

If frequency of bowel movements decreases or difficult passage of hard stools occurs, other symptoms of varying degrees of severity may develop, including anorexia, dull headache, lassitude, low back pain, abdominal discomfort, and abdominal distention The frequency of bowel movements in humans is quite variable but generally ranges from three times a day to three times a week. Persons in the latter category can be symptom-free and do not have any specific abnormality related to their individual pattern of defecation. Therefore, constipation cannot be defined solely in terms of the number of bowel movements in any given period. Regularity is what is "regular" or typical for the individual who experiences none of the classic symptoms of constipation. In some instances, self-care is inappropriate and medical referral is necessary, including all situations typified by so-called red flagoralann symptoms: (1) sudden changes in stool, (2) recent weight loss, (3) presence of abdominal pain, (4) blood in the stool, (5) fever, (6) anorexia, (7) nausea and vomiting. Other factors suggesting more than Read more [...]

Causes of constipation are numerous and include various medical conditions and medications; psychological and physiologic conditions (e.g., menopause or dehydration); and lifestyle characteristics. Some population groups are more susceptible to developing constipation as a result of one or more of the defined causes. Two distinct disorders of colorectal motility are characterized by constipation: slow-transit constipation (slower than normal movement of fecal contents) and pelvic floor dysfunction (storage of fecal contents for prolonged time in the rectum). Constipation of recent onset suggests a possible disease-related or drug-induced cause. If a disease is the underlying cause, referral for proper diagnosis and medical treatment will be necessary. Painful lesions of the anal canal such as ulcers, fissures, and thrombosed hemorrhoidal veins can lead to constipation if patients suppress defecation to avoid pain. Pain from various causes, including gallbladder disease, appendicitis, and regional ileitis, may inhibit gastrointestinal retlexes, leading to functional and acute symptomatology. Drugs Read more [...]

Constipation is a common gastrointestinal complaint. However, the complaint is viewed differently by health care providers and patients. Medical practitioners generally describe constipation as a decrease in the frequency of fecal elimination characterized by the difficult passage of hard, dry stools. It usually results from the abnormally slow movement of feces through the colon, resulting in their accumulation in the descending colon. Patients may describe constipation as (1) straining to have a stool; (2) the passage of hard, dry stool: (3) the passage of small stools: (4) feelings of incomplete bowel evacuation: or (5) bloating or decreased stool frequency. Although constipation is a common reason for visiting a primary care provider, it also is a common reason for undertaking self-care. A laxative is often the treatment of choice for constipation. Laxative sales in the United States exceed S750 million and are projected to top 1850 million by 2010. Despite numerous recognized indications for when to use laxatives, many patients use them inappropriately to alleviate what they incorrectly Read more [...]

A detailed history is important, and certain topics should be covered in particular (Table 2). A complete physical examination should be done, including assessment of growth and development. Table 2. Assessing The History Of The Child With Constipation AGE OF ONSET • Birth: consider anal abnormalities, Hirschsprung's disease PRECIPITATING EVENTS • Diet changes: breast milk to formula, formula to cow's milk • Toilet-training problems • Pain, bleeding with defecation APPETITE ABDOMINAL PAIN BOWEL ROUTINE • Soiling with small amounts of soft or liquid stool suggests impaction with paradoxical diarrhea URINARY SYMPTOMS GROWTH AND DEVELOPMENT • Developmental delay and growth failure in children with hypothyroidism • Increased incidence of constipation in children with cerebral palsy • Delayed bowel training in children with mental retardation BEHAVIORAL PROBLEMS FAMILY HISTORY PREVIOUS TREATMENT • Ask about punitive measures MEDICATIONS FOR OTHER REASONS Most Read more [...]

The chief, and perhaps the sole, reason for contemplating invasive investigation of constipated elderly patients is the detection of treatable carcinoma of the colon or rectum. Colorectal carcinoma has a reasonably good prognosis with early treatment. Even when spread has occurred, subsequent quality of life may be substantially enhanced by treatment. In light of this knowledge, many authors advocate a work-up of every constipated patient, to include a sigmoidoscopy and barium enema or colonoscopy. While this approach may make some sense for consultant gastroenterologists, it is absurd advice to offer primary care physicians. Based on United States incidence figures, an Ontario family physician who had a 3,000 patient practice with an age distribution corresponding to the provincial population could expect to encounter a new case of colorectal carcinoma once every 16 months among his geriatric patients. Given the fact that one in four elderly regards himself as constipated, investigation must clearly be done selectively. Aggressive investigation should be considered under the following circumstances: 1. Read more [...]