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Constipation:a symptom-based disorder which describes defecation that is…
Constipation:a symptom-based disorder which describes defecation that is unsatisfactory because of infrequent stools, difficulty passing stools, or the sensation of incomplete emptying.
Spontaneous bowel movements occuring <3 times a week
Stools often dry, hard or lumpy, may be abnormally large or small. Defined as passage of stools less frequently than the persons normal pattern
Chronic:symptoms present for at least 12 weeks. Faecal loading/impaction. functional (primary or idiopathic)
Diagnosis
Daily movements but excessive straining. Lower abdominal pain, distension and bloating
Consider in elderly
overflow diarrhoea
loss of appetite, nausea or vomiting
confusion or delirium, functional decline
urinary retention
Impaction/Faecal loading
Having to use manual methods to extract faeces
Overflow faecal incontinence, or loose stool.
Hard, lumpy stools, which may be large and infrequent (for example passed every 7–10 days), or small and relatively frequent (for example passed every 2–3 days).
Assessment
CONSIDER RED FLAGS
Abdominal examination- pain, distension, masses, or palpable colon, bowel sounds
Internal PR examination- haemorrhoids, masses, anal fissure,rectal prolapse, skin tags, rectocele, excoriation or erythema
Resting anal sphincter tone; rectal mass lesions and retained faecal masses, which may also be felt on external peri-anal palpation. Note: a faecal mass can be distinguished from a tumour or cyst, as firm pressure exerted by a finger will typically leave a palpable indentation in hard faeces.
Full Hx- Diet, lifestyle, normal bowel pattern, duration, frequency and consistency of constipation/stools, abdominal pain/distension/bloating, medication, weight, urinary symptoms.Fever, nausea, vomiting, loss of appetite. PMHx. FHx
Pelvic floor dysfunction (if appropriate) — while asking the person to 'bear down', there may be paradoxical contraction of the anal sphincter on straining.
Leakage of stool; rectal or anal pain.
Management
Short duration constipation: Dietary & Lifestyle advice. Stepped approach to laxatives. Bulk forming laxative first,ispaghula (patient requires to drink), step up to osmotic laxative e.g. macrogol, if ineffective offer lactulose . If stool soft but difficult to pass, offer stimulant (senna)
If opioid induced constipation- DO NOT offer bulk forming laxative. Osmotic or stimulant laxative should be offered
Self Management- dietary and lifestyle advice- NHS Choices
Chronic - if symptoms despite oral laxatives- adjust dose, choice ad combination of laxatives used. If at least 2 laxatives from different classes have tried at the highest tolerated recommended dose for 6 months and failed to relieve symptoms, where invasive treatment (supps, enemas, rectal irrigation) has been ineffective, consider prucalopride or lubiprostone
Faecal loading/impaction
If the response to oral laxatives is inadequate or too slow, consider prescribing: A suppository such as bisacodyl for soft stools; glycerol alone, or glycerol plus bisacodyl for hard stools:
A mini enema such as docusate (softener and weak stimulant) or sodium citrate (osmotic).
If response remains inadequate: A sodium phosphate or arachis oil retention enema (placed high if the rectum is empty but the colon is full). For hard stool it can be helpful to give the arachis oil enema overnight before giving a sodium phosphate (large volume) or sodium citrate (small volume) enema the next day.
Red Flags
Unexplained weight loss
Abdominal pain
anaemia
rectal bleeding
change in bowel habit