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Constipation

Updated : September 2, 2023





Background

Constipation is a common digestive disorder characterized by infrequent bowel movements or difficulty passing stools. It is a prevalent condition that affects people of all ages and can have various underlying causes. Here is an overview of the background and factors related to constipation.

Constipation is typically defined as having lesser than three bowel movements for a week. The stool may be complex, dry, and difficult to pass. Other common symptoms include straining during bowel movements, a sense of incomplete evacuation, abdominal discomfort or bloating, and decreased appetite.

Causes:

  • Lifestyle Factors: Inadequate dietary fiber intake, low fluid intake, lack of physical activity, and skipping the urge to defecate can contribute to constipation.
  • Medications: Certain medications, including opioids, antidepressants, antacids containing aluminum or calcium, and some blood pressure medications, can cause constipation as a side effect.
  • Medical Conditions: It can lead to constipation, such as irritable bowel syndrome (IBS), hypothyroidism, diabetes, Parkinson’s disease, multiple sclerosis, and structural abnormalities in the colon or rectum.
  • Hormonal Changes: Hormonal fluctuations during pregnancy can slow down bowel movements and cause constipation.
  • Age and Gender: Older adults tend to experience constipation more frequently. Additionally, women may experience changes in bowel habits during their menstrual cycle.
  • Risk Factors: Certain factors can enhance the risk of developing constipation, including:
  • Diet: A low-fiber diet, high in processed foods and lacking fruits, vegetables, and whole grains, can contribute to constipation.
  • Sedentary Lifestyle: Lack of physical activity or prolonged bed rest can affect bowel function.
  • Dehydration: Insufficient fluid intake can lead to hardening of stools and difficulty passing them.
  • Stress: Chronic stress or sudden emotional changes can disrupt regular bowel movements.
  • Certain Medical Conditions: Individuals with diabetes, hypothyroidism, or neurological disorders may have a higher risk of constipation.

Treatment and Prevention:

  • Dietary Modifications: Increasing fiber intake through fruits, vegetables, whole grains, and legumes can help soften stools and promote regular bowel movements.
  • Hydration: Drinking adequate water and fluids can prevent dehydration and soften stools.
  • Exercise: Regular physical activity can stimulate bowel movements and promote healthy digestion.
  • Medications: In some cases, laxatives or stool softeners may be recommended to relieve constipation, but they should be used under the guidance of professionals and for short-term relief.
  • Lifestyle Habits: Establishing a regular bathroom routine, avoiding delaying bowel movements, and managing stress can contribute to bowel regularity.

It’s important to note that a healthcare professional should evaluate chronic or severe constipation, as it could indicate an underlying medical condition requiring specific treatment.

Epidemiology

America

Persistent constipation is widely widespread and impacts roughly 15% of individuals in the American States. In 2006, the count of medical consultations attributed to constipation reached 5.7 million, and among these, 2.7 million, visits identified constipation as the main diagnosis.

Worldwide

Globally, around 12% of individuals experience self-reported constipation, with those in the American states and the Asia-Pacific region experiencing twice the prevalence compared to their European countries.

Age

Constipation can manifest across all age groups, spanning from newborns to the elderly. There is a noticeable rise in the occurrence of constipation as individuals age, with approximately 30%-40% of adults aged 65 years and above reporting constipation as a concern. The heightened prevalence of constipation in older adults might stem from various contributory factors, including changes in dietary habits, diminished muscle tone, and physical activity, as well as the utilization of medications that can potentially induce relative dehydration or hinder colonic motility.

Sex

In the American States, self-reported cases of constipation and hospital admissions related to constipation are more prevalent among women compared to men. The general ratio of females-males is nearly 3:1. Women also tend to seek medical care for constipation more frequently. The condition is quite common during pregnancy and often persists as a problem after childbirth. The surveys which is conducted on seemingly healthy young men, women reveal a slightly higher frequency of bowel movements among women.

Race

In the American States, non-white populations exhibit a constipation prevalence that is 30% higher compared to white populations. These two populations self-reported constipation and hospital admissions related to constipation are more frequent among black individuals compared to white individuals.

For Asian populations, constipation is less common, but for those who follow a Western diet culture, it leads to more common cause to constipation.

Anatomy

Pathophysiology

The pathophysiology of constipation involves the disruption of regular bowel movements and can vary depending on the underlying cause. Here are the critical mechanisms involved:

  • Decreased Colonic Motility: One of the primary factors contributing to constipation is decreased colonic motility. The colon moves stool through a series of coordinated contractions known as peristalsis. If the contractions become sluggish or weakened, it can slow down the movement of stool, leading to its accumulation in the colon. Reduced motility can occur due to a sedentary lifestyle, inadequate fiber intake, and certain medical conditions.
  • Insufficient Stool Bulk: Adequate stool bulk is essential for regular bowel movements. It is primarily achieved through the presence of dietary fiber in the colon. Fiber adds bulk to the stool, retains water, and promotes regular bowel movements. Inadequate fiber intake can result in small, hard stools that are difficult to pass.
  • Excessive Water Absorption: In a healthy digestive system, water is absorbed from the stool as it passes through the colon. However, excessive water absorption can occur when stool remains in the colon for an extended time. It can lead to the formation of hard, dry stools, making them difficult to pass.
  • Impaired Rectal Sensation: The rectum plays a crucial role in signaling the brain when it is time to evacuate the bowels. The sensation of rectal fullness triggers the urge to have a bowel movement. In some cases of constipation, the rectal sensation may be impaired, leading to a delay in recognizing the need to defecate.
  • Pelvic Floor Dysfunction: The pelvic floor muscles helps to control the passage of stool through the rectum. Dysfunction/weakness of these muscles can result in inadequate relaxation or coordination during bowel movements. This can lead to difficulties in evacuating stool effectively.
  • Medications and Medical Conditions: Certain medications can affect the gastrointestinal tract and contribute to constipation. For example, opioids can slow down colonic motility and increase water absorption. Medical conditions such as hypothyroidism, diabetes, and neurological disorders can also disrupt normal bowel function and contribute to constipation.
  • Psychological Factors: Stress, anxiety, and other psychological factors can influence bowel function. The brain-gut axis, which involves communication between the brain and the digestive system, can be disrupted, affecting the normal movement of the colon and leading to constipation.

Etiology

The etiology of constipation refers to the underlying causes or factors that can contribute to the development of constipation. It can involve lifestyle, dietary, medical, and physiological factors. Here are some common etiological factors associated with constipation:

  • Inadequate Dietary Fiber Intake: A diet low in fiber can lead to constipation. Fiber adds bulk to the stool, retains water, and helps facilitate regular bowel movements. Insufficient intake of fruits, vegetables, whole grains, and legumes can contribute to constipation.
  • Low Fluid Intake: Dehydration or inadequate fluid intake can result in stools’ hardening and difficulty passing them. Sufficient hydration is essential for maintaining regular bowel function.
  • Sedentary Lifestyle: Lack of physical activity or a sedentary lifestyle can contribute to constipation. Regular exercise promotes healthy bowel movements by stimulating intestinal contractions.
  • Ignoring the Urge to Defecate: Ignoring or suppressing the urgeness to have a bowel movement can disrupt the natural rhythm of the digestive system and lead to constipation.
  • Medications: Certain drugs can cause constipation as a side effect. Examples include opioids, antacids containing aluminum or calcium, antidepressants, anticonvulsants, and some blood pressure medications.
  • Medical Conditions: Various medical conditions can contribute to constipation, including:
  • Neurological disorders: Parkinson’s disease, multiple sclerosis, stroke, spinal cord injuries, and autonomic neuropathy.
  • Endocrine disorders: Hypothyroidism, diabetes, and hypercalcemia.
  • Structural abnormalities: Colorectal strictures, rectal prolapse, anal fissures, and pelvic floor dysfunction.
  • Gastrointestinal disorders: Irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), intestinal obstruction, and diverticulosis.
  • Hormonal Factors: Hormonal changes can influence bowel movements. For example, hormonal fluctuations during pregnancy can slow down bowel transit time and lead to constipation.
  • Aging: Due to decreased muscle tone and reduced colonic motility, constipation becomes more prevalent with age. Older adults may also have underlying medical conditions or take medications contributing to constipation.
  • Psychological Factors: Stress, anxiety, and depression can affect bowel function. The brain-gut axis, which involves bidirectional communication between the brain and the digestive system, can be disrupted, leading to constipation.
  • Other Factors: Changes in routine, travel, certain dietary habits (such as a diet low in fat), and hormonal contraceptives can also contribute to constipation in some individuals.

Genetics

Prognostic Factors

Prognostic factors in constipation refer to the factors that can influence the outcome or long-term course of the condition. These factors can help predict the severity, duration, and response to treatment for individuals with constipation. While each case is distinctive, here are some common prognostic factors that may be considered:

  • Duration of Constipation: The duration of constipation is an important prognostic factor. Generally, acute or short-term constipation, often caused by temporary factors like dietary changes or medication use, tends to resolve with appropriate interventions. On the other hand, chronic or long-term constipation, lasting for several weeks or more, may require more comprehensive management.
  • Underlying Cause: Identifying and addressing the underlying cause of constipation can impact the prognosis. Constipation due to reversible factors, such as medication side effects or dietary deficiencies, may resolve with appropriate interventions. However, constipation associated with chronic medical conditions or structural abnormalities may require ongoing management and treatment.
  • Severity of Symptoms: The severity of constipation symptoms can influence the prognosis. Individuals with mild or occasional constipation may respond well to lifestyle modifications and dietary changes. However, those with severe symptoms, such as persistent pain, fecal impaction, or bowel obstruction, may require more intensive treatments and close medical management.
  • Response to Treatment: The response to initial treatment interventions can provide insights into the prognosis. The prognosis is generally favorable if constipation improves with lifestyle modifications, dietary changes, or over-the-counter remedies. However, if symptoms persist despite initial interventions or require prolonged use of medications, the prognosis may be more guarded, and a comprehensive evaluation may be needed to identify underlying factors.
  • Comorbidities and Medical Conditions: The presence of underlying comorbidities or medical conditions can impact the prognosis of constipation. Chronic conditions like irritable bowel syndrome (IBS), hypothyroidism, or neurological disorders may require ongoing management and influence the long-term outlook for constipation.
  • Age: Age can be a prognostic factor, as constipation becomes more prevalent with advancing age. Older adults may have age-related physiological changes, comorbidities, and medication use that can affect the prognosis. However, with appropriate interventions, constipation in older adults can often be effectively managed.
  • Compliance and Adherence: The willingness and ability of individuals to adhere to treatment recommendations and make necessary lifestyle modifications can influence the prognosis. Those who actively engage in self-care, follow treatment plans and make sustainable changes tend to have better long-term outcomes.
  • Psychological Factors: Psychological factors, like stress, anxiety, and depression, can influence the prognosis of constipation. Addressing these factors through appropriate interventions, such as counseling or stress management techniques, can improve the overall prognosis.

Clinical History

Clinical history

The clinical presentation of constipation can vary depending on factors such as age, associated comorbidities or activity levels, and the acuity of the presentation. Here’s a breakdown of how constipation may present in different scenarios:

Age Group:

Infants and Young Children: In infants, constipation may manifest as difficulty passing stools, hard or pellet-like stools, and excessive straining during bowel movements. It can be accompanied by irritability, decreased appetite, and abdominal discomfort. In older children, symptoms may include infrequent bowel movements, pain during defecation, abdominal pain, and decreased appetite.

  • Adults: Adults may experience symptoms such as infrequent bowel movements (less than three for a week), a sense of incomplete evacuation, difficulty passing stools, straining during bowel movements, abdominal discomfort or bloating, and the need for manual maneuvers to facilitate defecation.
  • Older Adults: Constipation becomes more prevalent with advancing age. In older adults, symptoms may include infrequent bowel movements, difficulty passing stools, abdominal discomfort, bloating, and a higher risk of complications such as fecal impaction or bowel obstruction.

Physical Examination

Physical examination

During a physical examination for constipation, a healthcare professional will assess various aspects to gather information about the patient’s condition. Here are some components that may be included in a physical examination for constipation:

General Examination: The healthcare professional will evaluate the patient’s appearance, vital signs (blood pressure, heart rate, and temperature), and overall well-being. This helps assess the patient’s overall health status and provides a baseline for comparison.

Abdominal Examination: The healthcare professional will perform a thorough abdominal examination to assess for any signs of distention, tenderness, or masses. They will palpate (feel) the abdomen to identify any areas of discomfort or abnormality. The presence of a firm, palpable mass may suggest fecal impaction.

Rectal Examination: A rectal examination is commonly performed to evaluate the rectum and bottom part of the colon. This may involve:

  • Digital Rectal Examination (DRE): The healthcare professional inserts a gloved, lubricated finger into rectum to assess for fecal impaction, rectal tone, and abnormalities such as rectal prolapse or masses.
  • Anoscopy or Proctoscopy: In some cases, an instrument called an anoscope or proctoscopes may be used to visually examine the rectum and lower part of the colon. This allows the healthcare professional to visualize the rectal mucosa, check for hemorrhoids, or identify structural abnormalities.
  • Neurological Examination (if relevant): A neurological examination may be performed for individuals with constipation associated with neurological conditions. This evaluation assesses motor strength, reflexes, and sensory function to identify any neurological deficits that may contribute to constipation.
  • Pelvic Floor Assessment (if relevant): A pelvic floor assessment may be conducted in cases of suspected pelvic floor dysfunction contributing to constipation. This can involve a detailed evaluation of the pelvic floor muscles’ strength, tone, and coordination through various techniques, such as digital palpation or specialized tests.
  • Additional Investigations: Further investigations may be recommended depending on the findings from physical examination and the patient’s clinical presentation. These can include laboratory tests, imaging studies (such as abdominal X-rays or colonoscopy), or specialized tests to evaluate specific underlying causes or complications.

Age group

Associated comorbidity

Associated Comorbidity or Activity: 

Pregnancy: Hormonal changes during pregnancy can contribute to constipation. Pregnant individuals may experience infrequent bowel movements, difficulty passing stools, and increased abdominal pressure.

Neurological Disorders: Constipation can be a common symptom in neurological conditions like Parkinson’s disease, multiple sclerosis, and spinal cord injuries. In addition to infrequent bowel movements, individuals may experience reduced bowel motility, impaired rectal sensation, and weakened pelvic floor muscles.

Bedridden or Immobilized Patients: Individuals who are bedridden or have limited mobility may be prone to constipation. Reduced physical activity and changes in body position can contribute to sluggish bowel movements and difficulty passing stools.

Associated activity

Acuity of presentation

Acuity of Presentation:

Acute Constipation refers to the sudden onset of constipation symptoms. It may be associated with dietary changes, dehydration, medication use, or travel. Acute constipation can cause discomfort, but it is often manageable and reversible with appropriate interventions.

Chronic Constipation: Chronic constipation refers to constipation symptoms that persist for an extended period, typically lasting for several weeks or more. Chronic constipation may be associated with underlying medical conditions (e.g., irritable bowel syndrome, hypothyroidism) or lifestyle factors. It may require a more comprehensive evaluation and long-term management strategies.

Complications: Severe or prolonged constipation can lead to complications such as fecal impaction, bowel obstruction, hemorrhoids, anal fissures, or rectal prolapse. These complications may present with additional symptoms such as severe abdominal pain, rectal bleeding, or inability to pass gas or stool.

Differential Diagnoses

Differential Diagnosis

When evaluating a patient with constipation, healthcare professionals consider various possible differential diagnoses. These are alternative conditions or factors that may present similar symptoms to constipation. Here are some common differential diagnoses to consider:

  • Normal Bowel Variation: Infrequent bowel movements or temporary changes in bowel habits can be normal variations, mainly if no associated symptoms or complications exist. However, assessing for any underlying factors or changes in bowel habits that deviate from the patient’s usual pattern is essential.
  • Irritable Bowel Syndrome (IBS): IBS is a chronic functional gastrointestinal disorder characterized by repeated abdominal pain/discomfort associated with changes in bowel habits. It can present with alternating episodes of constipation, diarrhea, and other symptoms like bloating and abdominal distention.
  • Colorectal Cancer: Although less common, colorectal cancer can present with symptoms similar to constipation, such as changes in bowel habits, persistent constipation, or the feeling of incomplete evacuation. Additional symptoms may include rectal bleeding, unexplained weight loss, or abdominal pain.
  • Hypothyroidism: It is a condition, the thyroid gland exhibits insufficient production of thyroid hormones, which can cause constipation. Other associated symptoms may include fatigue, weight gain, dry skin, and cold sensitivity.
  • Medication-Induced Constipation: Certain medications, such as opioids, antacids containing aluminum or calcium, antidepressants, anticonvulsants, and some blood pressure medications, can contribute to constipation as a side effect.
  • Neurological Disorders: Neurological conditions like Parkinson’s, multiple sclerosis, spinal cord injuries, and autonomic neuropathy can affect bowel function and lead to constipation. These conditions may present with additional neurological symptoms.
  • Structural Abnormalities: These abnormalities in the gastrointestinal tract, such as colorectal strictures, rectal prolapse, anal fissures, or tumors, can cause constipation. These conditions may be associated with specific findings on physical examination or imaging studies.
  • Metabolic Disorders: Certain metabolic disorders, such as diabetes mellitus or hypercalcemia, can affect gastrointestinal motility and contribute to constipation.
  • Pelvic Floor Dysfunction: Pelvic floor dysfunction, including disorders like dyssynergic defecation or pelvic floor muscle dysfunction, can result in difficulties with evacuation and chronic constipation.
  • Psychological Factors: Stress, anxiety, depression, or other psychological factors can affect bowel function and contribute to constipation.
  • Inflammatory Bowel Disease (IBD): Inflammatory bowel diseases like Crohn’s disease and ulcerative colitis can cause symptoms such as chronic constipation, abdominal pain, and diarrhea. These conditions often present with additional gastrointestinal symptoms and require further evaluation.

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Treating constipation involves various approaches depending on the severity, underlying causes, and individual patient factors. Here are the general strategies and phases of management commonly used for treating constipation:

Modification of Environment and Lifestyle:

  • Increase dietary fiber: Consuming a diet rich in fiber from fruits, vegetables, whole grains, and legumes can helps to add bulk to the stool and promote regular bowel movements.
  • Increase fluid intake: Drinking adequate water and staying hydrated helps soften the stool and ease its passage.
  • Regular physical activity: Regular exercise or physical activity can stimulate bowel movements and promote healthy digestion.
  • Establish a regular toilet routine: Encouraging consistent timing and allowing adequate time for bowel movements can help establish a regular pattern.
  • Encourage proper toilet posture: Sitting on the toilet with knees higher than the hips (using a footstool if needed) can facilitate more effortless bowel movements.
  • Avoid delaying or ignoring the urge to defecate: Responding promptly to the urge to have a bowel movement can help maintain a healthy bowel routine.

Administration of a Pharmaceutical Agent:

If lifestyle modifications alone do not provide sufficient relief, healthcare professionals may recommend the use of pharmaceutical agents, such as:

  • Bulk-forming agents include fiber supplements (psyllium, methylcellulose) that helps to add bulkness to the stool and promote regular bowel movements.
  • Osmotic laxatives: Examples include polyethylene glycol (PEG), lactulose, or magnesium-based laxatives. These agents help soften the stool and facilitate its passage by drawing water into the intestines.
  • Stimulant laxatives: Medications like bisacodyl or senna stimulate bowel contractions to promote bowel movements. They are typically used for short-term relief.
  • Stool softeners: Docusate sodium or docusate calcium can helps to soften the stool, making it simple to pass.

Intervention with a Procedure:

In cases where constipation is severe, chronic, or unresponsive to conservative measures and medications, healthcare professionals may consider the following interventions:

  • Manual disimpaction: Manual removal of impacted stool by a healthcare professional.
  • Enemas or suppositories: These can provide short-term relief by softening the stool or stimulating bowel movements.
  • Transanal irrigation: This technique involves using a rectal catheter and water irrigation to help empty the rectum and colon.
  • Pelvic floor physical therapy: For individuals with pelvic floor dysfunction, specialized physical therapy can help improve pelvic floor muscle coordination and bowel function.

Phase of Management:

For individuals with chronic or recurrent constipation, long-term management strategies might involve a combination of the above approaches tailored to the individual’s needs. Regular follow-ups with a healthcare professional can help monitor progress, make necessary adjustments, and ensure ongoing management of constipation.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

 

psyllium

5

g

Capsules

oral

3 times a day

1

day

Adult 19-50 years : For Males 38 g/day, Females 25 g/day, Pregnancy 28 g/day and Lactation 29 g/day



senna

Liquid of 8.8 mg/5 ml:

10 - 15

ml

Orally

once a day


Maximum dose: 30 ml orally once a day
5-15 ml orally once a day of Senna Leaves
23 mg per cup orally once a day of Sennoside Extract Tea
8.6 mg of 2 tablets orally once a day at bedtime of Sennosides
Maximum dose: 8 tablets orally once a day

15 mg of 2 tablets orally once a day of Sennosides or 17.2 mg of 1 tablet orally once a day Maximum dose: 4 tablets orally once a day 20 mg of 1 tablet orally once a day of Sennosides or 25 mg of 2 tablets orally once a day The maximum duration of therapy is one week



bisacodyl

5 - 15

mg

Orally

once a day


For complete emptying 30 mg orally once a day



magnesium hydroxide

2 to 4 chewable tablets once a day (Do not exceed 4 tablets/24hrs)



lactulose

Solution: 15-30 ml (10-20 g) orally once daily and may be increased to 60 ml (40 g) once daily

Crystals: 10-20 g orally once a day; and may increase to 40 g/day



psyllium

Adults 19-50 years:
For Males 38 g/day, Females 25 g/day, Pregnancy 28 g/day and Lactation 29 g/day
Dose:
2.5-30 g/day orally in divided doses



senna/docusate 

8.6 - 50

mg

Tablets

Orally 

every day

may increase to 4 tablets every 12 hours



magnesium citrate 

Indicated as laxative:


195–300 mL PO, either as a single dose or split doses, with a full glass of water each day
Alternatively,2 to 4 tablets orally in the night-time



naloxegol 

25 mg orally each day in morning and provide at least 1 hour prior to meals or 2 hours after meals
Lowers dose to 12.5 mg/day if patient not able to resist 25 mg/day



bisacodyl rectal 

Enema: 1 bottle contents (i.e., 37 mL) rectally in a single dosage
Suppository: Remove the outer wrap & insert one suppository into the rectum



polyethylene glycol and electrolytes 

Mix 17g of each packet in 120 to 240 mL (4 to 8 oz) daily.
Unless otherwise ordered by a doctor, discontinue usage if symptoms persist for more than two to four weeks.



sorbitol 

Take dose of 30 to 150 ml orally one time
Rectal enema: Inject 120 ml of 25 to 30% solution one time



naldemedine 

Indicated for constipation induced by opioids in patients with chronic non-cancerous pain
0.2 mg orally each day



naldemedine 

Indicated for constipation induced by opioids in patients with chronic non-cancerous pain
0.2 mg orally each day
Dosage Modifications
In the case of hepatic impairment/ severe Child-Pugh C, avoid the usage of naldemedine



castor oil 


Indicated for Constipation
15ml-60ml orally one time a day
Colonic Evacuation
15ml-60ml orally one time a day, 16 hours prior to procedure



lubiprostone 

Opioid-Induced:

24 mcg orally 2 times a day



Dose Adjustments

Dosage Modifications
Hepatic impairment
Mild: dose adjustment is not necessary
Moderate (Child-Pugh score B)
CIC or OIC: 16 mcg orally 2 times a day; if the modified dosage is tolerated and not enough response has been produced after the appropriate time interval
IBS-C: dose adjustment is not necessary
Severe (Child-Pugh score C)
CIC or OIC: 8 mcg orally 2 times a day
IBS-C: 8 mcg orally everyday
if the modified dosage is tolerated and not enough response has been produced after the appropriate time interval

 

senna

Oral:
Sennosides:
Syrup (8.8 mg sennosides/5 mL):
Age: 2 to <6 years
2.5-3.75 ml orally at bedtime in divided doses
Age: 6 to <12 years
5-7.5 ml orally at bedtime in divided doses
Age: ≥12 years
10-15 ml orally at bedtime in divided doses
Tablets:
8.6 mg sennosides per tablet:
Age: 2 to <6 years
1/2 tablet orally at bedtime in divided doses
Age: 6 to <12 years:
1 tablet orally at bedtime in divided doses
Age: ≥12 years
2 tablets orally at bedtime in divided doses
15 mg sennosides-tablet:
Age: 6 to <12 years:
1 tablet orally in divided doses
Age: ≥12 years
2 tablets orally in divided doses
25 mg sennosides-tablet:
Age: 6 to <12 years:
1 tablet orally in divided doses
Age: ≥12 years
2 tablets orally in divided doses



bisacodyl

Age: 6-12 years
5 mg or 0.3 mg/kg orally at bedtime
Age: >12 years
5-15 mg orally at bedtime



magnesium hydroxide

Chronic: infants: 80 to 240 mg/kg in two divided doses per day.
Occasional:
2 to <6 years: 400 to 1200 mg/day in two divided doses.
6 to <12 years: 1200 to 2400 mg/day in two divided doses.
>12 years: 2400 to 4800 mg/day in two divided doses.



lactulose

0.7-2 g per kg once a day or 1-3 ml/kg once aday orally in divided doses.
do not exceed 40 g/day



magnesium sulfate

2 doses orally per day
Age: >12 years
2-4 teaspoons dissolved in 8 ounces water
Age: 6 to 11 years
1 to 2 teaspoons dissolved in 8 ounces of water
Age: Under 6 years:
Not recommended



psyllium

Age:6 to 11 years
1.25 to 15 g/day orally in divided doses
Age: ≥12 years
2.5 to 30 g/day orally in divided doses



senna/docusate 

8.6 - 50

mg

Tablet

Orally 

every day

<2 years: Safety and efficacy not established
2-6 years: one-half tablet orally every day, increase up to 1 tablet every 12 hours
6-12 years: one-half tablet orally every day, do not exceed two tablets for every 12 hours
>12 years:2-4 tablets orally every day or every 12 hours



magnesium citrate 

<2 years: Safety and Efficacy not established
2 to 6 years: 60 to 90ml orally in a single or divided dose. Do not exceed 90ml for 24 hours
6 to 12 years: 90 to 210ml orally in a single dose or divided doses with a full glass of water
>12 years: 195 to 300ml orally in a single dose or in divided doses with a full glass of water
Administer 2 to 4 tablets orally before bedtime



magnesium oxide 

For children who are 12 years of age or older
The recommended dosage is 2 to 4 caplets to be taken orally each day either as a single administration or divided into multiple doses
It is important not to exceed a maximum of 4 caplets within a 24-hour period
This therapy should be limited to a duration of 7 days or less



linaclotide 

Indicated for Functional Constipation:


Administer 72mg orally every day



bisacodyl rectal 

Enema
Above 12 yrs: As adults; 1 bottle contents (i.e., 37 mL) rectally in a single dosage
Suppository
6 to 12 yrs: Remove the outer wrap & insert one-half suppository into the rectum
Above 12 yrs: As adults; Remove the outer wrap & insert one suppository into the rectum



polyethylene glycol and electrolytes 

Neonates: Safety and efficacy not established
Adults, children, and infants: Administer 0.2 to 0.8g/kg/day orally
Do not exceed 17g/day
Do not administer for more than two weeks



polyethylene glycol and electrolytes 

Neonates: Safety and efficacy not established
Adults, children, and infants: Administer 0.2 to 0.8g/kg/day orally
Do not exceed 17g/day
Do not administer for more than two weeks



sorbitol 

Safety and efficacy not determined in less than two years old
2 to 11 years:
Take 2 ml/kg orally one time
Rectal enema: inject 30 to 60 ml as 25 to 30% solution
≥12 years:
Take dose of 30 to 150 ml orally one time
Rectal enema: inject 120 ml of 25 to 30% solution one time



castor oil 


Indicated for Constipation
Age >12 years
15ml-60ml orally one time a day
Age 2-12 years
5ml-15ml orally one time a day
Age <2 years
1ml-5ml orally one time a day



 

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Constipation

Updated : September 2, 2023




Constipation is a common digestive disorder characterized by infrequent bowel movements or difficulty passing stools. It is a prevalent condition that affects people of all ages and can have various underlying causes. Here is an overview of the background and factors related to constipation.

Constipation is typically defined as having lesser than three bowel movements for a week. The stool may be complex, dry, and difficult to pass. Other common symptoms include straining during bowel movements, a sense of incomplete evacuation, abdominal discomfort or bloating, and decreased appetite.

Causes:

  • Lifestyle Factors: Inadequate dietary fiber intake, low fluid intake, lack of physical activity, and skipping the urge to defecate can contribute to constipation.
  • Medications: Certain medications, including opioids, antidepressants, antacids containing aluminum or calcium, and some blood pressure medications, can cause constipation as a side effect.
  • Medical Conditions: It can lead to constipation, such as irritable bowel syndrome (IBS), hypothyroidism, diabetes, Parkinson’s disease, multiple sclerosis, and structural abnormalities in the colon or rectum.
  • Hormonal Changes: Hormonal fluctuations during pregnancy can slow down bowel movements and cause constipation.
  • Age and Gender: Older adults tend to experience constipation more frequently. Additionally, women may experience changes in bowel habits during their menstrual cycle.
  • Risk Factors: Certain factors can enhance the risk of developing constipation, including:
  • Diet: A low-fiber diet, high in processed foods and lacking fruits, vegetables, and whole grains, can contribute to constipation.
  • Sedentary Lifestyle: Lack of physical activity or prolonged bed rest can affect bowel function.
  • Dehydration: Insufficient fluid intake can lead to hardening of stools and difficulty passing them.
  • Stress: Chronic stress or sudden emotional changes can disrupt regular bowel movements.
  • Certain Medical Conditions: Individuals with diabetes, hypothyroidism, or neurological disorders may have a higher risk of constipation.

Treatment and Prevention:

  • Dietary Modifications: Increasing fiber intake through fruits, vegetables, whole grains, and legumes can help soften stools and promote regular bowel movements.
  • Hydration: Drinking adequate water and fluids can prevent dehydration and soften stools.
  • Exercise: Regular physical activity can stimulate bowel movements and promote healthy digestion.
  • Medications: In some cases, laxatives or stool softeners may be recommended to relieve constipation, but they should be used under the guidance of professionals and for short-term relief.
  • Lifestyle Habits: Establishing a regular bathroom routine, avoiding delaying bowel movements, and managing stress can contribute to bowel regularity.

It’s important to note that a healthcare professional should evaluate chronic or severe constipation, as it could indicate an underlying medical condition requiring specific treatment.

America

Persistent constipation is widely widespread and impacts roughly 15% of individuals in the American States. In 2006, the count of medical consultations attributed to constipation reached 5.7 million, and among these, 2.7 million, visits identified constipation as the main diagnosis.

Worldwide

Globally, around 12% of individuals experience self-reported constipation, with those in the American states and the Asia-Pacific region experiencing twice the prevalence compared to their European countries.

Age

Constipation can manifest across all age groups, spanning from newborns to the elderly. There is a noticeable rise in the occurrence of constipation as individuals age, with approximately 30%-40% of adults aged 65 years and above reporting constipation as a concern. The heightened prevalence of constipation in older adults might stem from various contributory factors, including changes in dietary habits, diminished muscle tone, and physical activity, as well as the utilization of medications that can potentially induce relative dehydration or hinder colonic motility.

Sex

In the American States, self-reported cases of constipation and hospital admissions related to constipation are more prevalent among women compared to men. The general ratio of females-males is nearly 3:1. Women also tend to seek medical care for constipation more frequently. The condition is quite common during pregnancy and often persists as a problem after childbirth. The surveys which is conducted on seemingly healthy young men, women reveal a slightly higher frequency of bowel movements among women.

Race

In the American States, non-white populations exhibit a constipation prevalence that is 30% higher compared to white populations. These two populations self-reported constipation and hospital admissions related to constipation are more frequent among black individuals compared to white individuals.

For Asian populations, constipation is less common, but for those who follow a Western diet culture, it leads to more common cause to constipation.

The pathophysiology of constipation involves the disruption of regular bowel movements and can vary depending on the underlying cause. Here are the critical mechanisms involved:

  • Decreased Colonic Motility: One of the primary factors contributing to constipation is decreased colonic motility. The colon moves stool through a series of coordinated contractions known as peristalsis. If the contractions become sluggish or weakened, it can slow down the movement of stool, leading to its accumulation in the colon. Reduced motility can occur due to a sedentary lifestyle, inadequate fiber intake, and certain medical conditions.
  • Insufficient Stool Bulk: Adequate stool bulk is essential for regular bowel movements. It is primarily achieved through the presence of dietary fiber in the colon. Fiber adds bulk to the stool, retains water, and promotes regular bowel movements. Inadequate fiber intake can result in small, hard stools that are difficult to pass.
  • Excessive Water Absorption: In a healthy digestive system, water is absorbed from the stool as it passes through the colon. However, excessive water absorption can occur when stool remains in the colon for an extended time. It can lead to the formation of hard, dry stools, making them difficult to pass.
  • Impaired Rectal Sensation: The rectum plays a crucial role in signaling the brain when it is time to evacuate the bowels. The sensation of rectal fullness triggers the urge to have a bowel movement. In some cases of constipation, the rectal sensation may be impaired, leading to a delay in recognizing the need to defecate.
  • Pelvic Floor Dysfunction: The pelvic floor muscles helps to control the passage of stool through the rectum. Dysfunction/weakness of these muscles can result in inadequate relaxation or coordination during bowel movements. This can lead to difficulties in evacuating stool effectively.
  • Medications and Medical Conditions: Certain medications can affect the gastrointestinal tract and contribute to constipation. For example, opioids can slow down colonic motility and increase water absorption. Medical conditions such as hypothyroidism, diabetes, and neurological disorders can also disrupt normal bowel function and contribute to constipation.
  • Psychological Factors: Stress, anxiety, and other psychological factors can influence bowel function. The brain-gut axis, which involves communication between the brain and the digestive system, can be disrupted, affecting the normal movement of the colon and leading to constipation.

The etiology of constipation refers to the underlying causes or factors that can contribute to the development of constipation. It can involve lifestyle, dietary, medical, and physiological factors. Here are some common etiological factors associated with constipation:

  • Inadequate Dietary Fiber Intake: A diet low in fiber can lead to constipation. Fiber adds bulk to the stool, retains water, and helps facilitate regular bowel movements. Insufficient intake of fruits, vegetables, whole grains, and legumes can contribute to constipation.
  • Low Fluid Intake: Dehydration or inadequate fluid intake can result in stools’ hardening and difficulty passing them. Sufficient hydration is essential for maintaining regular bowel function.
  • Sedentary Lifestyle: Lack of physical activity or a sedentary lifestyle can contribute to constipation. Regular exercise promotes healthy bowel movements by stimulating intestinal contractions.
  • Ignoring the Urge to Defecate: Ignoring or suppressing the urgeness to have a bowel movement can disrupt the natural rhythm of the digestive system and lead to constipation.
  • Medications: Certain drugs can cause constipation as a side effect. Examples include opioids, antacids containing aluminum or calcium, antidepressants, anticonvulsants, and some blood pressure medications.
  • Medical Conditions: Various medical conditions can contribute to constipation, including:
  • Neurological disorders: Parkinson’s disease, multiple sclerosis, stroke, spinal cord injuries, and autonomic neuropathy.
  • Endocrine disorders: Hypothyroidism, diabetes, and hypercalcemia.
  • Structural abnormalities: Colorectal strictures, rectal prolapse, anal fissures, and pelvic floor dysfunction.
  • Gastrointestinal disorders: Irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), intestinal obstruction, and diverticulosis.
  • Hormonal Factors: Hormonal changes can influence bowel movements. For example, hormonal fluctuations during pregnancy can slow down bowel transit time and lead to constipation.
  • Aging: Due to decreased muscle tone and reduced colonic motility, constipation becomes more prevalent with age. Older adults may also have underlying medical conditions or take medications contributing to constipation.
  • Psychological Factors: Stress, anxiety, and depression can affect bowel function. The brain-gut axis, which involves bidirectional communication between the brain and the digestive system, can be disrupted, leading to constipation.
  • Other Factors: Changes in routine, travel, certain dietary habits (such as a diet low in fat), and hormonal contraceptives can also contribute to constipation in some individuals.

Prognostic factors in constipation refer to the factors that can influence the outcome or long-term course of the condition. These factors can help predict the severity, duration, and response to treatment for individuals with constipation. While each case is distinctive, here are some common prognostic factors that may be considered:

  • Duration of Constipation: The duration of constipation is an important prognostic factor. Generally, acute or short-term constipation, often caused by temporary factors like dietary changes or medication use, tends to resolve with appropriate interventions. On the other hand, chronic or long-term constipation, lasting for several weeks or more, may require more comprehensive management.
  • Underlying Cause: Identifying and addressing the underlying cause of constipation can impact the prognosis. Constipation due to reversible factors, such as medication side effects or dietary deficiencies, may resolve with appropriate interventions. However, constipation associated with chronic medical conditions or structural abnormalities may require ongoing management and treatment.
  • Severity of Symptoms: The severity of constipation symptoms can influence the prognosis. Individuals with mild or occasional constipation may respond well to lifestyle modifications and dietary changes. However, those with severe symptoms, such as persistent pain, fecal impaction, or bowel obstruction, may require more intensive treatments and close medical management.
  • Response to Treatment: The response to initial treatment interventions can provide insights into the prognosis. The prognosis is generally favorable if constipation improves with lifestyle modifications, dietary changes, or over-the-counter remedies. However, if symptoms persist despite initial interventions or require prolonged use of medications, the prognosis may be more guarded, and a comprehensive evaluation may be needed to identify underlying factors.
  • Comorbidities and Medical Conditions: The presence of underlying comorbidities or medical conditions can impact the prognosis of constipation. Chronic conditions like irritable bowel syndrome (IBS), hypothyroidism, or neurological disorders may require ongoing management and influence the long-term outlook for constipation.
  • Age: Age can be a prognostic factor, as constipation becomes more prevalent with advancing age. Older adults may have age-related physiological changes, comorbidities, and medication use that can affect the prognosis. However, with appropriate interventions, constipation in older adults can often be effectively managed.
  • Compliance and Adherence: The willingness and ability of individuals to adhere to treatment recommendations and make necessary lifestyle modifications can influence the prognosis. Those who actively engage in self-care, follow treatment plans and make sustainable changes tend to have better long-term outcomes.
  • Psychological Factors: Psychological factors, like stress, anxiety, and depression, can influence the prognosis of constipation. Addressing these factors through appropriate interventions, such as counseling or stress management techniques, can improve the overall prognosis.

Clinical history

The clinical presentation of constipation can vary depending on factors such as age, associated comorbidities or activity levels, and the acuity of the presentation. Here’s a breakdown of how constipation may present in different scenarios:

Age Group:

Infants and Young Children: In infants, constipation may manifest as difficulty passing stools, hard or pellet-like stools, and excessive straining during bowel movements. It can be accompanied by irritability, decreased appetite, and abdominal discomfort. In older children, symptoms may include infrequent bowel movements, pain during defecation, abdominal pain, and decreased appetite.

  • Adults: Adults may experience symptoms such as infrequent bowel movements (less than three for a week), a sense of incomplete evacuation, difficulty passing stools, straining during bowel movements, abdominal discomfort or bloating, and the need for manual maneuvers to facilitate defecation.
  • Older Adults: Constipation becomes more prevalent with advancing age. In older adults, symptoms may include infrequent bowel movements, difficulty passing stools, abdominal discomfort, bloating, and a higher risk of complications such as fecal impaction or bowel obstruction.

Physical examination

During a physical examination for constipation, a healthcare professional will assess various aspects to gather information about the patient’s condition. Here are some components that may be included in a physical examination for constipation:

General Examination: The healthcare professional will evaluate the patient’s appearance, vital signs (blood pressure, heart rate, and temperature), and overall well-being. This helps assess the patient’s overall health status and provides a baseline for comparison.

Abdominal Examination: The healthcare professional will perform a thorough abdominal examination to assess for any signs of distention, tenderness, or masses. They will palpate (feel) the abdomen to identify any areas of discomfort or abnormality. The presence of a firm, palpable mass may suggest fecal impaction.

Rectal Examination: A rectal examination is commonly performed to evaluate the rectum and bottom part of the colon. This may involve:

  • Digital Rectal Examination (DRE): The healthcare professional inserts a gloved, lubricated finger into rectum to assess for fecal impaction, rectal tone, and abnormalities such as rectal prolapse or masses.
  • Anoscopy or Proctoscopy: In some cases, an instrument called an anoscope or proctoscopes may be used to visually examine the rectum and lower part of the colon. This allows the healthcare professional to visualize the rectal mucosa, check for hemorrhoids, or identify structural abnormalities.
  • Neurological Examination (if relevant): A neurological examination may be performed for individuals with constipation associated with neurological conditions. This evaluation assesses motor strength, reflexes, and sensory function to identify any neurological deficits that may contribute to constipation.
  • Pelvic Floor Assessment (if relevant): A pelvic floor assessment may be conducted in cases of suspected pelvic floor dysfunction contributing to constipation. This can involve a detailed evaluation of the pelvic floor muscles’ strength, tone, and coordination through various techniques, such as digital palpation or specialized tests.
  • Additional Investigations: Further investigations may be recommended depending on the findings from physical examination and the patient’s clinical presentation. These can include laboratory tests, imaging studies (such as abdominal X-rays or colonoscopy), or specialized tests to evaluate specific underlying causes or complications.

Associated Comorbidity or Activity: 

Pregnancy: Hormonal changes during pregnancy can contribute to constipation. Pregnant individuals may experience infrequent bowel movements, difficulty passing stools, and increased abdominal pressure.

Neurological Disorders: Constipation can be a common symptom in neurological conditions like Parkinson’s disease, multiple sclerosis, and spinal cord injuries. In addition to infrequent bowel movements, individuals may experience reduced bowel motility, impaired rectal sensation, and weakened pelvic floor muscles.

Bedridden or Immobilized Patients: Individuals who are bedridden or have limited mobility may be prone to constipation. Reduced physical activity and changes in body position can contribute to sluggish bowel movements and difficulty passing stools.

Acuity of Presentation:

Acute Constipation refers to the sudden onset of constipation symptoms. It may be associated with dietary changes, dehydration, medication use, or travel. Acute constipation can cause discomfort, but it is often manageable and reversible with appropriate interventions.

Chronic Constipation: Chronic constipation refers to constipation symptoms that persist for an extended period, typically lasting for several weeks or more. Chronic constipation may be associated with underlying medical conditions (e.g., irritable bowel syndrome, hypothyroidism) or lifestyle factors. It may require a more comprehensive evaluation and long-term management strategies.

Complications: Severe or prolonged constipation can lead to complications such as fecal impaction, bowel obstruction, hemorrhoids, anal fissures, or rectal prolapse. These complications may present with additional symptoms such as severe abdominal pain, rectal bleeding, or inability to pass gas or stool.

Differential Diagnosis

When evaluating a patient with constipation, healthcare professionals consider various possible differential diagnoses. These are alternative conditions or factors that may present similar symptoms to constipation. Here are some common differential diagnoses to consider:

  • Normal Bowel Variation: Infrequent bowel movements or temporary changes in bowel habits can be normal variations, mainly if no associated symptoms or complications exist. However, assessing for any underlying factors or changes in bowel habits that deviate from the patient’s usual pattern is essential.
  • Irritable Bowel Syndrome (IBS): IBS is a chronic functional gastrointestinal disorder characterized by repeated abdominal pain/discomfort associated with changes in bowel habits. It can present with alternating episodes of constipation, diarrhea, and other symptoms like bloating and abdominal distention.
  • Colorectal Cancer: Although less common, colorectal cancer can present with symptoms similar to constipation, such as changes in bowel habits, persistent constipation, or the feeling of incomplete evacuation. Additional symptoms may include rectal bleeding, unexplained weight loss, or abdominal pain.
  • Hypothyroidism: It is a condition, the thyroid gland exhibits insufficient production of thyroid hormones, which can cause constipation. Other associated symptoms may include fatigue, weight gain, dry skin, and cold sensitivity.
  • Medication-Induced Constipation: Certain medications, such as opioids, antacids containing aluminum or calcium, antidepressants, anticonvulsants, and some blood pressure medications, can contribute to constipation as a side effect.
  • Neurological Disorders: Neurological conditions like Parkinson’s, multiple sclerosis, spinal cord injuries, and autonomic neuropathy can affect bowel function and lead to constipation. These conditions may present with additional neurological symptoms.
  • Structural Abnormalities: These abnormalities in the gastrointestinal tract, such as colorectal strictures, rectal prolapse, anal fissures, or tumors, can cause constipation. These conditions may be associated with specific findings on physical examination or imaging studies.
  • Metabolic Disorders: Certain metabolic disorders, such as diabetes mellitus or hypercalcemia, can affect gastrointestinal motility and contribute to constipation.
  • Pelvic Floor Dysfunction: Pelvic floor dysfunction, including disorders like dyssynergic defecation or pelvic floor muscle dysfunction, can result in difficulties with evacuation and chronic constipation.
  • Psychological Factors: Stress, anxiety, depression, or other psychological factors can affect bowel function and contribute to constipation.
  • Inflammatory Bowel Disease (IBD): Inflammatory bowel diseases like Crohn’s disease and ulcerative colitis can cause symptoms such as chronic constipation, abdominal pain, and diarrhea. These conditions often present with additional gastrointestinal symptoms and require further evaluation.

Treating constipation involves various approaches depending on the severity, underlying causes, and individual patient factors. Here are the general strategies and phases of management commonly used for treating constipation:

Modification of Environment and Lifestyle:

  • Increase dietary fiber: Consuming a diet rich in fiber from fruits, vegetables, whole grains, and legumes can helps to add bulk to the stool and promote regular bowel movements.
  • Increase fluid intake: Drinking adequate water and staying hydrated helps soften the stool and ease its passage.
  • Regular physical activity: Regular exercise or physical activity can stimulate bowel movements and promote healthy digestion.
  • Establish a regular toilet routine: Encouraging consistent timing and allowing adequate time for bowel movements can help establish a regular pattern.
  • Encourage proper toilet posture: Sitting on the toilet with knees higher than the hips (using a footstool if needed) can facilitate more effortless bowel movements.
  • Avoid delaying or ignoring the urge to defecate: Responding promptly to the urge to have a bowel movement can help maintain a healthy bowel routine.

Administration of a Pharmaceutical Agent:

If lifestyle modifications alone do not provide sufficient relief, healthcare professionals may recommend the use of pharmaceutical agents, such as:

  • Bulk-forming agents include fiber supplements (psyllium, methylcellulose) that helps to add bulkness to the stool and promote regular bowel movements.
  • Osmotic laxatives: Examples include polyethylene glycol (PEG), lactulose, or magnesium-based laxatives. These agents help soften the stool and facilitate its passage by drawing water into the intestines.
  • Stimulant laxatives: Medications like bisacodyl or senna stimulate bowel contractions to promote bowel movements. They are typically used for short-term relief.
  • Stool softeners: Docusate sodium or docusate calcium can helps to soften the stool, making it simple to pass.

Intervention with a Procedure:

In cases where constipation is severe, chronic, or unresponsive to conservative measures and medications, healthcare professionals may consider the following interventions:

  • Manual disimpaction: Manual removal of impacted stool by a healthcare professional.
  • Enemas or suppositories: These can provide short-term relief by softening the stool or stimulating bowel movements.
  • Transanal irrigation: This technique involves using a rectal catheter and water irrigation to help empty the rectum and colon.
  • Pelvic floor physical therapy: For individuals with pelvic floor dysfunction, specialized physical therapy can help improve pelvic floor muscle coordination and bowel function.

Phase of Management:

For individuals with chronic or recurrent constipation, long-term management strategies might involve a combination of the above approaches tailored to the individual’s needs. Regular follow-ups with a healthcare professional can help monitor progress, make necessary adjustments, and ensure ongoing management of constipation.

psyllium

5

g

Capsules

oral

3 times a day

1

day

Adult 19-50 years : For Males 38 g/day, Females 25 g/day, Pregnancy 28 g/day and Lactation 29 g/day



senna

Liquid of 8.8 mg/5 ml:

10 - 15

ml

Orally

once a day


Maximum dose: 30 ml orally once a day
5-15 ml orally once a day of Senna Leaves
23 mg per cup orally once a day of Sennoside Extract Tea
8.6 mg of 2 tablets orally once a day at bedtime of Sennosides
Maximum dose: 8 tablets orally once a day

15 mg of 2 tablets orally once a day of Sennosides or 17.2 mg of 1 tablet orally once a day Maximum dose: 4 tablets orally once a day 20 mg of 1 tablet orally once a day of Sennosides or 25 mg of 2 tablets orally once a day The maximum duration of therapy is one week



bisacodyl

5 - 15

mg

Orally

once a day


For complete emptying 30 mg orally once a day



magnesium hydroxide

2 to 4 chewable tablets once a day (Do not exceed 4 tablets/24hrs)



lactulose

Solution: 15-30 ml (10-20 g) orally once daily and may be increased to 60 ml (40 g) once daily

Crystals: 10-20 g orally once a day; and may increase to 40 g/day



psyllium

Adults 19-50 years:
For Males 38 g/day, Females 25 g/day, Pregnancy 28 g/day and Lactation 29 g/day
Dose:
2.5-30 g/day orally in divided doses



senna/docusate 

8.6 - 50

mg

Tablets

Orally 

every day

may increase to 4 tablets every 12 hours



magnesium citrate 

Indicated as laxative:


195–300 mL PO, either as a single dose or split doses, with a full glass of water each day
Alternatively,2 to 4 tablets orally in the night-time



naloxegol 

25 mg orally each day in morning and provide at least 1 hour prior to meals or 2 hours after meals
Lowers dose to 12.5 mg/day if patient not able to resist 25 mg/day



bisacodyl rectal 

Enema: 1 bottle contents (i.e., 37 mL) rectally in a single dosage
Suppository: Remove the outer wrap & insert one suppository into the rectum



polyethylene glycol and electrolytes 

Mix 17g of each packet in 120 to 240 mL (4 to 8 oz) daily.
Unless otherwise ordered by a doctor, discontinue usage if symptoms persist for more than two to four weeks.



sorbitol 

Take dose of 30 to 150 ml orally one time
Rectal enema: Inject 120 ml of 25 to 30% solution one time



naldemedine 

Indicated for constipation induced by opioids in patients with chronic non-cancerous pain
0.2 mg orally each day



naldemedine 

Indicated for constipation induced by opioids in patients with chronic non-cancerous pain
0.2 mg orally each day
Dosage Modifications
In the case of hepatic impairment/ severe Child-Pugh C, avoid the usage of naldemedine



castor oil 


Indicated for Constipation
15ml-60ml orally one time a day
Colonic Evacuation
15ml-60ml orally one time a day, 16 hours prior to procedure



lubiprostone 

Opioid-Induced:

24 mcg orally 2 times a day



Dose Adjustments

Dosage Modifications
Hepatic impairment
Mild: dose adjustment is not necessary
Moderate (Child-Pugh score B)
CIC or OIC: 16 mcg orally 2 times a day; if the modified dosage is tolerated and not enough response has been produced after the appropriate time interval
IBS-C: dose adjustment is not necessary
Severe (Child-Pugh score C)
CIC or OIC: 8 mcg orally 2 times a day
IBS-C: 8 mcg orally everyday
if the modified dosage is tolerated and not enough response has been produced after the appropriate time interval

senna

Oral:
Sennosides:
Syrup (8.8 mg sennosides/5 mL):
Age: 2 to <6 years
2.5-3.75 ml orally at bedtime in divided doses
Age: 6 to <12 years
5-7.5 ml orally at bedtime in divided doses
Age: ≥12 years
10-15 ml orally at bedtime in divided doses
Tablets:
8.6 mg sennosides per tablet:
Age: 2 to <6 years
1/2 tablet orally at bedtime in divided doses
Age: 6 to <12 years:
1 tablet orally at bedtime in divided doses
Age: ≥12 years
2 tablets orally at bedtime in divided doses
15 mg sennosides-tablet:
Age: 6 to <12 years:
1 tablet orally in divided doses
Age: ≥12 years
2 tablets orally in divided doses
25 mg sennosides-tablet:
Age: 6 to <12 years:
1 tablet orally in divided doses
Age: ≥12 years
2 tablets orally in divided doses



bisacodyl

Age: 6-12 years
5 mg or 0.3 mg/kg orally at bedtime
Age: >12 years
5-15 mg orally at bedtime



magnesium hydroxide

Chronic: infants: 80 to 240 mg/kg in two divided doses per day.
Occasional:
2 to <6 years: 400 to 1200 mg/day in two divided doses.
6 to <12 years: 1200 to 2400 mg/day in two divided doses.
>12 years: 2400 to 4800 mg/day in two divided doses.



lactulose

0.7-2 g per kg once a day or 1-3 ml/kg once aday orally in divided doses.
do not exceed 40 g/day



magnesium sulfate

2 doses orally per day
Age: >12 years
2-4 teaspoons dissolved in 8 ounces water
Age: 6 to 11 years
1 to 2 teaspoons dissolved in 8 ounces of water
Age: Under 6 years:
Not recommended



psyllium

Age:6 to 11 years
1.25 to 15 g/day orally in divided doses
Age: ≥12 years
2.5 to 30 g/day orally in divided doses



senna/docusate 

8.6 - 50

mg

Tablet

Orally 

every day

<2 years: Safety and efficacy not established
2-6 years: one-half tablet orally every day, increase up to 1 tablet every 12 hours
6-12 years: one-half tablet orally every day, do not exceed two tablets for every 12 hours
>12 years:2-4 tablets orally every day or every 12 hours



magnesium citrate 

<2 years: Safety and Efficacy not established
2 to 6 years: 60 to 90ml orally in a single or divided dose. Do not exceed 90ml for 24 hours
6 to 12 years: 90 to 210ml orally in a single dose or divided doses with a full glass of water
>12 years: 195 to 300ml orally in a single dose or in divided doses with a full glass of water
Administer 2 to 4 tablets orally before bedtime



magnesium oxide 

For children who are 12 years of age or older
The recommended dosage is 2 to 4 caplets to be taken orally each day either as a single administration or divided into multiple doses
It is important not to exceed a maximum of 4 caplets within a 24-hour period
This therapy should be limited to a duration of 7 days or less



linaclotide 

Indicated for Functional Constipation:


Administer 72mg orally every day



bisacodyl rectal 

Enema
Above 12 yrs: As adults; 1 bottle contents (i.e., 37 mL) rectally in a single dosage
Suppository
6 to 12 yrs: Remove the outer wrap & insert one-half suppository into the rectum
Above 12 yrs: As adults; Remove the outer wrap & insert one suppository into the rectum



polyethylene glycol and electrolytes 

Neonates: Safety and efficacy not established
Adults, children, and infants: Administer 0.2 to 0.8g/kg/day orally
Do not exceed 17g/day
Do not administer for more than two weeks



polyethylene glycol and electrolytes 

Neonates: Safety and efficacy not established
Adults, children, and infants: Administer 0.2 to 0.8g/kg/day orally
Do not exceed 17g/day
Do not administer for more than two weeks



sorbitol 

Safety and efficacy not determined in less than two years old
2 to 11 years:
Take 2 ml/kg orally one time
Rectal enema: inject 30 to 60 ml as 25 to 30% solution
≥12 years:
Take dose of 30 to 150 ml orally one time
Rectal enema: inject 120 ml of 25 to 30% solution one time



castor oil 


Indicated for Constipation
Age >12 years
15ml-60ml orally one time a day
Age 2-12 years
5ml-15ml orally one time a day
Age <2 years
1ml-5ml orally one time a day



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