Laxative abuse

Laxative abuse

OVERVIEW:

Diarrhea caused by self-medication or by a patient simulating diarrhea by the addition of fluid (e.g., urine) to the stool.

System(s) affected: Gastrointestinal, Nervous
Genetics: N/A
Incidence/Prevalence in USA: N/A
Predominant age:
• 18 to 40 years with bulimia nervosa
• 40 to 60 years without bulimia.
Predominant sex: Female > Male

SIGNS AND SYMPTOMS:

• Diarrhea
• Additional symptoms - abdominal pain, rectal pain, nausea, vomiting, weight loss, muscle weakness, bone pain
• Additional signs - hypokalemia, skin pigmentation, finger clubbing, cyclic edema, kidney stones, melanosis coli
• The signs and symptoms will persist in spite of years of investigation and re-evaluation

CAUSES:

• Ingestion of any laxative agent
• Psychological factors
• Bulimia nervosa
• Secondary gain of attention
• Hysterical behavior
• Multiple personality disorders
• Inappropriate perception of normal bowel habits
• Chronic constipation

RISK FACTORS:

See Causes

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS:

Include any source of diarrhea of secretory or osmotic source

LABORATORY:

• Serum test - hypokalemia, metabolic alkalosis
• Urinalysis may be abnormal
• Stool Na+, K+
• Stool pH (alkalinization suggests presence of phenolphthalein)
• Stool for laxative titers
• Urine volume and electrolytes

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS:

• Melanosis coli
• Cathartic colon - refers to dilatation and ahaustral appearance on barium enema

SPECIAL TESTS:

Hospital room search

IMAGING:

Barium enema - cathartic colon

DIAGNOSTIC PROCEDURES:

• Carefully selected when needed to rule out other diseases
• Try not to repeat prior evaluations
• Sigmoidoscopy
• High index of suspicion

TREATMENT

APPROPRIATE HEALTH CARE:

Hospitalization may be needed (hypokalemia, malnutrition)

GENERAL MEASURES:

• Psychological support is essential
• Confrontation of the patient, gently and with support and understanding
• Discontinue laxative use
• Long term laxative abuse requires weaning
• Treat constipation

SURGICAL MEASURES:

N/A

ACTIVITY:

Physical exercise program

DIET:

• Ensure good nutritional habits
• Increase fiber intake
• Adequate calories, especially with bulimia

PATIENT EDUCATION:

See General Measures

MEDICATIONS

DRUG(S) OF CHOICE:

• Based on psychological assessment
• Non-stimulant laxatives if needed
• Senna best during pregnancy and lactation
• Lactulose
• Fiber

Contraindications: Danthron - hepatotoxic
Precautions: Patients will be manipulative in attempts to hide problem, and often large quantities of laxatives
Significant possible interactions:
• Increased rate of intestinal flow may affect rate of absorption of medications: antibiotics, hormones, etc.
• Docusate sodium may potentiate hepatotoxicity of other drugs

ALTERNATIVE DRUGS:

N/A

FOLLOW UP

PATIENT MONITORING:

• Careful psychological counseling
• Careful medical support. Show concern by frequent visits as needed.
• Assess serum electrolytes

PREVENTION/AVOIDANCE:

• Suspicion in patients with unsolved chronic diarrhea
• Monitor doctor hopping
• Avoid exploratory surgery
• Avoid repeated testing for diagnosis

POSSIBLE COMPLICATIONS:

• Risk of multiple tests and procedures and surgeries
• Malnutrition
• Electrolyte imbalances (hypokalemia)
• Renal failure
• Fatalities especially in children given laxatives by parents
• Renal calculi

EXPECTED COURSE AND PROGNOSIS:

• Protracted course
• Prognosis related to psychological response

MISCELLANEOUS

ASSOCIATED CONDITIONS:

N/A

AGE-RELATED FACTORS:

Pediatric:
• Death
• Life long laxative dependence
Geriatric:
• Unusual to start beyond age of 60 years
• Rectal incontinence
Others: N/A

PREGNANCY:

N/A

SYNONYMS:

• Factitious diarrhea
• Cathartic colon

ICD-9-CM:

305.9 Other mixed, or unspecified drug abuse

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Medical Diagnosis » L » Laxative abuse