Constipation

Gastroenterology

  • Definition

    • No objective definition because of great individual variation in normal bowel habit.
    • Normal frequency in western countries varies from 3/ day to 2/ week.

 

  • People present with constipation if

    • Defecation occurs less frequently
    • Stools are harder
    • Defecation causes straining
    • There is a sense of incomplete evacuation.

 

  • Causes;

    • Lifestyle

      • Inadequate dietary fibre
      • Inadequate fluid intake
      • Ignoring the need to pass a motion
      • Inadequate activity/ exercise

    • Medications

      • Aluminium and calcium containing antacids
      • Anticholinergics ( TCA’s, antipsychotics, antispasmodics, antiparkinsonians
      • Clozapine, Olanzipine, Risperidone, Quetiapine
      • Gabapentin
      • Iron Preparations
      • Opioids
      • Verapamil

    • Potentially serious medical causes

      • Dementia
      • Depression
      • Hypothyroidism
      • Hypercalcaemia
      • Obstruction- e.g from cancer
        • If an older person presents with recent constipation, or has additional symptoms eg rectal bleeding, then ix for bowel ca including rectal exam.

 

  • Constipation in Adults

    • 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,
    • If dietary and lifestyle modification are ineffective, and the pt is mildly constipated and ambulatory, then add a bulk- forming agent.

 

  • In the Elderly

    • One of the most common problems reported by older people
      • Changes in environment,
      • Decreased mobility
      • Drugs especially opioids
      • Diminished intake of fibre and fluid
      • Painful rectal problems- eg haemorrhoids anal fissures
      • Less exercise
      • Can be associated with depression and dementia
      • Co- morbidities which cause loss of muscle power- eg copd

 

  • Constipation in Kids

    • Frequency of bowel action varies widely in kids
    • Can occur as a result of withholding behaviour, slowed colonic transit, porr diet, reduced activity, inadequate fluid intake, anal fissure, and rarely- sexual abuse.
    • Can cause abdo pain, reduced appetite, irritability, may present with soiling from overflow incontinence
    • Assessment includes a thorough history, abdo palpation, anal inspection for cellulitis or a fissure, DRE not usually helpful, AXR’s aren’t usually necessary
    • Management part 1
      • Regular toileting – 2 -3 times a day- just sitting there helps
      • Education
      • High fibre diet
      • Adequate fluids
      • Adequate exercise
    • Management Part 2 if part 1 fails
      • Movicol half if aged 2 and up,             OR
      • Lactulose ( < 12/12 5mls, kids 1 – 6 10mls, kids 7 – 14 15mls,     OR
      • Liquid paraffin ( Parachoc) kids 3 and up, at least 2 hrs before lying down
      • A stimulant or osmotic can be added
    • Management Part 3
      • Failing to respond to simple measures may be due to either foecal impaction or poor compliance.
      • 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.
    • 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.

 

 

  • Laxatives;

    • Bulk Forming Laxatives; ( increase the bulk and moisture in the stool
      • Ispaghula powder ( Fybogel) 1 sachet bd, kids 6- 12 , ½ adult dose
      • Psyllium husk ( bioglan, Psylli Mucil Plus), q1tsp before breakfast
      • Psyllium Powder ( Metamucil), 1-2 teaspoons 1 – 3 times a day
    • Osmotic Laxatives ( when long term use is necessary, taken with fluid preferable fruit juice
      • Lactulose syrup ( actilax, duphalac, lac-dol, Lactocur) adults 15 -30mls daily kids variable dose
      • 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.
      • Osmolax PBS listed, no salty taste
      • Epsom Salts- 15g in 250ml of water
      • Sorbilax 20ml daily increase to tds if required
      • Fleet mixture 45ml in 125 ml of water
      • Picolax 1 sachet in 120 ml of water.
    • Enemas
      • Microlax
      • Fleet ( don’t use in kids)
    • Stool Softeners
      • Coloxyl and coloxyl drops for kids. ( any age)
    • Stimulant Laxatives ( not recommended for long term use, can cause cramps, stimulate intestinal motility
      • Bisalax, Dulcolax ages 6 and up
      • Senna leaf with dried fruit ( Nulax)
      • Senna powder
      • Sennetabs
      • Laxettes
    • Lubricant Laxatives
      • Liquid paraffin oil ( Agarol) from age 3 and up
      • Liquid paraffin ( Parachoc) from age 3 and up
    • Fibre; 25 – 30g: including soluble and insoluble fibre; sources giving at least 6ginclude;
      • Half a cup of muesli or all bran
      • Two slices of wholegrain bread
      • Half a cup of baked beans
      • Two tablespoons of psyllium husks.
    • Resistant starch found in peas corn barley and rice are also usefulas they stimulate good bacteria;
      • Pear juice- 150mls twice daily
      • Prunes
      • Rhubarb
      • Dried fruits

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.