Ballina Family Medical Centre
Constipation
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Definition
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No objective definition because of great individual variation in normal bowel habit.
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Normal frequency in western countries varies from 3/ day to 2/ week.
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People present with constipation if
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Defecation occurs less frequently
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Stools are harder
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Defecation causes straining
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There is a sense of incomplete evacuation.
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Causes;
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Lifestyle
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Inadequate dietary fibre
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Inadequate fluid intake
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Ignoring the need to pass a motion
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Inadequate activity/ exercise
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Medications
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Aluminium and calcium containing antacids
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Anticholinergics ( TCA’s, antipsychotics, antispasmodics, antiparkinsonians
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Clozapine, Olanzipine, Risperidone, Quetiapine
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Gabapentin
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Iron Preparations
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Opioids
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Verapamil
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Potentially serious medical causes
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Dementia
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Depression
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Hypothyroidism
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Hypercalcaemia
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Obstruction- e.g from cancer
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If an older person presents with recent constipation, or has additional symptoms eg rectal bleeding, then ix for bowel ca including rectal exam.
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Constipation in Adults
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Encourage diet and exercise- exercise reduces intestinal transit time, sit up straight on toilet, 30grams of fibre a day, for kids its age + 5 grams,
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If dietary and lifestyle modification are ineffective, and the pt is mildly constipated and ambulatory, then add a bulk- forming agent.
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In the Elderly
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One of the most common problems reported by older people
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Changes in environment,
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Decreased mobility
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Drugs especially opioids
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Diminished intake of fibre and fluid
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Painful rectal problems- eg haemorrhoids anal fissures
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Less exercise
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Can be associated with depression and dementia
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Co- morbidities which cause loss of muscle power- eg copd
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Constipation in Kids
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Frequency of bowel action varies widely in kids
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Can occur as a result of withholding behaviour, slowed colonic transit, porr diet, reduced activity, inadequate fluid intake, anal fissure, and rarely- sexual abuse.
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Can cause abdo pain, reduced appetite, irritability, may present with soiling from overflow incontinence
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Assessment includes a thorough history, abdo palpation, anal inspection for cellulitis or a fissure, DRE not usually helpful, AXR’s aren’t usually necessary
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Management part 1
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Regular toileting – 2 -3 times a day- just sitting there helps
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Education
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High fibre diet
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Adequate fluids
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Adequate exercise
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Management Part 2 if part 1 fails
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Movicol half if aged 2 and up, OR
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Lactulose ( < 12/12 5mls, kids 1 – 6 10mls, kids 7 – 14 15mls, OR
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Liquid paraffin ( Parachoc) kids 3 and up, at least 2 hrs before lying down
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A stimulant or osmotic can be added
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Management Part 3
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Failing to respond to simple measures may be due to either foecal impaction or poor compliance.
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Foecal impaction can be treated at home with movicol- kids 2 -4 yrs 2 sachets of movicol half, kids 5 – 12 4 sachets of movicol half, don’t use picoprep.
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Chronic constipation can cause overflow incontinence and considerable secondary emotional and behavioural difficulties. Encopresis ( Soiling) is usually the result of constipation. Many months of treatment is required to get the bowel ( size and sensation) back to normal.
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Laxatives;
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Bulk Forming Laxatives; ( increase the bulk and moisture in the stool
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Ispaghula powder ( Fybogel) 1 sachet bd, kids 6- 12 , ½ adult dose
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Psyllium husk ( bioglan, Psylli Mucil Plus), q1tsp before breakfast
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Psyllium Powder ( Metamucil), 1-2 teaspoons 1 – 3 times a day
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Osmotic Laxatives ( when long term use is necessary, taken with fluid preferable fruit juice
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Lactulose syrup ( actilax, duphalac, lac-dol, Lactocur) adults 15 -30mls daily kids variable dose
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Movicol sachets- adults 1 -2 daily, not recommended for kids < 2, kids 2 -12 ½ a sachet, for foecal impaction 8 sachets in a litre of water.
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Osmolax PBS listed, no salty taste
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Epsom Salts- 15g in 250ml of water
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Sorbilax 20ml daily increase to tds if required
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Fleet mixture 45ml in 125 ml of water
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Picolax 1 sachet in 120 ml of water.
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Enemas
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Microlax
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Fleet ( don’t use in kids)
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Stool Softeners
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Coloxyl and coloxyl drops for kids. ( any age)
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Stimulant Laxatives ( not recommended for long term use, can cause cramps, stimulate intestinal motility
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Bisalax, Dulcolax ages 6 and up
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Senna leaf with dried fruit ( Nulax)
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Senna powder
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Sennetabs
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Laxettes
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Lubricant Laxatives
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Liquid paraffin oil ( Agarol) from age 3 and up
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Liquid paraffin ( Parachoc) from age 3 and up
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Fibre; 25 – 30g: including soluble and insoluble fibre; sources giving at least 6ginclude;
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Half a cup of muesli or all bran
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Two slices of wholegrain bread
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Half a cup of baked beans
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Two tablespoons of psyllium husks.
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Resistant starch found in peas corn barley and rice are also usefulas they stimulate good bacteria;
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Pear juice- 150mls twice daily
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Prunes
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Rhubarb
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Dried fruits
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When opioid induced constipation is inadequately treated with laxatives in the palliative care setting then use “ Relistor” methylnaltrexone bromide, a s/c injection daily which blocks gut opiate receptors, apparently is vv effective, don’t use of they’ve got a bowel obstruction.
* For opioid induced constipation
ERIC- U.K childrens resource.