Pediatric constipation.

Young RJ
Gastroenterol Nurs (United States) May-Jun 1996, 19 (3) p88-95

The purpose of this article is to present an overview of pediatric constipation. Discussion of the definition from a medical and nursing point of view is included. Intestinal pathophysiology as well as etiological theories of pediatric constipation are reviewed. Current research to date and clinical treatment and experience in the area are presented. A rationale for further nursing research in this area is described. (93 Refs.)

Constipation and fecal incontinence in the elderly population.

Romero Y; Evans JM; Fleming KC; Phillips SF
Division of Gastroenterology and Internal Medicine, Mayo Clinic Rochester, Minnesota 55905, USA.
Mayo Clin Proc (United States) Jan 1996, 71 (1) p81-92

OBJECTIVE: To describe the assessment and management of constipation and fecal incontinence in elderly patients.

DESIGN: We reviewed pertinent publications in the recent medical literature and outlined effective management strategies for constipation and fecal incontinence in the geriatric population.

RESULTS: Constipation can be classified into two syndromes--functional constipation and rectosigmoid outlet delay. Evaluation consists of elicitation of a detailed history, directed physical examination, and selected laboratory tests. Management involves nonpharmacologic (such as exercise and fiber) and pharmacologic measures. Fecal incontinence in elderly patients can be due to stool impaction, medications, dementia, or neuromuscular dysfunction. Management options include modification of contributing disorders, pharmacologic therapy, and behavioral techniques.

CONCLUSION: Constipation and fecal incontinence are common and often debilitating conditions in elderly patients. Management should be highly individualized and dependent on cause, coexisting morbidities, and cognitive status. (73 Refs.)

Therapeutic availability of iron administered orally as the ferrous gluconate together with magnesium-L-aspartate hydrochloride.

Disch G; Classen HG; Spatling L; Leifert U; Schumacher E
Department of Pharmacology and Toxicology of Nutrition, University of Hohenheim, Stuttgart-Hohenheim, Germany.
Arzneimittelforschung (Germany) Mar 1996, 46 (3) p302-6

Since in vitro experiments had excluded interactions between Fe-gluconate (Fe-gluc) and magnesium-L-aspartate hydrochloride (MAH) in aqueous solutions the present in vivo studies seemed to be justified. Animal studies: Rats were kept on magnesium-(Mg)- and iron-(Fe)- sufficient and deficient diets. The intragastral administration of Fe-gluc significantly increased plasma Fe after 3 h, either given alone, or in combination with MAH (inducing hypermagnesemia). Same results were obtained when fortified diets were offered to Fe/Mg-deficient animals. Human studies: The combination of Fe-gluc (2 x 50 mg Fe per day, per os) plus MAH (2 x 7.5 mmol Mg per day, p.o.) was well tolerated by healthy volunteers. Single dose experiments revealed that Fe-gluc alone and in combination with MAH increased plasma Fe levels during 3 h to the same extent. Two groups of pregnant women with moderately reduced hemoglobin levels either received Fe-gluc (out-patients) or its combination with MAH (at least temporarily hospitalised because of preterm labor). Treatments were well tolerated. Hemoglobin levels did not further decrease, as expected without Fe supplements, during the course of pregnancy, thus indicating the therapeutic availability of the electrolytes in both study groups. Progesterone-induced constipation is frequently observed during pregnancy; hence stool softening reported by 50% of the women receiving Fe-gluc plus MAH (versus 33% in the Fe-gluc group) can be regarded as desirable effect. It is concluded that MAH does not interfere with the enteral absorption of Fe-gluc when both electrolytes are orally administered together. Taking both electrolytes together instead of 2 to 3 h apart from each other, as actually recommended, means a less complicated dosage regimen and probably improves compliance.

The osmotic and intrinsic mechanisms of the pharmacological laxative action of oral high doses of magnesium sulphate. Importance of the release of digestive polypeptides and nitric oxide.

Izzo AA; Gaginella TS; Capasso F
Department of Experimental Pharmacology, University of Naples Federico II, Italy.
Magnes Res (England) Jun 1996, 9 (2) p133-8

A common use for high doses of oral magnesium salts is to produce a laxative effect to treat constipation. In the intestinal lumen the poorly absorbable magnesium ions (and other ions such as sulphate) exert an osmotic effect and cause water to be retained in the intestinal lumen. This increases the fluidity of the intraluminal contents and results in a laxative action. Although the laxative action of magnesium is thought to be due to a local effect in the intestinal tract, it is also possible that released hormones such as cholecystokinin or activation of constitutive nitric oxide synthase might contribute to this pharmacological effect. Under normal circumstances the pharmacological administration of high doses of oral magnesium salts is safe and some salts--such as magnesium hydroxide--also have an antacid effect to neutralize stomach acid. However, high doses of magnesium or prolonged use may allow sufficient absorption into the systemic circulation to cause renal or other organ toxicity. (35

Small bowel obstruction caused by a medication bezoar: report of a case.

Tatekawa Y; Nakatani K; Ishii H; Paku S; Kasamatsu M; Sekiya N; Nakano H
Saiseikai Gose Hospital, Nara, Japan.
Surg Today (Japan) 1996, 26 (1) p68-70

We report herein the rare case of a 26-year-old woman who developed a small-bowel obstruction caused by a medication "bezoar" or enterolith, following the long-term ingestion of magnesium oxide cathartics for constipation. Medication bezoars resulting from laxatives or cathartics have rarely been reported and we were only able to find two other such cases in the literature.

Challenges in the treatment of colonic motility disorders

Reynolds J.C.
Gastroenterology and Hepatology Div., Allegheny Univ. of Health Sciences, Broad and Vine Streets, Philadelphia, PA 19102 USA
American Journal of Health-System Pharmacy (USA), 1996, 53/22 Suppl. (S17-S26)

The pathophysiology and treatment of colonic motility disorders are reviewed. Colonic dysfunction is a common reason for patients to seek medical care, although patients' perceptions may not reflect abnormal function. Abnormalities in colonic function can result from a primary disorder of the large intestine or from metabolic, neurologic, collagen vascular, neoplastic, or infectious diseases. Irritable bowel syndrome, a common disorder of colonic motility, can be caused by alterations in colonic neuromuscular functions, afferent neural function, or psychosocial factors. Colonic dysmotility can also result from malabsorption of carbohydrates. The most severe form of altered colonic motility is acute colonic pseudo-obstruction. Diagnostic studies should be limited to tests appropriate for the patient's symptoms and apparent severity of disease. Most motility disorders are functional disorders and do not result in abnormal studies. Pharmacotherapy should be directed by objective measures, the most useful of which are measurement of whole gut transit time and quantification of the water content of stools. Treatment should be determined by the nature of the disorder and the symptoms involved. For constipation, treatment should begin with changes in diet, fluid and fiber intake, and concurrent medications. Irritant laxatives can have damaging effects and should not be used habitually; however, polyethylene glycol-based purgatives can be helpful. Newer prokinetic agents, such as cisapride, have been shown to promote colonic motility. For selected patients with intractable constipation, surgery has a good success rate. For patients with functional diarrhea, opioid analogues can increase fluid absorption and delay transit.

Acute hypermagnesemia after laxative use

Qureshi T.I.; Melonakos T.K.
15268 South Monroe Street, Monroe, MI 48161 USA
Annals of Emergency Medicine (USA), 1996, 28/5 (552-555)

We present the case of a patient in whom hypotension, sudden cardiopulmonary arrest, and coma developed after a massive dose of a seemingly harmless cathartic agent. The diagnosis of hypermagnesemia was made 9 hours after the patient's admission, when the serum magnesium concentration was 21.7 mg/dL (8.9 mmol/L). The patient's condition improved with IV calcium, saline solution infusion, and cardiorespiratory support. The elimination half-life of magnesium in this case was 27.7 hours. Few cases have been reported in which patients have survived with serum levels greater than 18 mg/dL (7.4 mmol/L). This case provides evidence that hypermagnesemia may occur in patients with normal kidney function. The diagnosis of hypermagnesemia should be considered in patients who present with symptoms of hyporeflexia, lethargy, refractory hypotension, shock, prolonged QT interval, respiratory depression, or cardiac arrest.

The connection between dietary fibre intake and chronic constipation in children

Mooren G.C.A.H.C.M.; Van Der Plas R.N.; Bossuyt P.M.M.; Taminiau J.A.J.M. ; Buller H.A.
Academisch Medisch Centrum, Kinder AMC, Afd. Kindergastroenterologie/Voed ing, Meibergdreef 9, 1105 AZ Amsterdam Netherlands
Nederlands Tijdschrift voor Geneeskunde (Netherlands), 1996, 140/41 (2036-2039)

Objective. Evaluation of the feeding patterns of children with chronic constipation, in particular dietary fibres, energy and fluid intake and their influence on colonic transit time. In addition, the effect of dietary recommendations regarding fibres was assessed.

Design. Prospective randomized study.

Setting. Department of Paediatric Gastroenterology and Nutrition, Academic Medical Centre, Amsterdam, the Netherlands.

Method. Children with at least 2 months of complaints related to constipation were enrolled and both dietary intake and colonic transit time were evaluated. After dietary and laxative treatment, in some combined with biofeedback training, and a follow-up of 6 months, a randomized sample were again evaluated regarding their transit times and dietary patterns.

Results. In 73 consecutive children mean fibre intake was the same as in healthy controls, although energy and fluid intake were lower. Colonic transit time was increased compared with healthy controls and no relationship was established between fibre intake and transit time. At 6 months no significant increase in mean fibre intake was observed and no relationship was found between either transit time and change in fibre intake or cure and change in fibre intake. In the cured patients no increase of their mean fibre intake could be observed.

Conclusion. The amount of dietary fibres played no pathogenic part in chronic constipation. Dietary advice did not change the mean fibre content of the diet. In addition, changes in fibre intake had no effect on colonic transit time or cure.

Constipation in children

Leung A.K.C.; Chan P.Y.H.; Cho H.Y.H.
Alberta Children's Hospital, 1820 Richmond Rd. S.W., Calgary, Alta. T2T 5C7 Canada
American Family Physician (USA), 1996, 54/2 (611-630)

Constipation is a common childhood condition, estimated to occur in 5 to 10 percent of children. In most cases, the cause is functional. However, constipation may occasionally indicate a significant organic disorder, which can usually be determined by a thorough history and physical examination. Constipation that is present from birth or that begins in the neonatal period is most likely to be congenital in origin. Acute constipation usually has an organic cause, while chronic constipation usually has a functional cause. Failure to thrive and gross distention of the abdomen suggest the diagnosis of Hirschsprung's disease. Rectal examination of a child with constipation usually reveals a distended rectum that is full of stool. In patients with Hirschsprung's disease, the rectum is usually empty and tight. Laboratory Investigations are usually not necessary in patients with mild constipation. Treatment should be directed at the underlying cause. Functional constipation can be managed by changes in diet, regular bowel habits and, if necessary, pharmacologic therapy and biofeedback training.

Products for indigestion

Nathan A.
Department of Pharmacy, King's College London, London United Kingdom
Pharmaceutical Journal (United Kingdom), 1996, 256/6892 (678-682)

Indigestion, after headache, is the ailment most likely to be treated with a nonprescription medicine. In 1994, sales of indigestion remedies increased by 11.7 per cent in volume terms (16.1 per cent by value), some of which was due to the POM to P switch of H2-receptor antagonists. P products account for only 8.5 per cent of total indigestion remedy sales.

Antacids drugs: Multiple but too often unknown pharmacological properties

Vatier J.; Vallot T.; Farinotti R.
Departement de Pharmacie Clinique, Faculte de Pharmacie, 92290 Chatenay-Malabry France
Journal de Pharmacie Clinique (France), 1996, 15/1 (41-51)

This report considers recent procedures for evaluating the pharmacological properties of antacids, and the basis of their use in the treatment of gastroduodenal disorders. The described pharmacologic methods evaluate:

(1) antacid capacity and antacid mechanisms in dynamic conditions by using 'the artificial stomach-duodenum' model, capable of simulating gastroduodenal flux regulation;

(2) the pharmacological properties conferring a protective effect on the gastric mucosa, in vivo, by measuring
(a) the reduction of pepsin activity,
(b) the transepithelial potential difference, and

(3) the molecular structure of adherent mucus glycoproteins and, in vitro, by assessing their ability to adsorb the duodenogastric reflux material. Three groups of antacids can be distinguished.
(a) The aluminium-containing antacids which release aluminium in acid medium develop a potent buffering capacity, an action prolonged by their adsorption to the gastric mucosa. They induce a mucoprotective adaptation and adsorb the gastroduodenal reflux material. Their mechanism of H+ consumption is similar to that of proteins, which are natural antacids, i.e. H+ captation in acid medium and release of H+ ions which are normally neutralised by alkaline secretions in the duodenum. These long-acting antacids are indicated in the treatment of duodenal ulcer disease, in its prevention, and in that of gastritis.
(b) Aluminium and magnesium hydroxide mixtures which form aluminium-magnesium combinations or magnesium and calcium associations mainly exert a neutralising activity with a strong pH rise, inducing rapid gastric emptying, and thereby reducing their activity duration. They do not exert protective effects on the gastric mucosa. They are indicated in the treatment of disorders related to hyperacidity or dyspeptic symptoms (gastrooesophageal reflux, pyrosis, slow gastric emptying, etc.).
(c) Finally, alginic acid and alginate-containing antacids develop a pH gradient between acid contents and its surface, thus protecting the gastric and oesophageal mucosa; these preparations are indicated in the treatment of gastroesophageal reflux. Because these drugs are inexpensive and safe, they should be the first-time drugs of choice.

Treatment of retentive encopresis with diet modification and scheduled toileting vs. mineral oil and rewards for toileting: A clinical decision

Mellon M.W.; Houts A.C.; Lazar L.F.
Section of Behavioral Pediatrics, Arkansas Children's Hospital, 1120 Marshall Street, Little Rock, AR 72202 USA
Ambulatory Child Health (United Kingdom), 1996, 1/3 (214-222)

Objective: This clinical trial compared the effectiveness of diet modification and scheduled toileting (DS group) to mineral oil and rewards for toileting (MR group) in a sample of retentive encopretic children,

Design: Twenty-five (23 male, 2 female) subjects were randomly assigned to either DS or MR in a 2 (group)x 3 (pre-test, post-test, 6-month follow-up) design.

Setting/sample: Subjects were treated in a gastroenterology clinic of a children's hospital, Eighty-five percent of the total sample had a history of chronic constipation, with an average of 3.7 soiling accidents and 2,.6 appropriate bowel movements in the toilet per week. Intervention: Treatments compared increased dietary fiber and scheduled toileting with mineral oil and contingency management,

Results: A majority of subjects, regardless of assigned group, showed increased normal bowel movements, and 58% remained accident free at six-month follow-up yielding comparable global outcomes. However, treatments differed in both immediate and long-term benefits and liabilities, as MR lead to more bowel activity including accidents.

Conclusions/implications for practice: How parents perceive the increase in soiling with mineral oil or slower progress with dietary changes alone may suggest optimal matches of children to treatments in present clinical decision making and in future research.

Comparison of the effects of magnesium hydroxide and a bulk laxative on lipids, carbohydrates, vitamins A and E, and minerals in geriatric hospital patients in the eatment of constipation.

Kinnunen O, Salokannel J
Department of Internal Medicine, Health Centre Hospital, Oulu, Finland.
J Int Med Res 1989 Sep-Oct;17(5):442-54

In a crossover study the effects of magnesium hydroxide on serum lipids, carbohydrates, vitamins A and E, uric acid and whole blood minerals were compared with those of a bulk laxative containing plantago rind and sorbitol in 64 constipated, elderly long-stay patients, 55 of whom were receiving diuretics. Hypomagnesaemia occurred in 11 (17%) patients after bulk laxative and in two (2%) patients after magnesium hydroxide treatment. There was a slight reduction in low values of high-density lipoprotein cholesterol and high values of triglycerides after magnesium hydroxide treatment. There were no significant differences in plasma lipids, whole blood minerals or vitamins A and E using either laxative. Negative p correlations were found between the increase in serum concentrations of magnesium and glycosylated haemoglobin A1 (P less than 0.02) and the serum level of uric acid (P less than 0.01). These results suggest that the long-term effects of magnesium hydroxide and bulk laxative on the absorption of nutrients may not be significantly different. Magnesium hydroxide, however, may have beneficial effects on lipid disorders, impaired glucose tolerance and hyperuricaemia in magnesium deficiency due to diuretics and thus may be a favourable laxative for use in bedridden geriatric patients receiving diuretics.

[Magnesium: current concepts of its physiopathology, clinical aspects and therapy]

Acta Vitaminol Enzymol (Italy) 1982, 4 (1-2) p87-97

Functional constipation is not a life-threatening disease, but as a chronic state it worries the patient and causes him discomfort and often leads him to self-medication with potentially dangerous drugs. Ro 01-4709 contains as active substance dexpanthenol, which is the alcohol of pantothenic acid, a vitamin of the B-complex. In the cells, dexpanthenol is readily oxidized to pantothenic acid, which stimulates peristalsis when administered in therapeutically effective doses. Ro 01-4709 has already proven its efficacy in the prevention and treatment of adynamic ileus. Recently, several open and two double-blind studies have been carried out, investigating the efficacy of oral Ro 01-4709 in the treatment of chronic functional constipation. The two double-blind studies showed Ro 01-4709 to be superior to placebo in all parameters measured. The studies with an open design also demonstrated a favourable effect of Ro 01-4709 in the treatment of chronic functional constipation. Owing to its physiological action-which is in a favourable contrast to that of normal laxatives. Ro 01-4709 can be recommended for the treatment of functional constipation in pregnant women, children and the elderly.

[Treatment of constipation with vitamin B5 or dexpanthenol]

Guillard O; Delmotte JS; Filoche B; Pommelet P
Med Chir Dig (France) 1979, 8 (7) p671-4

No abstract.

Endogenous nitric oxide modulates morphine-induced constipation.

Calignano A, Moncada S, Di Rosa M
Department of Experimental Pharmacology, University of Naples Federico II, Italy.
Biochem Biophys Res Commun 1991 Dec 16;181(2):889-93

Administration of morphine in mice causes inhibition of the gastrointestinal transit of a charcoal meal. Morphine-induced constipation in mice seems to depend predominantly on action(s) on the central nervous system since N-methyl morphine, a quaternary derivative, inhibits intestinal transit only when administered intracerebroventricularly (i.c.v.). L- but not D-arginine, given intraperitoneally, reversed the constipation induced by both morphine and its quaternary analogue. L-arginine was ineffective when given i.c.v. and did not reverse atropine-induced constipation. These results suggest that L-arginine preferentially modulates opioid-induced constipation through a stereospecific and peripheral action(s). It is possible that the effect of L-arginine is achieved by increasing the amount of nitric oxide released by non-adrenergic, non-cholinergic nerves in the gut. Thus, L-arginine may represent a useful agent for the treatment of undesirable constipation associated with the use of narcotic analgesics.

Effectiveness of bran supplement on the bowel management of elderly rehabilitation patients.

Gibson CJ; Opalka PC; Moore CA; Brady RS; Mion LC
J Gerontol Nurs (United States) Oct 1995, 21 (10) p21-30

1. Constipation is a common problem in the elderly that affects up to 20% of those 65 years and older.

2. Patients receiving the fiber supplement had a significantly lower number of bowel agents per day as compared to the control patients.

3. Side effects from the additional fiber occurred in a subgroup of patients; thus, institution of additional fiber to the diets of ill, physically dependent patients is best done gradually and with close monitoring.

Mechanisms of constipation in older persons and effects of fiber compared with placebo.

Cheskin LJ, Kamal N, Crowell MD, Schuster MM, Whitehead WE
Division of Digestive Diseases, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA.
J Am Geriatr Soc 1995 Jun;43(6):666-9

OBJECTIVE: To investigate the mechanisms of constipation and the effect of fiber supplementation on physiology, mechanisms, stool parameters, and colonic transit times in a group of constipated older patients.

DESIGN: Single-blind, randomized, placebo-controlled fiber intervention with crossover.

SETTING: A university-based outpatient center.

PATIENTS: Ten community-living older men and women, healthy except for chronic constipation.

INTERVENTIONS: Patients were given either 24 g psyllium fiber or placebo fiber daily for 1 month, then crossed over to the other arm for an additional month. Structured testing, including total gut transit time and rectal and colonic manometry, was performed at the end of each intervention month. Patients recorded stool frequency, consistency, and weights daily.

RESULTS: The predominant mechanism for constipation in these patients was outlet delay caused by pelvic dyssynergia. Fiber decreased total gut transit time from 53.9 hours (placebo condition) to 30.0 hours (P < .05). Stool weights and consistency were not significantly improved by fiber, though there was a trend toward an increase in stool frequency (1.3 vs 0.8 bowel movements per day.) Pelvic floor dyssynergia was not remedied by fiber, even when constipation was clinically improved.

CONCLUSIONS: Fiber supplementation appeared to benefit constipated older patients clinically, and it improved colonic transit time, but it did not rectify the most frequent underlying abnormality, pelvic floor dyssynergia.