Constipation Management in Primary Care

Constipation

Passage of less than 3 stools per week, lump/hard stool, straining, feeling of incomplete evacuation.

Pathogenesis

  1. Colonic motility delay
    1. Many medical conditions: hypothyroid, hypercalcemia, hypokalemia, scleroderma, dM, neurologic disorders, MS, Parkinson, paraplegia
    2. Medications: CCB, narcotics, anticholinergics
    3. IBS
    4. Sedentary lifestyle/bedrest
  2. Stool volume
    1. Lack of fiber and/or fluid intake
  3. Patency of lumen

Clinical Manifestations

  1. History – pattern, consistency, associated symptoms (pain, gas, nausea, emesis, discomfort), dietary history, PMH, exercise, family Hx, medication
  2. General status, thyroid, skin, abdominal exam, rectal, neuro

Labs: not indicated for many cases but could include CBC, TSH, metabolic, Anoscopy, abd x-ray (obstruction), colonoscopy

Treatment

  1. Underlying cause
  2. Lifestyle
    1. Increase fluids = 8 x 8oz
    2. Increase fiber = bran, fruit, vegetables, beans, whole grains
      1. Target of 20 to 35g daily (increase over 2 to 3 weeks)
  3. Bulk-forming agents = high fiber, increase volume
    1. Side effects = bloating, gas
    2. Take with water
    3. Metamucil (psyllium) – 1 tablespoon qd to TID
    4. Citrucel (methylcellulose) – 1 to 3 tablespoons qd
    5. FiberCon (polycarbophil) – 1 tablet qd-tid
  4. Osmotic Laxative = nonabsorbale solutes -> draw fluid in
    1. Milk of Magnesia (Magnesium salts) = 2 to 4 tablets daily (5 to 10g)
      1. 400/5ml = 5 to 15ml up to 4 times daily
    2. PEG (Miralax, GoLytely) = 17 g powder dissolve 8 ozz water daily
      1. Titrate up to 34g daily
    3. Sorbitol 70% = 2-4 tablespoons daily (30g or 120mL)
    4. Lactulose = 1-2 tablespoons daily (10 -20g, 15 -30 mL)
    5. Side effects = bloating, gas, cramping
    6. Don’t give if renal failure
  5. Stimulant Agents -> stimulate smooth muscle
    1. Ex-Lax (phenolphthalein)
    2. Dulcolax (Bisacodyl) = 1-2 tablets daily (10 to 30mg)
    3. Senna (Senokot) = 2-3 tablets daily, 1-3 teaspoons (8.6mg)
  6. Stool Softners – decreases surface tension ->water and fat can mix
    1. Colace (Docusate) – for hard stools
      1. 1-2 (100mg) capsules daily
  7. Enemas & Suppositories ->stimulate rectum
  8. Linaclotide (Linzess) = 145 mocrograms daily for chronic idiopathic constipation
  9. Lubiprostone (amitiz) = 24mcg twice daily for CIC, IBS, Opioid induced
  10. Misprostol = 200 mcg daily or every other day give with 34g Miralax
  11. Cochicine = 0.6 mg TID