Pharmacy Practice IV

Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.

Constipation // Page 1 of 8
Constipation

1. Different people have different (wrong?) views about constipation:
a. Infrequent stools
b. Hard stools
c. Difficulty passing stools (straining)
d. Sense of incomplete emptying after a bowel movement

2. Affect everybody. More commonly in women, adults ages 65 and older, pregnant
women, following childbirth or surgery

3. Medically, constipation = fewer than three bowel movements per week. Severe
constipation = less than one bowel movement per week

4. The most common pattern is one bowel movement a day, but seen in less than 50% of
people only. No bowel movement for two or three days does not cause physical
discomfort, only mental distress for some people

5. Constipation is a symptom, not a disease.

6. Most constipation is temporary and not serious

7. Sometimes constipation can lead to complications:
a. Rectal prolapse and hemorrhoids. Some of the symptoms may be the same
bleeding and / or tissue that protrudes from the rectum. Difference: rectal
prolapse involves a segment of the bowel located higher up within the body, while
hemorrhoids develop near the anal opening
b. Anal fissures. Tears in the skin around the anus, caused when hard stool
stretches the sphincter muscle. Rectal bleeding may occur, appearing as bright
red streaks on the surface of the stool
c. Fecal impaction. Constipation may cause hard stool to pack the intestine and
rectum so tightly that the normal pushing action of the colon is not enough to
expel the stool. Mostly in children and older adults. Can be softened with mineral
oil taken by mouth and by an enema
Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 2 of 8
Causes

1. As food moves through the colon, the colon absorbs water from the food while it forms
waste products (stool). Muscle contractions in the colon then push the stool toward the
rectum. When the stool reaches the rectum it is solid, because most of the water has
been absorbed

2. Constipation occurs when stools become hard and dry:
a. Colon absorbs too much water or
b. Colons muscle contractions are slow or sluggish, causing the stool to move
through the colon too slowly

3. Common causes of constipation are:
a. Inadequate fiber (soluble or insoluble) in the diet. Recommended 20-35g per day.
Processed food remove natural fibre
b. Inadequate liquids. Liquids add fluid to the colon and bulk to stools, making bowel
movements softer and easier to pass. Liquids that contain alcohol and caffeine
worsen symptoms by causing dehydration
c. Lack of physical activity (especially in the elderly e.g. bed-ridden)
d. Medications:
narcotics codeine
antacids aluminum, calcium
calcium channel blockers diltiazem, nifedipine
antiparkinson drugs
antispasmodics
antidepressants amitriptylene and imipramine
iron supplements
diuretics
anticonvulsants phenytoin, carbamazepine
e. Irritable bowel syndrome. Constipation can also alternate with diarhhoea
f. Changes in life or routine:
pregnancy (hormonal changes or because the uterus compresses the intestine)
aging (slower metabolism results in less intestinal activity and muscle tone)
travel (normal diet and daily routine are disrupted)
g. Abuse of laxatives. Bisacodyl and senna are habit-forming. Chronic use damage
the nerves and muscles of the colon
h. Ignoring the urge to have a bowel movement. Bowel movements are under
voluntary control. Reasons cited: no toilets available, dont want to use public
toilets, emotional stress, too busy, dont want to stop playing (children)
Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 3 of 8
i. Neurological disorders. Stroke, spinal cord injuries
j. Hormonal disorders. Diabetes, menstrual periods when hormones are high
k. Systemic disorders. Lupus
l. Problems with colon and rectum (structure). Intestinal obstruction, scar tissue,
tumors, colorectal stricture, cancer
m. Problems with intestinal function
chronic idiopathic constipation. Unknown origin. Does not respond to standard treatment
functional constipation. Bowel is healthy but not working properly. Colonic inertia, delayed
transit (decrease muscle activity), and pelvic floor dysfunction (weakness of muscle) are
three types of functional constipation

Non-medicinal Treatment / Prevention

1. Goal of treatment bowel movement every 2 to 3 days without difficulty (without straining).
In most cases, these measures help relieve symptoms and prevent recurrence of
constipation. These measures may take weeks for full effects

2. Eat a well-balanced, high-fiber diet
a. Not digested by the human gastrointestinal tract
b. Bulk-forming laxative. Bind water and keep it in the intestine, forming soft, bulky
stool
c. 35g each day
d. Beans, bran, whole grains, fresh fruits, vegetables

3. Take prune juice (mild stimulant)

4. Drink plenty of liquids

5. Exercise regularly. People who lead sedentary lives are more frequently constipated than
people who are active

6. 500 mg vitamin C and 400 mg magnesium can prevent constipation. Dosage can be
increased up to a maximum of 5,000 mg vitamin C and 1,000 mg magnesium. If develops
diarrhoea, vitamin C should be decreased

7. Set aside time after meal for undisturbed visits to the toilet. Do not ignore the urge to have
a bowel movement
Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 4 of 8

8. Determine if there are drugs that you are taking that could be contributing to the
constipation. See if the drugs can be discontinued or changed

9. If the measures do not produce satisfactory results, they are not to be discontinued but
other measures should be added


Medicinal Treatment

If changes in diet and activity fail to relieve occasional constipation, laxative may be used for a
few days.

1. Bulk-forming laxatives (fibre supplements):
a. Doses introduced in stages. Insoluble fibre (psyllium and brans from grains like
wheat and oats) may give the patient flatulence at first - occurs because the bacteria
normally present within the colon are capable of digesting fiber to a small extent. The
bacteria produce gas as a byproduct of their digestion of fiber. May also occur with
soluble fibre (pectin, flax, and gums). Dose related and decrease over time
b. Considered the safest, but they can interfere with absorption of some medicines
c. Must be taken with water or they can cause obstruction
d. Many people also report no relief after taking bulking agents and suffer from a
worsening in bloating and abdominal pain

2. Peristaltic Stimulants:
a. Bisacodyl, senna
b. Cause rhythmic muscle contractions in the intestines. Propel their contents more
rapidly
c. Increase the amount of water in the stool, either by reducing the absorption of the
water in the colon or by causing active secretion of water in the small intestine
d. Very effective
e. Side effects: can cause severe diarrhea with resulting dehydration and loss of
electrolytes (especially potassium), intestinal cramping, chronic use may damage the
colon and worsen constipation. Should be used as a last resort because of the
possibility that they may permanently damage the colon and worsen constipation

3. Hyperosmolar laxatives:
Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 5 of 8
a. Lactulose, sorbitol, polyethylene glycol, macrogol
b. Indigestible, unabsorbable compounds that remain within the colon and retain the
water that already is in the colon
c. Cause fluids to flow in a special way through the colon, resulting in bowel distention
d. Useful for people with idiopathic constipation
e. Safe for long-term use
f. May be digested by colonic bacteria and turned into gas (bloating, flatulence) - dose-
related

4. Emollient laxatives (stool softeners):
a. Docusate
b. Moisten the stool and prevent dehydration. Improves the ability of water within the
colon to penetrate and mix with stool
c. May take a week or more to be effective
d. Used when there is a need to soften the stool temporarily and make defecation
easier. Often recommended after childbirth or surgery, hemorrhoids or anal fissures -
people who should avoid straining in order to pass a bowel movement
e. Prolonged use of this class of drugs may result in an electrolyte imbalance
f. May allow the absorption of mineral oil and some medications from the intestine. Not
recommended together with mineral oil or with certain medications. Emollient
laxatives are commonly used in some conditions (e.g., after surgery, childbirth).
They are also used for individuals with hemorrhoids or anal fissures

5. Lubricant laxatives:
a. Contain mineral oil
b. Grease the stool, enabling it to move through the intestine more easily
c. Oil stays within the intestine, coats the particles of stool, and presumably prevents
the removal of water from the stool, resulting in softer stool
d. Short-term
e. Long term usage can cause absorption of fat-soluble vitamins from the intestine and,
if used for prolonged periods, may lead to deficiencies of these vitamins
f. Particular concern in pregnancy during which an adequate supply of vitamins is
important for the fetus
g. May decrease the absorption of some drugs such as warfarin and oral contraceptives,
thereby decreasing their effectiveness

6. Saline laxatives:
Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 6 of 8
a. Contain non-absorbable ions such as magnesium, sulfate, phosphate, and citrate
b. Magnesium hydroxide, magnesium sulfate
c. These ions remain in the colon and cause water to be drawn into the colon. Act like a
sponge to draw water into the colon for easier passage of stool
d. Act within a few hours
e. Potent, should not be used on a regular basis
f. Magnesium is eliminated from the body by the kidneys. Individuals with impaired
kidney function may develop toxic levels of magnesium from chronic (long duration)
use of magnesium-containing laxatives

7. Enemas:
a. Phosphate enemas stimulate the colon to contract and eliminate stool
b. Saline enemas cause water to be drawn into the colon
c. Mineral oil enemas lubricate and soften hard stool
d. Emollient enemas contain agents that soften the stool
e. Useful when there is impaction
f. Defecation usually occurs between a few minutes and one hour after the enema is
inserted
g. For occasional use. Frequent use can cause disturbances of the fluids and electrolytes
in the body

8. Suppositories:
a. Stimulant suppositories containing bisacodyl
b. Glycerin suppositories are believed to have their effect by irritating the rectum

9. Combination products:
a. May be convenient and effective
b. Sometime contain stimulant laxatives dangerous if used long term

10. Miscellaneous drugs:
a. Colchicine (for gout)
b. Misoprostil (for stomach ulcers)
c. Orlistat (for slimming). Undigested fat is digested by bacteria within the intestine and
the products of this bacterial digestion promote the secretion of water.
d. Lubiprostone (not in Malaysia yet)

Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 7 of 8
Other methods

1. Biofeedback:
a. People with chronic constipation caused by anorectal dysfunction can use
biofeedback to retrain the muscles that control bowel movements

2. Surgery:
a. Problematic constipation due to diseases of the colon or laxative abuse
b. Most of the colon except for the rectum is removed. The cut end of the small
intestine is attached to the remaining rectum or sigmoid colon
c. An option for people with severe symptoms caused by colonic inertia
d. The benefits of this surgery must be weighed against possible complications,
which include abdominal pain and diarrhea

3. Electrical pacing:
a. Still in its experimental phases

4. Acupressure:
a. Said to relax the abdomen, ease discomfort, and stimulate regular bowel
movements when diet and exercise fail to do so

5. Aromatherapy:
a. Rosemary and thyme

6. Massage the abdomen

7. Herbal:
a. Chamomile, dandelion, burdock
b. Senna, buckthorn dangerous

8. Yoga:
a. Knee-chest position
b. Cobra position



Pharmacy Practice IV


Prepared by Ibrahim Abdullah, BPharm (Hons) Nottingham, UK.
Constipation // Page 8 of 8
When to Refer

1. No evidence that "toxins" accumulate when bowel movements are infrequent

2. No evidence that constipation leads to cancer

3. Refer in these cases:
a. Acute constipation requires urgent assessment because a serious medical illness
may be the underlying cause (e.g., tumors of the colon)
b. When constipation is of severe, worsening, associated with other worrisome
symptoms such as loss of weight, or is not responding to treatments



























This article is for educational purpose only. The writer welcomes any feedback, which may be sent to
ibrahim.lecturer@gmail.com