Change in bowel movement characterized by infrequent and difficult passage of stool.

1. Woman (women > men).
2. Greater than 65 years of age.
3. Infant and children.
4. Pregnancy.
5. Low-income.

1. Desire to defecate.
2. Relaxation of internal anal sphincter.
3. Tightening of abdominal wall muscles.

1. Valsalva maneuver forces stool down.

2. Voluntary relaxation of the external anal sphincter followed by elevation of the pelvic diaphragm.

3. Stool is expelled.

1. Separate hard lumps, like nuts (hard to pass).

2. Sausage-shaped but lumpy.

3. Like a sausage but with cracks on the surface.

4. Like a sausage or snake, smooth and soft.

5. Soft blobs with clear cut edges (passed easily).

6. Fluffy pieces with ragged edges (mushy stool).

7. Watery, no solid pieces (entirely liquid).

* Hard, small, or dry stool ("pellet-like").

* Feeling of incomplete bowel evacuation after defecation.

* Straining or grunting.

* Sensation of blockage.

* Lack of urgency to evacuate.

* Bloating.

* Unproductive calls.

* Abdominal cramping/abdominal discomfort.

* Fatigue.

* Headache.

* Nausea and vomiting.

1. Lifestyle or extrinsic factors.

2. Structural.

3. Idiopathic.

4. Drug-induced.

5. Disease state.

1. Insufficient dietary fiber.

2. Inadequate water intake.

3. Lack of exercise.

4. Poor bowel habits.

5. Avoiding the urge to defecate.

1. Colorectal infury, inflammation, or damage.
2. Impaired function of the pelvic floor.
3. Structural abnormalities such as hernia, tumors, strictures.

1. Decrease GI motility.
2. Astringent actions.
3. Decrease GI contractility.

1. Opioid analgesics.
2. Anticholinergics.

1. Aluminum.
2. Calcium.
3. Iron supplements.

Calcium Channel Blockers

1. Diuretics.
2. Antidiarrheals.
3. Sedative hypnotics.
4. Anxiolytics.
5. Muscle relaxants.

1. Hypothyroidism.
2. Diabetes mellitus.
3. Electrolyte abnormalities.
4. Irritable bowel syndrome.
5. Pituitary disorders.

1. Parkinsons.
2. Dementia.
3. Multiple sclerosis.
4. Cerebrovascular accident (stroke).

1. Depression.
2. Eating disorders.
3. Situational stress.

1. Episodic.
2. Usually less than 2 weeks.
3. Lifestyle related.

1. Food intake.
2. Change in environment.
3. Low fiber intake.
4. Dehydration.
5. Lack of exercise.

1. Medical condition related (related to disease state).
2. Medication related.

• Straining in 25% or more of bowel movements.
• Lumpy or hard stools in 25% or more of bowel movements.
• Sensation of incomplete evacuation in 25% or more of BM's.
• Sensation of anorectal obstruction/blockade in 25% or more of BM's.
• Manual maneuvers to facilitate defecation in 25% or more of BM's.
• Less than 3 BM's per week.
• Loose stool rarely present without use of laxatives.
  

1. Hemorrhoids.

2. Rectal prolapse.

3. Blood pressure surges.

4. Fecal impaction.

1. Sypmtom analysis.

2. Past medical history.

3. Medication history.

4. Social history.

5. Normal stool frequency.

6. Physical evaluation.

7. Past surgical history.

1. Diet.

2. Fiber intake.

3. Fluid intake.

1. Sharp, severe abdominal pain (7/10).

2. Nausea and/or vomiting.

3. Sudden change in bowel habits that persists for 2 weeks.

4. Use of laxative product for more than 7 days (unless directed to by their physician).

5. Occurence of rectal bleeding.

6. Lack of a bowel movement after laxative use at any time during treatment (discontinue OTC, and consult Dr).

1. Identify and treat the underlying cause.

2. Relieve constipation.

3. Prevent straining and complications.

4. Prevent recurrence.

1. Dietary changes.

2. Lifestyle changes.

Increase dietary fiber (to 25-30g per day).

- Do this by eating brans, fruits, vegetables, nuts, and prunes.

• Maintain adequate hydration.
• Increase exercise.
• Bowel training
• Go soon after waking in the morning.
• Allow enough time, and never ignore the urge.
  

1. Bulk forming agents.

2. Emollients.

3. Lubricating agents.

4. Saline laxatives.

5. Hyperosmotic agents.

6. Stimulant laxatives.

1. psyllium (Metamucil).

2. methylcellulose (Citrucel).

3. calcium polycarbophil (FiberCon)

*4. wheat dextrin (Benefiber) -- Not FDA approved for constipation.

Follow package instructions

(usu. 2-3g per day).

1. Anaphylaxis if inhaled.

2. Esophageal obstruction -- FDA warning.

1. Patients with difficulty swallowing or esophageal strictures.

2. Fluid restricted patients (heart failure, kidney disease).

3. Bed bound patients on opioids.

1. Replaces missing fiber.

2. Safe for long-term use.

3. NOT absorbed systemically.

4. Considered "natural" by patients.

*** Space all bulk-formers by 2 hours!! ***

polycarbophil (FiberCon) may decrease absorption of some Rx meds due to calcium chelation (tetracyclines, fluoroquinolones).

1. MUST stay hydrated!

2. If in powder form: Mix in 8 oz of water and drink immediately.

3. Separate from other medications by 2 hours.

Anionic surfactant that reduced surface tension of the oil-water interface of stool which enhances incorporation of water and fat into the stool ("Mush")

aka- Stool softener

100 - 250mg BID

Up to 500mg/day divided into 1 to 4 doses.

Abdominal cramping

Diarrhea

docusate sodium

Colace ®

1. Not systemically absorbed.

2. Useful for preventing constipation.

1. May increase absorption of mineral oil!

2. Syrup tastes terrible.

Weakness, sweating, muscle cramps, arrhythmias (usually associated with higher than recommended doses).

1. Patients who need to avoid straining (surgery, postpartum, hemorrhoids, arrhythmia, severe hypertension).

2. Opiate-induced constipation (used with a stimulant laxative).

1. Take with a full glass of water, milk, or juice.

2. Stop if stools become loose.

Liquid: 6-8 hours.

Rectal enema: 5-15 minutes.

5 - 45 mL PO daily.

118 mL PR (single dose).

1. Lipid pneumonia.

2. Anal leakage (and itching/irritation associated with large doses).

3. Abdominal cramps, diarrhea, nausea, vomiting.

1. Children less than 6 years of age.

2. Geriatric patients.

3. Bedridden patients.

4. Patients with difficulty swallowing.

5. Pregnant patients.

1. Avoid in pregnancy.

2. Hypersensitivity with repeated and prolonged use.

1. Risk of asiration when taken orally.

2. Can NOT be taken with an Emollient.

1. Remain upright when taking orally.

2. Do NOT take oral formulation before bed.

3. Take 2 hours before or after meals.

4. Impairs vitamin absorption, and increases systemic absorption of mineral oil.

5. Reduce dose if anal leakage occurs.

Oral: Creates an osmotic gradient to draw water into the colon, causes distention and stimulates evacuation.

Rectal: Local irritant that stimulates lower bowel evacuation.

Polyethylene glycol (PEG)- 3350

MiraLax ®

Fleet suppository ®

glycerin

Oral: 24 to 72 hours.

Rectal: 15 to 30 minutes.

Oral: 17g daily

Rectal: glycerin 3g daily.

Rectal irritation.

Abdominal bloating/cramping.

Diarrhea.

Can cause rectal irritation.

Chronic use can lead to decreased serum potassium levels.

1. Minimal systemic absorption.

2. No DDI.

3. Useful in idiopathic constipation because safe!

4. Can mix with juice for kids!

1. Patients with renal disease should talk to Physician first.

2. Mix Miralax with 4-8 oz of water, juice, or soda.

1. Ions draw water into the colon, resulting in an increase of intraluminal pressure and stimulates motility.

2. Magnesium stimulates secretion of cholecystokinin to stimulate bowel motility and fluid secretion.

Oral: 30 min to 3 hours.

Rectal: 2 to 5 minutes.

1. magnesium hydroxide: Phillips' Milk of Magnesia ®

2. magnesium citrate: Evac-Q-Mag ®

sodium phosphate

Fleet Saline Enema ®

1. Fluid overload.

2. Hypermagnesemia.

3. Hyperphosphatemia.

1. Avoid in patients with renal insufficiency.

2. Avoid in patients with chronic heart failure.

3. Recommend against in Mg/phosphorus/Na restricted diets.

4. Mg products may lower absorption of some medications.

mycophenolate

doxycyline

ciprofloxacin

Rapid onset of action

Cheap.

May be absorbed systemically.

Electrolyte imbalance with chronic use.

1. Drink 8 oz of clear liquids with each dose.

2. Separate from other medications by 2 hours (to avoid DDI's)

Do NOT give OTC.

FDA placed a black box warning on oral sodium phosphate due to the accumulation of sodium or phosphate in the kidney causing acute kidney impairment.

1. anthraquinone: Sennosides --> Senna ® or Senokot ®.

2. diphenylmethane: Bisacodyl --> Dulcolax ®

3. castor oil

1. Bad abdominal cramping.

2. Urine discoloration.

Oral: 6 to 10 hours.

Rectal: 15 to 60 minutes.

Separate from antacids by atleast 1 hour.

Do not use with H2RA's and PPI's and/or milk.

(Bisacodyl is enterically coated, and will break down in the stomach instead of gut if pH of stomach is increased = MUCH greater abdominal cramping).

Do NOT recommend to pregnant women.

(May stimulate uterine contraction and induce labor!!)

1. Barley malt extract (safe for infants).

2. Glycerin suppositories (less than 5 years old).

3. Miralax, milk of magnesia, magnesium citrate (okay for children over the age of 1 yr).

1. Mineral oil.

2. Stimulant laxatives.

3. Sodium phosphate enemas.

Bulk-forming agents

Docusate sodium

Glycerin suppositories.

Miralax (safe for cardiac/renal patients).

Senna

Saline enemas for acute episodes (only if rec by physician).

1. Uterus compresses the colon.

2. Prenatal vitamins and mineral supplements (Ca, Fe).

bulk-forming agents

docusate sodium

Mineral oil (interferes with vit absorption)

Castor oil (induction of labor)

Saline laxatives (systemic absorption)