Review Question - QID 103305

The correct answer is Psyllium. This patient’s symptoms are suggestive of functional constipation, for which the first-line treatment is lifestyle modifications such as increased fluid and fiber intake. Psyllium is a bulk-forming laxative that can help increase dietary fiber.

Constipation is common in the elderly and children and can present with abdominal pain and trouble having bowel movements. When severe, it can lead to nausea, vomiting, and delirium (in the elderly). The best initial step in management in the treatment of constipation is to recommend the patient increase their fiber and water intake (with supplements such as psyllium being frequently used) as well as to engage in exercise. In patients who do not respond to bulk-forming laxatives and dietary changes, additional classes of medications can be tried, including osmotic laxatives, stimulant laxatives, or emollient laxatives. Osmotic laxatives increase the amount of water in the colon and small intestine, thereby improving the pliability and passage of the stool (examples include milk of magnesia, magnesium citrate, and polyethylene glycol). Stimulant laxatives increase the motor activity of the bowel walls to expedite stool passage (examples include senna and bisacodyl). Emollient laxatives add moisture to the stool by coating the inside of the colon with oil, thereby decreasing water reabsorption (examples include mineral oil and docusate).

The study by Chey et al. conducted a comparative effectiveness trial evaluating the impact of kiwifruit, psyllium, and prunes on patients with chronic constipation (CC) in the United States. The study found that all three treatments significantly increased the weekly rate of complete spontaneous bowel movements (CSBMs). Stool consistency improved significantly with kiwifruit and prunes, while straining improved with all three treatments. Interestingly, patients in the kiwifruit group reported significant improvement in bloating scores. Adverse events were most common with psyllium and least common with kiwifruit. At the end of the treatment, fewer patients were dissatisfied with kiwifruit compared to prunes or psyllium. The study concluded that kiwifruit, prunes, and psyllium all improve constipation symptoms in patients with CC, with kiwifruit associated with the lowest rate of adverse events and dissatisfaction with therapy.

Incorrect Answers:

Answer 1: Bisacodyl is a stimulant laxative that increases intestinal motility. It is typically used for short-term relief of acute constipation or for bowel preparation before medical procedures but is not the first-line treatment for chronic functional constipation.

Answer 2: Docusate is an emollient or stool softener that makes the stool easier to pass. It is often used for preventing constipation in patients taking opioid medications but is not the first-line treatment for functional constipation.

Answer 3: Lactulose is an osmotic laxative that draws water into the intestines to soften the stool and stimulate bowel movements. It is often used for treating constipation in patients with liver disease but is not the first-line treatment for functional constipation.

Answer 4: Polyethylene glycol is an osmotic laxative that can be used for treating chronic constipation if lifestyle modifications and bulk-forming laxatives are insufficient.

Bullet Summary: The first-line treatment for functional constipation includes lifestyle modifications such as increased fluid and fiber intake (with psyllium being a common agent for increasing fiber intake).