Constipation Flashcards
Give the general definition of constipation
infrequent defecation involving straining and passage of lumpy, hard uncomfortable stools
What is the Rome II criteria to diagnose someone with constipation (6)
Two or more of the following for at least 12 weeks out of the last 12 months:
. Straining at defecation for at least 1/4 of the time
.lumpy or hard stools for at least 1/4 of the time
.sensation of the an0-rectal obstruction for at least 1/4 of the time
.sensation of incomplete evacuation for at least 1/4 of the time
.manual manoeuvres
.three or fewer bowel movements a week
What type of stools indicate inflammation ?
- mushy consistency with ragged edges
-liquid consistency with no solid pieces
What type of stool indicates a lack of fibre?
Soft blobs with clear cut edges
What type of stools indicate constipation
-separate hard lumps
-lumpy and sausage like (lightly constipated)
What percent of the general population suffers with constipation ?
2 - 27 %
What groups of people are more likely to suffer from constipation (6)?
- increases with age, more common in elderly
- women are 2-3 times more likely to suffer from constipation than men
- pregnancy (40%) due to diet changes
- increased in institutional settings, common in nursing homes
- increased in black patients
- increased in deprived socio-economic groups
Explain why constipation occurs, relating your reason to the GI tract
Undigested food swept along the GI tract by peristalsis (contraction of gut muscles), eventually leading to the urge to defaecate.
Constipation is dependant on the net uptake of fluid during transit time. When the gut motility is altered, transit time is affected thus amount of fluid absorbed affected.
The longer the transit time in the GI tract, the more fluid absorbed =harder stools
What does primary/ idiopathic constipation mean?
When constipation arises with no known cause
What factors may contribute to secondary constipation (9)
- poor dietary fibre/calorie intake
- poor fluid intake
- poor bowel habit ( limited access to toilet, change in the normal routine, recommend squatting when using toilet )
- travel
- pregnancy: hormonal changes=slow gut movements, baby takes up room which puts pressure on the rectum
-reduced mobility - laxative abuse, bowel starts relying on laxative
- medicines can have constipation side effects (e.g. iron/ calcium supplements )
- underlying conditions: poor mobility, Parkinson’s disease, eating disorders, anxiety/ depression, hypothyroidism
What are some symptoms of constipation (6)?
- discomfort on passing stool
- abdominal discomfort or cramps
- bloating
- feeling of incomplete emptying of rectum
-feeling of obstruction/ blockage - a need to manually assist defaecation
What questions should be asked to a patient with constipation (6) ?
Ask about:
- Their regular and current bowel habit
Duration> 14 days - referral - Age?
Elderly -common
Child- refer - Pain on passing stool?
Anal fissure? Haemorrhoids? - Any blood present ?
Anal fissure? Haemorrhoids? - Other symptoms present?
Abdominal pain? Bloating ? - Changes in diet/ lifestyle/ new medications?
What complications can constipation cause (6) ?
- Haemorrhoids
- Faecal impaction- large stool gets stuck
- Faecal and urinary incontinence- problem holding in urine or stool
- Rectal bleeding
- Anal fissure (tear in anus )
- Rectal prolapse
When should patients be referred? (6)
- Unexplained weight loss
- Blood in stool; indicates anal fissure
- Constipation with nausea and vomiting
- impacted (stool stuck )
- Suspected laxative abuse:
Dehydration
Damage to nerves and muscles of gut - suspect bowel cancer
What can be some symptoms of bowel cancer (4) and when should the GP be seen?
Most people with these symptoms do not have bowel cancer but they can still be an indication.
See GP if patient has 1 or more symptoms persisting for more than 4 weeks.
. A persistent change in bowel habit
. Blood in stools
. Abdominal pain, discomfort or bloating brought on by eating
. Constipation, where you pass harder stools less often, rarely caused by serious bowel conditions
What medication could be causing constipation that could be changed? (8)
-opiates
- aluminium salts
- antidepressants
- anti-Parkinson
- anticholinergics (inhibits acetylcholine, used to treat urinary incontinence)
- iron
- phenothiazines (allergy treatment)
- laxative abuse
What lifestyle changes could be implemented to help with constipation? (5)
. Fibre
30g daily recommended
Adds bulk to faeces as undigested
Increase fibre gradually to avoid bloating
. Adequate fluid - 2L/day
.foods contains sorbitol- acts like natural osmotic laxative
. Exercise
. toileting- go when needed, unhurried, regular routine, squatting position recommended
Bulk- forming/(first line) laxatives:
- What is the general mechanism
- What precautions to take
- State the side effects
- How long do they take to start working?
- Increase faecal volume like fibre, retains fluid in stool, often faeces, stimulates peristalsis (muscular relaxation/ contractions in intestines)
- Must drink lots of water to stay hydrated and most not take more than recommended dose as it can cause side effects.
- May increase flatulence+ bloating in first few weeks
- Usually works within 12-24 hours
What is an example of a bulk forming laxative?
Fybogel (natural fibre drink, sachets )
Osmotic (second line) laxatives :
- What is the general mechanism of osmotic laxatives
- What precautions to take when using osmotic laxatives
- How long does it take for osmotic laxatives to work?
- What are the side effects
- Draw water from intestinal wall into gut lumen. This raises intra- luminal pressure thus increasing volume of contents, stimulating peristalsis ( intestine muscles relax and contract )
- Magnesium absorbed so not recommended for chronic use.
- Can take 4hrs to 72 hours depending on drug.
Lactulose: 48-73hrs
Magnesium sulphate: 4hrs
Macrogols: 8 hrs
Glycerol: (suppository) dual effect meaning it is a an osmotic and stimulant laxative : 30-60 minutes - Side effects : abdominal pain, bloating
Give an example of an osmotic laxative
Movicol - example of a macrogol
Stimulant laxatives:
- State their general mechanism
- How long does it take for them to work
- What are the side effects?
- Stimulate nerves in large intestine, increasing peristalsis and gut motility
- Usually work within 8-12 hours, take bedtime dose to go in the morning
- Side effects include: abdominal cramps, diarrhoea
What are some examples of stimulant laxatives (4)
Senna (senokot)
Bisacodyl ( dulcolax )
Glycerol
Docusate sodium (dual action )
Stool softener laxatives
- What are the two types of stool softener laxatives and what are their general mechanisms and side effects?
Faecal softeners:
Antionic surfactant, lowers surface tension of the intestinal content, allowing fat and fluid to penetrate , emulsify and soften faecal matter
Faecal lubricants:
Penetrates and softens faeces, coats surface to facilitate passage.
Side effects: anal seepage, skin irritation, lipid pneumonia
Example : liquid paraffin (no longer used)
Give an example of a POM for constipation
Prucalopride
. Helps with peristalsis
. For chronic constipation when other laxatives have failed
What type of treatment should be recommended to children with constipation
- dietary advice, more fibres
- increase activity
- use osmotic/ stool softeners/ stimulant
