OTC - constipation

Question 1

Symptoms?

Answer 1

• small hard stools passed less frequently than normal (less than 3 times a week)

Associative symptoms:

• straining
• incomplete emptying
• abdominal cramps/bloating
• nausea

Question 2

Referral criteria?

Answer 2

• blood in stools (black, tarry abd mixed in stool = upper GI bleed? bright red on stool surface = anal fissure, haemorrhoid?)
• unexplained weight loss, appetitie loss (cancer?_
• patietns over 40 with a sudden change in bowel habit (cancer?)
• medication ADR (opioids, iron, TCAs, SSRIs, Antimuscarinics, diuretics, aluminium antacids, verapamil, antihistamines)
• constipation and lethargy, weight gain, coarse thinning hair, dry skin (hypothyroid?)
• stimulant laxative abuse (overuse = lazy bowel syndrome, misused for weight loss)
• obstruction = vomiting, abdominal distension and colic pain
• constipation > 2 weeks (underlying cause? if chronic constipation previously diagnosed - no referral necessary)

Question 3

OTC products ?

Answer 3

FIRST LINE: LIFESTYLE ADVICE
SECOND LINE: BOSS LAXATIVES

Bulk forming
Osmotic
Stimulant
Stool softener

Question 4

Bulk forming laxatives?

Answer 4

• ideal for small, hard stools and fiber- deficient diets
• ispaghula husk 6+ (fybogel)
• sterculia 6+ (normacol)
• methylcellulose (celevac)
• works by increasing feacal mass, works within 24 hours but takes 2-3 days for full effect
• side effects = oesophageal or intestinal obstruction, abdominal distension and flatulence
• counselling = swallow with water and not immediately before bed. maintain adequate fluid intake

Question 5

Osmotic laxatives?

Answer 5

• ideal for hard stools
• macrogol 12+/2-11 (movicol) - chronic constipation
• lactulose 3 month +
• magnesium sulphate 12+ (epsom salts)
• increases water in colon.
• draws fluid from body or retains fluid administered with
• works in 2-3 days but 48 hours for lactulose
• side effects = discomfort, flatulence and cramps at the start of lactulose treatment

Question 6

Stimulant kris?

Answer 6

• ideal for stools that are soft but difficult to pass. for short term use - 1 week
• senna 6+/12+ (senokot tabs) - colour urine brown
• bisacodyl 10+ (dulcolax)
• sodium picosulfate 10+ (dulcolax picoliquid)
• docusate sodium 18+ (dulcoease) - stool softener
• works by increasing intestinal motility by irritating gut lining.
• works in 6-12 hours
• glycerin suppositories = work in 15-30mins. 4g for adults, 2g for children under 12 and 1g for infants

Question 7

Stimulant side effects and counseling?

Answer 7

• side effect = abdominal cramps
• excessive use = hypokalaemia, diarrhoea, lazy bowel
• counselling = take at night to go in the morning, senna colours urine yellow-brown

Rectal administration counselling:

1. wash hands thoroughly with soap and water
2. remove the wrapper, if present
3. lie on your side with your lower leg straightened out and your upper leg bent forwards towards your stomach
4. lift upper buttock to expose rectal area
5. insert the suppository, pointed end first until it is 1/2 to 1 inch inside the rectum. Hold buttocks together for a few seconds
6. remain lying down for 5 minutes to avoid the suppository coming out
7. discard used materials and wash your hands thoroughly

Question 8

Stool softener laxatives?

Answer 8

• liquid paraffin 3+ - not recommended!

- harsh side effect = anal seepage, lipiod pneumonia and malabsorption of fat soluble vitamins ADEK

Question 9

Constipation in pregnant women?

Answer 9

FIRST LINE = bulk-forming or lactulose

• avoid stimulant laxatives (can induce uterine contractions and avoid in breastfeeding - present in milk)

Question 10

Constipation in elderly?

Answer 10

• take caution recommending bulk-forming laxatives, risk of gut obstruction, difficult to increase fluid intake

Question 11

Constipation in children?

Answer 11

• lactulose first line after lifestyle

Question 12

Opioid induced constipation?

Answer 12

• lactulose and stimulant laxative concomitantly

- avoid bulk-forming laxatives - risk of obstruction

Question 13

Lifestyle advice for constipation?

Answer 13

(Takes 2 weeks for effect)

• 5 portions of fruit and veg
• 18-30g of fibre per day (e.g. whole meal breads)
• exercise 30 mins/ 5 days a week
• alcohol 2-3 units a day with several alcohol free days (max 14 units men and women each week)
• toileting habits (squat, dont hurry, attempt in the morning or 30 mins after a meal , dont hold it in)