Transcript Constipation in the Elderly

Constipation in the Older
Patient
Hassan Saadatnia M.D
Professor of medicine & Gastroenterology
MUMS , Mashad , Iran
Burden of the problem
Constipation: 20 %of all people and (30-40 ) %of
olrders have constipation
women are more affected
Majority of patients have no underlying disease
Definition
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Research criteria vs “patient’s impression”
Patients describe:
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Hard stools, infrequent stools, excessive straining, a sense
of incomplete bowel evacuation, and excessive time spent
on the toilet or in unsuccessful defecation
Rome III describes:
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Inability to evacuate stool completely and spontaneously
three or more times per week for at least 3 month
Risk factors for Constipation
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Acquired neuromuscular disorders
Metabolic disease
Pathophysiologic changes with aging
Medications
Physical inactivity
Depression
Low dietary fiber
Risk Factors: Disease
• Neurologic: Parkinson’s disease;
Multiple sclerosis, CVA , paraplegia
• Metabolic: diabetes mellitus,
Hypokalemia , hypercalcemia,
hypothyroidism
• Structural: tumors, strictures, extrensic
pressure, diverticula anal fissure ,
Medications
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Opiates
- codeine,morphine
Anticholinergics - Artan
Antipsychotics - chlorpromazine
Antidepressants - tricyclics
Antiparkinson - levodopa
Antispasmodics - dicyclomine , hyocine
Antihistamines - diphenhydramine
Ca blockers
- verapamil
Is colonic transit slow in
constipated patients?
– Normal-transit (59 %)
– Slow-transit ( colonic inertia 13%)
– Impaired rectal evacuation (25%)
– Mixed (3%)
Normal-Transit Constipation
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Stool transit is normal, frequency is normal, yet
patients believe they are constipated
Perceived difficulty with evacuation or the presence
of hard stools
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Bloating, abdominal pain or discomfort, increased
psychosocial distress
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Symptoms of constipation usually respond to
therapy with dietary fiber alone or with the addition
of a laxative .
Slow-Transit Constipation
(colonic inersia )
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Patients with slow transit may benefit from
stimulant laxatives if neuromuscular function is
intact
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If neuromuscular function severely impaired: may
need surgery
Impaired Rectal Evacuation
Dyssynergic defecation
• Important to identify because treatment is
different – laxatives may not be effective
• Dysfunction of the pelvic floor or anal
sphincter
May be associated with structural problems
– Anal fissure
– Rectocele
Back to the clinic: History
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Screen for secondary causes , Medication use
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Prolonged straining, unusual postures, support of
perineum, digitations of rectum, posterior vaginal
pressure
– Suggests anorectal dysfunction
Physical Examination
“ Rectal Exam”
• Inspection
– Anal pathology: hemorrhoids, prolapse , Fissures
– Ask patient to strain: anus moves laterally,
ballooning of perineum (rectocele)
– mucosal prolapse or anterior rectal wall defect
– Ask to strain: perineum descends on finger
Laboratory Tests ?
• Thyroid function tests
• Potassium
• Calcium
• CBC
Does patient needs
colonoscopy
• New onset constipation , age above 50 Years
– Weight loss,macroscopic or microscopic
blood, FH of colon CA, anemia, undiagnosed
abdominal pain
• Chronic constipation:
– Anemia, weight loss, change in stool pattern,
undiagnosed abdominal pain
• F.R.S and Barium enema for young patients ?
GCC 9/5/06
Additional Examination
• Anoscopy
– fissure, fistula, stricture, carcinoma in
rectum
• If you suspect defecatory disorder
– Anorectal manometry & balloon expulsion
test
– Defecography if above equivocal or
suspect structural abnormality
Management : Patient education
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Increase physical activity
Take more fluids
Take fibers
Pay attention to gastrocolic reflex in the
morning
• Take a glass of cold or hot drink in the
morning
Anorectal dysfunction
• Biofeedback Therapy
-- Success rate is up to ~70 percent with
biofeedback
-- The benefits appear to be long-lasting
--Not available to all Patients
--Suppositories and enema are superior to oral
laxatives
Bulk forming laxatives
-- Increases colonic residue stimulating
peristalsis
--Psyllium
,Wheat Bran : takes about two
weeks to act , Coarse bran is superior
– Side effects: flatulence, distention, bloating,
and unpleasant taste
Osmotic agents
PEG
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MOM
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Lactulose
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Sorbitol
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• If fiber doesn’t work, or patient is “very
constipated” - use an osmotic laxative
• Increase dose gradually over several
days until loose stools are formed
Osmotic laxatives
• In patients with renal insufficiency or
cardiac dysfunction, may cause
electrolyte and volume overload from
absorption of sodium, magnesium
Stimulant laxatives
C- lax ( sena ) , Caster oil , Bisacodyl
Increase intestinal motility and secretion
Effective within hours and may cause abdominal
cramps
Long term use may cause cathartic colon
(loss of haustration and dilatation of the colon)
Oral versus suppository
Stimulant Laxatives
Useful in multifactorial refractory constipation
without obstruction
• Diphenylmethane derivatives
– Bisacodyl :Tabs , suppository
Castor oil - Ricinoleic acid may cause cathartic
colon
New drugs
– Lubiprostone
– Linactodide
– Misoprostol ?
– Colchicine?
Lubiprostone
• Selectively activates type 2 chloride
channels (ClC-2) in apical membrane of
the gastrointestinal tract
• Increased fluid secretion into lumen
• No significant systemic absorption
Linactodide
• An agonist of guanylate cyclase –C receptor
Stimulates intestinal fluid secretion and transit
“Prokinetic Drugs”
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Cisapride
Increased risk of cardiac arrhythmias
Does patient needs Surgery
• Less than 5 % of of all patients are selected
for surgery
• After extensive W/U in tertiary referral
centers and for STC
• Total or subtotal colectomy
• Anal fissures , Hemorrhoids , Cancer and
strictures , Rectocele , Cystocele
Surgery
For refractory constipation
Total colonic resection and ileorectostomy
Colonic resection is generally reserved for patients
with slow-transit constipation
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40 – 70 % improvement , only relieves constipation
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Very little data in older patients
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Complications
Fecal impaction : A serious condition
GCC 9/5/06