Administration Of Laxatives Research Articles

Effects of thickened beverages fortified with inulin on beverage acceptance, gastrointestinal function, and bone resorption in institutionalized adults

Objectives We wanted to develop thickened beverages that contain soluble fiber (inulin) with acceptable consistency, taste, and texture and to determine the effects of these beverages on bone resorption markers (to determine calcium retention), bowel frequency, and indicators of gastrointestinal function in institutionalized adults bound to wheelchairs. Methods A double-blind, 3-wk, cross-over study testing 13-g/d inulin-fortified versus isocaloric standard modified starch-thickened beverages was conducted in institutionalized adults who were bound to wheelchairs and had dysphagia or did not have dysphagia. Beverage acceptability, as assessed by discriminative and descriptive sensory testing, bowel frequency, fecal output, and laxative use, were determined by direct testing or by nursing charts. Bone resorption was measured by using the urinary excretion of fasting calcium and of cross-linked N-telopeptides of collagen. Results Sensory panelists were unable to detect a difference between beverages thickened with modified starch and those fortified with inulin. Few differences were found between the control and inulin-fortified beverages for sensory descriptors. No significant difference was found in frequency of bowel movements between treatments; however, weighted bowel movement frequency increased by 13% with inulin ( P < 0.01), whereas enema and laxative administration decreased by 13% ( P < 0.05). Bone resorption, as an indicator of calcium retention, remained unchanged. Conclusions Inulin was incorporated into thickened beverages, with no decrease in acceptability; when consumed, perceived stool output increased in residents of long-term care facilities.

Magnetic resonance imaging of the small bowel in Crohn's disease

ObjectiveThere may be advantages in using magnetic resonance imaging (MRI) in small-bowel disease. The aims of this study were to optimize the MRI examination technique and to evaluate the capabilities of MRI compared with those of conventional enteroclysis (CE).Material and methodsMRI and CE were performed in 36 patients suspected of Crohn's disease. Based on 26 pilot studies optimal oral administration of plum juice and bulk fibre laxative was found. T2-weighted and gadolinium enhanced T1-weighted images were obtained using a breath-holding technique and butylscopolamine. Virtual endoscopy was performed. Conventional enteroclysis entailed duodenal intubation and administration of barium and air. Two radiologists evaluated the examinations independently. Finally, each patient scored the degree of discomfort, and preference for either MRI or CE was found.ResultsThe MRI technique ensured sufficient distension of the small bowel and small-bowel changes were found in 12 patients. In 3 patients this was not seen on conventional enteroclysis, which did not reveal any pathology that was not already seen on MRI. Pathological abdominal changes were found in 70% more patients during MRI than during conventional enteroclysis (p<0.001). Endoscopic examination corresponded with the MRI findings. The examination quality decreased with increasing age (p = 0.002) and the interobserver agreement of the pathological changes was high (p<0.001). Virtual endoscopy resulted in excellent demonstration of the mucosal surface. The examination discomfort scores obtained during the MRI were lower than those during conventional enteroclysis (p<0.001).ConclusionsMRI using the current technique is preferable to conventional enteroclysis because of superior demonstration of the entire small-bowel pathology, low level of patient discomfort and absence of radiation exposure.

Nursing role in the management of constipation: use of laxatives.

Constipation is extremely common and may affect a variety of patients from different age groups. This article outlines the causes of constipation and describes the nurse's role in the management of patients with constipation, from assessment to intervention. The skills required of the nurse, including taking a detailed history from the patient, the subsequent examination, and the administration of laxatives are discussed in detail. Nurses are best placed to assess, plan, implement and evaluate care for patients presenting with constipation. The article stresses the need for healthcare professionals to aim to prevent constipation and to identify early those patients at risk of developing constipation, to ensure that patients' needs are met fully. Recommendations for good practice are given.

Increased stool frequency occurs when finely processed pea hull fiber is added to usual foods consumed by elderly residents in long-term care

Dietary fiber fortification of food offers a preventative strategy that is a less invasive alternative to laxatives and enemas in the management of constipation in elderly individuals. To determine if a moderate increase in fiber provided in foods would increase bowel movement frequency among elderly institutionalized residents, data were collected on the same elderly residents (n=114) before and during a 6-week intervention. The intervention consisted of adding finely processed pea hull fiber (1–3 g/serving) to 3 to 4 foods each day. Laxative and enema use was monitored. Mean number of bowel movements/month increased from 18.7±9.4 to 20.1±9.6 (n=114, P=.034), and in 17 residents with low baseline frequency, the increase was highly significant (8.8±1.0 to 12.6±3.8 bowel movements/month, P=.001). With treatment, prune-based laxative administration decreased ( P<.001). Thus, addition of a moderate amount of finely processed fiber to foods results in increased bowel frequency in institutionalized elderly individuals.

Safety profile assessment of risperidone and olanzapine in long-term care patients with dementia.

To assess the adverse events associated with the appropriate use of oral risperidone and oral olanzapine in long-term care patients with behavioral and psychotic disturbances associated with dementia. Observational analysis. Analysis was performed at five consulting pharmacist sites across the United States. Participants were recruited at 89 skilled nursing facilities by consultant pharmacists who provided services at each site. A total of 730 men and women with dementia who had been residents of a skilled nursing facility for at least 90 days were included in the study. Alzheimer's disease was the primary diagnosis in 47% of patients. Patients were treated with risperidone < or =2 mg/day or olanzapine < or =10 mg/day for at least 90 days. Targets for antipsychotic use included nonaggressive symptoms of psychosis and verbally and physically aggressive behaviors. The effects of risperidone and olanzapine were determined from progress notes, psychotropic monitoring forms, and physicians' order forms after 91 days of treatment. Adverse events of particular significance in the elderly population, including agitation/anxiety, laxative use, dry eyes, and falls, were collected from audited medical records. The evaluation period extended from 3 months before to 3 months after initiation of treatment with risperidone or olanzapine. There were 474 patients in the risperidone group and 256 patients in the olanzapine group. Mean dosages of risperidone at Days 1 and 91 (0.7 +/- 0.3 mg/day and 1.0 +/- 0.5 mg/day, respectively) and olanzapine (3.3 +/- 1.4 mg/day and 4.7 +/- 2.1 mg/day, respectively) were at least 50% lower than the maximum dosages recommended by the Center for Medicare and Medicaid Services for elderly patients with psychosis or behavioral symptoms of dementia. The need for eye lubrication was minimal in both groups and did not differ significantly between them. Anxiolytic use decreased in the risperidone group and remained constant in the olanzapine group, with no significant difference between groups. In the olanzapine and risperidone groups, the number of patients with orders for laxatives increased 10.2% and 1.8%, respectively (P = 0.003), the mean number of days of laxative administration increased 19.1% and 4.3%, respectively (P < 0.001), and the mean number of doses of laxative administered increased 14.2% and 4.1%, respectively (P = 0.001). Among patients qualifying for analysis, falls were recorded for 17.9% of patients receiving olanzapine and 6.9% receiving risperidone (P = 0.001). Among long-term care residents with dementia who received low doses of risperidone or olanzapine, the incidence of adverse events was low. When considering adverse events of particular concern in the elderly, specifically falls and laxative use, risperidone may be preferred over olanzapine in this population.

Safety Profile Assessment of Risperidone and Olanzapine in Long-Term Care Patients with Dementia

<h3>Objective</h3> To assess the adverse events associated with the appropriate use of oral risperidone and oral olanzapine in long-term care patients with behavioral and psychotic disturbances associated with dementia. <h3>Design</h3> Observational analysis. <h3>Setting</h3> Analysis was performed at five consulting pharmacist sites across the United States. Participants were recruited at 89 skilled nursing facilities by consultant pharmacists who provided services at each site. <h3>Patients</h3> A total of 730 men and women with dementia who had been residents of a skilled nursing facility for at least 90 days were included in the study. Alzheimer's disease was the primary diagnosis in 47% of patients. <h3>Intervention</h3> Patients were treated with risperidone ≤2 mg/day or olanzapine ≤10 mg/day for at least 90 days. <h3>Measurements</h3> Targets for antipsychotic use included nonaggressive symptoms of psychosis and verbally and physically aggressive behaviors. The effects of risperidone and olanzapine were determined from progress notes, psychotropic monitoring forms, and physicians' order forms after 91 days of treatment. Adverse events of particular significance in the elderly population, including agitation/anxiety, laxative use, dry eyes, and falls, were collected from audited medical records. The evaluation period extended from 3 months before to 3 months after initiation of treatment with risperidone or olanzapine. <h3>Results</h3> There were 474 patients in the risperidone group and 256 patients in the olanzapine group. Mean dosages of risperidone at Days 1 and 91 (0.7 ± 0.3 mg/day and 1.0 ± 0.5 mg/day, respectively) and olanzapine (3.3 ± 1.4 mg/day and 4.7 ± 2.1 mg/day, respectively) were at least 50% lower than the maximum dosages recommended by the Center for Medicare and Medicaid Services for elderly patients with psychosis or behavioral symptoms of dementia. The need for eye lubrication was minimal in both groups and did not differ significantly between them. Anxiolytic use decreased in the risperidone group and remained constant in the olanzapine group, with no significant difference between groups. In the olanzapine and risperidone groups, the number of patients with orders for laxatives increased 10.2% and 1.8%, respectively (<i>P</i> = 0.003), the mean number of days of laxative administration increased 19.1% and 4.3%, respectively (<i>P</i> < 0.001), and the mean number of doses of laxative administered increased 14.2% and 4.1%, respectively (<i>P</i> = 0.001). Among patients qualifying for analysis, falls were recorded for 17.9% of patients receiving olanzapine and 6.9% receiving risperidone (<i>P</i> = 0.001). <h3>Conclusion</h3> Among long-term care residents with dementia who received low doses of risperidone or olanzapine, the incidence of adverse events was low. When considering adverse events of particular concern in the elderly, specifically falls and laxative use, risperidone may be preferred over olanzapine in this population.

Molecular Analysis of Intestinal Microbiota Composition to Evaluate the Effect of PEG and Lactulose Laxatives in Humans

Methods using bacteriological cultures allow only 30–50% of colonic bacterial populations to be detected. Our aim was to assess the effect of osmotic laxative administration on fecal bacteria during chronic idiopathic constipation, by a culture-independent molecular method. Forty-eight constipated patients were included in a randomized blinded trial and received either polyethylene glycol (PEG, n =23) or lactulose ( n= 25) for 28 days. Non-fermentable laxative (PEG) should not affect the bacterial groups, whereas fermentable (lactulose) could modulate them. The treatment dosage was 20 g per day for a 7-day period, then adjusted according to ef? cacy for 7 days and constant from 10 to 30 g per day for 14 days. Stools were collected at d0, d21 and d28, and analyzed by quantitative dot-blot hybridization using 16S ribosomal RNA-targeted oligonucleotide probes. We used a new Bifidobacterium group specific probe and five other probes to monitor the dominant groups of the intestinal bacteria: Bacteroides -Prevotella-Porphyromonas , Lactobacillus -Enterococcus- Streptococcus , enterobacteria: Clostridium coccoides and Clostridium leptum . Lactulose and PEG administration were associated with an increase of bifidobacterial rRNA index in 72% (18/25) and 17% (4/23) of cases, respectively. In the lactulose group, bifidobacterial rRNA index increased from [mean (SEM)] 1.1% (0.2%) at d0 (a), to 4.3% (1.2%) at d21 (b) and 4.5% (1.1%) at d28 (b), (a ≠ b, p=0.011). Lactulose treatment when administered at doses usually prescribed for constipation selectively stimulated bifidobacteria within the intestinal microbiota. The quantitative rRNA dot-blot hybridization method is an efficient tool to quantify intestinal bacteria, without the limitations of classical culture methods. Keywords: constipation, lactulose, quantitative dot-blot hybridization, Bifidobacterium probe, 16S rRNA.

Significant Increase in Prostaglandin E-Main Urinary Metabolite by Laxative Administration: Comparison with Ulcerative Colitis

Objective: To assess the production of prostaglandin E₂, an important chemical mediator in diarrhea induced by laxative administration, a prostaglandin E-main urinary metabolite (7α-hydroxy-5,11-diketotetranor-prosta-1,16-dioic acid, PGE-MUM) was measured in healthy volunteers and compared with the values of patients with ulcerative colitis. Methods: PGE-MUM was determined by a simplified immunoassay of bicyclic PGE-MUM and analyzed for the influence of laxative administration and active/remission phases of ulcerative colitis. Results: Administration of laxatives induced a significant increase in PGE-MUM in healthy volunteers. A significant elevation was also found in the active as compared with the remission phase of ulcerative colitis. The PGE-MUM levels were significantly correlated with our modified Talstad scores, clinical disease activity indices in ulcerative colitis. It was confirmed by time course studies of individual patients that changes in PGE-MUM correlated well with colitis activity. Conclusion: Laxative administration induces production of prostaglandin E₂ as one of the chemical mediators, although its production grade is relatively low as compared with ulcerative colitis in the active phase.

Recurrence of symptoms in Clostridium difficile infection—relapse or reinfection?

We have fingerprinted Clostridium difficile isolates from patients with symptomatic recurrences of infection, using random amplified polymorphic DNA (RAPD). The medical records of 55/79 patients were examined, from whom multiple C. difficile-positive faeces were received during hospitalization at least five days, but no more than two months, apart. In 20 of these cases symptoms either did not recur (i.e., absent for at least three-days between episodes), or were explainable by other causes, such as laxative administration. Of the remaining 35 patients, 27 sets of C. difficile isolates (23 pairs and four triplicates) were available for RAPD fingerprinting. Differing C. difficile DNA fingerprints (at least three major bands difference) were obtained for 15/27 patients, and hence at least 56% of the clinical recurrences of infection were in fact due to re-infection as opposed to relapse. Since we found that an endemic C. difficile clone was present in 18 out of 27 patients (67%) and accounted for 53% (31/58) of all isolates, it is probable that the majority of symptomatic recurrences are in fact re-infections, with either a different or the same C. difficile strain. We conclude that more attention must be given to preventing the re-infection ot C. difficile symptomatic patients. Isolation of symptomatic individuals is the preferred option for the protection of other patients, but measures must be taken to ensure that further strain acquisition by the index cases does not occur.

A CASE OF ACUTE NECROTIC INTESTINAL ISCHEMIA WITH A RECTAL CANCER

A case of acute necrotic intestinal ischemia with a rectal cancer is described. A 63-year-old woman was admitted to the hospital because of constipation and abdominal pain with an episode of bloody stool. A rectal cancer was detected by clinical examination, but no other significant changes were seen in the colonic mucosa. After administration of a preoperative laxative, severe abdominal pain occurred. On laparotomy, extensive necrotic bowel ischemia revealed in the colon. Rectosigmoidectomy, total colectomy and ileostomy were performed. But, after massive colectomy this patient died of ischemic necrosis of the lower part of the ileum. Pulsation of the main mesenteric artery and of colonic arterial arcade were preserved at the time of surgical operation. Histological examination showed that multiple fresh fibrin thrombus were observed in mucosal or submucosal small vessels. We think that complicated combination of the vascular and intestinal factors might contribute to the pathogenesis in this case.

NG-Nitro- l-arginine methyl ester reduces senna- and cascara-induced diarrhoea and fluid secretion in the rat

Senna (60 mg/kg orally) and cascara (800 mg/kg orally)-induced diarrhoea and net fluid secretion were studied in rats for a time period of 1–8 h. N G-Nitro- l-arginine methyl ester (L-NAME) (2.5–25 mg/kg i.p. twice, 15 min before and 4 h after laxative administration), an inhibitor of nitric oxide synthase, reduced the diarrhoeal response. This effect was counteracted by l-arginine (600 and 1500 mg/kg i.p. 15 min before laxative administration), the precursor of nitric oxide (NO). The senna- and cascara-stimulated fluid secretion was reduced by N G-nitro- l-arginine methyl ester 25 mg/kg i.p. (twice, 15 min before and 4 h after laxative administration), while the stereoisomer N G-nitro- d-arginine metyl ester (D-NAME) 25 mg/kg i.p. was without effect. These results suggest a possible involvement of NO in senna- and cascara-induced diarrhoea and fluid secretion.

Facing the Reality: The World Cannot Afford Uremia Therapy at the Start of the 21st Century

Although remarkably successful in prolonging useful life, there is minimal probability that the majority of the world's population will benefit from contemporary therapy for irreversible renal failure because of its inordinately high cost in light of available resources. While affluent nations establish priorities for allocation of slots for maintenance dialysis of recipients of organ transplants, poor and developing countries must await the development of inexpensive, low technology treatments to substitute for absent kidney function. One attractive potential alternative to contemporary uremia therapy is the use of the intestine as a giant substitute and somewhat displaced nephron. Possible means of extracting wastes via the gut include ingestion of a mixed oral sorbent, instillation of bacterial crystallized enzymes to transform nitrogenous wastes to essential amino acids, or administration of high osmolality laxatives to promote diarrhea containing nitrogenous wastes. Any of these approaches may extract sufficient solute and water to sustain anephric life. An optimistic view of evolving uremia therapy is that within the next decade pills and purges for the poor may supplant more effective though expensive high technology approaches now encompassed in so-called modern nephrology.

Unrecognized constipation in patients with advanced cancer: A recipe for therapeutic disaster

Morphine-induced constipation can lead to therapeutic disasters by several mechanisms. It can be readily prevented by administration of appropriate laxatives, but the importance of this simple intervention is often overlooked. Problems resulting from uncontrolled constipation include not only fecal impaction and spurious diarrhea, but also pseudoobstruction of bowel causing abdominal pain, nausea and vomiting, and serious interference with drug administration and absorption. Cancer pain may also be exacerbated. All of time contribute unnecessarily to morbidity and costs of health care. A case that exemplifies many of these problems is presented and discussed.

Prescribe with Care: The Role of Laxatives in the Treatment of Constipation

The use of laxatives is widespread throughout North American hospitals and long-term care facilities. Although constipation is a frequent complaint among the elderly, the use of laxatives is not always warranted; increases in physical activity, fluid intake, and dietary fiber may be sufficient to control constipation. The occasional use of a laxative is not harmful, but the daily use of these drugs for achieving a bowel movement may be detrimental to the resident because of the side effects they can produce and drug interactions that can occur with other medications. Potential solutions to the overuse of laxative agents include the use of dietary bran; less regular administration of stimulant and osmotic agents; more regular administration of bulk-forming laxatives and stool softeners; an increase in the awareness of normal gastrointestinal physiology; and the role of non-drug factors.

A Case of Pseudo-Bartter's Syndrome Associated with Hypergastrinemia, Thrombocytosis and Increased Serum Thyroxine-Binding Globulin.

A housewife, 40 years of age, was admitted with dysesthesia of the extremities, muscle weakness, and attacks of adynamia and thirst. She had been taking a laxative for more than 20 years. On physical examination, blood pressure was 94/56 mmHg. Laboratory tests revealed thrombocytosis, low serum K and marked increases in both plasma renin activity and serum aldosterone. Serum TBG was increased. Serum gastrin was also markedly increased and could not be enhanced by exogenous secretin. Both angiotensin 11 loading test and noradrenalin loading test failed to increase blood pressure. Ammonium chloride loading to examine the disturbance of urinary acidification was abnormal in the short term test and borderline in the long term test. Following a diagnosis of pseudo-Bartter's syndrome induced by long term intake of laxative and repeated diarrhea, the administration of laxative was interrupted and potassium, indomethacin and spironolactone were administered. However, serum K remained low. Hypergastrinemia, thrombocytosis and a high serum TBG level also persisted, the causes of which remain unknown. This is the first reported case of pseudo-Bartter's syndrome associated with hypergastrinemia, thrombocytosis and increased serum TBG.

Sennosides and human colonic motility.

The effects of stimulant laxatives on colonic motility in man still remain controversial. Stimulation of peristalsis or a decrease of intraluminal pressure has been described manometrically after intraluminal administration of laxatives including senna. In contrast to manometry, electromyographic methods using an endoluminal probe enable continuous colonic motor recordings over a long colonic segment for at least 24 h, and consequently studies following the course of laxative effects after oral administration, the classical therapeutic route, are possible. Preliminary results using sennosides obtained with few subjects provide evidence for an increase in propulsive activity expressed as an increased number of migrating long-spike bursts in the left and sigmoid human colon. This motor colonic pattern seems to be a common feature in nonspecific or induced diarrhoea.

Munchausen Syndrome by Proxy: Considerations in Diagnosis and Confirmation by Video Surveillance

Munchausen syndrome by proxy is a form of abuse in which the child suffers from a factitious illness induced by a parent. A case report of an 18-month-old boy who suffered from intractable diarrhea because of the surreptitious administration of laxatives by his mother is presented. The evolution of this case is discussed, as are the legal and ethical considerations in the diagnosis of Munchausen syndrome by proxy.

Melanosis coli. Ultrastructural study of 45 patients.

Melanosis coli was diagnosed histologically in colon biopsies of 45 patients with prolonged administration of anthraquinone laxatives. Colonoscopies performed for increased constipation, abdominal pains, or distention disclosed discoloration of the mucosa in only 14 patients. Radiographic studies revealed motility disorders of the colon. In several cases, a circular stenosis occurred at the junction of the colon and the sigmoid, simulating a tumor. Electron microscopy showed abnormalities of the absorptive epithelial cells. The lamina propria contained pigment-laden macrophages, plasma cells, and several nerve fibers in different stages of degeneration. The most striking changes of autonomic nerve elements occurred in patients with the most serious motility disorders.

Studies on the defecation relfex in man.

In patients with cecostomies and in patients with urinary bladder substitutes obtained from either the sigmoid colon or the cecum, the motor activity in different parts of the large bowel was recorded with the aid of open tip tubes and a pressure-recording apparatus after administration of a contact laxative (Dulcolax®). Administration of Dulcolax® into the cecum of patients with cecostomy produced motor activity locally as well as in the transverse colon and in the sigmoid. When the drug was administered into the cecum of patients with isolated cecal bladder replacements, motor activity was recorded in the cecum but not in the sigmoid. Rectal application of Dulcolax® initiated motor activity in the intact sigmoid as well as in the isolated sigmoid bladder substitute but not in the cecum in patients with cecostomies nor in the cecal bladder replacements. The experiments indicate that only the left colon is engaged in the defecation mechanism elicited by rectal stimulation. The motor response in the left colon after rectal stimulation is mediated by a reflex with its afferent limb from the rectal ampulla. The motor response in the sigmoid after cecal stimulation is elicited by impulses mediated by intrinsic nervous pathways in the intestinal wall.

駆虫薬の基礎的研究 (第6報)

Examinations were made on the improvement of a process of preparation of 4-iodothymol, which has extremely strong ascaricidal action against earthworm and hog ascaris and is yet weak in toxicity against animals (mice and rats), and its anthelmintic activity against human parasitic worms, especially ascaris. As a result, improvement of preparative process raised the yield of 4-iodothymol to 88.5%. Anthelmintic rate in those infected with hookworm was 53.3-62.5% while that in those infected with ascaris was 20.0-46.6%, showing that it was quite effective against hookworm. The side effect was extremely small and the limitation of food or simultaneous administration of laxative for this treatment is not necessary. Therefore, it is believed that much can be expected of 4-iodothymol as a remedy for hookworm infection.