Constipation

Question 1

Explain constipation

Answer 1

Dec number of stools, <3/week, straining, painful/difficult to pass stools, feeling of obstruction of incomplete evacuation

Question 2

who is affected by constipation?

Answer 2

Prevalent in all age groups, most common in elderly (25-40% >65 y/o are constipated)

Question 3

What is the typical defecation range in western populations?

Answer 3

three times a day to once every three days

Question 4

Symptoms of constipation

Answer 4

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

Question 5

What questions should you ask when someone presents with constipation?

Answer 5

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?

Question 6

What is the most likely cause of constipation in community pharmacy?

Answer 6

Changes in eating habits or routine

Question 7

What is a likely cause of constipation in community pharmacy?

Answer 7

Medication

Question 8

What is an unlikely cause of constipation in community pharmacy?

Answer 8

IBS, preg, depression, functional causes (children)

Question 9

What is a very unlikely cause of constipation in community pharmacy?

Answer 9

colorectal cancer, hypothyroidism

Question 10

When should you refer someone with constipation?

Answer 10

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

Question 11

Which medications are most likely to cause constipation?

Answer 11

Opioids, iron supplements (ferrous sulphate), alpha blockers, antidepressants (e.g. amitriptyline)

Anticholinergics (oxybutynin), antipsychotics, antiepileptics (carbamazepine), beta blockers, PPI, antacids, non-dihydropyridine CCB (verapamil)

Question 12

Mention/explain some differential diagnoses for constipation

Answer 12

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

Question 13

What is the first line treatment of constipation?

Answer 13

Fluid intake, fibre intake, activity levels

Results in 3-5 days

Question 14

Highlight the step-wise approach for treatment of constipation in adults

Answer 14

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.

Question 15

Highlight the step-wise approach for treatment of constipation in children

Answer 15

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)

Question 16

Discuss bulk forming laxatives

Answer 16

Effectively a fibre supplement, inc stool bulk, water content, and colonic bacterial load = inc stool

Important that appropriate fluid is taken with supplement

Question 17

Are bulk forming laxatives safe in pregnancy?

Answer 17

Safe but not recommended = patients are immobile, opioid induced constipation or patient with functional bloating

Question 18

Name some bulk forming laxatives, how long do they take to work?

Answer 18

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)

Question 19

Discuss osmotic laxatives

Answer 19

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.

Question 20

Name some osmotic laxatives, how long do they take to work?

Answer 20

effect in 2-48 hrs, regular small doses are more effective

Lactulose, sorbitol, macrogol 3350, magnesium salt

Question 21

Discuss stimulant laxatives

Answer 21

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

Question 22

Name some stimulant laxatives, how long do they take to work?

Answer 22

Senna, bisacodyl, sodium picosulfate

Available in combinations with stool softners

Effects seen in 6-12 hours

Question 23

Discuss stool softeners

Answer 23

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)

Question 24

Name some stool softeners. how long do they take to work?

Answer 24

Docusate, liquid paraffin (not used anymore)

poloxamer (coloxyl drops) = preferred in children <3 y/o

Question 25

Discuss the use of enemas and suppositories in constipation

Answer 25

Useful for when urgent/quick resolution is required

Action in up to 60 minutes

Question 26

Mention some suppositories and enemas

Answer 26

Glycerol suppository, bisacodyl suppository

Sorbitol enema

Question 27

What to tell a patient present with constipation

Answer 27

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

Question 28

Advice for child constipation

Answer 28

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