Constipation Flashcards
Explain constipation
Dec number of stools, <3/week, straining, painful/difficult to pass stools, feeling of obstruction of incomplete evacuation
who is affected by constipation?
Prevalent in all age groups, most common in elderly (25-40% >65 y/o are constipated)
What is the typical defecation range in western populations?
three times a day to once every three days
Symptoms of constipation
Inability to defecate, bloating, abdominal discomfort, straining, feeling of incomplete evacuation, children may be irritable wit dec appetite, specks of blood in toilet, pain due to straining
What questions should you ask when someone presents with constipation?
What is normal? Any recent diet changes? change of routine? lifestyle changes?
Fluid intake (dehydrated?)?
Pain on defecation, presence of blood
Duration of symptoms (acute, chronic)
Current medications?
Pregnant or breastfeeding?
What is the most likely cause of constipation in community pharmacy?
Changes in eating habits or routine
What is a likely cause of constipation in community pharmacy?
Medication
What is an unlikely cause of constipation in community pharmacy?
IBS, preg, depression, functional causes (children)
What is a very unlikely cause of constipation in community pharmacy?
colorectal cancer, hypothyroidism
When should you refer someone with constipation?
Pain on defecation causing suppression of defecatory reflex, blood or mucous in stool
Patient >40 w/ sudden change in bowel habits (no obvious cause)
duration >14 days, tiredness, unexplained weight loss, anorexia, vomiting
Medication related cause (beta-blockers, calcium, iron)
Constipation alternating with diarrhoea
Change in bowel habits recurring over 3 or more months
Persistent constipation after 1 week of laxative use, 2 weeks of dietary change
Which medications are most likely to cause constipation?
Opioids, iron supplements (ferrous sulphate), alpha blockers, antidepressants (e.g. amitriptyline)
Anticholinergics (oxybutynin), antipsychotics, antiepileptics (carbamazepine), beta blockers, PPI, antacids, non-dihydropyridine CCB (verapamil)
Mention/explain some differential diagnoses for constipation
IBS = abdominal discomfort relieved by defecation, bloating, faecal urgency, passing of mucous, alternating constipation/diarrhoea
Haemorrhoids/anal fissure = bleeding, swollen lump on anus, anorectal
Bowel cancer = blood +/- mucous in stool, unexpected change in bowel habits (alternating const/diarr), fatigue, weakness, pallor
Diverticulitis = pain left lower quadrants, nausea, vomiting, flatulence, bloating
Large bowel obstruction = abdominal distension, nausea, vomiting, cramping abdominal pain, inability to pass stool or gas
What is the first line treatment of constipation?
Fluid intake, fibre intake, activity levels
Results in 3-5 days
Highlight the step-wise approach for treatment of constipation in adults
1) bulk forming laxatives with appropriate fluid intake
2) add or change to osmotic laxative
3) add or substitute a stimulant laxative
Laxative selection based on = symptoms, preference for onset, side effects, cost.
Highlight the step-wise approach for treatment of constipation in children
Dietary/behavioural changes may be enough if constipation is mild
Ensure adequate dietary fibre in children
1) regular doses stool softener or osmotic laxative
2) short term stimulant laxative
3) if first two therapies ineffective = combination of laxatives (osmotic and stimulant)
4) glycerol suppositories (not routinely used)
Discuss bulk forming laxatives
Effectively a fibre supplement, inc stool bulk, water content, and colonic bacterial load = inc stool
Important that appropriate fluid is taken with supplement
Are bulk forming laxatives safe in pregnancy?
Safe but not recommended = patients are immobile, opioid induced constipation or patient with functional bloating
Name some bulk forming laxatives, how long do they take to work?
Ispaghula husk/psyllium - granules or powder mixed with water
Sterculia - granules placed by dry on the tongue and swallowed or sprinkled on soft foods (e.g. yogurt)
Take 48-72 hrs for full effect (initial effect 12-36 hours)
Discuss osmotic laxatives
Pull water into or keep water in the stool, allows for softer but larger stool
Safe in preg/breastfeeding
Not recommended in functional bloating and IBS
Recommended for nonambulant or immobile patients, chronically constipated, common ADRs of flatulence, abdominal pain, colic.
Name some osmotic laxatives, how long do they take to work?
effect in 2-48 hrs, regular small doses are more effective
Lactulose, sorbitol, macrogol 3350, magnesium salt
Discuss stimulant laxatives
Stimulate or increase intestinal motility by stimulating colonic nerves
Useful for immobile/nonamublant patients
ADR = abdominal cramping
Practice point = prolonged use may damage colon, avoid in preg/elderly
Name some stimulant laxatives, how long do they take to work?
Senna, bisacodyl, sodium picosulfate
Available in combinations with stool softners
Effects seen in 6-12 hours
Discuss stool softeners
Soften stool by assisting water to mix into the stool
Useful for patients who need to soften their stools, avoid a stimulant but wont take an osmotic laxative
no recommended for those with swallowing difficulties (paraffin)
Name some stool softeners. how long do they take to work?
Docusate, liquid paraffin (not used anymore)
poloxamer (coloxyl drops) = preferred in children <3 y/o
Discuss the use of enemas and suppositories in constipation
Useful for when urgent/quick resolution is required
Action in up to 60 minutes
Mention some suppositories and enemas
Glycerol suppository, bisacodyl suppository
Sorbitol enema
What to tell a patient present with constipation
Ensure adequate dietary fibre (25-30g adults, >5 y/o children)
Gradual inc in fibre, limit bloating
Sufficient fluid intake (not tea, coffee, alcohol)
30 mins exercise a day
Go to toilet when urge is felt, sit with knees higher than hips
Advice for child constipation
Encourage child to sit on toilet for 3-5 mins throughout day, no longer than 10 mins
Reinforce good toileting behaviour, record in diary
Avoid prune juice, contains natural bowel irritant
