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Nature's Quick Constipation Cure

The First Step-by-step Plan To Cure Constipation Using A Combination Of Unique All-natural Remedies. This plan uses a strategically organized and ordered combination of the safest and most effective natural remedies for constipation. Everything used in this plan is from natures garden. No use of harmful laxatives. People who have used these swear they work Better than over-the-counter laxatives! Every strategy is carefully researched for safety and effectiveness. Each remedy builds on the last while helping out the next. The plan takes into account human physiology, anatomy, nutrition, metabolic needs and deficiencies while using specific dietary remedies and the almost always neglected but extremely powerful, mechanical remedies. All of these have been carefully planned and refined to provide you the most powerful, synergistic constipation relief plan that will relieve you of even the most stubborn of constipation episodes within as quick as 15 minutes and less than 24 Hours. Read more here...

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Drugs Useful for Treating Constipation

There is a great deal of variability in bowel habits from person to person a normal stool frequency may vary from three stools per week up to three stools per day. Constipation is defined as the infrequent passage of stool. It may be secondary to sluggish colonic motility, in which soft stool is seen throughout the colon, or to difficulties with evacuation in which firm stool is seen primarily in the sigmoid and rectum. Laxatives are used to increase stool frequency and reduce stool viscosity. Even with long-term use, bulk laxatives and pure osmolar laxatives do not predispose patients to formation of a cathartic-type colon and should be the initial agents used for chronic constipation after a structural obstructing lesion has been excluded. Laxatives are also used before radiological, en-doscopic, and abdominal surgical procedures such preparations quickly empty the colon of fecal material. Nonabsorbable hyperosmolar solutions or saline laxatives are used for this purpose....

Conservative Management of Constipation

Constipation is a common complaint in medical practice. Estimates of the frequency of constipation in the American population have varied from 2 to 28 .' This wide range in estimated frequency is in part related to differences in definitions. Not all patients who complain of constipation experience the same symptoms. Physicians typically define constipation as inadequate frequency of bowel movements. Normal frequency of bowel movements can vary from three times per day to three times per week. These parameters have led to one of the more commonly accepted definitions of constipation, i.e., a frequency of defecation of two times per week or less. However, a patient's definition of constipation may be quite different. Many patients believe that any frequency of less than a daily bowel movement is abnormal. Other patients will consider themselves constipated if their stools are too hard or too small, if defecation is associated with pain or excessive straining, or if they experience a...

Is there a prior history of similar episodes Chronic constipation and straining with stools Does patient have cystic

Straining at stools or with urination can predispose to rectal prolapse. Children with chronic constipation or cystic fibrosis are at risk for recurrence of rectal prolapse. Any history of surgery for imperforate anus Prior history of polyps Does patient have spina bifida Patients with pelvic floor weakness (eg, those with myelomeningocele) often have paralysis of the levator ani muscle in addition to increased intra-abdominal pressure.

Bowel Retraining for Constipation

The surgeon's first priority when faced with a patient complaining of constipation is to eliminate mechanical obstruction as the cause of the constipation. A complete history and physical examination should be performed. The history needs to focus on multiple factors, but specific attention should be given to the patient's medications as well as their diet and exercise regimen. If mechanical obstruction has not been ruled out before evaluation of the patient, this should be done either by colonoscopy or barium enema. Diets low in fiber coupled with poor bowel habits are common causes of constipation. Management requires reassurance and simple guidance. Patients, especially those with fast-paced and stressful lifestyles, should be advised not to ignore the call to stool because it can lead to stasis and impaction. Regular exercise (e.g., a walk every morning) promotes regularity. Narcotics, diuretics, calcium channel blockers, antidepressants, and irritant laxatives may all result in...

Treatment of refractory constipation

Lavage solutions (CoLyte, GoLYTELY) are used for refractory constipation. These agents contain a balanced electrolyte solution. A gallon can be administered in 4 hours to relieve an impaction. Eight to16 oz a day can be prescribed to prevent recurrence. E. Combination therapy with an osmotic agent combined with a lavage solution and a prokinetic agent may be used for refractory constipation. F. Enemas may relieve severe constipation. Low-volume tap water enemas or sodium phosphate (Fleet) enemas can be given once a week to help initiate a bowel movement.

Diagnostic criteria for constipation 2 or more of the following

The time of onset of constipation, stool frequency and consistency, the degree of straining, a sensation of complete or incomplete evacuation should be determined. 2. Chronic suppression of the urge to defecate contributes to constipation. Determine the amount of fiber and fluid consumed. Obstetric, surgical and drug histories, history of back trauma or neurologic problems should be assessed. E. Secondary causes of constipation 1. Fissure in ano, hemorrhoids, fistulas, ischiorectal abscess, colonic neoplasms, hypothyroidism, hypercalcemia, diabetes, Hirschsprung's disease, Parkinson's disease, multiple sclerosis, or cerebrovascular disease may cause constipation. 2. Inadequate fiber intake commonly causes constipation. 3. Drugs that cause constipation include opiate analgesics, aluminum-containing antacids, iron and calcium supplements, antidiarrheals, antihistamines, antidepressants, antiparkinson agents, and calcium channel blockers. 4. If secondary causes have been excluded, the...

Anorectal Coordination Maneuver for Constipation and Dysfunctional Voiding

The goal is to produce a coordinated movement that consists of increasing intraabdominal (intrarectal) pressure while simultaneously relaxing the pelvic muscles. During the initial sEMG evaluation of the Valsalva maneuver, patients are asked to bear down or strain as if attempting to void or evacuate, which may elicit an immediate pelvic muscle contraction and closure of the anorectal outlet. This correlates with symptoms of constipation including excessive straining and incomplete evacuation. The results of the sEMG activity observed on the screen display must first be explained and understood by the patient before awareness and change can occur. Change begins with educating the

The Constipation Scoring System

The clinical presentation of constipation includes a broad spectrum of symptoms, partially attributed to the myriad etiologies. Specifically, constipation may result from slow transit,pelvic outlet obstruction,or other mechanical,phar-macologic, metabolic, endocrine, and neurogenic reasons. Generally, physicians use the term constipation to define infrequent,incomplete,difficult,or prolonged evacuation or to describe stools that are too difficult to pass. However, many patients are more obsessed by the associated nonspecific symptoms of bloating, abdominal and pelvic pain, and nausea. Therefore, objective scoring systems have been developed to better describe this difficult problem, as well as to obtain a universally objective definition of constipation. The Rome II criteria are the most widely accepted to define constipation (Chapter 7-4). However,the Rome II criteria do not qualify the severity of disease. Therefore, our constipation score is derived based on answers to questions in...

Docusate sodium Colace

Senna (Senokot, Senna-Gen) 10-20 mg kg PO PR qhs prn (max 872 mg day) granules 362 mg teaspoon supp 652 mg syrup 218 mg 5mL tabs 187, 217, 600 mg F. Sennosides (Agoral, Senokot, Senna-Gen), 2-6 years 3-8.6 mg dose PO qd-bid 6-12 years 7.1515 mg dose PO qd-bid > 12 years 12-25 mg dose PO qd-bid granules per 5 mL 8.3, 15, 20 mg liquid 33 mg mL syrup 8.8 mg 5 mL tabs 6, 8.6, 15, 17, 25 mg

Constipation

Constipation is the accumulation of hard fecal material in the large intestine. It is a common occurrence for the elderly due to insufficient water intake and poor dietary habits. Other factors that cause constipation are fecal impaction, bowel obstruction, chronic laxative use, neurologic disorders such as paraplegia, a lack of exercise, and ignoring the urge to have a bowel movement. Drugs such as anticholinergics, narcotics, and certain antacids can also cause constipation. Constipation can be treated nonpharmacologically and pharmacologically. The nonpharmacological approach is to include bulk (fiber) and water in the patient's diet and have the patient exercise and develop routine bowel habits. The normal number of bowel movements is between 1-3 per day to 1 to 3 per week. Normal bowel movements vary from person to person. The pharmacological approach is to administer laxatives and cathartics to eliminate fecal matter. Laxatives promote a soft stool and cathartics promote a...

Osmotic Laxatives

Osmotic laxatives (e.g., lactulose, sorbitol) are poorly absorbed or nonabsorbable compounds that draw additional fluid into the GI tract. Lumen osmolality increases, and fluid movement occurs secondary to osmotic pressure. Lactulose is a synthetic disaccharide that is poorly absorbed from the GI tract, since no mammalian enzyme is capable of hydrolyzing it to its monosaccharide components. It therefore reaches the colon unchanged and is metabolized by colonic bacteria to lactic acid and to small quantities of formic and acetic acids. Since lactulose does contain galactose, it is con-traindicated in patients who require a galactose-free diet. Metabolism of lactulose by intestinal bacteria may result in increased formation of intraluminal gas and abdominal distention. Lactulose is also used in the treatment of hepatic encephalopathy. Polyethylene glycol (Miralax) is another osmotic laxative that is colorless and tasteless once it is mixed.

Saline Laxatives

Saline laxatives are soluble inorganic salts that contain multivalent cations or anions (milk of magnesia, magnesium citrate, and sodium phosphate Fleet Phospho Soda ).These charged particles do not readily cross the intestinal mucosa and therefore tend to remain in the lumen of the GI tract, where they help retain fluid through the osmotic effect exerted by the unabsorbed ions. The volume in the GI tract is increased, distending the colon and producing a physiological stimulus for peristalsis through activation of stretch receptors. This explanation of the mechanism by which the saline laxatives exert their effects, however, may be too simplistic, since active secretion of fluid into the gut lumen has These salts should always be given with substantial amounts of water otherwise the patient may be purged at the expense of body water, resulting in dehydration. Sodium-containing laxatives should not be used in patients with congestive heart failure, since the patient may absorb...

Stool Softeners

Docusate dioctyl sodium sulfosuccinate (Colace), dioctyl calcium sulfosuccinate (Surfak), and dioctyl potassium sulfosuccinate (Diocto-K) are surface-active agents that produce fecal softening in 1 or 2 days. By means of its detergent properties, docusate allows water to penetrate and soften colonic contents when it is administered as a retention enema. Orally ingested docusate may also act as a stool softener by stimulating the secretion of water and electrolytes into the intestinal lumen. Docusate has been used both alone and in combination with other laxatives. Although by itself it appears to be relatively nontoxic, it may, when taken in combination with other laxatives, increase their absorption and lead to liver toxicity. Caution is necessary when docusate is prescribed together with mineral oil, since the detergent increases the absorption of the oil.

Delirium in the elderly

Delirium in this population, alone or superimposed on dementia, is described in Chapter8.5.1. The elderly are considerably more susceptible than younger adults. They may become delirious due to otherwise minor physical problems such as constipation or urinary tract infection, or to combinations thereof. Prescription of multiple medicines (including psychotropics, especially hypnotics), dehydration, and chronic medical conditions are frequently contributing factors. Those with pre-existing dementia are especially vulnerable to developing delirium indeed, an episode of delirium is frequently the first presentation of patients with dementia to medical services.

Chronic Treatments and Side Effects of Mixed Inhibitors of NEP and APN

As expected from their mechanims of action, the mixed inhibitors are devoid of the main drawbacks of morphine (i.e., respiratory depression (21), constipation and physical and psychic dependence 22,23 Fig. 3 ). This is due mainly to the weaker, but more specific, stimulation of the opioid-binding sites by the tonically or phasically released endogenous opioids, thus minimizing receptor desensitization or down-

AMaltsupex 1 tsp in 8 oz of formula or Dark Kayro syrup

Polyethylene glycol 3350 (MiraLax). Effective in stool-impacted children without initial enema. f. For slower cleansing. Use MiraLax daily over 2 weeks a 3-6-month regimen may be necessary before resumption of normal bowel pattern is seen. VI. Problem Case Diagnosis. Findings of palpable stool on abdominal exam and large, hard stool in the rectum of this well-appearing, age-appropriate child led to the diagnosis of functional constipation. VIII. Teaching Pearl Answer. It is common for infants younger than 6 months of age to cry, strain, and appear to have pain with passing stool. If stool is soft, infant is not constipated but rather exhibiting what is known as infant dyschezia. Reassure parents that these symptoms will resolve over time.

Altered intestinal function in critical illness

A number of factors may contribute to the diarrhea associated with altered intestinal function. Splanchnic vasoconstriction is a physiological response to hypotension. Ischemia reduces the supply of energy substrates to the gut and may limit, for example, energy-dependent reabsorption of sodium and water from the gut. Loss of enteral feeding deprives the gut mucosa of this contribution to mucosal nutrition. Colonic mucosa normally receives 60 to 70 per cent of its energy substrate needs from the bowel lumen. Without enteral nutrition, mucosal enzyme activity rapidly decreases and there is loss of villus height, inducing malabsorption through impaired digestion and reduced absorptive capacity. Changes to the intestinal flora are common in severe illness. Contributory factors are loss of enteral nutrition, colonization of the upper gastrointestinal tract by Gram-negative organisms or yeasts, the effects of drugs on intestinal secretion and motility, and bacterial selection in patients...

Is this an acute or chronic problem

Are there risk factors that suggest a specific cause Risk factors include day care, winter season, ill contacts, drugs, travel, animal exposure, constipation, excessive juice intake, poorly prepared or stored poultry or salads, untreated water sources, prior abdominal surgery, immunodeficiency, and prematurity.

Immediate Questions

Any feeding difficulties In an infant, choking, slow feeding, tiring with feeding, poor suck, vomiting, or regurgitation suggests GI, cardiac, or neurologic disorder. In a toddler or older child with decreased appetite, consider dental disease, constipation, chronic illness, or apathy.

Magnesium European Pharmacopoeia 231

The test identifies the substance to be examined as a salt of magnesium, Mg2+. Reference to magnesium is currently made in about 15 monographs. With a few exceptions they are simple inorganic salts used as inactive excipients or for the treatment of magnesium deficiency. The carbonate, sulfate, and oxide are used as antacids and laxatives. Magnesium is exclusively found as the bivalent cation Mg2+. Its oxide, hydroxide, carbonate, and phosphate salts are insoluble in water, whereas the rest of its common inorganic salts are water soluble. Due to its insoluble hydroxide, its water solubility shows a high dependency on pH and this is utilized in the identification test. Sample preparation in the majority of the monographs is done by simply dissolving the substance to be examined in water or acidified water. In the case of magnesium stearate the stearic acid is first removed from the test solution by liquid-liquid extraction. Magnesium aspartate dihydrate is ignited to incinerate the...

Pharmacological Effects

Pentazocine (Talwin) is a potent analgesic with antagonistic activity in opioid-addicted patients. It incompletely blocks the effects of morphine in such patients but will precipitate withdrawal. To eliminate abuse of the drug via IV administration, pentazocine is combined with naloxone (Talwin-NX). IV administration of Talwin-NX will produce no analgesic or euphoric effects because naloxone blocks the pentazocine moiety. However, the drug will retain its analgesic potency when administered orally, since naloxone is not active orally. Pentazocine produces as much respiratory depression as morphine but does not produce the same degree of constipation or the biliary constriction observed with morphine. Pentazocine may increase GI motility if used in high doses. Unlike morphine, penta-zocine increases heart rate and blood pressure by releasing norepinephrine. Pentazocine also may increase uterine contractions in pregnancy.

Classical anorexia nervosa postpubertal

Additional harmful behaviours which should be enquired into include self-induced vomiting, purgative abuse, and self-injury. Vomiting and purgative abuse are similar to the behaviours that occur in bulimia nervosa (see C.haP.teL,4,1.0,2.). In anorexia nervosa they may occur without the prelude of overeating and the patient's motive is simply to accelerate weight loss. Even so, vomiting is most likely to occur after the patient's frugal meals, and the laxative abuse is often at the end of the day. The favourite laxatives in the United Kingdom are Nylax, Senokot, and Dulcolax, and the patient is likely to take them in increasing quantities to achieve the wanted effect as tolerance develops. Self-injury should also be enquired into, and the skin of the wrists and forearms inspected for scratches or cuts with sharp instruments.

Introduction Origins of the concept

The history of the diagnosis bulimia nervosa begins as recently as 1979. It was in this year that Russell published his now seminal paper 'Bulimia nervosa an ominous variant of anorexia nervosa' in which he described 30 patients (28 women and two men), seen between 1972 and 1978, who had three major features in common. First, they had recurrent episodes of uncontrolled overeating second, they regularly used self-induced vomiting or laxatives as means of weight control and third, they had a morbid fear of becoming fat. Russell described many other features shared by these patients, including a history of anorexia nervosa (present in 80 per cent), the presence of severe depressive symptoms, and the fact that in most cases their body weight was in the healthy range. He noted that the disorder tended to run a chronic course and that it was 'extremely difficult to treat'. Finally, he suggested that this clinical picture should be viewed as a syndrome, distinct from anorexia nervosa, and he...

Clinical features

Some patients are asymptomatic, especially when their neoplasm is identified by screening or surveillance. Haemato-chezia and anaemia are common presenting features due to bleeding from the tumour. Many patients experience change in bowel habit in the right colon, the fluid faeces can pass exophytic masses, whereas in the left colon the solid faeces are more often halted by annular tumours so that constipation is more common. There may be associated abdominal distension. Rectosigmoid lesions can produce tenesmus. Other symptoms include fever, malaise, weight loss, and abdominal pain. Some patients present with the complications of obstruction or perforation.

Pharmacologic Therapy

The anticholinergic antimuscarinic agents are the most commonly used drugs to treat OAB and urge incontinence (Table 7-1.1). This class of drugs remains the standard of care, and is recommended as the first line pharmacologic therapy for patients with detrusor overactivity by the Agency for Health Care Policy and Research (AHCPR) (www.ahrq.gov clinic uiovervw.htm). These agents suppress muscarinic receptors on the bladder smooth muscle, but the relative lack of selectivity for the bladder over other organ systems accounts for significant adverse side effects such as xerostomia, constipation, and blurred vision. These adverse effects result in a high rate of discontinuation that has led to a search for receptor subtype-specific antimus-carinic agents with improved tolerability profiles. When reduction of urge incontinence episodes is used as the

Transdermal Oxybutynin

When we initiate oxybutynin therapy, we will offer patients either 10 mg of Ditropan XL or a 3.9-mg patch. Depending on the response, tolerability, and other factors, some patients may increase the dosage to 15 mg of Ditropan XL or 1.5 to 2 patches weekly. Alternatively, patients may supplement the oxybutynin dosage by adding 2.5 to 5mg of immediate-release oxybutynin as necessary for a social event or travel. As with any anticholinergic agent, it is contraindicated in patients with narrow-angle glaucoma, severe constipation, or an allergy to the medication.

Therapy Of Bone Pain Due To Osteoblastic Metastases

The treatment of cancer-induced bone pain involves analgesics, with or without radiation and chemotherapy. The pattern of analgesic use is generally based on the World Health Organization's (WHO's) three-step approach to pain relief, beginning with nonsteroidal inflammatory medications, followed, if necessary, by level II drugs (relatively weak opiates). If these are insufficient, more potent opiate analgesics such as morphine are employed. Opiates have often distressing side effects, including sedation, nausea, and constipation, so that the dose of these should be as low as possible to maintain the patient's overall quality of life. In an attempt to lower these doses of analgesics, radiation and chemotherapy are employed. Radiation is usually given with teletherapy, either in a single dosage of 8 Gy or in fractionated dosages of about 30 Gy. These two radiother-apeutic approaches have equal initial efficacy, but the latter has a longer lasting effect in most patients. This form of...

Food And Drug Interactions

Others can cause diarrhea. Alcohol should be avoided when taking some medicines. Supplements, over-the-counter products, and herbs also can interact with medicines. Always consult with your healthcare provider when considering taking anything in addition to those medicines that are specifically prescribed for you. If more than one provider has prescribed medicine for you, be sure that they are all aware of the medicines the others have prescribed.

Pertinent Historical Information

Are there renal symptoms (polyuria or polydipsia) GI complaints (eg, loss of appetite, nausea, constipation, weight loss) CNS symptoms (weakness, fatigue, depression) 9. Blue diaper syndrome. Tryptophan malabsorption nephro-calcinosis, constipation, fever, failure to thrive, absence of aminoaciduria.

Treatment of iron deficiency anemia

Side effects from oral iron replacement therapy are common and include nausea, constipation, diarrhea and abdominal pain. To minimize side effects, iron supplements should be taken with food however, this may decrease iron absorption by 40 to 66 percent. Changing to a different iron salt or to a controlled-release preparation may also reduce side effects.

Tetracyclines and Drug Drug Interactions

Give tetracycline 1-3 hours before or after giving the patient antacids, calcium supplements, choline and magnesium salicylates, iron supplements, magnesium salicylate, or magnesium laxatives, foods containing milk and milk products. These lower the absorption of tetracycline.

Irritable Bowel Syndrome

Based on the pattern of bowel alteration, IBS can be described as diarrhea- or constipation-predominant nevertheless, an alternating pattern in which patients go from one extreme to the other is also seen. Diarrhea-predominant IBS is more common in women. Nocturnal occurrence is quite rare and suggestive of organic etiologies. Fecal incontinence is not uncommon. In constipation-predominant cases, bloating, incomplete evacuation, and changes in stool shape, along with the presence of mucus is a typical scenario.

Therapeutic Drug Monitoring

Safe and effective use of the TCA drugs requires monitoring of serum levels. The importance of this monitoring is based on the relatively narrow range between therapeutic and toxic doses (therapeutic index of 3) of each agent. While annoying side effects (sedation, dry mouth, constipation) begin to occur at subtherapeutic serum concentrations, life-threatening cardiac and CNS effects develop in a dose dependent fashion above serum levels of 500 ng mL. The metabolism and elimination rates vary 10- to 30-fold among individuals taking TCA drugs. For this reason, it is estimated that only 50 of the patients receiving a standard dose of a TCA drug would achieve an optimal therapeutic serum concentration. Of additional concern, 3 to 5 of patients will be deficient in hepatic enzymes that metabolize the TCA drugs and may develop life-threatening serum levels on standard doses. Therefore, steady-state serum levels of TCA drugs (drawn 10 to 12 hours after the last dose) are monitored to avoid...

Irritable Bowel Anismus

The causes of constipation and altered defecation are mul-tifactorial, and the manifestations are varied. Etiologies of constipation or altered defecation can be divided into two categories - slow transit constipation, and pelvic outlet obstruction. Pelvic outlet obstruction includes etiologies such as paradoxical or nonrelaxation of the puborectalis muscle or anismus (nonrelaxation of the anal canal), rectal prolapse or intussusception, and nonemptying rec-toceles. Associated findings may include perineal descent and solitary rectal ulcer syndrome.

Psychiatric disorders

Hypochondriasis that develops during an episode of major depression and that remits with successful treatment should not receive a separate diagnosis, according to DSM-IV and ICD-10. However, the distinction between hypochondriasis and depression may present difficulties. (35) Certain authors have suggested that the former represents masked depression or a depressive equivalent. There is no empirical evidence for this notion, but hypochondriasis and somatic symptoms often obscure depression in primary care. Still, the typical symptoms of depression can usually be elicited from such patients. The somatic symptoms of depression (fatigue, weight loss, constipation) often become a focus of hypochondriacal concern.

Pharmacological management of psychiatric disorders in the dying

Antidepressant use in the dying may be more problematic due to the adverse effects of sedation, seizures, hypotension, and constipation and urinary retention. For this reason, the choice of drug needs to be individually tailored. Dosage has to be carefully adjusted, beginning at low doses and increasing gradually. The use of psychostimulants (dextroamphetamine, methylphenidate) is worth considering. These drugs are used infrequently in general psychiatry because of the risks of dependence, but in the terminally ill they may have advantageous 'energizing' properties, including increased energy, improved concentration, increased appetite, and, possibly, a faster onset of action.

Physical Examination

Typically, gynecologists consider repair of the rec-tocele indicated for obstructive defecation symptoms, lower pelvic pressure and heaviness, prolapse of posterior vaginal wall, and pelvic relaxation with enlarged vaginal hiatus. However, one should be cautioned that although repair of rectoceles may correct abnormal anatomy and alleviate these symptoms,colorectal dysfunction, including constipation, may persist.

Results of Surgical Repair

Although frequently performed, posterior colporrhaphy has been described as among the most misunderstood and poorly performed gynecologic surgeries.13 Although many authors have reported satisfactory anatomic results, conflicting effects on bowel and sexual function postoper-atively have been noted. Several authors have reported high sexual dysfunction rates of up to 50 of women reporting dyspareunia or apareunia after posterior colporrhaphy.14 Some authors caution the performance of rectocele repair in patients with preoperative abnormal colonic transit studies secondary to continued constipation postopera-tively.15 Other authors performed preoperative defecogra-phy on all patients and found that the grade of rectocele emptying did not influence long-term outcome. In addition, pre- and postoperative defecography was reported to show an increase in maximal anal resting pressure postop-eratively, suggesting that it may be caused by levator plication (Table 8-5.1).16 this surgery, along...

Rectal Prolapse Therapy

The etiology of rectal prolapse is unclear. However, factors involved in the development of rectal prolapse may be congenital or acquired. Moreover, there are conditions that can be associated or predispose to the development of rectal prolapse. These problems include intestinal disorders such as constipation and chronic straining, neurologic diseases, especially spinal cord abnormalities and depression, nulliparity, lack of rectal fixation to the sacrum, previous anorectal surgery, and pelvic floor defects. In addition, rectal prolapse is almost always a condition of the female gender.1 Despite the implication of multiple pregnancies in the etiology of rectal prolapse, this pathology is more frequent in nulliparous patients. However, the association of rectal prolapse with chronic constipation is less well understood. A history of constipation is found in 25 to 50 of patients with rectal prolapse.1,2

Introduction To Normal Physiology

Approximately 1 to 1.5 L of fluid is ingested per day, and coupled with secretions from the stomach, pancreas, and proximal duodenum, approximately 8 L of chyme enters the jejunum per day. Reabsorption of 6 to 7 L occurs within the small bowel, leaving a residual of 1.5 L fluid, 90 of which is reabsorbed in the colon. This pattern of liquid reabsorption permits the elimination of fecal waste containing an average of 0.1 to 0.2 L fluid per day. Diarrhea occurs if there is an altered rate of intestinal motility, if mucosal function or permeability is altered, or if the fluid load entering the colon overwhelms colonic reabsorption. Constipation may occur if intestinal movement is inhibited or if there is a fixed obstruction.

Changes in gastrointestinal and liver function

Changes in gastrointestinal motility during pregnancy include decreased lower esophageal pressure, decreased gastric peristalsis, and delayed gastric emptying. Gastrointestinal motility is generally inhibited during pregnancy, with reduced small- and large-bowel transit times. These changes may be partially responsible for the common symptoms of constipation, nausea, and vomiting in early pregnancy.

Anterior Resection with Rectopexy

The addition of rectal fixation to the sacrum may provide better results regarding the decrease in recurrence rate. This operation is safe and presents the lowest recurrence rate. The reported recurrence rate after sigmoid resection with proctopexy varies from 2 to 10 .1 Initial procedures used the circumferential wrap. However, postoperative complications, including constipation and obstruction have led surgeons to modify the technique leaving the anterior rectum free. Others avoid the placement of the mesh altogether, adopting the use of nonabsorbable sutures to fixate the rectum to the presacral fascia.We currently prefer the latter approach to treat surgically fitted individuals with rectal prolapse.

Rectoanal Intussusception Solitary Rectal Ulcer and Sigmoidoceles

Successful defecation requires the smooth coordination of neurologic and muscular events by the pelvic floor and rectum. Deterioration of a single component of this process may lead to symptomatic rectal dysfunction manifested as constipation from the inability to evacuate. Prolonged untreated dysfunction with straining may ultimately lead to occult or overt rectal prolapse with concomitant rectal ulceration or fecal incontinence.1-3 The etiology of rectal dysfunction remains obscure but is believed to be multi-factorial in nature, involving electromyogenic, psychologic, aging, and hormonal mechanisms. In addition, rectal dysfunction is usually one component of a pathophysiologic process that involves the entire pelvic floor. As a result, several clinical manifestations may occur together or separately as part of the spectrum of this disease process and include nonrelaxation of the puborectalis muscle,rectoanal intussusception, rectal prolapse, perineal descent, solitary rectal ulcer...

Solitary Rectal Ulcer Syndrome

Solitary rectal ulcer syndrome is notorious for its chronicity and refractory nature to treatment. No single treatment is entirely satisfactory and therefore the main goal is to adjust patient symptoms and resolve bleeding. Once the diagnosis is established, all patients should undergo a trial of medical management. Initial treatment consists of fiber and hydration maintenance to aid in retraining the bowel and promoting normal motility topical agents such as steroid or Carafate enemas have a limited role because they do not address the underlying pathophysiology. Judicious use of laxatives and enemas facilitate evacuation with minimal straining.

S Evidence statements

One systematic review of seven RCTs that assessed the effects of different management strategies for faecal incontinence and constipation in people with neurological diseases was identified. The results showed that psyllium was superior to placebo in terms of bowel movements and stool weight. A comparison of different suppositories indicated that

Specific drugs used in addiction treatment

Pharmacokinetics peak plasma level occurs 2 to 4 h after oral dosing, and 1 h after intramuscular injection half-life is 25 h after regular oral use. Side-effects similar to other p-opioids, including mental blunting, sweating, constipation, nausea, and analgesia. Toxic effects acute overdose leads to respiratory depression and pulmonary oedema.

The Importance Of Quoting Reporting Rates

Comparing the rates of IMMP (intensified) spontaneous reporting of specific events with the rates from using PEM questionnaires. An-gioedema urticaria, extrapyramidal effects and blood dyscrasias were as likely to be reported spontaneously as with PEM. Conversely, cardiac dysrythmias, dry mouth, dyspepsia, constipation, death and events suggesting immunological disorders were, by comparison, very unlikely to be reported spontaneously. Other events ranged between these two extremes. It needs to be emphasised that this refers to IMMP intensified spontaneous reporting which has a higher rate of reporting than the standard spontaneous reporting programme in NZ. It follows therefore that studies on specific drugs are not comparable unless the reporting rates are similar. Similarly, rates of reporting may provide a guide as to what types of reactions may have been missed.

Longterm Care and Outcome in Open Myelomeningocele

Again, bladder and bowel continence depends chiefly upon the level of the neurological lesion. Most children manage the bladder with clean intermittent catheterization and many are able to perform this for themselves. Management of the bowel depends upon a combination of bulk laxatives and enemas, avoidance of constipation and the use of a Shandling catheter 11 .

The Oped And The Pdnj

The OPED database covers the county of Funen (population approximately 470 000) persons and PDNJ covers the county of Jutland (approximately 490 000 persons). Together they have covered a representative sample of 18 of the Danish population (Gaist et al., 1997 Nielsen et al., 1997) since 1992. Dispensing claims data that are collected in the systems comprise a unique patient identifier, the civil registration number (CRN), which allows longitudinal tracking of the patient through different layers of the healthcare system the date of dispensing, the product code (unique for brand, quantity and formulation) and the ATC code. The computerised drug-dispensing histories contain data concerning the dispensed drug, type of prescriber, dispensing date, dispensed amount, prescribed dose regimens, and the legend duration (prescription length). The prescribed dosing regimen (and therefore legend duration) is not recorded in the systems. Over-the-counter medication and non-reimbursed drugs (such...

Specific Investigations

After medical treatment fails and no abnormality is found on laboratory values, specific investigations are per-formed.2 At our institution, this would consist of a multiple contrast defecating proctogram, a colonic transit study, and anal physiology testing. The multiple contrast defecating proctogram involves contrast given from the oral, bladder, vaginal, and rectal route. The aim is to identify enteroceles, rectoceles, sigmoidoceles, or internal intussusception, all of which can lead to debilitating constipation. Paradoxical puborectalis contraction may also be seen, but this is usually diagnosed with anal physiology testing.

Anal Physiology Testing

Anal physiology testing is used at our institution to verify that the puborectalis muscle relaxes when straining occurs. Paradoxical puborectalis contraction occurs when this does not happen and is treated with biofeedback. We also use anal physiology testing to look for an anorectal inhibitory reflex. Absence of this points to Hirschsprung's disease. A small number of adults with lifelong constipation are found annually in our institution with short segment Hirschsprung's. Verification that a patient can defecate a balloon transanally placed in the rectum is also done and is performed in the anal physiology laboratory.

Pelvic Ileal Pouch Procedure

For the few patients who continue to have constipation after colectomy and IRA, completion proctectomy and ileal pelvic pouch is considered.6 In a select few, this will eliminate the problem. The anal sphincters must function well, as the stool produced after a pouch is looser and more frequent than that after the IRA. Pelvic Floor Function should be assessed to avoid continued problems after this more involved procedure. This may be difficult to assess, but excessive perineal descent with strain may be one clue that warns against the pelvic pouch.

Patient Education and Behavior Modification

Frequently observed behavioral pattern, common among elderly women with symptoms of urinary incontinence, is the restriction of fluid intake to avoid leakage in fact, this may worsen symptoms of constipation as well as symptoms of urinary incontinence. A bowel and bladder diary can be used to accurately document fluid intake and voiding habits along with any symptoms of urgency, incontinence, or constipation.

Estimated Therapeutic and Loael Doses of Resveratrol

Quinones are a group of over 1,200 naturally occurring compounds. Many quinones have been reported to possess antibacterial and fungicidal properties. Quinone-rich plants have also been used as dyes (for example, henna), and as laxatives (rhubarb root, aloe resin, senna leaf, and Cascara sagrada bark). In this section, we discuss two anticancer quinones, emodin and hypericin.

Bowel Retraining for Functional Disorders of the Colon Rectum and Anus

Bowel retraining refers to physiotherapeutic, or nonoperative, approaches to functional colorectal disorders. These nonsurgical or conservative measures may form the initial management for patients with both constipation and anal incontinence. They also provide means of effective therapy for mild forms of functional colonic disorders, high-risk surgical candidates, and for those patients who decline an operation. They may be as an adjunct to surgical therapy, or as part of a continuum once surgery has been completed. Bowel retraining involves diet manipulation, medical intervention, and biofeedback therapy.1-3 In this chapter, bowel retraining will be discussed with respect to the two major classes of functional colorectal disorders, constipation and fecal incontinence.

Neuromuscular junction disorders

Other causes of neuromuscular junction blockade are rare and the diagnosis is usually obvious from the clinical setting. Suspect botulism when autonomic features, dry mouth, constipation, poorly reactive pupils, ptosis, and bulbar palsy have heralded acute descending paralysis. In the early stages the symptoms and signs are entirely anticholinergic and the reflexes are normal. These symptoms have usually been immediately preceded by nausea, vomiting, abdominal pain, and diarrhoea from eating foul smelling food contaminated by Clostridium botulinum.27 Magnesium-containing antacids and aperients in patients with impaired renal function can produce severe hypermagnesaemia. The increased magnesium interferes with the release of acetylcholine so as to cause weakness, which may develop into respiratory failure.28 The aminoglycoside and polymyxin antibiotics and some other drugs also cause neuromuscular blockade by interfering with the release of acetylcholine.29 This is usually only...

Reduction of Rectal Prolapse

Evaluation for Predisposing Conditions. Treat underlying causes (ie, constipation, diarrhea, cystic fibrosis). Problem Case Diagnosis. The 2-year-old patient, who has a chronic history of constipation, is diagnosed with simple rectal prolapse. It is noted to occur while squatting. After reduction of the prolapse, therapy for the underlying constipation is begun.

Alosetron Withdrawn In The United States

In August, Glaxo Wellcome issued a Dear Health Care Professional'' letter in the United States advising of important new safety information regarding constipation and ischaemic colitis associated with alosetron (Lotronex), and the product labelling was updated accordingly.817 2 The warnings followed post-marketing reports of serious complications of constipation associated with the use of this treatment for irritable bowel

Renal tubular dysfunction

The kidney is normally very efficient in ensuring that electrolyte concentrations are maintained. However, this can be severely disrupted by cytotoxic drugs, particularly cisplatin and ifosfamide, which may cause tubular dysfunction and excessive loss of calcium, magnesium, potassium, and sodium in the urine. Electrolyte loss results in lethargy, constipation, confusion, and, in severe cases, seizures. Patients receiving these drugs require regular monitoring of electrolyte concentrations and replacement where necessary.

Rubinstein Taybi syndrome Prevalence and causes

This syndrome is associated with mental retardation and dysgenesis of corpus callosum. Characteristically broad thumbs, broad great toes, and persistent fetal finger pads are associated with this condition. Facial features include short upper lip, pouting lower lip, hypoplastic maxilla, beaked nose, slanted palpebral fissures (antimongoloid slant), long eyelashes, ptosis, epicanthic fold, strabismus, glaucoma, and iris coloboma. Common cardiac problems are pulmonary stenosis, pulmonary hypertension, mitral valve regurgitation, patent ductus arteriosus, and the risk of cardiac arrhythmias being induced by succinylcholine. Other features include keloid formation on surgical scars, shawl scrotum, hypoplastic kidneys, cryptorchidism, constipation, megacolon, and easily collapsible larynx leading to sleep apnoea and difficulty with anaesthesia. Most individuals with Rubinstein-Taybi syndrome are described as happy and loving, but 10 per cent have sleep disturbances, 50 per cent show...

Congenital hypothyroidism

This results from loss of thyroid function, usually due to failure of the thyroid gland to develop correctly. The incidence is 1 in 3500 to 4000, which may be higher in Asian families, being 1 in 918 in the north-west of England. Neonates are usually normal at birth. Prior to the establishment of neonatal screening programme, hypothyroidism used to be a major cause of mental retardation. (59 If the condition remains untreated, neonates develop lethargy, difficulty with feeding, constipation, enlargement of the tongue, and umbilical hernia. As the development of the brain and normal growth are dependent upon normal levels of thyroid hormone, congenital hypothyroidism leads to growth retardation and mental retardation. Treatment with thyroxine needs to begin as soon as the diagnosis is made even a delay of 6 months can lead to significant reduction in the IQ. (6,9

Pharmacological Effects Of The Narcotics

(1) Decrease gastrointestinal motility. Narcotics decrease the peristaltic (wavelike) movements of the gastrointestinal tract. Consequently, they may cause constipation. This effect of narcotics is the basis of their being used to treat diarrhea. When used to treat diarrhea, the agents are referred to as antidiarrheals.

Vitamindrug Interactions

Drug interactions and the adverse effects that can result are a special concern. Although vitamins are not always thought of as being drugs, these nutrients can interact with drugs and result in a variety of effects. Vitamin-drug interactions can produce either a decrease or an increase in the effectiveness of the drug conversely, the intake of drugs can affect the disposition of vitamins in the body. Many drugs, such as some laxatives and cholestyramine, can produce vitamin malabsorption or fecal nutritional loss, resulting in drug-induced nutrient depletion and hypovitaminosis. Both fat-soluble and water-soluble vitamins can be affected by drug intake.

Qualityof Life Assessment Tools

The nature of pelvic floor dysfunction as multifactorial with involvement of multiorgan systems makes severity and impact assessment an exceedingly challenging aspect of the evaluation of a symptomatic patient. Various factors such as organ system function, anatomic alterations, lifestyle impact, and psychological well-being may be impacted differently by the disease process, and more importantly, by the therapy received by a patient with pelvic floor dysfunction. Historically, outcome assessment was limited to continence and normal anatomy restoration. As recently as 10 years ago, outcome assessment was focused solely on objective parameters such as urodynam-ics. Aspects of day-to-day living of great importance to the patient, such as lifestyle alterations, work capability, and interpersonal intimacy, were not addressed by clinicians. It is inappropriate to assess outcomes of a multiorgan system dysfunction by assessing only one-dimensional factors. This is particularly true in the...

Other Plant And Animal Allergens

Glues and gums are occasional causes of human allergy. Impure gelatin is the adhesive obtained from the bones and hides of terrestrial animals and fish bones. Other natural glues are made from casein, rubber, and gum arabic. Synthetic adhesives recently have minimized the glue allergy problem, although the amine hardeners used in the manufacture of epoxies have caused asthma and rhinitis in factory workers. In addition to gum arabic, other vegetable gums (acacia, chicle, karaya, and tragacanth) have been reported to cause allergy by inhalation or ingestion. These are used in candies, chewing gum, baked goods, salad dressings, laxatives, and dentifrices. They also are used as excipients in medications. Guar gum is a vegetable gum that recently has been shown to induce IgE-mediated asthma. This gum is used in the carpet industry and affects about 2 of workers in carpet-manufacturing plants. The gum is used to fix colors to carpeting. It is also Enzymes used in laundry detergents to...

Concept and diagnostic entity

Eventually it became clear that the expanding kaleidoscope of symptoms should be managed in a way that made some sense. Beard approached this problem by organizing the symptoms into subtypes of neurasthenia cerebrasthenia (cerebral exhaustion) characterized by symptoms that were directly or indirectly connected with the head myelasthenia (spinal exhaustion) was defined by symptoms related to the involvement of the spinal cord digestive asthenia was characterized by dyspepsia, constipation, and flatulence. As time went on more subtypes were added by other investigators and specific treatment approaches were developed. The first list of symptoms Freud proposed for neurasthenia proper included headache, spinal irritation, dyspepsia with flatulence, and constipation. Later, he added sexual weakness and fatigue.

Treatment of depression

Tricyclic antidepressants are effective but require monitoring of cardiac function and drug levels in patients who are prone to toxicity and side-effects. Constipation and dry mouth are undesirable in cancer patients, especially those on opioids. Response time is also longer, which is often a problem. The side-effects of sedation and weight gain can be used to advantage. The tricyclic antidepressants are also well proven to be good adjunct analgesic agents, especially for neuropathic pain. They may be administered intramuscularly or by suppository when the patient cannot tolerate medication by mouth. Moreover, they are more affordable than other antidepressants. The commonly used antidepressants and their starting dose are outlined in Ta.ble6. Several antineoplastic agents utilize the hepatic cytochrome P-450 system, and the 3A4 isoenzyme appears to be particularly significant because it is also used by several antidepressants. For example, nefazodone and fluvoxamine inhibit the 3A4...

Pharmacologic options

To be safe in the treatment of obese patients with well-controlled hypertension 39, 40 . The most commonly reported side effects of sibutramine include headache, dry mouth, constipation and insomnia, all of which are generally mild and well tolerated. It is advisable to monitor blood pressure and heart rate monthly when starting patients on sibutramine. Contraindications to sibutramine use include uncontrolled hypertension, congestive heart failure, symptomatic coronary heart disease, arrhythmias or history of stroke.

Bowel Retraining for Anal Incontinence

Pseudo-incontinence, or overflow incontinence, may develop in patients with fecal impaction secondary to constipation. This cause of incontinence can be elicited from physical examination and is treated by removing the impaction and implementing a bowel regimen that prevents constipation and stool stasis.

Clinical manifestation

The onset of clinical manifestation is usually insidious with gradual development of signs and symptoms, each of which is non-specific alone. Increasing weakness, fatigue, lassitude, anorexia, myalgia, and weight loss are the first symptoms in gradually developing primary hypoadrenalism. Weight loss, which is mostly due to anorexia but can also be caused by dehydration, may be substantial. Vomiting and constipation, apathy, depression, and even psychosis may also occur. Vomiting and abdominal pain often herald an adrenal crisis. In some instances a history of craving for salt or salty foods may be present. Blood pressure is usually low and signs of dehydration are common. Hyperpigmentation, particularly of the lips, buccal mucosa, gingiva, palmar and plantar creases, areolas, and previous scars, is characteristic of primary hypoadrenalism but may be absent in hypoadrenalism of recent onset. Hyperpigmentation may be generalized, creating a darkish cast to the skin resembling a sun tan....

Neurologic Evaluation of the Pelvic Floor

Pudendal Electromyography

Constipation In patients with constipation, we use an intra-anal sponge electrode (Dantec) for surface EMG recording of the external anal sphincter muscle, instead of the concentric needle electrode. By avoiding needle-related discomfort, the kinetic activity of the anal sphincter during voluntary and reflexive contraction (squeeze and cough), and during simulated defecation is more accurately assessed, eliminating pain-induced contraction that may mimic paradoxical anal muscle contraction.6

Chemical Name Bisacodyl bisaoedill

Brand Name Dulcolax tablet or suppository (U.S.) Bisacolax tablet or suppository (Canada) Description Bisacodyl is an over-the-counter stimulant laxative that can be used in either oral or suppository form. Stimulant laxatives encourage bowel movements by increasing the muscle contractions in the intestinal wall that propel the stool mass. Although stimulant laxatives are popular for self-treatment, they are more likely to cause side effects than other types of laxatives. Laxatives are to be used to provide short-term relief only, unless otherwise directed by the nurse or physician who is helping you to manage your bowel symptoms. A regimen that includes a healthy diet containing roughage (whole grain breads and cereals, bran, fruit, and green, leafy vegetables), six to eight full glasses of liquids each day, and some form of daily exercise is most important in stimulating healthy bowel function. If your physician has recommended this laxative for management of constipation, follow...

The Food Guide Pyramid

Following this program can add needed vitamins and minerals to your daily food intake cut your risk of heart disease, cancer and digestive diseases help control cholesterol prevent constipation and can help manage your body weight and percent body fat. Additionally, many fruits and vegetables contain antioxidants (see Glossary) and other nutrients that can be beneficial to your health. Some ideas to incorporate more fruits and vegetables in your diet can be found in Appendix A.

Differential Diagnosis

The most common proctologic disorder during infancy and childhood. Most cases occur in infants younger than 1 year of age. May be associated with diarrhea, causing per-ineal irritation, but more commonly is associated with constipation. Recurrent fissures or perianal excoriation are associated with perianal -hemolytic Streptococcus and pinworm infections.

Gluten and caseinfree diet Opiod excess theory

Whilst I love my boys and their differences dearly, I would give the world to ensure they are healthy and happy. For them, that meant eradicating their bowel problems. Many children on the autistic spectrum have bowel problems - not all, but many. Indeed there seems to be a growing number of autistic children who have a combination of autism, food intolerances and bowel disorders. As I have already written in Joe's story, Joe had horrendous and seemingly inexplicable diarrhoea. Luke had always suffered from a lesser degree of diarrhoea, stomach pains and bloatedness and always looked ill, having a white face and black rings around his eyes. Ben on the other hand suffered from dreadful constipation necessitating an outreach nurse to visit weekly and administer enemas. Over the years, he has been given every laxative available, had anal stretches, torn his back passage and generally had a life of torment, so severe was the constipation. Watching them suffer in this way has been heart...

Effective use of morphine

Constipation There are second-line opioids for moderate to severe cancer pain. The potential benefit in a switch from one opioid to another is a better balance between analgesia and unwanted effects. There are no controlled trial data at present to indicate definite benefits of one opioid over another. However, the following is suggested TTS-Fentanyl may cause less constipation than morphine. Suitable for stable pain. Time to peak blood levels is 12 hrs (up to 48 hrs in some patients) and terminal half-life after patch removal is up to 24 hrs. It is usually unsuitable in uncontrolled pain. The manufacturer's conversion chart is about right.

Anticholinergic drugs

These agents have some preference for the central nervous system but some peripheral anticholinergic effects are to be expected. Blockade of vagal tone in the heart produces tachycardia. Other adverse effects include decreased bladder function and urinary retention and decreased bowel motility leading to constipation and impaction. Decreased saliva and bronchial secretion contribute to dry mouth and increased dental caries while decreased sweating increases the risk of heat stroke. Blockade of muscarinic receptors in the eye cause pupillary dilation and inhibition of accommodation, leading to photophobia and blurred vision. Rarely, narrow-angle glaucoma may ensue. The muscarinic receptors in the basal ganglia are predominantly M 2 whereas those in the periphery are M1. The rank order of the anticholinergic drugs for relative selectivity for the M 2 receptor is biperiden, procycliden, trihexylphenidyl, and benztropine. All these agents can cause dry mouth, blurred vision, urinary...

Phytochemicals As Nutraceuticals

The oligosaccharides are fermented by colonic microflora in the large intestine, a bifidogenic effect, and they are called prebiotics. Organic acids are produced (lactate, proprionate, butyrate, and acetate) by the fermentation process, and two distinct effects are observed (1) the local intestinal pH is lowered, which dissolves calcium-phosphate-magnesium complexes that have been formed during transit through the small intestine and (2) intestinal concentration of ionized minerals is raised. Interestingly, improved absorption also leads to improved bone mineralization and an increased resistance against bone fracture and osteoporosis. Prebiotics induce the reduction of growth of harmful bacteria such as E. coli and Clostridium. Thus, the severity and incidence of diarrhea are diminished in addition, relief of constipation and reduction of putrefactive substances in the colon have been observed.41,42

Timed Voiding and Fluid Management

This recommendation.15 Constipation, which is a common problem that can worsen incontinence, can be lessened by adequate fluid consumption. Caution should be taken when advising patients to decrease fluid intake because this may lead to constipation, urinary tract infections, and dehydration. Adequate fluid intake ensures nonirritating, dilute urine, which reduces incontinence. Only patients with abnormally high fluid intake should be counseled to decrease fluid intake.

Cisapride and Tegaserod

Tegaserod is being developed as a treatment for constipation-predominant irritable bowel syndrome (IBS). Within the first week, patients treated with tegaserod had significant improvements in abdominal pain and discomfort, constipation, and overall well-being. Efficacy was maintained throughout the treatment period. Tegaserod also demonstrated significant improvements in the three bowel-related assessments (stool frequency, stool consistency, and straining) within the first week, and these improvements were sustained throughout the treatment period. The most common adverse events reported thus far are headache and diarrhea.

Diarrhea as a complication of treatment

Many different classes of drugs have diarrhea as a side-effect. The list in Table. is not exhaustive. Cumulative effects of laxatives given during hospital admission and antibiotics are amongst the most common drug-induced causes of diarrhea. When drugs are administered as elixirs, the amount of sorbitol given with an adult dose is often enough for it to act as an osmotic purgative (Edes etal 1990).

Neurotoxic Effects in Humans

Both clinical and behavioral effects in humans have been observed following inhalation of metallic mercury vapor and organic mercury compounds ingestion or dermal application of inorganic mercury-containing medicinal products such as teething powders, ointments, and laxatives and ingestion or dermal exposure to organic mercury-containing pesticides or ingestion of contaminated seafood. Specific neurologic symptoms include tremors, emotional lability, insomnia, memory loss, muscle weakness, fasciculations, headaches, polyneuropathy, and performance deficits in tests of cognitive and motor function. Although improvement has been observed upon removal of persons from the source of exposure, some changes may be irreversible. Autopsy findings of degenerative changes in the brains of poisoned patients exposed to mercury support the functional changes observed 204-208 .

Contraindications Cautions and Drug Interactions

Dietary intake of vitamin K and prior or concomitant therapy with a large number of pharmacologically unrelated drugs can potentiate or inhibit the actions of oral anticoagulants. Laxatives and mineral oil may reduce the absorption of warfarin. The patient's pro-thrombin time and international normalized ratio (INR) should be monitored when a drug is added or removed from therapy. Selected drug interactions involving oral anticoagulants are summarized in Table 22.1.

Tricyclic and tetracyclic antidepressants

The cyclic compounds do not have significantly different efficacy in treating depression but do show a variety of side-effect profiles. Adverse effects are closely related to their chemical structure and their affinity for postsynaptic receptors. Amitriptyline, clomipramine, and doxepin have a high affinity for muscarinic cholinergic receptors and cause more anticholinergic side-effects (dryness of mouth, blurred vision, constipation, urinary retention) than the other cyclic compounds. Sedation and orthostatic hypotension are two other side-effects that occur frequently with some, but not all, cyclic antidepressants. The ability of cyclic antidepressants to interfere with normal cardiac conduction and potentially lead to lethal cardiac arrhythmias makes them dangerous in the hands of suicidal patients.

Clinical Manifestations of Hypothyroidism

The hallmarks of infantile hypothyroidism (e.g., retardation of mental development and growth) become manifest only in later infancy and are largely irreversible. Consequently, early recognition and initiation of replacement therapy are crucial. In the absence of thyroid hormone therapy, the symptoms of infantile hy-pothyroidism include feeding problems, failure to thrive, constipation, a hoarse cry, and somnolence. In In adults, the signs and symptoms of hypothyroidism include somnolence, slow mentation, dryness and loss of hair, increased fluid in body cavities (e.g., the pericardial sac), low metabolic rate, tendency to gain weight, hy-perlipidemia, subnormal temperature, cold intolerance, bradycardia, reduced systolic and increased diastolic pulse pressure, hoarseness, muscle weakness, slow return of muscle to the neutral position after a tendon jerk, constipation, menstrual abnormalities, infertility, and sometimes myxedema (hard edema of subcutaneous tissue with increased...

Stimulants contact or irritants

Stimulant laxatives increase peristalsis by irritating sensory nerve endings in the intestinal mucosa. Stimulant laxatives include those containing phenolphthalein (Ex-Lax, Feen-A-Mint, Correctol), bisacodyl (Dulcolax), cascara sagrada, senna (Senokot), and castor oil (purgative). Bisacodyl and phenolphthalein are two of the most frequently used and abused laxatives because they can be purchased over-the-counter. Results occur in 6 to 12 hours. Stimulant laxatives such as bisacodyl are used to empty the bowel before diagnostic tests (for example, barium enema) because they are minimally absorbed from the GI tract. Most are excreted in feces. However, a small amount of bisacodyl absorption excreted in the urine changes the color to reddish-brown. With excessive use, fluid and electrolyte imbalances can occur (especially potassium and calcium). Mild cramping and diarrhea are side effects. Caster oil is a harsh laxative (purgative) that acts on the small bowel and produces a watery stool...

Noncognitive symptoms Aggression and agitation

Medical causes of a deterioration in the cognitive state need to be excluded. Sources of pain and fear should be considered, as well as the possibility of sleep loss or constipation, cold or hunger. A history from the family may indicate phobic disorder, which is now manifest as agitation, or a lifelong tendency to aggression. Alcohol or other drug abuse must be addressed. Enquiry about the behavioural disturbance and examination of the mental state should look for evidence of anxiety, depression, or psychosis and persecutory delusions, as well as the patient's explanation for their aggression.

Colectomy with Ileorectal Anastomosis

Surgical treatment is guided by the results of the specific investigations.3-5 Patients with slow transit constipation, as demonstrated by the failure to eliminate all markers by 7 days during the colonic transit study should be considered for a colectomy and ileorectal anastomosis (IRA). However, this may not be the best option for patients who are unable to evacuate a balloon in the anal physiology laboratory as A frequent dilemma is the order in which to manage patients who exhibit slow transit constipation and paradoxical puborectalis contraction. Traditionally, some surgeons thought that the paradox should be managed with biofeedback before the surgical intervention. However, many patients fall into the paradoxical muscle problem because they need to strain and bear down in any attempt to evacuate stool and gain relief. In our experience, until the need to excessively strain is eliminated, biofeedback is not as helpful, therefore, the colectomy should be performed first. If the...

The cognitivebehavioural account of anorexia nervosa and bulimia nervosa

A second vicious circle links the binge eating and compensatory 'purging' (the term used for self-induced vomiting or the misuse of laxatives or diuretics). Since these patients (mistakenly) view these forms of behaviour as effective means of compensating for binge eating (see C.h.a.pt L 4 10.2), once they have been adopted a barrier against overeating is removed. In the case of self-induced vomiting, binge eating is further encouraged by the fact that it is easier to vomit if the stomach is full. As illustrated in Fig 1, once this vicious circle is established, the repeated purging further worsens self-esteem.

Anorectal Dysfunction

Movement frequency and defecatory dysfunction and noted the latter in 67 of PD patients, compared with only 29 who reported decreased bowel movement frequency (see above). As with slow transit constipation, anorectal dysfunction can also appear early in the course Clinical neurophysiological and radiographic studies have shed considerable light on the pathophysiological basis for disordered defecation in PD. As described earlier, for effective defecation to occur the coordinated contraction and relaxation of a surprising array of muscles must take place. It is now clear from studies such as anorectal manometry, anorectal electromyography, and defecography that this does not always occur in individuals with PD and that dyscoordination may actually be the rule. In one study such abdominopelvic (or pelvic floor) dyssynergia was present in over 60 of PD patients.178 Lower basal sphincter pressure and difficulty maintaining sphincter pressure have been noted on anorectal manome-try in PD...

Mechanical obstruction

Approach Ileus

Before extensive investigation is undertaken for possible bowel obstruction, it is prudent to assess any intraintestinal or intraperitoneal tubes or drains present. Balloon catheters used as feeding or drainage conduits may cause intraluminal obstruction. Internal hernias and volvulus may occur around the point of fixation of jejunal feeding catheters, and extrafascial stomal prolapse at colostomy or ileostomy sites may also cause remediable obstruction. A digital rectal examination (or digital exploration of stomas), followed by gentle saline enemas, is an often neglected yet essential initial maneuver, which may relieve existing fecal impaction. Aside from the more common surgical causes of obstruction, one etiology seen occasionally in the coagulopathic patient is a submucosal intestinal hematoma which can arise spontaneously. The typical finding on an upper gastrointestinal contrast study is the 'picket-fence' appearance of the mucosa at the site of obstruction.

Practical Aspects of Biofeedback Therapy for Pelvic Floor Dysfunction

Practical aspects of biofeedback therapy for PFM dysfunction to treat symptoms of urinary incontinence, voiding dysfunction, constipation, and fecal incontinence include the technical, therapeutic, behavioral, and pelvic muscle rehabilitation (PMR) components. The technical component involves the instrumentation used to provide meaningful information or feedback to the user. Devices include surface electromyography (sEMG), water-perfused manometry systems, and the solid-state manometry systems with a latex balloon. Although each system has inherent advantages and disadvantages, most systems provide reproducible and useful measurements. A solidstate system is preferable to a water-perfused system because there is no distraction or embarrassment from leakage of fluid and the patient can be moved to a sitting position without adversely affecting calibration. Surface electromyography instrumentation is widely used and proven effective for biofeedback training. Although not suitable for...

Rectoanal Intussusception

Rectoanal intussusception, also known as occult rectal prolapse or internal procidentia, is an intussusception of the rectal wall that does not protrude through the anus. It may be asymptomatic or associated with incontinence or constipation. Although it is strongly associated with mucosal prolapse, full-thickness rectal prolapse, and perineal descent, the finding of occult rectal prolapse is not necessarily pathologic. Diagnosis is made by defecography and is seen in up to 50 to 60 of the defegrams of asymptomatic healthy volunteers.4 In addition, the presence of intussusception does not correlate with rectal emptying,5 and it seldom leads to rectal prolapse.6 Care must be taken when associating symptoms with rectal intussusception because it is usually not a cause of symptoms but a marker for underlying rectal dysfunction in symptomatic individuals and is frequently found with other abnormalities of the pelvic floor. For patients with internal intussusception and constipation from...

Anterior Sacral Meningocele

An out-pouching of dura containing CSF may occur through a defect in the body of the sacrum (anterior spina bifida). This may be an isolated defect or may be in association with a more severe developmental abnormality of the whole caudal region of the embryo, as in caudal agenesis, where abnormalities of the genitourinary tract, rectum and anus may also occur in association with sacral agenesis. Presumably, the defect in the bone is the primary abnormality and, with the pressure of CSF, the meningocele gradually enlarges. The meningocele may contain sacral nerve roots. As the meningocele enlarges into the pelvis or retroperitoneal space, it produces symptoms of compression of the pelvic organs, including constipation, urinary frequency and abdominal or pelvic pain, as well as low back pain. Anterior sacral meningoceles are more common in females and may present as an incidental mass identified on pelvic examination or ultrasound. The diagnosis is

Ganglionic Blocking Agents

The ganglionic blocking agents are extremely potent antihypertensive agents and can reduce blood pressure regardless of the extent of hypertension. Unfortunately, blockade of transmission in both the sympathetic and parasympathetic systems produces numerous untoward responses, including marked postural hypotension, blurred vision, and dryness of mouth, constipation, paralytic ileus, urinary retention, and impotence. Owing to the frequency and severity of these side effects and to the development of other powerful antihypertensive agents, the ganglionic blocking agents are rarely used.

Potential Risk Factors

There are other factors correlated with urinary dysfunction, including chronic obstructive lung diseases,27 smoking,28 diabetes,3 constipation, fecal incontinence,25 impaired function of levator muscles, genital prolapse,29 previous gynecologic surgery, perineal suturing,30 and history of childhood enuresis.31

Available Qualityof Life Assessment Tools

Coexistence of functional bladder or bowel pathology will affect QOL impact. This is particularly true in patients with chronic constipation, with a high degree of fixation on bowel function. Because QOL questionnaires do not collect this information and are not modified based on their presence, the clinician must keep these issues in mind when evaluating QOL impact.

Surgical Considerations in the Cancer Patient

Neutropenia and anemia pulmonary fibrosis cardiac dysfunction stomatitis alteration in mucosal integrity of the gastrointestinal tract constipation bowel perforation nausea vomiting diarrhea hypercoagulability Pulmonary fibrosis difficulty with wound healing Hypercoagulability

Chemical Name Docusate doekoosate

Brand Name Colace (U.S. and Canada) Description Docusate is an over-the-counter stool softener (emollient) that helps liquids to mix into dry, hardened stool, making the stool easier to pass. Laxatives are to be used to provide short-term relief only, unless otherwise directed by the nurse or physician who is helping you to manage your bowel symptoms. A regimen that includes a healthy diet containing roughage (whole grain breads and cereals, bran, fruit, and green, leafy vegetables), six to eight full glasses of liquids each day, and some form of daily exercise is most important in stimulating healthy bowel function. If your physician has recommended this laxative for management of constipation, follow his or her recommendations for its use. If you are treating yourself for constipation, follow the directions on the package insert. Do not take any laxative for more than 1 week unless you have been told to do so by your physician. Many people tend to overuse laxatives, which often...

Pseudobulbar affect See Affective release

Pseudo-exacerbation A temporary aggravation of disease symptoms, resulting from an elevation in body temperature or other stressor (e.g., an infection, severe fatigue, constipation), that disappears once the stressor is removed. A pseudo-exacerbation involves symptom flare-up rather than new disease activity or progression.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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