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New Approaches to Treating Chronic Constipation

Posted Aug 24 2008 1:49pm
ANNOUNCER: Constipation affects millions of Americans. But they don't all describe it the same way.

LAWRENCE R. SCHILLER, MD: We see that some patients have mainly infrequency, where they go for longer than usual periods of time without having a bowel movement. But, for many patients, it's just problems with the actual process. It's painful, it may be difficult to evacuate the stools, the stools may seem hard or there may be changes in stool form that attract their attention and get labeled as constipation.

ANNOUNCER: Constipation is considered "chronic" when these problems last several months. When a patient sees a doctor about constipation that just won't go away, the doctor's first task is to rule out several possible, potentially serious, causes.

LAWRENCE R. SCHILLER, MD: When we interview a patient, we try to discover whether they might have some underlying health problem. For instance, you could have an obstructing tumor in the rectum that would block the ability to defecate. You could have a problem with your thyroid gland and be hypothyroid and have a problem with constipation. You could have diabetes and have a problem with constipation.

ANNOUNCER: But usually there's no specific cause, and the process of treating constipation can begin. Traditionally, the starting point has been a recommendation for several so-called "lifestyle changes."

JOHN F. JOHANSON, MD: And those things would include drinking more water, trying to exercise more, eating more fiber in your diet, or adding fiber supplements if you're not able to eat enough fiber in your diet. Unfortunately, a lot of times, particularly those with chronic constipation, these interventions don't work very well.

ANNOUNCER: The next step is likely to be a laxative.

LAWRENCE R. SCHILLER, MD: The laxatives that we prefer to treat patients with are what are called osmotic laxatives. These are agents that retain water within the gastrointestinal tract and thereby soften the stools and increase the amount of stool that's formed each day. The most common and readily available of these would be milk of magnesia or similar products.

ANNOUNCER: Other laxatives are bulking agents, usually containing fiber. There are also lubricants, such as mineral oil. Still other laxatives stimulate the colon. Despite the variety, laxatives don't help everybody.

JOHN F. JOHANSON, MD: I think the benefits of a laxative in patients with chronic constipation are variable based on the individual patient. Some people will get some benefit from the laxative, but have side effects and so they won't feel any better. Other people won't get any benefit from the laxative for their constipation.

ANNOUNCER: When laxatives are not effective, there's a new option. But first, some background about the digestive system.

LAWRENCE R. SCHILLER, MD: The intestine is a very carefully regulated structure. We often don't give it much thought. We eat our food and go about our business without thinking about all the miracles that are happening inside our bodies. The nervous system of the intestine is very complex. There are as many nerve cells in the wall of the intestine as there are in the entire spinal cord.

JOHN F. JOHANSON, MD: We've found that serotonin is an important neurotransmitter or a chemical that facilitates movement of the gut. What happens is the serotonin will stimulate other neurotransmitters which make the colon work the way it should. There're neurotransmitters that cause contraction. There're neurotransmitters that cause relaxation and so what the serotonin does is make that coordinated effort so that downstream the colon will relax, upstream it will contract and move things through.

ANNOUNCER: A new drug targets these nervous-system pathways to combat constipation.

LAWRENCE R. SCHILLER, MD: The newest drug introduced to treat chronic constipation is Zelnorm or tegaserod. This is an agent that mimics the effect of serotonin on a special kind of serotonin receptor in the nerves in the gut. And this is a very specific activity that enhances peristalsis in the intestine.

ANNOUNCER: Tegaserod is approved for patients 65 and under, for periods of up to twelve weeks. Studies show as many as 45 percent of patients experienced an improvement in their constipation using tegaserod, a 17 point increase over the number of patients who improved on a placebo.

JOHN F. JOHANSON, MD: The main side effects that we see in patients with constipation are headache. Some people will get nausea. These are relatively low occurring events, probably less than 5 percent. The headache is a little bit more common. But in clinical practice, I've just not seen that. The third one is diarrhea and that one occurs about 8 to 10 percent of individuals with constipation. Again, in my practice, most of my chronically constipated patients are happy when they get diarrhea.

ANNOUNCER: Only a short time ago, doctors were taught that constipation was usually "in a patient's head." But research has shown the problem is often a disorder of the nervous system. Now, doctors take complaints of constipation seriously. And they have a wide range of therapies to provide relief.

LAWRENCE R. SCHILLER, MD: I think the important message to remember about constipation is that physicians can help many patients who have this problem to reduce their symptoms and allow them to lead fuller lives. We realize now that constipation is a problem that can affect people's quality of life and is something that is deserving of treatment to improve that quality of life. And I urge people who are suffering with this to consult with their doctors to see what can be done to help them with this important problem.

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