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Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.

1. Pearl 1: High Yield Reversible Causes and Complications of Constipation
   1. There are two types of constipation: 
      1. Primary constipation/Chronic idiopathic constipation: diagnosed using the
         1. Patients must have two or more of the following for the last 3 months with symptom onset at least 6 months prior to diagnosis:
            1. Straining during more than ¼ (25%) of defecations
            2. Lumpy or hard stools more than ¼ (25%) of defecations
            3. Sensation of incomplete evacuation more than ¼ (25%) of defecations
            4. Sensation of anorectal obstruction/blockage more than ¼ (25%) of defecations
            5. Manual maneuvers to facilitate more than ¼ (25%) of defecations (e.g., digital evacuation, support of the pelvic floor)
            6. Fewer than three SBM per week
            7. Loose stools are rarely present without the use of laxatives
            8. Insufficient criteria for irritable bowel syndrome
      2. Secondary constipation: which can be remembered using the mnemonic LMNOP
   2. Lifestyle: 
      1. Patients who are bedbound or immobile, those with eating disorders and those with low fiber and water intake are at a higher risk of constipation
   3. Metabolic: 
      1. Hypercalcemia, hypokalemia, hypomagnesemia and can contribute to constipation
   4. Neurologic: 
      1. Ensure that patients with (e.g. spinal cord defects, history of CVA, dementia, Parkinson disease, multiple sclerosis) have aggressive bowel regimens on admission
   5. Obstructive
      1. Consider structural causes of constipation including anal or intestinal strictures and obstructive tumors
   6. Pharmacologic
      1. Prescribed medications which are common offenders are antipsychotics, anticholinergics, narcotics, calcium channel blockers, tricyclic antidepressants
      2. including iron supplements, aluminum containing drugs, calcium supplements, antacids and antihistamines
2. Pearl 2: Deep Dive into Fiber, Hydration and Bulk-Forming Laxatives
   1. Fruits vs Psyllium
      1. have been shown to be more effective for reducing constipation that psyllium 
      2. may slightly increase stool frequency compared to psyllium
   2. Fiber Supplementation (Psyllium, methylcellulose)
      1. : increases stool weight which can reduce transit time, increase water collection and bacterial mass from fermentation
      2. Although there is evidence showing that (E.g. psyllium, inulin, oatmeal) improve constipation, the evidence for insoluble fiber (E.g. wheat bran) is inconsistent.  
      3. Psyllium should be taken at least 2 hours before or after other medications (e.g. levothyroxine, calcium supplements, zinc supplements) as it can
   3. Hydration 
      1. There is no benefit of increased hydration in patients who are
3. Pearl 3: Osmotic and Stimulant Laxatives
   1. Osmotic laxatives 
      1. : draws fluid into the lumen of the bowels through osmosis
      2. Time of onset: 
         1. Lactulose:
         2. Magnesium citrate:
         3. Magnesium oxide:
         4. Polyethylene glycol: up to
      3. Side effects and considerations 
         1. Magnesium oxide can be used in patients with , but keep an eye on the magnesium level. 
         2. Lactulose can cause more  
   2. Stimulant laxatives:
      1. : direct stimulation of colonic neurons 
      2. Time of onset: up to and used as a rescue laxative
      3. Side effects and considerations
         1. There is no good evidence of their efficacy after
         2. Studies have shown that stimulant laxatives do damage the enteric nervous system
         3. Tolerance to stimulant laxatives is .
4. Pearl 4: Suppositories and Enemas
   1. Suppository vs enema 
      1. A suppository is a small solid capsule and an enema is a liquid medication
   2. Types of enemas 
      1. Osmotic enemas: sodium phosphate enema, glycerine enema, lactulose enema
      2. Lubricating enemas: mineral oil enema
      3. Hypotonic enemas: tap water enema, soap sud enema
   3. Considerations
      1. Sodium phosphate enemas can cause , especially in elderly patients and those with renal dysfunction 
      2. Mineral oil enemas require patient retention
      3. Discuss what is most comfortable for the patient
      4. Discuss timing and preparation with your nursing colleagues
5. Pearl 5: Opioid Induced Constipation
   1. of opioids: act on the mu opioid receptors which cause inhibition of GI motility and water secretion and absorption in the GI tract resulting in constipation. 
   2. formulations of opioids are shown to have less incidences of opioids induced constipation in comparison to oral
   3. Peripherally acting mu opioid receptor antagonists (PAMORAs)
      1. : blocks the actions of opioids in the gut but do not affect pain control 
      2. It is recommended to prior to starting PAMORAs
      3. : abdominal pain, diarrhea, nausea

Contributors

Shreya Trivedi, MD, ACP Member – Host, Editor
Kalaila Pais, MD – Host, Editor
Allen Lee, MD – Guest*
Taylor Thompson, PharmD - Guest
Jack Sibilia, RN - Guest

Reviewers

Adam Strauss, MD
Brian Persaud, MD

* Allen Lee, MD – Consultant – GSK

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.  All relevant relationships have been mitigated.

Release Date:  April 30, 2025

Expiration Date: April 29, 2028

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Ñî¹óåú´«Ã½ and Core IM.  The Ñî¹óåú´«Ã½ is accredited by the ACCME to provide continuing medical education for physicians.

The Ñî¹óåú´«Ã½ designates this enduring material (podcast) for .5 AMA PRA Category 1 Creditâ„¢.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

ABIM Maintenance of Certification (MOC) Points

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to .5 medical knowledge MOC Point in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program.  Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

How to Claim CME Credit and MOC Points

After listening to the podcast, complete a brief multiple-choice question quiz. To claim CME credit and MOC points you must achieve a minimum passing score of 66%. You may take the quiz multiple times to achieve a passing score.