Constipation—modern laxative therapy

It is estimated that one third of the population in Western industrial countries suffers from constipation at least from time to time. Constipation may have somatopathic or functional causes. Furthermore, a great number of substances are known to cause medication-induced constipation, i.e. opioid-induced constipation is caused by linkage of the opioid to opioid receptors in the bowel and the central nerve system. Whenever possible, causal therapy should be undertaken. Patients in palliative care mostly suffer from chronic functional constipation. The treatment consists of basic measures and the application of laxatives. According to their mode of action, they are divided into bulk-forming laxatives, osmotic laxatives, stimulant laxatives, lubricating agents and others. Bulk-forming laxatives are not recommended for use in palliative care patients, for such patients are normally not able to take in the required amount of fluids. Osmotic laxatives are divided into (magnesium) salts, saccharine, alcohols and macrogols. Lactulose is the most popular saccharine laxative. Because of its side effects (flatulence, bloating and abdominal cramping), lactulose is not a laxative of our choice; instead, we prefer to give macrogol. Orally administered, macrogol is not metabolised and pH value and bowel flora remain unchanged. Macrogol hydrates hardened stools, increases stool volume, decreases the duration of colon passage and dilates the bowel wall that then triggers the defecation reflex. Even when given for some time, the effectiveness of macrogol will not decrease. Because of its high effectiveness and commonly good tolerance, macrogol has become the laxative of first choice in palliative care patients with all kinds of chronic constipation, if these patients are able to take in the necessary amount of fluids. From the general medical point of view, lubricating agents have become obsolete. In palliative care patients, however, they are still important laxatives for prophylactic treatment or therapy of constipation. Due to clinical experience, in palliative care a laxative ladder has proven successful.Presented as an invited lecture at the 15th International Symposium Supportive Care in Cancer, Berlin, Germany, June 18–21, 2003.     

A review of laxative therapies for treatment of chronic constipation in older adults

Background: Multiple studies have addressed the treatment of chronic constipation in adults in general; however, less guidance is available for treating this condition in older patients.Objective: The aim of this paper was to review the effectiveness of laxatives for chronic constipation in the elderly.Methods: Medline, Web of Science, international Pharmaceutical Abstracts, and the Cochrane database of Systematic Reviews were searched for english-language articles evaluating the treatment of chronic constipation in older individuals from the inception of the databases until October 2010. Search terms included constipation, treatment, laxative, elderly, and geriatric. Articles were excluded if the mean age was <65 years.Results: Thirty-one trials were identified. These studies varied widely in terms of methodology, quality, sample size, efficacy end points, and duration. Mean stool frequency was 9.08 bowel movements per week with psyllium and 8.29 per week with calcium polycarbophil (P = 0.04). docusate sodium daily, docusate sodium q12h, and docusate calcium daily for 3 weeks produced a mean stool frequency of 1.95 bowel movements per week versus 1.50 for placebo (P = NS), 2.29 versus 1.76 (P = NS), and 2.83 versus 1.75 (P<0.02), respectively. Mean stool frequency with lactulose versus placebo was 0.7 and 0.5 bowel movements per day (P<0.02). in patients receiving polyethylene glycol or lactulose, mean stool frequency was 1.3 and 0.9 bowel movements per day (P = 0.005). in a study comparing senna plus a bulking agent with lactulose, mean stool frequency was 4.5 per week for the combination product versus 2.2 per week for lactulose (P<0.001). A study comparing sodium picosulfate with senna reported a mean stool frequency of 0.71 and 0.63 per day (P value not reported). Lubiprostone was associated with 5.69 spontaneous bowel movements per week versus 3.46 per week for placebo (P = 0.001).Conclusions: Higher-quality trials evaluating the treatment of constipation in older patients are needed to create a basis for more definitive recommendations in this population. The approach to older adults with constipation should be individualized.     

Treating constipation during pregnancy

Question Many of my patients experience constipation during pregnancy, even after increasing dietary fibre and fluids. Are there any safe treatments I can recommend to them?Answer Although the recommended first-line therapy for constipation includes increasing fibre, fluids, and exercise, these are sometimes ineffective. Therefore, laxatives such as bulk-forming agents, lubricant laxatives, stool softeners, osmotic laxatives, and stimulant laxatives might be considered. Although few of the various types of laxatives have been assessed for safety in pregnancy, they have minimal systemic absorption. Therefore, they are not expected to be associated with an increased risk of congenital anomalies. However, it is recommended that osmotic and stimulant laxatives be used only in the short term or occasionally to avoid dehydration or electrolyte imbalances in pregnant women.     

Managing a patient's constipation with physical therapy

BACKGROUND AND PURPOSE: Constipation is a prevalent condition in the United States, with typical treatment consisting of diet modification, stool softeners, and laxatives. These interventions, however, are not always effective. The purpose of this case report is to describe the use of abdominal massage in physical therapist management for a patient with constipation. CASE DESCRIPTION: An 85-year-old woman with constipation was referred for physical therapy following unsuccessful treatment with stool softeners. The patient was instructed in bowel management as well as a daily, 10-minute home abdominal massage program. OUTCOMES: Upon re-examination, the patient reported a return of normal bowel frequency and function without the need to strain or use digital evacuation. DISCUSSION: Physical therapy incorporating abdominal massage appeared to be helpful in resolving this patient's constipation. Unlike medical management of constipation, no known side effects have been identified with abdominal massage.     

Non-pharmacological interventions to improve constipation amongst older adults in long-term care settings: A systematic review of randomised controlled trials

Constipation is a highly prevalent condition amongst older adults in long-term care settings and laxatives are not always the solution. We aimed to examine the characteristics and the effects of non-pharmacological interventions to improve constipation amongst older adults in long-term care settings. Eligible studies were identified using PubMed, CINAHL, Scopus, Web of Science, Cochrane and EMBASE (up to April 2019). We included 7 studies with a total of 657 patients. Five interventions improved the number of bowel movements (i.e. laxative tea, fermented oat drink, patient education, probiotics and multi-component intervention). The administration of probiotic capsules and fermented oat drinks also improved stool form. Auricular acupressure improved constipation symptoms and constipation-related quality of life. After appraising the trials’ methodological quality and risk of bias, we cannot recommend any non-pharmacological interventions to improve constipation amongst older adults in long-term care settings until more robust studies have been conducted.     

Constipation in elderly long-stay patients: its treatment by magnesium hydroxide and bulk-laxative

Sixty-four geriatric long-stay patients aged 65 years or older participated in the trial. All were using laxatives prior to the study. For the study laxatives the mean dose of magnesium hydroxide was 25 ml daily and for bulk-laxative 8.7 g daily. Magnesium hydroxide caused a more frequent bowel habit (13.2 vs. 10.4/4 weeks, p less than 0.001) than bulk-laxative and additional laxative bisacodyl was not needed as often as with bulk-laxative (2.3 vs. 3.3/4 weeks, p less than 0.01). Also the stool consistency was more normal during the magnesium hydroxide treatment. In two patients serum magnesium was over 1.25 mmol/l after the magnesium hydroxide treatment but there were no clinical signs of hypermagnaesemia. Our study indicated magnesium hydroxide to be more efficient than bulk-laxative in treating constipation in elderly long-stay patients.     

Diagnostic approach to chronic constipation in adults

Constipation is traditionally defined as three or fewer bowel movements per week. Risk factors for constipation include female sex, older age, inactivity, low caloric intake, low-fiber diet, low income, low educational level, and taking a large number of medications. Chronic constipation is classified as functional (primary) or secondary. Functional constipation can be divided into normal transit, slow transit, or outlet constipation. Possible causes of secondary chronic constipation include medication use, as well as medical conditions, such as hypothyroidism or irritable bowel syndrome. Frail older patients may present with nonspecific symptoms of constipation, such as delirium, anorexia, and functional decline. The evaluation of constipation includes a history and physical examination to rule out alarm signs and symptoms. These include evidence of bleeding, unintended weight loss, iron deficiency anemia, acute onset constipation in older patients, and rectal prolapse. Patients with one or more alarm signs or symptoms require prompt evaluation. Referral to a subspecialist for additional evaluation and diagnostic testing may be warranted.     

Constipation in advanced cancer patients

Constipation is a frequent, distressing, and underestimated complication in patients with advanced cancer. It may develop from general disturbances that may or may not be cancer related, but the use of opioids is one of the main causes in this population. Opioids affect the intestine by reducing motility and secretions and by increasing fluid absorption and blood flow. Untreated constipation may lead to several complications. Effective management of constipation starts with a careful assessment of the patient, including the history of the frequency and difficulty of defaecation, symptoms caused by constipation, and physical and rectal examinations. When the diagnosis of constipation is unclear, an abdominal X-ray may be required. The treatment of constipation includes general interventions, such as the availability of comfort and privacy or the elimination of medical factors that may contribute to constipation, and therapeutic interventions including oral or rectal laxatives and the use of prokinetic drugs and naloxone. The purpose of this paper is to review the pathophysiology and causes of constipation and the effects of opioids on the gastrointestinal tract, and to propose an approach for its assessment and management. Randomized clinical trials between different laxatives and/or prokinetic agents in cancer patients are needed, and future studies should focus on the validation of different clinical assessment tools for constipation.     

Patient and physician evaluation of a new bulk fiber laxative tablet.

Occasional constipation is a frequent complaint in medical practice. Bulk-fiber laxatives are often recommended as a safe and effective treatment of this disorder. The viscous suspensions required for administering most bulk-fiber laxatives, however, can negatively affect compliance. This study summarizes physician and patient assessment of a new, oral bulk-fiber laxative caplet following 2 weeks of open-label use for the treatment of constipation and related disorders. Forty-two patients recruited from colorectal surgical practices and who were recommended bulk-fiber as part of their treatment completed the study. Recommended dosage was 2 caplets b.i.d., with each 2-caplet dose providing 1 gram of methylcellulose. Patient diaries reported average daily use of 3.13 +/- 1.20 caplets/day and a total of 577 patient-days of use (calculated as total days product used x number of subjects). Ninety percent of the diaries reported at least one bowel movement daily. Fourteen days of treatment progressively and significantly increased the percentage of complete bowel movements, bowel movements having normal stool consistency, and reduced straining. Physicians rated more than 75% of patients' responses to treatment with methylcellulose caplets as "very good" or "excellent," and considered the responses equal or better than that expected for a fiber treatment in 90% of subjects. Among 24 patients who had previously used fiber, 21 preferred the caplets over prior fiber products. Methylcellulose tablets may provide a useful alternative for improving compliance among patients using fiber therapy.     

How to deal with chronic constipation. A stepwise method of establishing and treating the source of the problem

Chronic constipation is a common medical complaint encountered often in a primary care setting. Most patients can be treated successfully with simple measures, including education, bowel habit training, increased fluid and fiber intake, and use of laxatives. Chronic constipation is usually considered idiopathic, but secondary causes should be excluded. In about 1% of patients with severe, intractable constipation, further diagnostic testing (e.g., endoscopy, colonic transit study) is needed. Patients with colonic inertia can be treated with judicious use of laxatives, but surgery may be necessary in a few cases. Patients with outlet inertia should be referred for biofeedback treatment.     

A volunteer model for the comparison of laxatives in opioid-related constipation

Loperamide was used to provide a source of opioid-induced constipation in healthy volunteers. Each volunteer took a sequence of three dose levels of loperamide. One of three laxatives was used to counterbalance the effect of loperamide and restor bowel function to what the individual considered normal at each stage before the dose of loperamide was increased. Lactulose, senna, and codanthrusate were selected as examples of a softening, a stimulant, and a combination laxative, respectively. Outcome measures were the doses of laxative used, stool form and frequency, ease of defecation, a rating scale of subjective bowel function, and the occurrence of adverse effects. Each laxative was taken by ten volunteers, and all proved capable of maintaining normal bowel function. A combination of stimulant and softening laxatives was most likely to maintain normal bowel function at the lowest dose and least adverse effects. The mean final dose of lactulose was excessive for use in ill patients. Senna was associated with significantly more adverse effects than the other laxatives, mainly abdominal pain (P < 0.001). This model of constipation may provide a standardized means of assaying the clinical effectiveness of oral laxatives.     

The use of novel promotility and prosecretory agents for the treatment of chronic idiopathic constipation and irritable bowel syndrome with constipation

Chronic idiopathic constipation (CIC) and irritable bowel syndrome with constipation (C-IBS) are commonly reported gastrointestinal (GI) disorders that have a major impact on health and quality of life. Patients experience a range of symptoms of which infrequency of bowel movement is but one and report that straining, the production of hard stools, and unproductive urges are more bothersome than stool infrequency. Additionally, in C-IBS, patients report abdominal pain and bloating as particularly troubling. Traditional treatments, such as laxatives, are often ineffective, especially in more severe constipation over the long term. In a population-based survey of constipation sufferers, half were not satisfied with their current treatment, due predominantly to poor efficacy. 5-Hydroxytryptamine receptor 4 (5-HT₄) agonists stimulate GI motility and intestinal secretion, and tegaserod has demonstrated efficacy in improving bowel habit. Tegaserod also improves constipationassociated symptoms including bloating, abdominal discomfort, stool consistency, and straining in patients with both CIC and C-IBS. However, tegaserod has been withdrawn due to an association with serious adverse cardiovascular effects. Further 5-HT₄ receptor agonists, including prucalopride and TD-5108 are in development and show exciting results in clinical studies in CIC patients, suggesting further product approvals are likely. Headache and diarrhea are the most commonly reported adverse event with this class of agent. Recently a novel prosecretory agent has been approved for the treatment of both CIC and C-IBS. Lubiprostone stimulates chloride secretion through activation of type-2 chloride channels, increasing intestinal secretion and transit, and its use has been associated with improvements in bowel habit and symptoms of constipation. Nausea, diarrhea, and headache are the most commonly reported adverse events. Linaclotide also stimulates intestinal chloride secretion, but this molecule achieves this indirectly, through the activation of guanylate cyclase C. Data are emerging, but the efficacy and safety profile of this agent in the treatment of CIC and C-IBS appears encouraging.     

Prescribe with care. The role of laxatives in the treatment of constipation

The use of laxatives is widespread throughout North American hospitals and long-term care facilities. Although constipation is a frequent complaint among the elderly, the use of laxatives is not always warranted; increases in physical activity, fluid intake, and dietary fiber may be sufficient to control constipation. The occasional use of a laxative is not harmful, but the daily use of these drugs for achieving a bowel movement may be detrimental to the resident because of the side effects they can produce and drug interactions that can occur with other medications. Potential solutions to the overuse of laxative agents include the use of dietary bran; less regular administration of stimulant and osmotic agents; more regular administration of bulk-forming laxatives and stool softeners; an increase in the awareness of normal gastrointestinal physiology; and the role of non-drug factors.     

Fruit and fibre (Pajala porridge) in the prevention of constipation

BACKGROUND AND AIMS: Constipation is a common problem in geriatric wards and in the elderly population. Although high-fibre diets can help relieve constipation non-pharmacologically in many patients, traditional laxatives still remain the standard treatment. A fibre supplement in the form of raw bran is not always well tolerated. We wanted to study the effects of a daily consumption of a fruit- and fibre-rich porridge on stool frequency, perceived well-being and the costs for laxatives, when compared with traditional treatment with laxatives, in geriatric patients. METHODS: Twenty patients in secondary geriatric wards (hospital rehabilitation wards) were randomized into an intervention group (porridge group) and a control group (standard diet without porridge) for a 1-week run-in and 2-week study, with registration of clinical data, e.g. medical treatment, laxative consumption, stool frequency and perceived well-being. RESULTS: The patients in the porridge group had a daily defaecation without laxatives on average 76% of the time (10.7/14 days) compared with 23% of the time (3.3/14 days) in the non-porridge group (p = 0.003). The discomfort was less in the porridge group (2.5 vs. 6.5 on a 10-degree visual analogue scale, p = 0.008) when compared with the control group. The cost for laxatives was 93% lower in the intervention group (2.5 vs. 37.5) for the 2-week study. CONCLUSIONS: A fibre-rich porridge was effective, well liked and tolerated and reduced the need for laxatives in geriatric patients. We conclude that a daily fibre-rich meal ought to be included in the treatment strategies of constipation in hospital wards.     

Diagnosis and Management of IBS in Adults

Irritable bowel syndrome is defined as abdominal discomfort or pain associated with altered bowel habits for at least three days per month in the previous three months, with the absence of organic disease. In North America, the prevalence of irritable bowel syndrome is 5 to 10 percent with peak prevalence from 20 to 39 years of age. Abdominal pain is the most common symptom and often is described as a cramping sensation. The absence of abdominal pain essentially excludes irritable bowel syndrome. Other common symptoms include diarrhea, constipation, or alternating diarrhea and constipation. The goals of treatment are symptom relief and improved quality of life. Exercise, antibiotics, antispasmodics, peppermint oil, and probiotics appear to improve symptoms. Over-the-counter laxatives and antidiarrheals may improve stool frequency but not pain. Treatment with antidepressants and psychological therapies are also effective for improving symptoms compared with usual care. Lubiprostone is effective for the treatment of constipation-predominant irritable bowel syndrome, and alosetron (restrictions for use apply in the United States) and tegaserod (available only for emergency use in the United States) are approved for patients with severe symptoms in whom conventional therapy has been ineffective.     

Pediatric sigmoid volvulus of an extremely long sigmoid colon with hypoganglionosis: a case report

Sigmoid volvulus is an extremely rare cause of intestinal obstruction in pediatric patients. This condition occurs when a redundant sigmoid loop with a narrow mesenteric base of attachment to the posterior abdominal wall rotates around its mesenteric axis. This situation might result in vascular occlusion and large bowel obstruction. There are only a few predisposing factors of sigmoid volvulus, such as a long-term history of constipation or pseudo-obstruction with an excessive sigmoid colon. Underlying hypoganglionosis can also lead to large bowel obstruction. There have only been two reported cases of hypoganglionosis with sigmoid volvulus, and both were in adults. Sigmoid volvulus usually presents with abdominal pain, nausea, vomiting, constipation and abdominal distension, an absence of stool, or the presence of melenic stool in the rectum. Initial treatment options are non-surgical for stable patients, although surgical management might be necessary. If sigmoid volvulus is not recognized and resolved, it may lead to serious complications and death. Pediatric sigmoid volvulus is frequently the fulminant type, and therefore, a decision about treatment must be prompt. We present an unusual pediatric case of an extremely long sigmoid colon with hypoganglionosis, which twisted and caused obstruction. This condition was resolved with surgical resection.     

Older people and laxative use: literature review and pilot study report

This study explored older adults' perceptions of constipation, and the measures taken if they believed themselves to be afflicted by this condition. The paper provides an overview of the current literature surrounding laxative use, followed by a discussion of the pilot study and its findings. The objectives of the pilot study were to establish older people's definitions of the term 'constipation'; identify prescribed laxatives, over-the-counter laxatives, and home remedies used by older people to manage constipation; produce a detailed account of when these products are used; identify the older person's belief system underpinning their concepts of constipation, and their consequent use of laxative products; and produce information which will inform nursing practice, with a particular focus on nurses in community practice. People who identified themselves as being constipated were interviewed on a one to one basis. Participants shared their stories of loneliness, social isolation and anxiety related to constipation and the need to use laxatives on a daily basis, and described persistent unpleasant and often painful physical symptoms such as bloating, urges, excessive flatus, nausea and cramps, commonly associated with laxative ingestion. Nurses are challenged to work with older people within a 'wellness' framework, helping clients to maintain their bowel function, rather than fall back on short-term options, which provide only brief relief of symptoms, while ignoring the underlying causes.     

Pharmacological management of chronic constipation in older adults

Chronic constipation in older adults has multiple etiologies, and many of these factors are interrelated. An initial medical history and physical examination can provide relevant clues to the causes of the problem. The Rome III classification system of functional constipation is useful in clinical practice to help clinicians identify symptoms and confirm a diagnosis. Additionally, the Bristol Stool Scale is a valuable medical aid designed to assist patients in describing bowel patterns in a way that is more useful for diagnosis and evaluation of treatment methods. Pharmacological management, along with dietary changes and patient education, is the initial approach to treat patients with idiopathic chronic constipation. Consensus statements support a five-step care approach for patients with constipation. Knowledge of this approach will help clinicians in prescribing the appropriate medications along with patient education.     

两种肠道清洁剂对便秘患者肠道准备效果影响因素分析

目的：分析复方聚乙二醇(Polyethylene glycol,PEG)电解质散和20%甘露醇对便秘患者肠道准备的效果和影响因素。方法：选取2015年9月-2016年12月结肠镜诊疗前口服PEG或20%甘露醇的便秘患者,对其肠道准备情况进行分级,并记录患者年龄、性别、便秘病程、平时是否服用促动力药或缓泻剂、肠道准备期间饮食情况、活动情况、耐受情况等。结果：本研究共纳入544例便秘患者,PEG组239例,20%甘露醇组305例。肠道准备总无效率为22.79%,其中PEG组无效率为24.27%,20%甘露醇组无效率为21.64%。便秘病程、平时是否服用促动力药或缓泻剂、肠道准备期间活动情况是PEG在肠道准备无效的影响因素;便秘病程是20%甘露醇在肠道准备无效的影响因素。结论：便秘患者在进行肠道准备时,可对其进行个体化处理,有助于提高肠道准备质量。