constipation 2 Flashcards
management of short duration constipation (full steps)
- try dietary measures first. if ineffective,
- 1st line = bulk forming laxative + adequate fluid intake
- if stools remain hard, add or switch to osmotic
- if stools are soft but difficult to pass/inadequate emptying, + stimulant
avoid the following laxative in opioid induced constipation
avoid bulk forming laxatives
bulk forming laxatives increase bulk of faeces by absorbing water into the stool and promotes peistalsis (in normal functioning bowel). however opioids reduce bowel motility, slowing down movement in intestines - risk of bowel obstruction
management of opioid induced constipation
- give osmotic (or docusate to soften stools) + stimulant laxative
- naloxegol recommended when response to other laxatives inadequate
- methylneltrexone bromide licensed when response to other laxatives inadequate
treatment of faecal impaction depends on ….
And how would you treat each type?
stool consistency
e.g. hard stools: consider high dose oral macrogol
e.g. soft stools, or hard stools after a few days of above treatment: switch or + stimulant
if response to oral laxatives inadequate,
soft stools: rectal bisacodyl
hard stools: glycerol, or glycerol + bisacodyl
alt: docusate enema or sodium citrate enema
response still insufficient? sodium acid phosphate with sodium phosphate or arachnis oil retention enema
hard stools: overnight arachnis oil enema, next day give enema of sodium acid phosphate with sodium phosphate or sodium citrate the next day
enemas may be need to be repeated several times to clear hard impacted faeces
management of chronic constipation - all steps
- bulk forming laxative + fluid intake
- if stools remain hard, + or switch to osmotic (e.g. macrogol first, lactulose alt)
- if response inadequate, + stimulant
adjust dose laxative to produce 1-2 soft, formed stools a day
When can you consider prulacopride (women only) for chronic constipation
- If at least 2 laxatives from different classes have been tried at the highest tolerated recommended doses for at least 6 months, consider prucalopride (women only)
- If ineffective after 4 weeks, re-examine patient and reconsider benefit of continuing treatment
withdrawing laxatives
- Can be slowly withdrawn when regular bowel movements occur without difficulty, according to frequency and consistency of stools
- If a combination of laxatives has been used, reduce and stop one laxative at a time
- If possible, reduce and stop stimulants first - but may also need to adjust dose of osmotic laxative to compensate
when you are withdrawing laxatives, which would you try to reduce and stop first?
If possible, reduce and stop stimulants first - but may also need to adjust dose of osmotic laxative to compensate
management of constipation in pregnancy
- dietary and lifestyle
- fibre supplements (wheat, bran)
- bulk forming laxatives
osmotic may be used
if stimulant effect needed, give bisacodyl or senna
can also use docusate (stimulant+softener) glycerol (lubricant+rectal stimulant) suppositories
This laxative is fine to use in pregnancy, however avoid it near term OR if history of unstable pregnancy
senna
true or false - stimulants are more effective than bulk forming laxatives but are more likely to cause SE e.g. diarrhoea, abdominal discomfort
true
management of constipation in BF
- 1st line: dietary measures
- If insufficient, bulk-forming laxative
- Osmotic may be used if stools remain hard
- Alternatives: short course of stimulant may be considered
constipation in children - why is it important to have early diagnosis and treatment
- Without early diagnosis and treatment, acute episodes can lead to anal fissure and become chronic
- Early identification and effective treatment improves outcomes
management of constipation in children - no faecal impaction
1st line: laxative + dietary modification & behavioural intervention
1st line laxative is macrogol (osmotic), adjust dose according to symptoms and response
if inadequate, + stimulant or if not tolerated, switch to stimulant
if stools remain hard, + lactulose or stool softenders (e.g. docusate)
chronic constipation: continue laxative for several weeks after a regular pattern of bowel movements or toilet training is established
is dietary modification alone in children with constipation recommended?
○ Diet modification alone not recommended as 1st line, should be combined with use of laxative (macrogol 1st line)
○ Increase dietary fibre, adequate fluid intake, exercise
○ Balanced diet: veg, fruit, high-fibre brad, bakes beans, wholegrain breakfast cereals
