constipation 2

Question 1

management of short duration constipation (full steps)

Answer 1

• try dietary measures first. if ineffective,
• 1st line = bulk forming laxative + adequate fluid intake
• if stools remain hard, add or switch to osmotic
• if stools are soft but difficult to pass/inadequate emptying, + stimulant

Question 2

avoid the following laxative in opioid induced constipation

Answer 2

avoid bulk forming laxatives
bulk forming laxatives increase bulk of faeces by absorbing water into the stool and promotes peistalsis (in normal functioning bowel). however opioids reduce bowel motility, slowing down movement in intestines - risk of bowel obstruction

Question 3

management of opioid induced constipation

Answer 3

• give osmotic (or docusate to soften stools) + stimulant laxative
• naloxegol recommended when response to other laxatives inadequate
• methylneltrexone bromide licensed when response to other laxatives inadequate

Question 4

treatment of faecal impaction depends on ….

And how would you treat each type?

Answer 4

stool consistency

e.g. hard stools: consider high dose oral macrogol
e.g. soft stools, or hard stools after a few days of above treatment: switch or + stimulant

if response to oral laxatives inadequate,
soft stools: rectal bisacodyl
hard stools: glycerol, or glycerol + bisacodyl
alt: docusate enema or sodium citrate enema

response still insufficient? sodium acid phosphate with sodium phosphate or arachnis oil retention enema

hard stools: overnight arachnis oil enema, next day give enema of sodium acid phosphate with sodium phosphate or sodium citrate the next day

enemas may be need to be repeated several times to clear hard impacted faeces

Question 5

management of chronic constipation - all steps

Answer 5

1. bulk forming laxative + fluid intake
2. if stools remain hard, + or switch to osmotic (e.g. macrogol first, lactulose alt)
3. if response inadequate, + stimulant

adjust dose laxative to produce 1-2 soft, formed stools a day

Question 6

When can you consider prulacopride (women only) for chronic constipation

Answer 6

• If at least 2 laxatives from different classes have been tried at the highest tolerated recommended doses for at least 6 months, consider prucalopride (women only)
• If ineffective after 4 weeks, re-examine patient and reconsider benefit of continuing treatment

Question 7

withdrawing laxatives

Answer 7

• Can be slowly withdrawn when regular bowel movements occur without difficulty, according to frequency and consistency of stools
• If a combination of laxatives has been used, reduce and stop one laxative at a time
• If possible, reduce and stop stimulants first - but may also need to adjust dose of osmotic laxative to compensate

Question 8

when you are withdrawing laxatives, which would you try to reduce and stop first?

Answer 8

If possible, reduce and stop stimulants first - but may also need to adjust dose of osmotic laxative to compensate

Question 9

management of constipation in pregnancy

Answer 9

1. dietary and lifestyle
2. fibre supplements (wheat, bran)
3. bulk forming laxatives

osmotic may be used
if stimulant effect needed, give bisacodyl or senna
can also use docusate (stimulant+softener) glycerol (lubricant+rectal stimulant) suppositories

Question 10

This laxative is fine to use in pregnancy, however avoid it near term OR if history of unstable pregnancy

Answer 10

senna

Question 11

true or false - stimulants are more effective than bulk forming laxatives but are more likely to cause SE e.g. diarrhoea, abdominal discomfort

Answer 11

true

Question 12

management of constipation in BF

Answer 12

• 1st line: dietary measures
• If insufficient, bulk-forming laxative
• Osmotic may be used if stools remain hard
• Alternatives: short course of stimulant may be considered

Question 13

constipation in children - why is it important to have early diagnosis and treatment

Answer 13

• Without early diagnosis and treatment, acute episodes can lead to anal fissure and become chronic
• Early identification and effective treatment improves outcomes

Question 14

management of constipation in children - no faecal impaction

Answer 14

1st line: laxative + dietary modification & behavioural intervention
1st line laxative is macrogol (osmotic), adjust dose according to symptoms and response
if inadequate, + stimulant or if not tolerated, switch to stimulant
if stools remain hard, + lactulose or stool softenders (e.g. docusate)

chronic constipation: continue laxative for several weeks after a regular pattern of bowel movements or toilet training is established

Question 15

is dietary modification alone in children with constipation recommended?

Answer 15

○ Diet modification alone not recommended as 1st line, should be combined with use of laxative (macrogol 1st line)
○ Increase dietary fibre, adequate fluid intake, exercise
○ Balanced diet: veg, fruit, high-fibre brad, bakes beans, wholegrain breakfast cereals

Question 16

is unprocessed bran recommended in children with constipation

Answer 16

○ Unprocessed bran NOT recommended - can cause bloating, flatulence, reduced absorption of micronutrients

Question 17

true or false - treatment of faecal impaction can initially increase symptoms of soiling and abdominal pain

Answer 17

true

Question 18

1st line for faecal impaction in children

Answer 18

oral preparation containing a macrogol
this is given to clear faecal mass and establish and maintain soft well-formed stools

Question 19

treatment of faecal impaction in children under 1

Answer 19

• use escalating dose regimen with oral prep containing a macrogol
• if disimpaction doesn’t occur after 2 weeks of macrogol treatment, + stimulant
• if macrogol not tolerated, change to stimulant alone, or if stools hard, also use osmotic laxative
• long term regular use is essential to maintain well formed stools and prevent recurrence of faecal impaction

Question 20

true or false - intermittent use of laxative in pt with faecal impaction/Hx of it can provoke relapse

Answer 20

true. long term regular use is essential to maintain well formed stools and prevent the recurrence of faecal impaction