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Constipation - Coggle Diagram
Constipation
Assessment
Nausea, vomiting, loss of appetite, weight loss
Urinary symptoms: urinary incontinence or retention, dyspareunia
Associated symptoms such as rectal discomfort, excessive straining, feeling incomplete evacuation or blockage, rectal bleeding, abdominal pain or distention
Family history of colorectal cancer or inflammatory bowel disease
Frequency and consistency of stool
How symptoms affect the person, quality of life and daily functioning
Duration of constipation
Any self help measures in place
Ask about normal pattern of defecation and what they mean by 'constipation'
Ask about red flag symptoms
Assess for risk factors including: diet, fibre and fluid intake, normal routine, level or activity, toileting habits, associated psychological or mental health conditions, drug treatment or underlying organic cause.
Assess for faecal loading/impaction: history of faecal incontinence, excessive wiping, loose stools, use of manual evacuation methods.
Red Flags
Weight loss
Abdominal pain
Bloody stools
Rectal bleeding
Iron deficiency anaemia
Sudden change in bowel habit
See the CKS topic on Gastrointestinal tract (lower) cancers - recognition and referral for more information.
Diagnosis
Lower abdominal pain, discomfort, distention or bloating.
Elderly: Non-specific symptoms: Confusion, delirium, functional decline, nausea or loss of appetite, overflow diarrhoea, urinary rentention
Daily movement but associated symptoms such as excessive straining
Suspect faecal loading or impaction if: hard lumpy stools - large and infrequent or small and frequent. Manual methods. Overflow faecal incontinence.
Typical movements < 3 times per week
Suspect if difficulty passing stool, or sensation of incomplete emptying or anorectal blockage
Follow Up
If oral laxatives prescribed arrange regular follow up dependent on clinical judgement
If symptoms ongoing or refractory consider blood tests for FBC, thyroid functions, HbA1c, serum electrolytes and calcium to exclude underlying cause.
Seek specialist advise/ referral to gastroenterologist/colorectal surgeon for specialist investigations/management if - serious underlying cause, constipation caused by underlying cause and cannot be managed in primary care, symptoms persist or recur despite optimal management.
Arrange referral to local continence service if there are symptoms of faecal incontinence
Refer to dietician if support with dietary changes are required
Management
Faecal loading or Impaction
Soft stool or ongoing hard stool after few days treatment with oral macrogol consider oral stimulant laxative
If response inadequate or too slow - consider suppository or mini enema
If response remains inadequate consider - sodium phosphate enema or arachis oil enema
Reinforce lifestyle advise
Consider need for regular laxative
Hard stools - consider high dose oral macrogol
Review every few days to assess the response to treatment dependent on clinical judgement
Chronic Constipation
Follow as short duration
Consider treatment with prucalopride if at least two laxatives from different classes have been tried at highest tolerated doses for at least 6 months and failed to relieve symptoms where invasive treatment is being considered.
Short Duration Constipation
Identify if faecal impaction is present
Advise on lifestyle measures
Investigate, exclude and manage any underlying secondary causes
Offer bulk-forming laxative first line such as ispaghula.
If stool remains hard or difficult to pass, add or switch to an osmotic laxative such as macrogol (Lactulose second line)
Stool soft but difficult to pass or sensation of incomplete emptying add stimulant laxative
Opioid-induced laxative do not use bulk forming - offer osmotic and stimulant
Advise to gradually reduce and stop when producing soft, formed stool without straining at least three times per week
Review regularly dependent on clinical judgement
Self Management
Fibre intake
Adequate fluid intake
Eating healthy, balances diet
Increasing activity and exercise levels
Advice on sources of information
Toileting routines
Risk factors
Psychological
Anxiety/depression
Somatization disorders
Eating disorders
History of sexual abuse
Physical
Pyrexia, poor fluid intake/dehydration, immobility
Sitting position on a toilet seat
Older age
Female sex
Social
Lack of exercise or reduced mobility
Limited privacy when using the toilet
Difficult access to toilet, or change in normal routine/lifestyle
Low educational levels or socio-economic deprivation
Low fibre diet or low calorie intake
Family history of constipation
Examination
Abdominal assessment - abdominal pain, distention, masses, or palpable colon
DRE - anal fissures, haemorrhoids, skin tags, rectal prolapse, rectocele, skin erythema or excoriations, resting anal sphincter tone, rectal mass lesions or retained faecal masses, pelvic floor dysfunction, leakage of stool, rectal or anal pain.
Assess for signs of weight loss and general nutritional status
Secondary causes
Medication
Analgesics eg opioids and NSAIDs
Antimuscarinics
Aluminium-containing antacids
Antidepressants
Antipsychotics
Antiepileptic drugs
Antihistamines
Antispasmodics
Calcium-channel blockers
Diuretics
Organic causes
Myopathic condition eg myotonic dystrophy
Neurological conditions eg MS, Parkinson's disease, spinal cord injuries
Endocrine and metabolic disease eg diabetes etc.
Structural abnormalities eg haemorrhoids, fissures, IBD
Other: IBS
Constipation is a heterogeneous, symptom-based disorder. Patients describe defecation that is problematic because of infrequent and/or hard stools, difficulty passing stools (often involving straining), or the sensation of incomplete emptying or anorectal blockage. Chronic constipation usually describes symptoms which are present for at least three months. Faecal loading/impaction describes retention of faeces to the extent that spontaneous evacuation is unlikely. Functional (primary or idiopathic) constipation is chronic constipation without a known cause. Secondary (organic) constipation is constipation caused by medication or an underlying medical condition, including endocrine, metabolic, neurological or primary diseases of the colon, for example stricture, malignancy, or proctitis.