Flashcards in Constipation Deck (21)
What is NICE CKS definition of constipation ?
less than 3 times a week
What are the red flag symptoms of constipation ?
new-onset constipation in over 50 years
unexplained weight loss
over or occult blood
What is the 1st line treatment for short-duration constipation ?
Advise on lifestyle measures, such as increasing dietary fibre, fluid intake, and activity levels.
If not effective then bulk forming laxatives ( fybogel, methylcelullose, sterculia)
How does bulk forming laxatives work ?
swells in gut to increase feacal mass to stimulate peristalsis, works within 24 hours but takes 2-3 days ( 72 hours) for full effect.
What are the side effects of bulk forming laxatives ?
bloating, cramping, flatulence, and gut obstruction
How should you counsel patients on bulk forming laxatives ?
drink an adequate fluid intake
take it not immediately before food
What is the handling and storage of isphagula husk ?
contains potent allergens: hypersensitivity reactions
What is the 2nd line treatment for constipation ?
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.
How does osmotic laxatives work ?
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.
What are the side effects of lactulose ?
discomfort, flatulence, cramps, nausea, when starting lactulose.
Nausea reduced by administering with water, fruit juice or meals.
What is the third line treatment for constipation ?
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)
How does stimulant laxatives work ?
increases intestinal motility by irritating gut lining
glycerol suppositories work in about 15-30 min
works within 6-12 hours
What are the side effects of stimulant laxatives ?
Senna colours urine yellow-brown
excessive use: hypokalaemia, diarrhoea, lazy bowel
What are the other laxatives that are only used in palliative patients and why they only reserved for palliative care ?
Dantron is genotoxic and carcinogenic
what are the side effects of Dantron ?
local irritation/ excoriation; avoid prolonged contact with skin in incontinent patients
What are other laxatives with stool softening properties ?
decussate sodium ( weak stimulant)
glycerol ( rectal stimulant)
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 ?
consider prucalopride ( women only) or lubiprostone
What is the choice of treatment for opioid induced constipation ?
osmotic or decussate sodium + stimulant
methylnaltrexone/naloxegol: peripheral opioid receptor antagonist when response to laxatives inadequate
avoid bulk forming laxatives
What is the treatment for chronic constipation ?
same as for short duration
What is the treatment for constipation in children ?
add stimulant if inadequate response
add lactulose or faecal softener if stools remains hard