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Natures Quick Constipation Cure Overview

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Psyllium Bran and Other Herbs for Constipation

Psyllium is an herb used to relieve constipation. It is of potential importance to people with MS because constipation is a relatively frequent symptom of the disease. Clinical studies have shown that psyllium effectively treats constipation. Unlike most other herbs, psyllium is approved by the FDA. It is referred to as a bulk-producing laxative because it increases in size, or bulk, when it comes in contact with water. Psyllium, probably the most popular bulk-producing laxative, is used daily in some form by approximately four million Americans. Other herbal therapies are available for constipation. One source of fiber is bran, the outer coat of grains, including wheat, oats, and rice. Bran may be consumed as a breakfast cereal, in tablet form, or as crude fiber. Other fiber-rich foods include apples, citrus fruits, and beans. Other herbs that appear to be effective for relieving constipation and are generally safe for short-term use (1 to 2 weeks) include buckthorn, cascara, castor...

Constipation and Diverticulitis

Constipation is a disorder characterized by the need to strain to pass hard stools and decreased frequency of stools (two to three times a week). Chronic constipation can lead to diverticulosis, in which multiple small sacs of the colonic mucosa are pushed out through the muscular wall of the colon. Diverticulosis occurs because chronic straining to pass feces produces increased pressure inside the colon. Inflammation often develops within the small sacs (diverticula) producing diverticulitis, with abdominal pain and bleeding. Constipation and diverticulitis are so-called diseases of civilization. They occur in near epidemic proportions in the industrialized countries, where one-fifth of the adult population suffers from chronic constipation and diverticu-losis occurs in about one-third of people older than 65 years.

Micronutrients Constipation

Pulls water into the colon and softens stools. Start with 250 mg and increase gradually until constipation improves. Take as single dose on arising in the morning Deficiency can aggravate constipation High-dose calcium supplements (more than 2 g day) may worsen constipation. Chronic use of laxatives should be avoided. Most interfere with normal colonic function and reduce absorption of nutrients. They can also precipitate development of irritable bowel syndrome.

Treatment of Symptoms and Constipation as Causes for Secondary Anorexia Cachexia

In patients with advanced, progressive, incurable disease, the causes of anorexia, decreased oral intake and loss of weight are complex. Besides the primary (paraneoplastic) catabolic processes, a number of important causes for loss of appetite or weight may occur, such as severe symptoms (i.e. pain, shortness of breath, depression), syndromes (i.e. constipation, mucositis, bowel obstruction) or prolonged bed rest 12 . Poor assessment of interfering symptoms (see Chp. 9.11) by not acknowledging risk factors for symptom expression and insufficient symptom management (i.e. pain, depression, social distress), or negligence of the syndromes constipation 13 or sedation 14 can lead to sub-standard management.

Diet Constipation

The primary cause of both constipation and diverticulosis are highly refined and processed diets that are low in dietary fiber. Dietary fiber passes into the colon intact and absorbs water - increasing the bulk of the stool and softening it.1 This stimulates peristalsis in the colon, pushing the stool forward more rapidly. Dietary fiber is found in large amounts in whole grains, corn, vegetables, fruits (dried prunes, apples, raisins, and figs), seeds, and legumes. Increasing intake of these foods will soften the stool, and often eliminate constipation. Supplements of fiber, such as corn or wheat bran and psyllium-seed preparations, can also be beneficial. However, because large amounts of fiber can produce gas and abdominal discomfort, fiber intake should be increased gradually as tolerated overa period of several weeks. Ample fluid intake (8-10 large glasses per day) should accompany increases in dietary fiber.2

Head Computerized Tomographic CT Scan

FIGURE 3.10 Opioid bowel colonic ileus in a methadone abuser. Abdominal radiograph (KUB) that demonstrates air distension of the small bowel and transverse colon consistent with chronic constipation and colonic ileus in a methadone abuser. (Courtesy of Carlos R. Gimenez, M.D., Professor of Radiology, LSU School of Medicine, New Orleans, LA.)

Cereals Bread Wheat Bran and Wheat Germ

Whole grains are the best natural sources of complex carbohydrates and fiber. Populations eating large amounts of whole-grain products (e.g., Africa and Asia) have far fewer intestinal and bowel problems-such as constipation, hemorrhoids, diverticulitis, and colon cancer-compared to Western populations consuming mainly refined carbohydrates.30

Decontamination Cathartics

Use Most organic and inorganic materials, ASA, acetaminophen, barbiturates, glu-tethamide, phenytoin, theophylline, TCAs. Dose Early (within 1-4 hours) administration of a flavored 8 1 water slurry, 10 1 AC drug, 1-2 g kg body weight (bw). Side effects Vomiting, aspiration, diarrhea, later constipation, possibly small bowel obstruction (SBO) AC is usually combined with a cathartic, particularly 70 sorbitol preferred over Mg citrate.

Principles of Pediatric Pain Management

Stool stimulants are to be considered when extended use of an opioid is projected. Stool softeners may be inadequate because they do not cause propulsion of feces. Stool stimulants are warranted when defecation is absent after 3 days of opioid administration because tolerance of side effects, such as constipation, can take 1 week or more to occur (50).

Other thoracic malignancies

A Phase I study has been underway at the M.D. Anderson Cancer Center for patients with advanced unresectable gastric, gastroesophageal, or esophageal cancer (48). Patients must not have had previous treatment, and eligibility criteria regarding a baseline hema-tologic and liver function tests are standard. Previous treatment with irinotecan or topotecan (Hycamtin) or prior radiotherapy were exclusion criteria. The treatment plan consisted of a Phase I dose-escalation study beginning at 30 mg m2 and extending to a dose of 70 mg m2. A weekly dose of irinotecan was modified according to blood counts. Radiotherapy treatment consisted of 45-50 Gy in 1.8 Gy fractions for a total of 2528 fractions delivered over 5 wk. The irinotecan was administered 1 h prior to administration of radiation therapy on d 1 of each week of radiotherapy. In 18 patients enrolled between January and November of 1998, there were 12 patients evaluable for toxicities and response. There was a male predominance of 16...

General Symptom Data on Children at the End of Life

A retrospective chart review examined the signs and symptoms occurring at the end of life in 28 children dying from cancer in Japan. All children experienced anorexia, 82.1 had dyspnea, and 75 had pain. Other symptoms included fatigue (71.4 ), nausea vomiting (57.1 ), constipation (46.4 ), and diarrhea (21.4 ) (4). This symptom profile parallels that of the North American reviews of the symptoms of dying children (2,5,6).

Monoamine Transport Inhibitors

The tricyclic antidepressants (TCAs) were originally designed to improve upon the efficacy and side effect profile of the phenothiazine class of antipsychotics. Their pharmacological spectrum was quite well understood in that these compounds interact with multiple brain neurotransmitter systems. The TCAs inhibit reuptake of monoamine neurotransmitters (dopamine (DA), 5HT, and NE) increasing their levels and function in the brain. TCAs include imipramine, desipramine, nortriptyline, amitriptyline, clomipramine, and doxepin (Figure 5). These compounds also interact with a variety of biological targets like muscarinic receptors, complicating their pharmacology and contributing to side effects such as orthostasis, dry mouth, and constipation. Clomipramine is the most effective TCA for panic disorder, OCD, and SAD87 but more selective reuptake inhibitors have displaced the use of the tricyclics due to their improved side effect profile.

Studies in MS and Other Conditions

People with MS also may experience bowel incontinence. Biofeedback may be beneficial for this problem. In people with bowel incontinence related to conditions other than MS, biofeedback produces improvement in approximately 70 percent. In a small study of the effects of biofeedback on 15 people with MS-related constipation or stool incontinence, five showed improvement. Those who benefited from biofeedback had mild to moderate disability and had relatively stable disease during the time of treatment.

Irritable Bowel Syndrome

IBS can be subclassified into three groups based on altered bowel habit constipation predominant, diarrhea-predominant, and alternating (5,8-11). Another subclass has now been added, postinfectious IBS (12). However, despite this heterogeneous population of patients, enhanced colonic mechanosensation is a hallmark of all subtypes of IBS and as such increased perception of mechanical distension of the distal colon rectum has become the best-characterized clinical manifestation of IBS (1,13,14). The extent of this enhanced colonic sensation is considerable, as a colorectal distending volume of approximately 60 mL evokes pain in less than 10 of normal subjects compared with greater than 50 of IBS patients. Therefore there is leftward shift in the psychophysical function of IBS patients suggesting the presence of hyperalgesia in IBS (13). There is a general agreement that this visceral hyper-sensitivity and hyperalgesia correlates well with the overall severity of the disease (1,15),...

Social Causes of Weight Loss

Hospitalised AIDS patients, who take in only 70 of resting energy expenditure (REE) needs and 65 of protein needs, excluding the extra needs resulting from the hypermetabolism associated with fever, acute infections, and physical activity. Dietetic deficits in protein and calorie consumption interfere with the natural course of the main disease, emphasising subjective symptoms such as sickness, asthenia, anorexia, emesis, and constipation, which in turn interfere with feeding. A close relationship exists between susceptibility to infectious diseases and nutritional status regular nutrition and general good health make individuals more resistant to infections. Similarly, anergy to cutaneous tests (PPD, candidin, DNCB, etc.) is closely related to body-weight insufficiency and hypoalbuminaemia. The pre-surgical correction of denutrition reduces the incidence of post-surgical infectious complications, favouring the healing of the wounds and a quicker return to health 18-20 .

Changing Therapeutics in the Management of Intractable Pain in Children at the End of Life 19952005

Children do not necessarily report opioid side effects voluntarily (e.g., constipation, pruritus, dreams, etc.) and should be asked specifically about these problems. An assessment of opioid side effects is included in an assessment of analgesic effectiveness. All opioids can potentially cause the same constellation of side effects. If opioid side effects limit opioid dose escalation, then consideration should be given to an opioid switch. Tolerance to some opioid side effects (e.g., sedation, nausea and vomiting, pruritus) often develops within the first week of starting opioids. Children do not develop tolerance to constipation, and concurrent treatment with laxatives should be provided.

Diseases with Akinetic Rigidity Idiopathic Parkinsons Disease

Combinations of extrapyramidal disorders and auto-nomic dysfunctions, frequently accompanied by neuro-psychiatric symptoms, define the disease. The cardinal motor symptoms are cogwheel rigidity of muscle tone, bradykinesia akinesia, postural instability, and pill-rolling tremor at rest. A stooped posture, shuffling and festinating gait, lack of facial expression, micrographia, weak monotonous speech, and dysphagia are additional characteristic features. In some patients, akinetic-rigidity predominates in others, resting tremor. Characteristic autonomic dysfunctions include orthostatic hypotension, seborrhea, sialorrhea, hyperhydrosis, constipation, bladder disorder, sleep disorder, and, rarely, sexual dysfunction. Anxiety, depression, psychosis, hallucination, and cognitive decline may emerge at any time during the course of the disease, which ranges from 10 to 20 years. No specific diagnostic tests are available. PET and SPECT show diminished striatal dopamine uptake.

Other Dietary Considerations in MS

Constipation is a frequent complaint in people with MS. One way to improve constipation is to increase the amount of fiber in the diet. Good sources of fiber include whole grain breads and cereals, as well as fruits and vegetables. An increased intake of water and other fluids also may be beneficial for constipation six to eight 8-oz. glasses of fluid daily generally are recommended. Some people with MS may have frequent urinary tract infections, and increased fluid intake also may be helpful for this problem. Finally, for some people with MS-associated fatigue, it may be beneficial to avoid large increases or decreases in the blood sugar level. This may be accomplished by eating small meals and snacks throughout the day.

Management of Cyclic Antidepressant Side Effects

Side effects of TCAs include anticholinergic effects (dry mouth, constipation, blurry vision, urinary hesitancy, and delirium) and orthostatic hypotension. Most of the anticholinergic effects can be managed with dosage adjustment and adjunctive agents. Dry mouth is relieved by sucking on hard, preferably sugarless candies or by chewing gum. A 1 solution of pilocarpine used as a mouthwash every 3 or 4 hours also has been reported to be helpful (Bernstein 1983). Constipation can be managed with stool softeners, bulk laxatives, and adequate fluid intake. Blurry vision may respond to 1 pilocarpine eyedrops, one drop every 4-6 hours as needed. In milder cases, artificial tears usually suffice. Urinary hesitancy is often responsive to oral bethanechol, 1030 mg three times a day. Patients, particularly men, are instructed to be aware of the possibility of complete urinary obstruction and to have appropriate plans should complete obstruction occur (e.g., to report to the nearest emergency...

Clinical Features

Ataxia of gait is usually the presenting cerebellar symptom, followed by ataxia of limbs, dysarthria, and ocular signs such as nystagmus, ocular dysmetria, fixation instability, and jerky pursuit movements. The parkinsonian features include rigidity, bradykinesia-akinesia, postural instability, hypokinetic dysarthria, and tremor. The autonomic failure consists of orthostatic hypotension, bladder dysfunction (urinary frequency, urgency, retention), bowel dysfunction (constipation), and sexual (male erectile) dysfunction. Spasticity, hyper-reflexia, sleep disorder, respiratory stridor, and hypoventilation add to the syndrome. The course averages from 6 to 10 years. MRI demonstrates cerebellar atrophy and

Presenting Signs and Symptoms

The most common presenting signs and symptoms of an ovarian tumor are abdominal pain, palpable abdominal mass, increasing abdominal girth, urinary frequency, constipation and dysuria 10, 28 . Some tumors, however, are asymptomatic and only discovered during routine examinations. Abdominal pain is most often chronic, but torsion of the ovary can be associated with acute pain. Since normal sex cord-stromal cells are involved in steroid hormone produc

Tricyclic Antidepressants

Effective in diabetic neuropathy, postherpetic neuralgia, tension headache, migraine, atypical facial pain, fibromyalgia and low back pain. In neuropathic pain, TCAs relieve brief lancinating pain, constant dysesthetic pain, allodynia and spontaneous pain. The pain relief from TCAs is generally moderate in degree. Side effects such as sedation, postural hypotension, dry mouth and constipation are common. The sedative property of this class of drugs is often exploited when pain is accompanied by sleep difficulty by administering them in the evening. TCAs with a balanced inhibition of serotonin (5-hydroxytryptamine or 5-HT) and norepinephrine (NA) reuptake, such as amitriptyline, imipramine and clomipramine, as well as agents with greater NA reuptake inhibition such as desipramine and nortriptyline, appear to be effective analgesics. The mechanism of action is unknown. It is probably multi - factorial as these agents are capable of multiple actions of relevance to pain transmission 8 .

Pheochromocytoma and Weight Loss

Gastrointestinal symptoms can also contribute to weight loss. They include nausea, vomiting, abdominal pain, and, occasionally, constipation or diarrhoea. Constipation may reflect direct inhibitory effects of catecholamines on gut smooth-muscle contraction. The so-called watery diarrhoea, hypokalaemia, achlorydria syndrome ( WDHA , also known as Verner-Morrison syndrome) in patients with PCC is secondary to the ectopic production of vasoactive intestinal polypeptide (VIP) 35 . These symptoms, including weight loss, resolve after the tumour is removed 26,35 .

Clinical Manifestations

Typhoidal 5-day prodrome, fever, chills, sore throat, joint pain, rose spots (30 ) cramps, hepatosplenomegaly (H S) (50 ), neuropsychi-atric symptoms, lymphadenopathy, constipation, no diarrhea, bradycardia, CFR < 30 . Complications Bowel perforations from perforated Peyer's patch, osteomyelitis. Warning Infants and elderly in homes with pet amphibians and reptiles turtles > lizards (iguanas) > snakes.

Unmet Medical Needs

In the case of inflammatory or nociceptive pain, opioids provide significant analgesic efficacy however, long-term use of these analgesics is limited by both opioid-mediated side effects including constipation, and regulatory concern of opioid dependence and abuse liability. NSAIDs also provide moderate pain relief in these pain states, but are associated with GI disturbances. The COX-2 inhibitors represent an analgesic advance due to their enhanced GI safety profile however, the long-term cardiovascular safety of these agents is controversial.

Diagnosis Symptoms and clinical Signs

Most common symptom is vague, usually generalized abdominal pain 18, 26, 29, 35, 36 . Localizing abdominal pain is usually an indication of peritoneal involvement or perforation. This pain is occasionally suggestive of appendicitis 35, 37, 38 . Weight loss is relatively common according to our recent review of St. Jude patients in which approximately two-thirds noted weight loss median loss 20 lbs (9.1 kg) range 5-81 lbs (2.3-36.8 kg) 39 . Other less frequent associated symptoms include nausea, vomiting, constipation, diarrhea, pallor, anorexia, rectal bleeding, abdominal distension, dysuria, and intestinal obstruction 18, 26, 29 . In one review of 29 patients, 13 presented acutely whereas 16 had more chronic symptomatology 29 . In our experience, the duration of symptoms before diagnosis has ranged from 3 days to 12 months, with a median of 2 months 18 . A mass or fullness may or may not be palpable on physical exam 26, 35, 37 . Primary tumors of the right colon usually present with...

Evidence for Autonomic Nervous System Dysfunction

Increased sympathetic activity has been demonstrated in patients with IBS. Heitkemper et al. studied urinary catecholamine (NE and epinephrine) and cortisol levels in women diagnosed with IBS against women who reported similar symptoms but did not seek health care services and asymptomatic control women (122). Women with IBS had significantly higher urinary levels of all of these neuroendocrine indicators of arousal suggesting heightened sympathetic nervous system activation. Whether greater symptom distress in the IBS women resulted in increased sympathetic activation and health care seeking or the higher sympathetic activation increased pain perception leading to health care seeking is unclear. These investigators later demonstrated significantly lower parasympathetic tone and higher ANS balance in constipation-predominant compared to diarrhea-predominant subgroups of IBS but only when symptom severity scores were high. No difference was seen between IBS and control women, and...

Evidence for Alterations in Descending Pain Modulation

Demonstrate the activation of brain stem regions in the context of central sensitization in healthy human volunteers (68). Using 3T fMRI, they compared whole brain responses, including the brain stem, to punctuate mechanical stimulation in an area of secondary hyperalgesia (induced by heat capsaicin sensitization model) or in a control area. They found greater activation during stimulation of the hyperalgesic region in several cortical regions, including posterior insula and anterior and posterior cingulate cortex, as well as the thalamus and pons. The brain stem activation was localized to the NCF and the PAG, two regions that receive inputs from corticolimbic networks (including the rostral ACC), send projections to the rostro-ventral medulla, and are part of a corticolimbic pontine pain modulation circuit (69,70). These intriguing findings correlate nicely with recent findings in rodents demonstrating the upregu-lation of spino bulbo spinal loops, which play a role in the...

Sex Differences in Brain Responses to Visceral Stimuli

Berman et al. reported the first study of brain responses in two samples of a total of 30 IBS patients (13 females 6 with constipation-predominant bowel habit) with H215O-PET in response to rectal distension (18). Despite similar subjective stimulus ratings by male and female patients, regional brain activations were stronger in males. In males, but not females, rectal distension was associated with activation of regions within the central pain matrix (including anterior insula and dACC). Insula activation correlated most strongly with the objective intensity of the stimulus (rectal pressure), whereas ACC activation correlated most strongly with the subjective discomfort rating of the stimulus. The authors interpreted their

Modulation of Brain Responses by Pharmacological Treatments

Morgan et al. studied 22 females with pain-predominant IBS (Rome II positive, 11 with diarrhea, 7 with constipation, and 4 with alternating bowel habit) (75). No patients had significantly elevated symptoms for depression, anxiety, and general psychological distress on the Symptom Check List-90 (SCL-90) instrument. The study was designed as a randomized, placebo-controlled, double-blind crossover trial. Patients initially took 25 mg (one week), and later 50 mg, of amitriptyline at bedtime for three weeks, followed by a three-week washout before switching over to the alternate treatment. Cerebral activation during controlled rectal distension (15, 30, and 50 mmHg distension pressure) was compared between placebo and amitriptyline groups by fMRI. Distensions were performed alternately during auditory stress (babies crying) and relaxing music (stress reduction tape), and a total number of nine distensions in random order were given during each condition. Subjective ratings of rectal pain...

Differential Diagnosis

UTI, constipation, and comorbid psychiatric disorder, should be assessed and ruled out as appropriate (Figure 9-1). Other causes of nocturnal incontinence should be excluded, for example, those leading to poly-uria (diabetes mellitus, renal disease, diabetes insip-idus) and, rarely, nocturnal epilepsy.

Pharmacotherapeutic Considerations

The existing range of pharmacotherapeutic options for pain management is not contra-indicated per se in persons with mental illness, and similarly, the psychotropic drugs used to treat mental illness are not per se contra-indicated in those with chronic pain. However, such combinations may cumulatively contribute to specific side-effects. The use of opiates and psychotropics may both contribute to exacerbate a common side-effect of both classes, namely decreased gastrointestinal motility and subsequent constipation. Further, the use of opiates in combination with sedating psychotropic drugs may contribute to further sedation and psycho-motor retardation, as well as possible cognitive impairment 6 .

Assessment Instruments for Eating Related Distress

Traditional instruments, such as the FAACT (Functional Assessment of Anorexia Cachexia Therapy) for anorexia cachexia, or widely used quality-of-life instruments, such as the EORTC-QlQ-c30, carry some items related to distress, but they were not specifically developed for the purpose of assessing distress. The FAACT 19 , as an example, asks at least three distress-related questions 'I am worried about my weight' (item 3), 'I am concerned how thin I look' (item 5), and 'my family or friends are pressuring me to eat' (item 8). In the general section of the FACT, there is a question regarding the impact of physical function on social contacts (item 3). In the EORTC-QlQ-c30, questions assessing interference with (physical) function (items 6, 7) or social contacts (items 26, 27) may depict issues related to cachexia and weakness, but not directly to eating. As a solitary symptom, only the impact of pain on daily life (item 19) is included in the EORTC-QLQ-C30, but there are no items...

Thalidomide And Dexamethasone

Thalidomide 100-200 mg daily with dose increase to 400 mg day allowed (median maximum dose achieved was 200 mg day), and dexamethasone 20 mg m2 on the same schedule as in the Mayo trial.69 As would be predicted from trials involving patients with relapsed refractory MM,65' 66 thalidomide therapy caused neuropathy, sedation, and constipation. Thrombotic complications occurred in 12 and 15 of patients treated in these two induction trials. In the MDACC study, a 25 thrombosis rate was observed in the first 24 patients treated, despite prophylaxis with 1 mg of coumadin daily. The next 16 patients received therapeutic doses of coumadin or low-molecular-weight heparin and no thrombotic events occurred.69 Based on the results of these Phase II trials, a randomized study comparing TD to dexamethasone alone was undertaken by ECOG. In this study, after four cycles of randomized therapy, patients with at least stable disease were given the option of proceeding to HDC ASCS. Although a...

Lenalidomide Cc5013 Revlimid

Is very different than that of thalidomide, with thrombocytopenia and neutropenia predominating, and essentially no sedation, constipation, or neuropathy. The response rate among 34 patients with newly diagnosed MM treated with lenalidomide 25 mg daily for 21 out of every 28 days with pulse dexamethasone (40 mg day on days 1-4, 9-12, 17-20) was 91 (CR 6 ).122 ECOG has completed accrual to a large randomized study of lenalidomide with two different doses of dexamethasone, and the Southwest Oncology Group is currently conducting a 500-person randomized, double-blinded study comparing dexamethasone to dexamethasone plus lenalidomide (LD). The results of these two studies will establish whether LD could be an appropriate front-line regimen for patients with MM.

Palliative Nutritional Endpoints and Decision Making

About the goals of an intervention is important to avoid both extremes neglect and overactivity. The focus on amount of intake, optimisation of nutrients or weight is curative in nature, since it does not aim to relieve primarily suffering. Treatment of the sensation of loss of appetite, decreasing the distress related to social interactions associated with meals, is palliative in nature. However, the optimal management of constipation leading to (almost) complete reversal of anorexia, or stenting the colon to improve bowel obstruction, aim to relieve suffering but are curative in nature. In both cases a pure palliative approach to relieve anorexia, visceral pain, and nausea in constipation and bowel obstruction would probably be of minor quality in many patients.

Palliative Symptom and Syndrome Management

Constipation often causes symptoms such as anorexia, early satiety or nausea before it is perceived as a symptom (feeling of incomplete evacuation, fullness of the bowel, etc.). It needs to be diagnosed as a syndrome (history, X-ray abdomen, rectal examination), not as a symptom.

The Diagnosis of Cancer Cachexia and its Implications

Pre-treatment weight loss has long been identified as an important prognostic factor in oncology 6 and the objective clinical consequences of cachexia are profound - reduced survival, impaired response to anti-cancer therapy, impaired immunity, lower performance status, increased symptomatology, reduced physical activity, impaired quality of life. It is important to identify potentially reversible conditions that can exacerbate cachexia (e.g. mechanical causes of inadequate nutritional intake, malabsorption, metabolic disorders such as hyper-calcaemia, and depression) and to manage adequately other problems that may confront cancer patients (e.g. pain, nausea, constipation and infection). Common treatment-related side-effects (e.g. gastrointestinal sequelae of chemotherapy or radiotherapy such as nausea, mucositis, diarrhoea, food aversion) should also be anticipated. In addition, there is a suggestion that some cytotoxic drugs may themselves generate cachexia-like side-effects 7 .

Nutritional Therapy Background

Patients with advanced cancer may have an inadequate nutritional intake and fail to increase appropriately their intake in response to increased resting energy demands 18 . Intake may be reduced by 'primary' mechanisms induced by the cachexia syndrome (and manifesting as anorexia or early satiety) or may be 'secondary' to problems such as mechanical gut obstruction or impaired swallowing, nausea, constipation, depression, gastrointestinal fungal infection and treatment side-effects (e.g. opiates, antibiotics, chemotherapy, radiotherapy). Such secondary problems should be proac-tively sought and appropriately managed. In addition, the medical team should also be alert to the risk of deteriorating nutritional status when patients are hospitalised 19,20 .

Immunomodulatory Analogs Of Thalidomide

The efficacy of thalidomide has been limited by adverse effects, which include sedation, neuropathy, constipation, and deep vein thrombosis. This spurred the development of thalidomide-derived immunomodulatory analogs, known as immunomodulatory drugs (ImiDs). Like thalidomide, IMiDs inhibit angiogenesis and act directly on MM cells to induce both apoptosis and growth arrest in resistant cells. They also block the adhesion of myeloma cells to bone marrow stromal cells and the associated protection against apoptosis, and thus affect myeloma cell growth, survival, and migratory factors such as IL-6, tumor necrosis factor a (TNFa), and VEGF. In addition, they expand natural killer cell and T-cell numbers, and improve function against human myeloma cells and enhance their susceptibility to antibody-dependent cell-mediated cyto-toxicity in vivo.54-56 The addition of an amino group at position 4 of the phthaloyl ring in thalidomide structure led to the generation of CC-4047, and with the...

The Standard of Care in Cachexia Trials

When designing an intervention trial it is important to bear in mind the hypothesis that the trial is attempting to prove. Most commonly, an intervention is compared with a placebo the two cohorts of patient subjects should otherwise receive the same standard of care. However, the standard of care pertaining to the general management of cachexia remains currently undefined. The issue of standardisation of care in cancer cachexia is a complex field that can be divided into general medical issues and specific issues. General medical issues include patients' pain, constipation, depression, fatigue, malabsorption and diabetes, to name but a few. All must be adequately controlled if any

Current Treatment of Irritable Bowel Syndrome

The goal of IBS treatment is to provide rapid, sustained, global relief of the multiple symptoms of IBS with a single, effective, well-tolerated agent. However, because of the complexity and overlap of the neural circuitry of the gut and CNS and potential occurrence of multiple pathophysiological disturbances, it has proved difficult to identify a single optimal therapeutic target. The choice of therapy has traditionally been based on the primary bowel symptom. Because of the multiplicity of symptoms associated with IBS, patients often need to use a variety of agents to achieve relief. Traditional treatment approaches rely on a combination of dietary changes, bulking agents, laxatives, antispasmodics, antidiarrheal agents, and antidepressants. These therapies, in general, target individual symptoms and therefore do not address the multiple-symptom complex.142 Clear-cut evidence for their use in patients with IBS is lacking. An evidence-based review of IBS therapies concluded that,...

New Research Areas

* Constipation is a side effect In development for treatment of patients with chronic idiopathic constipation, IBS-C, and postoperative ileus Major adverse effect is nausea diarrhea and headache also reported IBS CNS adverse effects an issue for CB1 Cilansetron 3 is a 5HT3 antagonist under development for the treatment of patients with IBS-D. It is presumed to have the same mechanism of action as alosetron - inhibition of colonic transit and visceral sensory mechanisms. In two phase III trials of patients with IBS-D (a 3-month dose-ranging US study and a 6-month international study), combined analysis showed that a significantly greater proportion of patients who were administered cilansetron (2 mg three times daily) reported adequate relief of abnormal bowel habits and abdominal pain than control patients.209 Individual measures, such as relief of urgency, stool frequency, and stool consistency, also were better with cilansetron. Subset analyses showed that cilansetron is of...

Dsmivtr Diagnostic Criteria

One-third to one-half of the usual initial dose) are advised and only agents with minimal anticholinergic activity should be employed. Appropriate choices would be the selective serotonin reuptake inhibitors such as paroxetine, fluoxetine, sertraline, citalopram, and escitalopram. Although sertraline, citalopram and escitalopram are least likely to cause drug-drug interactions, even these agents have the potential to increase confusion in Alzheimer's individuals. Agents such as trazodone and mirtazapine have occasionally been employed because of their sedating properties. If tricyclic antidepressants are used, the secondary amines (e.g., desipramine, nortriptyline) are recommended over the tertiary ones (e.g., amitriptyline, doxepin). Careful attention to the possible side effects of these agents, particularly orthostatic hypotension, lowering of the seizure threshold, excessive fatigue, urinary retention, constipation, confusion, and accelerated memory impairment, is suggested. Most...

Dementia Due to Parkinsons Disease

The clinical features of Parkinson's disease are well described, with the cardinal triad being tremor, rigidity, and bradykinesia. Associated features include postural instability, a festinating gait, micrographia, sebor-rhea, urinary changes, constipation, hypophonia, and

Hydroxytryptamine Receptors

In terms of drug development, 5-HT3 and 5-HT4 receptors have been in the focus of interest, because their pharmacologic manipulation may correct both the functional disturbances in the gut and the pain associated with FBDs (12). This is particularly true for 5-HT3 receptors, which are present on vagal afferent neurons originating in the nodose ganglia, spinal afferents originating in the DRG, enteric neurons, and other cells of the gut. 5-HT-evoked excitation of extrinsic sensory neurons is primarily mediated by 5-HT3 receptors (10,12,18). Antagonism of 5-HT3 receptor-mediated stimulation of vagal afferents inhibits emesis induced by release of 5-HT from enterochromaffin cells (10), and blockade of 5-HT3 receptor-mediated activation of spinal afferents by alosetron depresses the afferent signaling of colorectal distension in the rat (19). Accordingly, alosetron has been found to reduce the discomfort and pain in female patients suffering from functional dyspepsia or...

Symptoms And Management

Most patients with cancer actually have several pains. Most have chronic pain with transient flares of acute pain.17 In approximately one-third, neuropathic pain will be prominent, though many will have a mixed pattern of neuropathic and nociceptive pain.18 Both the type of pain, pain intensity, and the temporal nature of pain govern the analgesic dosing strategy. Therapy needs to be individualized.19 20 Opioids should be used for moderate to severe pain.1920 Eighty percent of patients with severe pain will have pain controlled by morphine or other potent opioids. Opioid titration to response is a cardinal principle of treatment. An effective drug will be ineffective if underdosed potent opi-oids do not have a ceiling dose. Twenty percent of patients will require a complex approach to pain management of opioid (route) conversion, opioid rotation to an alternative opioid, opioid sparing (by adding an adjuvant analgesic), or maintenance of opioid dosing with simultaneous treatment of...

Managing The Actively Dying

Dying patients require symptom management, physical expressions of love, the presence of significant others, truth telling, and dignity through meticulous maintenance of personal hygiene.98,99 Patients should not be subject to venipuncture and procedures for curiosity sake when the goals of care are comfort. Family education, frequent visits, and intensive low-technology care are other elements to good end of life care. Symptoms change during the course of illness. At the end, pain, delirium, nausea, vomiting, and secretions are the important symptoms to control.99-101 Opioids should be maintained despite changing mentation. Families often mistake the dying process for drug toxic-ity and need to understand the difference. Terminal agitation or restlessness may arise from a full rectum or bladder, poorly controlled pain, or delirium. Patients should be examined for fecal impaction and a distended bladder, and measures should be taken to relieve either one if present. As patients become...

Summary of the Effects of Popular Dietary Supplements

Oligomeric proanthocyanidins Possibly immune-stimulating Passionflower Possibly fatigue-producing Propolis No definite therapeutic effects unknown safety Psyllium U.S. Food and Drug Administration (FDA)-approved for constipation should not be used by people with swallowing difficulties

Overview and Comparison of Drug Classes

The first nonstimulant therapy designed for ADHD, Strattera (atomoxetine, Lilly), was introduced in January 2003 and has rapidly gained acceptance. Atomoxetine is not a scheduled drug, has a low risk for abuse and dependency, has a nonstimulant side-effect profile (although sleep and growth disturbances are shared with stimulants), and is the first indicated product for adults with ADHD. Unlike stimulants, for example, atomoxetine lacks methylphenidate-like drug reinforcement properties in monkeys,77 leading to the conclusion of reduced likelihood for abuse potential in human patients. On the other hand, there is no consensus that patients with ADHD abuse prescribed stimulants.46 The efficacy of atomoxetine is not better, and perhaps less, than methylphenidate. In one clinical report,78 atomoxetine was reported to have better effects on inattentive symptoms compared to the hyperactive impulsive symptoms consistent with the proposed role for norepinephrine in measures of...

Diseases That Lead to an Increased Risk of Kidney Failure

Potassium deficiency is another cause of kidney failure, though it is uncommon. Kidney function decreases in severe potassium deficiency and may never recover. Chronic diarrhea or overuse of laxatives can induce chronic potassium deficiency and renal failure. The ability of the kidneys to produce highly concentrated urine, and to decrease the output of urine in response to dehydration is characteristically impaired in patients with potassium deficiency, so these patients tend to excrete large volumes of urine (despite their reduced kidney function). Replenishing potassium stores usually restores kidney function, but not always. Laura Melton came to Johns Hopkins at the age of 56. She told us that in order to lose weight, she had been taking laxatives every day for 30 years and still takes 2 to 3 pills daily. She had first exhibited urinary protein in an exam 11 years earlier. Three years before, she had 500 mg per day of urinary protein (normal urinary protein amounts to less than 150...

Treatment of Excessive Potassium

In less urgent cases, sodium polystyrene sulfonate, an exchange resin taken in the sodium form that is not absorbed in the intestine, but takes up potassium in exchange for sodium and is excreted in the stool, can be taken by mouth. This drug is expensive and difficult to take. (It tastes like sand.) It is usually dispensed in sorbitol suspension so as to reduce its constipating effects. However, in some patients the sorbitol leads to diarrhea or to more serious intestinal problems. Other laxatives may be safer and may in fact lower potassium somewhat when given alone (that is, without the SPS). SPS without sorbitol is also available (Kionex). In mild cases, reduction of dietary potassium also may help, though in my opinion that idea is a nonstarter. I never use this last option because small doses of SPS are so effective and these patients already struggle with a multitude of dietary restrictions. If there is associated acidosis and the hyperkaliemia is...

Salt and Water Deficit

Other individuals drink fluids compulsively. This is not connected with chronic kidney disease, except that the occurrence of both compulsive water drinking and chronic kidney disease in the same person makes hyponatremia very likely. This occurrence is greater than one would predict from chance alone, because neuropsychiatric disorders, including bipolar disorders and compulsive taking of laxatives, can both lead to the development of kidney disease (see Chapter 2), and compulsive water drinking can be associated with either of these disorders.

Vegetarian Diets

What are the health benefits of a vegetarian or semivegetarian diet Vegetarians are less at risk for heart attack and diabetes.41 The risk of vegetarians suffering a heart attack is around two-thirds lower than that of meat eaters.42 High blood pressure, obesity, and high blood cholesterol are also less likely in vegetarians. Vegetarians suffer less from many digestive disorders, including gallbladder disease, constipation, and colon cancer.4143 Studies in

Effectiveness

The evidence-base for the effectiveness of interventions and strategies in managing pain is large 36-38 although the issue of what works, where and when remains inconclusive 39-41 . While the evidence base is continuously being updated, incorporating potential new therapeutic areas, interventions and management programs 25, 42-46 , questions remain relating to the quality of studies and their relevance for policy and practice 47, 48 . Further, the nature and extent of adverse events associated with some interventions have also resulted in debate as to what actually constitutes effectiveness when efficacy and safety are combined. For example, a systematic review of over 5000 patients confirmed that most patients would experience at least one adverse event resulting from opioid use in chronic pain, and that substantial minorities would experience common adverse events of dry mouth, nausea, and constipation, and would not continue treatment because of intolerable adverse events 49 .

Eating Disorders

Although the name of this diagnostic class focuses on the fact that the disorders in this section are characterized by abnormal eating behavior (refusal to maintain adequate body weight in the case of anorexia nervosa and discrete episodes of uncontrolled eating of excessively large amounts of food in the case of bulimia nervosa), of near equal importance is the individual's pathological overemphasis on body image. A third category, which is being actively researched but has not been officially added to the DSM-IV-TR, is binge-eating disorder (included in the appendix of Criteria Sets and Axes Provided for Further Study). Like bulimia nervosa, individuals with binge-eating disorder have frequent episodes of binge-eating. However, unlike bulimia nervosa, these individuals do not do anything significant to counteract the effects of their binge-eating (i.e., they do not purge, use laxatives or diet pills, or excessively exercise). All three disorders are described in Chapter 38.

Hpi Pe

Primary hypersecretion of parathyroid hormone ijnay be caused by an adenoma (vast majority of cases), chief-cell hyperplasia, or carcinoma of the parathyroid glands it is commonly asymptomatic and is frequently recognized during routine physijcal exams. When it is symptomatic, peptic ulcer pain, polyuria, polydipsia, constipation, and pancreatitis may be the presenting symptoms. May be associated with multiple endocrine neoplasia (MEN) syndromes I and II.

Clinical Care

Another survey of pain practices conducted across Canada heard from 26 organizations that provide pediatric cancer care, including care in the context of palliative and end-of-life management. There were no protocols in 21 of the centers to manage the most common problems related to this aspect of care, including seizures, excessive secretions, constipation, respiratory distress, and nausea and vomiting. The difficulties in providing adequate care within the home was noted by several respondents.

Thalidomide

A phase II trial was conducted at Rush University Medical Center in which 83 MDS patients of all subtypes were given thalidomide 100 mg once a day escalating to a target dose of 400 mg a day.44 The overall response rate was 19 . Fifty-one patients were evaluable at 12 weeks, of whom 16 (almost 30 ) had an erythroid response using the IWG criteria, 2 3 of which were major responses, most of those becoming transfusion independent or achieving a > 50 reduction in transfusion requirements. Improvement in thrombocytopenia or neutropenia was less significant. The most common reason patients were unable to complete the trial was due to toxicities, namely neuropathy, constipation, fatigue, and fluid retention at a dose beyond 200 mg a day. For 10 of the 16 responders, the median time to response was 16-20 weeks, and the majority of responders had lower risk disease refractory anemia (RA) or refractory anemia with ringed sideroblasts (RARS), or a low or int-1 IPSS.

Nervous System

Rological effects, alcoholic dementia and Wernicke-Korsakoff syndrome were discussed earlier. Hepatic encephalopathy occurs in the setting of severe liver failure as a result of either severe alcoholic hepatitis or cirrhosis. Early manifestations of encephalopathy include inappropriate behavior, agitation, depression, apathy, and sleep disturbance. Confusion, disorientation, and depressed mental status develop in the advanced stages of encephalopathy. Physical examination may demonstrate asterixis, tremor, rigidity, hyperreflexia, and fetor hepaticus. Treatment requires the elimination of the offending condition, dietary protein restriction, and removal of nitrogenous waste from the gut with osmotic laxatives and antibiotics (lactulose and neomycin, respectively) (Adams & Victor, 1989).

Opioids

Unfortunately there are side effects. A systematic review of over 5000 patients confirmed that most patients would experience at least one adverse event resulting from opioid use in chronic pain, and that many would experience common adverse events of dry mouth, nausea, and constipation, and would not continue treatment because of intolerable adverse events 60 .

Anorexia Nervosa

In the restricting type of AN, the affected person has not regularly engaged in binge eating or purging behaviour during his or her active episode of the disease (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). By contrast, in the binge-eating purging type of AN, the affected person has regularly engaged in binge eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

The Uterus

Endometriosis, while not exclusively an uterine phenomenon, is a common clinical disorder that is often accompanied by severe dysmenorrhea (painful menstruation), painful defecation, chronic pelvic pain, and dyspareunia (pain during sexual intercourse), and thus is relevant to this discussion. It is characterized by the growth of uterine tissue outside of the uterus and has been modeled in both the rat (100) and the mouse (101), although behavioral data is only currently available in the rat (102). One uterine horn is removed surgically from animals and placed in culture medium at 37 C, where it is cut into equal-sized fragments (three to six, depending upon species and laboratory), each of which is then sutured to a blood vessel in the mesentery of the small intestine, lower abdominal wall, ovary, or all three (note that autotransplants to the abdominal wall rarely produce cysts, and only small ones when they do). Following wound closure, the animal is allowed to recover. In all...

Treatment

When iron deficiency is diagnosed, its treatment is generally simple oral tablets of ferrous sulfate. These tablets are usually 325 mg each, and the required dose may be from one to three tablets daily. Unfortunately, digestive disturbances such as diarrhea, constipation, or gastric distress

Digestive System

Liver function also declines in older adults, decreasing clearance of many drugs and increasing the potential for adverse drug-nutrient interactions (see appendix I). Constipation is a common complaint in older adults. Immobility, dehydration, and foods low in fiber contribute to this problem. Increasing physical activity, consuming more dietary fiber - eating whole-grain products, legumes, fruits, and vegetables - and drinking from six to eight glasses of water per day is beneficial. Additional vitamin C (0.5 g-1.0 g) per day may also help soften and ease passage of the stool.

Increasing Motility

If estrogen is not eliminated quickly from the bowel (due to constipation), more estrogen will re-enter the blood stream. Reduced circulating estrogen can be achieved with a veg etarian, high fiber, low saturated fat diet (31). Women who eat a vegetarian, high-fiber diet that is low in saturated fat excrete threefold the amount of estrogen in their feces than their omnivorous, lower-fiber consuming counterparts they have 15 to 20 lower blood levels of estrogen. A healthy digestive system effectively eliminates estrogen from the body. A diet high in fiber helps move and eliminate waste in the colon. A diet high in fat slows down removal and allows the reabsorption of toxic estrogens. Estrogen becomes water soluble and easily eliminated when combined with glucuronic acid. A high-fat diet increases the activity of beta-glucuronidase, an enzyme responsible for separating (or deconjugating) estrogen from glucuronic acid, thus resulting in estrogen re-entering the bloodstream and remaining...

Energy Intake

Several factors may contribute to the decreased intake of food in cancer patients. Anorexia, due to the disease itself or its treatment, is commonly recognised. Cancer patients may frequently suffer from symptoms affecting the gastrointestinal tract, for instance due to physical obstruction, constipation, or malabsorption. The effects or consequences of treatment by opiates, radiotherapy, or chemotherapy may all explain decreased food intake in the palliative care of cancer patients. However, reports on the degree of anorexia do not always indicate low intakes. Cohn et al. assessed energy and protein intake in relation to lean body mass in 22 oncology patients and found no difference from normal subjects, unless weight loss was present 4 . Parkinson et al., in a study of the effects of oral protein and energy supplements in 30 cancer patients, reported a mean intake of 1515 Kcal day, corresponding to 25 Kcal kg day 5 . Simons et al. studied the effects of medroxyprog-esterone acetate...

Antimitotics

Vinorelbine is a semisynthetic derivative of vinblastine that also inhibits tubulin polymerization and disrupts spindle assembly in the M phase. This compound has a higher specificity for mitotic microtubules and a lower affinity for axonal microtu-bules, reducing neuropathy. Vinorelbine is indicated in the treatment of lung cancer, breast cancer, and ovarian cancer. Adverse reactions are similar to those produced by vinblastine include myelosuppression, nausea, vomiting, and constipation altered liver function, requiring more frequent liver function tests alopecia neurotoxicity hypersensitivity and syndrome of inappropriate antidiuretic hormone secretion (SIADH).

Hypercalcemia

Clinically, hypercalcemia is associated with lethargy, confusion, polydypsia, polyuria, constipation, and nausea.11 Untreated hypercalcemia will lead to renal insufficiency, a problem to which patients with MM are already prone. Therefore, prompt treatment once recognized is essential.

Vinca Alkaloids

Toxicity Although vincas are structurally similar, their spectra of activity and adverse effects differ significantly. The dose-limiting toxicity of vincristine is neurotoxicity, likely due to inhibition of microtubule effects related to neuronal transmission.65 This can manifest as sensory and or motor neuropathy and is characterized by paresthesias, palsies, and pain. Autonomic complications, such as abdominal pain, orthostatic hypotension, constipation, and paralytic ileus, may also occur. For this reason, vincristine doses have traditionally been limited to 2 mg, although recent protocols are challenging this maximum dose. Other adverse effects associated with vincristine include SIADH and alopecia. Fatal cases of intrathecal administration have been reported.66 While the potential for myelosuppression exists with vincristine, it is uncommon at standard doses. Conversely, the dose-limiting toxicity for vinblastine and vinorelbine is myelosuppression. Anemia and thrombocytopenia...

Retinoids

Virtually all patients experience some degree of vitamin A toxicity, including headache, fever, weakness, and fatigue.42 These adverse effects are seldom permanent or irreversible, nor do they usually require interruption of therapy. Other common adverse drug reactions include flushing, hypotension, increase in serum cholesterol and triglycerides, and gastrointestinal toxicity such as abdominal pain, constipation, and diarrhea.42

Tramadol

The analgesic potency of tramadol is only 10 of that of morphine status-post parenteral administration. Tramadol produces less constipation and problems with dependence than equianalgesic dosages of opioids (265). There are no respiratory or cardiovascular problems associated with the drug (297).

Encopresis Diagnosis

Encopresis is usually defined as the intentional or involuntary passage of stool in inappropriate places in the absence of any identified physical abnormality in children older than 4 years. The distinction is drawn between encopresis with constipation (retention with overflow) and encopresis without constipation. Other classification schemes include making a primary-secondary distinction (based on having a 1-year period of continence), or soiling with fluid or normal feces. The main efforts during the diagnostic process are to establish the presence or absence of constipation and, to a lesser extent, distinguish continuous (primary) from discontinuous (secondary) soiling (Figure 9-2). Three types of identifiable encopresis in children have been identified (1) it is known that the child can control defecation, but she or he chooses to defecate in inappropriate places (2) there is true failure to gain bowel control, and the child is unaware of or unable to control soiling and (3)...

Depression

Item 12 of the Hamilton depression rating scale records appetite disturbances and considers different gastrointestinal symptoms, such as constipation, diarrhoea, or a heavy feeling in the abdomen, as a whole. Nonetheless, simple selection according to this item leads to a subgroup of untreated depressed patients with or without gastrointestinal symptoms. In a recent study 7 , the authors compared platelet 5-HT concentration and apparent kinetic parameters of 5-HT uptake in these two subgroups in order to test the hypothesis that platelet serotonergic parameters are affected by certain somatic symptoms of major depression. The results could provide important information, because 5-HT in the gut seems to be a mucosal transmitter that stimulates sensory nerves and initiates peristaltic and secretory reflexes 8 . Based on findings that 5HT knock-out mice (lack of serotonin transporter) show an increase in intestinal motility (diarrhoea) along with episodes of decreased motility...

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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