Constipation

Question 1

What are symptoms of constipation?

Answer 1

passage of hard, dry stools less frequently than the persons normal bowel movements (this can range from 2-3 times a day to 1-2 times a week, depending on the individuals routine).
also
Abdominal discomfort, bloating and nausea

Question 2

When would you refer a pt with constipation?

Answer 2

1. Continuous use of stimulant laxatives can cause the contents of the gut to be expelled such that no bowel movement occurs for 1-2 days
2. use of laxatives can be abused by people who believe that they can help to control weight
3. Constipation accompanied by weight and appetite loss - carcinoma?
4. Tarry, red, black, blood stools indicate underlying condition - haemorrhoids, gastric ulcer, carcinoma
5. Constipation with weight gain, lethargy, coarse hair, dry skin - hypothyroidism
6. Constipation caused by drugs - opioid, hyoscine, SSRIs, TCAs, iron, chlorphenamine, bendroflumethiazide, propranolol, aluminium-containing antacids, verapamil
7. Greater than 7 days for a child
8. Greater than 14 days for an adult
9. Pain on defecation

Question 3

What is first line treatment for pts with constipation?

Answer 3

Manage any underlying secondary cause - - stop any meds causing constipation

• increase fruit and fibre intake
• keep hydrated
• perform regular exercise (30-60 minutes of - physical activity five or more days of the week
• toileting routines - dont hold in or rush

Question 4

What is second line tx for pts with constipation?

Answer 4

• Bulk-forming laxatives (ispaghula, methylcellulose, sterculia)
  The laxative effects usually occurs within 24 hours but can take 2-3 days to reach full effect

Question 5

How do bulk-forming laxatives work? w

Answer 5

swell up in the gut to increase faecal mass so that peristalsis is stimulated

Question 6

What is third line tx for constipation?

Answer 6

Switch or add an osmotic laxative (macrogols, lactulose)

Question 7

How do osmotic laxatives work?

Answer 7

maintaining the volume of fluid in the bowel
It may take up to 2-3 days to work OR add a stimulant laxative (senna, bisacodyl, sodium picosulfate, glycerol suppositories)

Question 8

How do stimulant laxatives work?

Answer 8

directly stimulates peristalsis through increasing release of water and electrolytes by the intestinal mucosa.

Question 9

How quickly do stimulant laxatives work?

Answer 9

6-12 hours (overnight) or even quicker if applied as a suppository (within an hour)

Question 10

What is docusate sodium?

What age can it be used?
Can it be used in BF/P?

Answer 10

has both stimulant and stool-softening properties

> 6 months
Yes

Question 11

What are side effects that can occur from lactulose?

Answer 11

flatulence, cramps, abdominal discomfort in about 20% of patients especially at the start of tx.

Question 12

What are the side effects of bukl laxatives?

Answer 12

risk of oesophageal and intestinal obstruction if not taken with sufficient water

Question 13

What are counselling points you would a give a patient that has constipation?

Answer 13

healthy, balanced diet, plenty of whole grains, certain fruits/veggies, gradual increase in dietary fibre - takes a few weeks to benefit

drinking plenty of water

Question 14

Why do pregnant women get constipated?

Answer 14

raised progesterone levels during pregnant mean that the gut muscles are more relaxed

Oral iron can also cause constipation

Question 15

What laxatives should pregnant women avoid taking?

Answer 15

stimulant especially in third trimester

Question 16

What are the side effects of senna?

Answer 16

colour the urine yellow-brown to red colour because it is excreted via the kidney

Question 17

What age can the following be used? 
Senna 
Bisacodyl 
Glycerol 
Sodium picosulfate 

Can they be used in BF/P?

Answer 17

1. Senna: > 6 years
2. Bisacodyl: > 4 years
3. Glycerol: infant upwards
4. Sodium picosulfate > 10 years

Yes but use others first

Question 18

What age can lactulose be used? what age can macrogol be used for?
Are they safe for P/BF?

Answer 18

infant upwards - lactulose

Yes but bulkforming first line

Question 19

what age is ispaghula/sterculia/methylcullose husk used?

Can they be used in P/BF?

Answer 19

Ispaghula: >6 years
Sterculia: >6 years
Methylcellulose: > 12 years

Yes they can - first line