Constipation

Question 1

What is meant by constipation

Answer 1

Infrequent, difficult stools- most common in women, the elderly and pregnant

Question 2

What are the red flags in constipation

Answer 2

Blood in stools
Anaemia
Abdominal pain
Weight loss
New onset constipation over 50 years

Question 3

What is the non- drug treatment for constipation

Answer 3

Increase in dietary fibre
Adequate fluid intake
Exercise is advised

Review of medication as this may be causing it

Question 4

What medications can cause constipation

Answer 4

Opioids
Aluminium
Clozapine ( red Flag!!!)

Question 5

What is meant by bulk forming laxatives

Answer 5

These are methylcellulose, ispaghula husk and sterculia

• small hard stools- increases the faecal mass, stimulating peristalsis
• takes 2-3 days to work
• must be taken with enough water to prevent intestinal blockage

Question 6

What is meant by stimulant laxatives

Answer 6

Bisacodyl, sodium picosulfate, senna, docusate and glycerol

• stimulating colonic nerves - peristalsis
• takes 6-12 hours to work
• avoid in intestinal obstruction
• co-danthramer and co-danthrusate used in terminal illness due to carcinogenicity (red urine )

Question 7

What are faecal softeners

Answer 7

Liquid paraffin, docusate, glycerol

• increases water penetration into the stool
• quickest acting ( docusate enema takes 5-20 minutes)
• liquid paraffin is avoided due to anal seepage, granulomatous disease of the GI tract, lipoid pneumonia on aspiration

Question 8

What is meant by osmotic laxatives

Answer 8

Lactulose and macrogol

• increases the amount of fluid in the large bowel - peristalsis
• takes 2-3 days to work
• also has faecal softening properties

Question 9

What is the drug treatment of constipation for short duration

Answer 9

Bulk forming and good hydration - then move to osmotic

Question 10

What is the drug treatment of chronic constipation

Answer 10

Chronic lasts more than 6 months

Bulk forming and good hydration

• if stool remains hard - add or change to macrogol ( or lactulose 2nd line)
• if there is still no change after 6 months - prucalopride (women only)
• withdraw laxative slowly when patient improves

Question 11

What is the drug treatment for faecal impaction in constipation

Answer 11

Hard stools - macrogol + stimulant once softened

Soft stools - stimulant

Rectal bisacodyl and/or glycerol used if still there

Question 12

What is the drug treatment for opioid induced in constipation

Answer 12

Osmotic and stimulant

Naloxegol if no response to the first line

AVOID BULK FORMING because the peristalsis is already slow and can cause faecal impaction

Question 13

What is the drug treatment for pregnancy and breastfeeding for constipation

Answer 13

Dietary and lifestyle- fibre supplements such as bran or wheat

Bulk forming - lactulose

Bisacodyl or Edna if that doesn’t work ( don’t use senna near term)

Question 14

What is the drug treatment for constipation in children

Answer 14

First line: dietary advice and macrogol ( if no faecal impaction) then use a stimulant such as senna ( be careful of age as can be contraindicated)

Is stool is hard- lactulose or docusate