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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.
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