Constipation & Diarrhoea

Constipation is generally defined as infrequent and/or unsatisfactory defecation fewer than 3 times per week.
Patients may define constipation as passing hard stools or straining, incomplete or painful defecation. It's a symptom NOT a disease.
Constipation has many causes and may be a sign of undiagnosed disease.

1. Vinay Gupta Department of pharmacology Up rural institute of medical sciences & research Saifai , etawah , india

2. Toilet Troubles Constipation affects twice as many women as men.

3. What is constipation? Constipation is generally defined as infrequent and/or unsatisfactory defecation fewer than 3 times per week. Patients may define constipation as passing hard stools or straining, incomplete or painful defecation. Constipation is a symptom, NOT a disease. Constipation has many causes and may be a sign of undiagnosed disease.

4. Risk factors for constipation The following factors can increase a person’s likelihood of becoming constipated; however, these do not need to be present for constipation to occur: Female gender - Pregnancy Over 65 years of age Low caloric intake (eating less food) Greater number of medications used Sedentary lifestyle (lack of exercise) Ignoring the urge to defecate Smoking – Tobacco addiction

5. Prevention of constipation High fibre diet M inimum fluid consumption of 1500mL daily Regular, private toilet routine Heed the urge to defecate Use of a laxative if using constipating medication or in presence of diseases associated with constipation

6. I’m constipated, now what? Two approaches to consider: Non-drug Approach Drug Approach

7. constipation A) Acute – functional Constipation B) Chronic – Organic Constipation A) Acute – functional Constipation -Dehydration - Acute illness -Sedentary Life style -Lack of dietary fibers -Acute intestinal Obstruction

8. B) Chronic – Organic Constipation Endocrine disorder Psychiatric disorder Drug Induces Anorectal disorder Pelvic disorder Metabolic disorder

9. classification Drug Measures: Purgatives / Cathartics / Aperients / Evacuant / Laxatives Laxatives / Aperients – milder in action, elimination of soft & formed stool. Purgatives / Cathartics - Stronger in action, evacuation of more fluids. Many drugs act in low concentration as laxatives & in high concentration as purgatives.

10. There are many different types of drugs that can be used for constipation: 1) Bulk-forming Agents 2) Stool Softeners 3) Osmotics 4) Stimulants

11. I’m constipated, now what? 1) Bulk-Forming Agents: Are the drug of choice for prevention; not for immediate relief. Dietary fibers Bran Ispaghula husk (seeds of Plantago ovata ) Methyl cellulose

12. 2) Stool Softeners Docusate (DOSS) – Di Octyl Sodium Sulfosuccinate Liquid Paraffin Eg – Cremmafin ( Liq Paraffin + Mag sulphate)

13. 3) Osmotics : Magnesium salts (Hydroxide & Sulphate) Sodium salts (Sulphate & Phospahte ) Sod. Pot. Tartrate Lactulose Eg - Milk of Magnesia

14. 4) Stimulants: A) Diphenyl Methanes Phenolphthalin Bisacodyl Sod. Picosulfate B) Anthraquinones (glycosides) Seena (Cassia) Cascara sargada C) 5-HT 4 agonist – Tegaserod D) Fixed oil – Castor Oil emulsion -Examples: Senokot , Dulcolax ( bisacodyl ) -This group produces rhythmic muscle contractions in the intestines and may be recommended if osmotic laxatives fail or are not tolerated . -Are usually given at bedtime and they usually provide overnight relief (work within 8-12 hours).

15. Summary Constipation is very common in the elderly and nursing home residents. There are many causes of constipation; it should be considered a symptom, not a disease. There are many options for prevention and treatment. The choice should be tailored to each individual person. Talk to your health care provider if you have any concerns or if constipation lasts for longer than one week.

16. Diarrhoea

17. -Increase in frequency, size or loosening of bowel movements. -Differentiate from fecal incontinence or functional bowel disease- normal stool weight

18. Pathophysiology Increased active anion secretion Decreased absorption of water and electrolytes

19. Types Transmissible agents Noninfectious - abnormal mucosa Inflammatory Bowel disease Celiac disease, microscopic colitis, eosinophilic and allergic gastroenteritis, radiation enteritis Noninfectious - normal mucosa Osmotic diarrhea Mal-absorption

20. Infectious diarrhea Mostly feco-oral route Bacterial Viral Parasitic

21. Bacterial Watery Enterotoxigenic- Vibrio cholera Enterotoxigenic E.coli Food borne toxins- Bacillus cereus Clostridium perfringens Mycobacterium avium-intracellular complex

22. Bacterial Bloody Invasive Campylobacter jejuni Destructive Shigella Enteropathogenic E.coli Clostridium difficile

23. Viral Rotavirus Children less than 2 years Most common cause of diarrhea in children all over the world Norwalk Older children and adults These viruses injure the small intestinal mucosa Watery diarrhea CMV Immunocompromised

24. Parasitic Protozoa Giardia lamblia Entamoeba histolytica Cryptosporidium Helminths Ascaris lumbricoides Ancylostoma Strongyloides stercoralis Trichinella spiralis Capillaria philippensis

25. History Is it truly diarrhea? Duration- acute <3 weeks Chronic >4 weeks Texture Frequency Blood?

26. Physical Chronic diarrhea Malnutrition Weight loss Muscle wasting Tetany Oral and skin lesions Peripheral neuropathy Ataxia Edema

27. Labs Stool culture Positive in only 40 to 60% Stool for ova and parasites Stool for Clostridium difficile toxin Stool Sudan test for fat Stool Electrolytes-differentiates secretory diarrhea from osmotic diarrhea Stool pH-<7 indicates carbohydrate malabsorption

28. Management Fluid therapy Persons with moderate to severe diarrhea lose large amounts of Na, CL, K, HCO3 & H20 Pre renal azotemia, hypokalemia, metabolic acidosis ORS IV Fluids

29. ORS-principle Saline solution (water plus Na+) by mouth - no beneficial effect Na+ absorption is impaired in the diarrhoeal state if the Na+ is not absorbed water cannot be absorbed. Excess Na+ in the lumen of the intestine causes increased secretion of water and the diarrhoea worsens.

30. ORS Glucose - absorbed through the intestinal wall - unaffected by the diarrhoeal disease state - sodium is carried in conjunction through by a co-transport coupling mechanism. This occurs in a 1:1 ratio, one molecule of glucose co-transporting one sodium ion (Na+).

31. Starch – metabolized in the intestine to glucose and therefore it has the same properties of enhancing sodium absorption less osmotic effect in the lumen of the intestine.

32. Citrate, a base precursor, corrects acidosis and enhances the absorption of water and electrolytes

33. ORS-History First developed in the early 1950’s and was formulated to mirror ions lost in stool. In the early 1960’s the mechanism by which ORT works, the coupled transport of sodium and glucose, was discovered. 6 In 1971, the efficacy of ORT demonstrated during an epidemic of cholera in a refugee camp in Bangladesh. ORT reduced the death rate from more than 50% to only 5%. 7 By the early 1970’s a consensus was reached about the effectiveness of ORT.

34. ORS Sodium Chloride - 2.6gm -3.5 gm Potassium Chloride- 1.5 gm -1.5gm Tri Sod Citrate- 2.9 gm -2.9gm Glucose 13.5 gm -20gm

35. IV Fluids Must contain Potassium and a base Ringer’s lactate

36. Chronic Diarrheas Zn and Magnesium replacement

37. Antimotility agents Should be avoided Concern for promoting bacterial invasion or prolonging the infection

38. Good nutrition and hygiene can prevent most diarrhea. Thank You!