Constipation

Question 1

What is NICE CKS definition of constipation ?

Answer 1

less than 3 times a week

Question 2

What are the red flag symptoms of constipation ?

Answer 2

new-onset constipation in over 50 years
anaemia
abdominal pain
unexplained weight loss
over or occult blood

Question 3

What is the 1st line treatment for short-duration constipation ?

Answer 3

Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels.
If not effective then bulk forming laxatives ( fybogel, methylcelullose, sterculia)

Question 4

How does bulk forming laxatives work ?

Answer 4

swells in gut to increase feacal mass to stimulate peristalsis, works within 24 hours but takes 2-3 days ( 72 hours) for full effect.

Question 5

What are the side effects of bulk forming laxatives ?

Answer 5

bloating, cramping, flatulence, and gut obstruction

Question 6

How should you counsel patients on bulk forming laxatives ?

Answer 6

drink an adequate fluid intake

take it not immediately before food

Question 7

What is the handling and storage of isphagula husk ?

Answer 7

contains potent allergens: hypersensitivity reactions

Question 8

What is the 2nd line treatment for constipation ?

Answer 8

If stools remain hard or difficult to pass, add or switch to an osmotic laxative (lactulose, magnesium hydroxide), such as a macrogol. If a macrogol is ineffective or not tolerated, offer treatment with lactulose second-line.

Question 9

How does osmotic laxatives work ?

Answer 9

Increases water in colon by drawing fluid from the body or retains fluid administered with.
Lactulose: causes osmotic diarrhoea of low feacal ph.
Macrogols: sequester fluid in bowel.
Osmotics works within 2-3 days. 48 hours for lactulose.

Question 10

What are the side effects of lactulose ?

Answer 10

discomfort, flatulence, cramps, nausea, when starting lactulose.
Nausea reduced by administering with water, fruit juice or meals.

Question 11

What is the third line treatment for constipation ?

Answer 11

If stools are soft but difficult to pass, or there is a sensation of inadequate emptying, add a stimulant laxative (bisacodyl, sodium picosulfate, Senna, glycerol, docusate sodium)

Question 12

How does stimulant laxatives work ?

Answer 12

increases intestinal motility by irritating gut lining
glycerol suppositories work in about 15-30 min
works within 6-12 hours

Question 13

What are the side effects of stimulant laxatives ?

Answer 13

abdominal cramps
Senna colours urine yellow-brown
excessive use: hypokalaemia, diarrhoea, lazy bowel

Question 14

What are the other laxatives that are only used in palliative patients and why they only reserved for palliative care ?

Answer 14

co-danthramer, co-dathrusate

Dantron is genotoxic and carcinogenic

Question 15

what are the side effects of Dantron ?

Answer 15

carcinogenic
red urine
local irritation/ excoriation; avoid prolonged contact with skin in incontinent patients

Question 16

What are other laxatives with stool softening properties ?

Answer 16

methylcelullose
decussate sodium ( weak stimulant)
glycerol ( rectal stimulant)

Question 17

If at least two laxatives ( from different classes ) have been tried at the highest tolerated doses for at least 6 months, which two other laxatives can be considered ?

Answer 17

consider prucalopride ( women only) or lubiprostone

Question 18

What is the choice of treatment for opioid induced constipation ?

Answer 18

osmotic or decussate sodium + stimulant
methylnaltrexone/naloxegol: peripheral opioid receptor antagonist when response to laxatives inadequate
avoid bulk forming laxatives

Question 19

What is the treatment for chronic constipation ?

Answer 19

same as for short duration

Question 20

What is the treatment for constipation in children ?

Answer 20

Macrogol
add stimulant if inadequate response
add lactulose or faecal softener if stools remains hard

Question 21

What is the treatment for constipation for pregnancy ?

Answer 21

1st line bulk forming
osmotic laxatives
bisacodyl or Senna if a stimulant effect is needed.