Constipation

Question 1

What is constipation?

Answer 1

symptom-based disorder which describes defectation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying

Question 2

What diagnostic criteria exists for constipation and what does this define as constipation?

Answer 2

• Rome IV diagnostic criteria for constipation
• includes spontaneous bowel movements occuring <3 times a week

Question 3

What is the character of the stool in constipation?

Answer 3

• dry, hard or lumpy, may be abnormally large or small
• passage of stools less frequently than the person’s normal pattern (= diagnosis in reality)

Question 4

What is meant by chronic constipation?

Answer 4

symptoms which are present for at least 12 weeks in the preceding 6 months

Question 5

What is meant by ‘faecal loading’/impaction?

Answer 5

retention of faeces to the extent that spontaneous evacuation is unlikely

Question 6

What is overflow faecal incontinence?

Answer 6

leakage of liquid stool from the proximal colon around impacted faeces, where small quantities of stool may be passed frequently and without sensation

Question 7

What is functional (aka primary or idiopathic) constipation?

Answer 7

chronic constipation without a known cause

Question 8

What are 3 physiologic subtypes of functional constipation?

Answer 8

1. Normal transit: constipation with no time delay in passage of stool through colon
2. Slow transit: prolonged delay in passage of stool through colon
3. Outlet delay (or obstructed defecation): can be caused by pelvic floor dyssynergia - uncoordinated, contract rather than relax during atempted defecation

Question 9

What is the most common type of functional constipation?

Answer 9

normal transit

Question 10

What is secondary (organic) constipation?

Answer 10

caused by medication or underlying medical condition

Question 11

What are 3 groups of risk factors for developing constipation?

Answer 11

1. Social (diet, exercise, limited privacy)
2. Psychological (anxiety, depression)
3. Physical (female, age, dehydration)

Question 12

What are 4 examples of social risk factors for developing constipation?

Answer 12

1. Low fibre diet or low calorie intake
2. Difficult access to toilet, or changes in normal routine or lifestyle
3. Lack of exercise or reduced mobility
4. Limited privacy when using the toilet

Question 13

What are 4 examples of psychological risk factors for constipation?

Answer 13

1. Anxiety and/or depression
2. Somatisation disorders
3. Eating disorders
4. History of sexual abuse

Question 14

What are 4 physical risk factors for constipation?

Answer 14

1. Female sex
2. Older age
3. Pyrexia, dehydration, immobility
4. Sitting position on a toilet seat compared with squatting position for defecation

Question 15

What are 10 examples of drug causes that can cause secondary constipation?

Answer 15

1. Aluminium-containing antacids
2. Iron or calcium supplements
3. Analgesics e.g. opiates, NSAIDs
4. Antimuscarinics e.g. procyclidine, oxybutynin
5. Antidepressants, such as TCAs, antipsychotics e.g. clozapine
6. Antiepilptics e.g. carbamazepine, gabapentin, pregabalin, phenytoin
7. Antihistamines
8. Antispasmodics e.g. dicycloverine or hyoscine (anti-muscarinic type)
9. Diuretics e.g. furosemide
10. CCBs e.g verapamil

Question 16

What are 5 groups of organic causes of constipation?

Answer 16

1. Endocrine and metabolic diseases
2. Myopathic conditions
3. Neurological conditions
4. Structural abnormalities
5. IBS, slow transit constipation, pelvic or anal dyssynergia

Question 17

What are 7 endocrine and metabolic diseases that can cause constipation?

Answer 17

1. Diabetes mellitus (with autonomic neuropathy)
2. Hypercalcaemia and hyperparathyroidism
3. Hypermagnesaemia
4. Hypokalaemia
5. Hypokalaemia
6. Hypothyroidism
7. Uraemia

Question 18

What are 3 myopathic conditions which can cause constipation?

Answer 18

1. Amyloidoss
2. Myotonic dystrophy
3. Scleroderma

Question 19

What are 6 neurological conditions which can cause constipation?

Answer 19

1. Autonomic neuropathy
2. Cerebrovascular disease
3. Hirschprung’s disease
4. Multiple sclerosis
5. Parkinson’s disease
6. Spinal cord injury, tumours

Question 20

What are 6 structural abnormalities that can cause constipation?

Answer 20

1. Anal fissures, strictures, haemorrhoids
2. Colonic strictures (e.g. following diverticulitis, ischaemic, surgery)
3. Inflammatory bowel disease
4. Obstructive colonic mass lesions e.g. due to colorectal cancer
5. Rectal prolapse or rectocele
6. Postnatal damage to the pelvic floor or third degree tear

Question 21

What are 3 complicatios of chronic constipation?

Answer 21

1. Haemorrhoids or anal fissure
2. Progressive faecal retention, distension of the rectum, loss of sensory and motor function
3. Faecal loading and impaction

Question 22

What are 6 complications of chronic faecal loading and impaction?

Answer 22

1. Faecal incontinence, which can be embarrassing and distressing
2. Chronic dilatation of the colon may cause megacolon
3. Bowel obstruction, perforation or ulceration
4. Recurrent UTIs, obstructive uropathy
5. Rectal bleeding
6. Rectal prolapse

Question 23

What are 4 things that should make you suspect a diagnosis of constipation?

Answer 23

1. Bowel movements <3x a week
2. Daily bowel movements but associated symptoms such as excessive straining
3. Additional symptoms may include lower abdominal pain or discomfort, distension, or bloating
4. Less frequent passage of stools compared with normal pattern

Question 24

What are 4 possible symptoms of constipation in the elderly?

Answer 24

1. Confusion or delirium, functional decline
2. Nausea or loss of appetite
3. Overflow diarrhoea
4. Urinary retention

Question 25

What are 3 things that should make you suspect a diagnosis of faecal loading or impaction?

Answer 25

1. Hard, lumpy stools, which may be large and inferquent (e.g. every 7-10 days) or small and relatively frequent (every 2-3 days) 2. Having to use manual methods to extract faeces 3. Overflow faecal incontinence, or loose stool

Question 26

What are 10 aspects of the assessment of a patient with suspected constipation?

Answer 26

1. Ask about red flag symptoms e.g. suggesting colorectal cancer 2. Ask about normal pattern of defecation 3. Symptoms of constipation 4. Fever, nausea, vomiting, loss of appetite and/or weight 5. Urinary symptoms 6. FH of colorectal cancer or infalmmatory bowel disease 7. Impact on QoL 8. Any measures tried 9. Ask quetsions about faecal loading 10. Examination with informed consent

Question 27

What are 4 symptoms of faecael loading and/or impaction to ask about?

Answer 27

1. History of faecal incontinence e.g. underwear regularly soiled 2. Excessive wiping 3. Loose stools 4. Whether person has needed to use manual measures to relieve constipatoin

Question 28

What are 4 examples of manual methods to relieve constipation?

Answer 28

1. A finger having to be inserted into the vagina suggests a rectocele. 2. A finger in the rectum to push away a flap suggests a rectal ulcer. 3. Pressure behind the anus may assist defecation if the levator muscles are weak. 4. Digital rectal evacuation of faeces confirms severe faecal loading and/or impaction.

Question 29

What are 7 aspects of an examination in a person with constipation?

Answer 29

1. Signs of weight loss and nutritional health status 2. Abdominal examination: pain, distension, masses, palpable colon 3. Internal rectal examination for fissures, haemorrhoids, skin tags, rectal prolapse, rectocele, skin erythema or excoriation (may be sign of faecal leakage) 4. Resting anal sphincter tone, rectal mass leions, retains faecal masses 5. Pelvic floor dysfunction - ask person to ear down, may be paradoxical contraction of anal sphincter on strianing 6. Leakage of stool 7. Rectal or anal pain

Question 30

What are 5 aspects of lifestyle advice to give in constipation?

Answer 30

1. Sources of information and support e.g. NHS PIL on Constipation and Bowel Incontinence 2. Eating a healthy, balanced diet and having regular meals 3. Drinking an adequat fluid intake, especially if there is a risk of dehydration 4. Increasing activity and exercise levels if needed 5. Helpful toileting routines

Question 31

What are 4 aspects of eating a balanced, healthy diet that you should advise for constipation?

Answer 31

1. Whole grains 2. Fruits high in sorbitol e.g. apples, apricots, grapes, peaches, pears, plums, raspberries, strawberries 3. Vegetables 4. Fibre intake should be gradually increased, aim for 30g a day

Question 32

What are 4 types of advice on helpful toileting routines you can give?

Answer 32

1. Advise on regular, unhurried toilet routine, giving time to ensure defecation complete 2. Advise on responding immediately to sensation of needing to defecate 3. Ensure people with limited mobility have appropriate help to access toilet and adequate privacy 4. Ensure person has access to supported seating if they are unsteady on the toilet

Question 33

What are 6 aspects of the management of short-duration constipation?

Answer 33

1. Manage any underlying secondary cause, stop drug treatment that can contribute 2. Lifestyle measures 3. Offer treatment with **oral laxatives** using stepped approach if other methods haven't worked 4. If opioid induced constipation, don't prescribe bulk-forming laxatives, offer osmotic + stimulant laxative 5. Advise to gradually reduce and stop laxatives once producing soft, formed stool without srtaining at least 3x a week 6. Arrange to review person regularly, depending on clinical judgement

Question 34

What are 4 aspects of the stepped approach to treating short-duration constipation with laxatives?

Answer 34

1. Bulk forming laxative first-line e.g. ispaghula 2. Then add or switch to osmotic laxative e.g. a macrogol 3. If macrogol ineffective or not tolerated, offer treatment with lactulose second line 4. If stools soft but difficult to pass/inadequate emptying, add stimulant

Question 35

What is the management of opioid-induced constipation?

Answer 35

* do NOT prescribe bulk-forming laxatives * offer an osmotic laxtive and stimulant laxative (or docusate - stool-softening properties)

Question 36

What are 7 aspects of the management of chronic constipation?

Answer 36

1. Manage any underlying secondary cause/drugs causing 2. Advise on lifestyle measures 3. Manage any faecal loading/impaction first, if present 4. If ongoing symptoms, offer drug treatment with laxatives stepped approach 5. consider treatment with prucalopride if at least 2 laxatives from different classes have been tried at highest doses for at least 6 months 6. Gradually titrate doses up or down aiming for soft, formed stool without straining at least 3x a wek 7. Arrange to review regularly

Question 37

What is the stepped approach with oral laxatives for chronic constipation?

Answer 37

same as for short-duration

Question 38

What is prucalopride? How does it work?

Answer 38

prokinetic: selective, high affinity, serotonin receptor agonist stimulates gastrointestinal motility

Question 39

What course of treatment is given when prucalopride is indicated?

Answer 39

4 week prescription; if no symptom response, reconsider benefit of continuing treatment

Question 40

What is the management of faecal impaction/ loading? 6 aspects

Answer 40

1. If hard stools, consider prescribing **high dose of oral macrogol** 2. If soft stools or ongoing hard stools after few days treatment with macrogol, consider starting or adding **oral stimulant laxative** 3. If no response, can prescribe 1. **suppository** e.g. bisacodyl for soft stools; glycerol alone, or glycerol plus bisacodyl 2. mini **enema** e.g. docusate or sodium citrate 4. If still inadequate, consider **sodium phosphate** or **arachis oil retention enema** 5. Reinforce lifestyle advice 6. Consider need for regular laxative to maintain bowel movements, or intermittent for episode of faecal loading

Question 41

What should you warn patients about when prescribing enemas?

Answer 41

may need district nurse to help administer can cause diarrhoea and faecal overflow before disimpaction is complete

Question 42

What are the 4 steps of management of constipation in pregnancy with laxatives?

Answer 42

1. Offer bulk-forming laxative first-line, e.g. ispaghula 2. Next add or switch osmotic laxative such as lactulose 3. If sitll inadequate, consider short course of stimulant e.g. senna 4. if still inadequate, consider glycerol suppository

Question 43

What are the 4 steps of management of constipation in breastfeeding with laxatives? What are 2 ways that this differs from pregnancy?

Answer 43

1. Offer bulk-forming laxative first-line, e.g. ispaghula 2. Next add or switch osmotic laxative such as lactulose **or macrogol** 3. If sitll inadequate, consider short course of stimulant e.g. senna **or bisacodyl** 4. if still inadequate, consider glycerol suppository can use marcrogol/ bisacodyl

Question 44

How should laxatives be stopped?

Answer 44

do not stopped suddenly, weaning may take several months should be guided by frequency and consistency of stools reduce gadually e.g. after 2-4 weeks when regular bowel movements are comfortable

Question 45

How should you stop laxatives when more than one has been used?

Answer 45

reduce and stop one laxative at a time, starting with stimulant laxatives if possible may need to adjust doses of other laxatives to maintain regular bowel movements

Question 46

What should you consider if symptoms are ongoing or refractory to laxative treatment?

Answer 46

* check blood tests - FBC, TFTs, HbA1c serum electrolytes and calcium - for underlying cause * could it be a defecatory disorder e.g. pelvic floor dyssynergia

Question 47

What are 3 situations to consider specialist advice for constipation?

Answer 47

1. serious underlying cause e.g. colorectal cancer suspected 2. underlying secondary cause suspected that can't be managed in primary care 3. symptoms persist or recur despite optimal management in primary care

Question 48

What are 2 additional services you could consider referring a patient with constipation to, other than gastro/colorectal surgeon?

Answer 48

1. local continence service (if available) 2. dietitian if needed

Question 49

What are 7 types of specialist investigations for constipation?

Answer 49

1. Flexible sigmoidoscopy 2. Colonoscopy 3. Computed tomographic colonography 4. Abdominal x-ray 5. Anorectal manometry 6. Defectation proctogram 7. Colon transit time studies with radio-opaque markers or wireless capsule to determine which subtype is involve (e.g. slow colonic transit or pelvic floor dyssynergia)

Question 50

What are 2 types of specialist management of constipation?

Answer 50

1. Biofeedback training by physiotherapist for some defecation disorders e.g. pelvic floor dyssynergia 2. Surgery e.g. subtotal colectomy with ileorectal anastomosis

Question 51

How do bulk-forming laxatives work?

Answer 51

retain fluid with the stool and increase faecal mass, stimulating peristalsis; also have stool-softening properties

Question 52

What are 3 examples of bulk-forming laxatives?

Answer 52

1. Isaghula husm 2. Methylcellulose 3. Sterculia

Question 53

How do osmotic laxatives work?

Answer 53

increase amount of fluid in the large bowel producing distension, which leads to stimulation of peristalsis. lactulose and macrogols also have stool-softening properties

Question 54

What are 3 examples of osmotic laxatives?

Answer 54

1. Lactulose 2. Macrogols (polyethylene glycols) 3. Phosphate and sodium citrate enemas

Question 55

What is the mechanism of action of stimulant laxatives?

Answer 55

cause peristalsis by stimulaing colonic nerves (senna) or colonic and rectal nerves (bisacodyl, sodium picosulfate)

Question 56

What are 4 examples of stimulant laxatives?

Answer 56

1. Senna 2. Bisacodyl and sodium picosulfate 3. Docusate

Question 57

What is an example of a prokinetic laxative?

Answer 57

prucalopride

Question 58

What are 8 situations when you should not prescribe laxatives?

Answer 58

if there's suspected: 1. intestinal obstruction or perforation 2. paralytic ileus 3. colonic atony or faecal impaction (bulk-forming laxatives don't prescribe) 4. Crohn's disease or UC 5. Toxic megacolon 6. Severe dehydration (bisacodyl) 7. Galactosaemia (lactulose) 8. History of hypersensitivity to peanuts (arachis oil enema)

Question 59

What might happen if you prescribe lactulose in lactose interolance?

Answer 59

diarrhoea

Question 60

When should you take caution when prescrbing Movicol?

Answer 60

it's high in sodium - be careful if on a low salt diet

Question 61

When should bulk-forming laxatives such as Ispaghula and sterculia be considered first line?

Answer 61

if difficultt o get adequate dietary fibre (better tolerated than bran)

Question 62

What are 3 examples of macrogols?

Answer 62

1. Idrolax 2. Movicol-Half 3. Movicol

Question 63

Which laxatives should you be careful of prescribing in cardiovascular disease?

Answer 63

macrogols

Question 64

What is a common side effect of bulk-forming laxatives?

Answer 64

flatulence and bloating

Question 65

What are 3 side effects of osmotic laxatives?

Answer 65

1. abdo pain or cramps 2. blating 3. nausea and vomiting

Question 66

What are 4 side effects of stimulant laxatives?

Answer 66

1. abdo cramps 2. diarrhoea 3. nausea and vomiting 4. senna may cause yellowish-brown discolouration of urine

Question 67

What are 4 side effects of prucalopride?

Answer 67

1. Headache 2. Nausea 3. Diarrhoea 4. Abdominal pain