CONSTIPATION
DEFINITION:
- Passing harder/smaller stools less frequently than normal (there is NO ideal range)
- Many people misdiagnose themselves as constipated laxative OVERUSE
CAUSES:
- Inadequate fibre intake
- Pregnancy Where possible, always TREAT the
- Drug ADRs: Opiates, Al3+-containing antacids, AMs underlying cause FIRST (like in
- Underlying Disease: Anxiety, Parkinson’s, IBS emesis, coughs, insomnia,
hyperlipidaemia)
WHEN TO REFER:
- Blood in stools/ black stools (Bowel Cancer)
- Palpable abdominal mass (Bowel Cancer)
- Unexplained weight loss
- Pelvic/lower abdominal pain (esp in women – Endometriosis)
- Unresponsive to OTC drugs
COMPLICATION of unmanaged constipation = Faecal Impaction = Large mass of hardened
stool which is STUCK in rectum
TREATMENT in ADULTS (short- & long-term constipation):
- 1st Line: Bulk-forming agents (BFA)
- 2nd Line: ADD Osmotic (can be used ALONE)
- 3rd Line: ADD Stimulant (often NOT used alone here)
- 4th Line: REFER – normally give Prucalopride (a 5-HT agonist)
Always check for FAECAL
TREATMENT in CHILDREN (under 18s) IMPACTION BEFORE giving
- 1st Line: Osmotic (Macrogol 1st, Lactulose 2nd) laxatives – see below
- 2nd Line: ADD Stimulant (CAN be used ALONE here)
- 3rd Line: ADD Stool Softener (e.g. Docusate)
TREATMENT of FAECAL IMPACTION: (Adults AND under <18s)
- 1st Line: Macrogol
Adults & Kids - 2nd Line: ADD Stimulant (can ADD STOOL SOFTENER e.g. Docusate)
rd
Adults ONLY - 3 Line: Suppositories (Bisacodyl for SOFT stools, Glycerol for HARD stools – CAN
COMBINE)
- 4th Line: Enemas (Mini 1st, Oil Retention 2nd)
TREATMENT in PREGNANCY (similar to ADULT treatment):
- 1st Line: BFA
- 2nd Line: ADD Osmotic (can be used ALONE) ALL OTC laxatives are SAFE
- 3rd Line: ADD Stimulant in PREGNANCY & BF
- 4th Line: ADD Glycerol suppositories
, BFAs are NOT used in OIC –
risk of FAECAL IMPACTION
TREATMENT in OPIOID-INDUCED CONSTIPATION (OIC):
- 1st Line: Stimulant w/ EITHER Osmotic OR Softener
- 2nd Line: Naloxegol (opioid-receptor antagonist – SPECILAIST)
Naloxegol is the only opioid blocker that works in the PERIPHERY, NOT in CNS (unlike
Naloxone & Naltrexone) – so only INDICATED in OIC
BULK FORMING AGENTS (BFAs) – Ispaghula Husk, Sterculia, Methylcellulose
MOA: Mimics action of fibre – increases water retention in stools increases stool mass
promotes peristalsis
INDICATIONS:
- 1st Line in Adults (NO faecal impaction)
- 1st Line in Pregnancy
SIDE EFFECTS:
- Faecal Impaction (also a CI)
- Bloating & Flatulence: fibre = PRE-BIOTIC for GIT microbiome gas
IMPORTANT POINTS:
- Take sachets w/ LOTS of WATER – helps it work & avoid impaction
- Onset = 2-3 days for MAX effect (like Osmotics)
- Fybogel Dose = 1 sachet BD – AVOID taking BEFORE BED (worsen bloating)
- Age = 6+ (although these are NOT in NICE guidance for <18s)
OSMOTIC LAXATIVES – Macrogol (PEG), Lactulose
MOA: Draws water into GIT from GI-epithelium softened, lubricated stools
INDICATIONS:
- 1st Line in Children
- 1st Line in Faecal Impaction (Macrogol - Adults & Kids)
- 1st Line in OIC (w/ Stimulants)
- 2nd Line in Adults & Pregnancy
- Hepatic Encephalopathy (Lactulose)
SIDE EFFECTS:
- Flatulence
- Dehydration (Take w/ LOTS of WATER)
- HYPOkalaemia (Xanthines, Digoxin, Insulin, β-agonists, Loops & Thiazides)
IMPORTANT POINTS:
- Onset = 2-3 days for MAX EFFECT (like BFAs)
- Macrogol OTC Age = 12+ (paediatric forms = POMs)
- Lactulose OTC Age = Birth
- Do NOT give Lactulose in IBS – worsens BLOATING
DEFINITION:
- Passing harder/smaller stools less frequently than normal (there is NO ideal range)
- Many people misdiagnose themselves as constipated laxative OVERUSE
CAUSES:
- Inadequate fibre intake
- Pregnancy Where possible, always TREAT the
- Drug ADRs: Opiates, Al3+-containing antacids, AMs underlying cause FIRST (like in
- Underlying Disease: Anxiety, Parkinson’s, IBS emesis, coughs, insomnia,
hyperlipidaemia)
WHEN TO REFER:
- Blood in stools/ black stools (Bowel Cancer)
- Palpable abdominal mass (Bowel Cancer)
- Unexplained weight loss
- Pelvic/lower abdominal pain (esp in women – Endometriosis)
- Unresponsive to OTC drugs
COMPLICATION of unmanaged constipation = Faecal Impaction = Large mass of hardened
stool which is STUCK in rectum
TREATMENT in ADULTS (short- & long-term constipation):
- 1st Line: Bulk-forming agents (BFA)
- 2nd Line: ADD Osmotic (can be used ALONE)
- 3rd Line: ADD Stimulant (often NOT used alone here)
- 4th Line: REFER – normally give Prucalopride (a 5-HT agonist)
Always check for FAECAL
TREATMENT in CHILDREN (under 18s) IMPACTION BEFORE giving
- 1st Line: Osmotic (Macrogol 1st, Lactulose 2nd) laxatives – see below
- 2nd Line: ADD Stimulant (CAN be used ALONE here)
- 3rd Line: ADD Stool Softener (e.g. Docusate)
TREATMENT of FAECAL IMPACTION: (Adults AND under <18s)
- 1st Line: Macrogol
Adults & Kids - 2nd Line: ADD Stimulant (can ADD STOOL SOFTENER e.g. Docusate)
rd
Adults ONLY - 3 Line: Suppositories (Bisacodyl for SOFT stools, Glycerol for HARD stools – CAN
COMBINE)
- 4th Line: Enemas (Mini 1st, Oil Retention 2nd)
TREATMENT in PREGNANCY (similar to ADULT treatment):
- 1st Line: BFA
- 2nd Line: ADD Osmotic (can be used ALONE) ALL OTC laxatives are SAFE
- 3rd Line: ADD Stimulant in PREGNANCY & BF
- 4th Line: ADD Glycerol suppositories
, BFAs are NOT used in OIC –
risk of FAECAL IMPACTION
TREATMENT in OPIOID-INDUCED CONSTIPATION (OIC):
- 1st Line: Stimulant w/ EITHER Osmotic OR Softener
- 2nd Line: Naloxegol (opioid-receptor antagonist – SPECILAIST)
Naloxegol is the only opioid blocker that works in the PERIPHERY, NOT in CNS (unlike
Naloxone & Naltrexone) – so only INDICATED in OIC
BULK FORMING AGENTS (BFAs) – Ispaghula Husk, Sterculia, Methylcellulose
MOA: Mimics action of fibre – increases water retention in stools increases stool mass
promotes peristalsis
INDICATIONS:
- 1st Line in Adults (NO faecal impaction)
- 1st Line in Pregnancy
SIDE EFFECTS:
- Faecal Impaction (also a CI)
- Bloating & Flatulence: fibre = PRE-BIOTIC for GIT microbiome gas
IMPORTANT POINTS:
- Take sachets w/ LOTS of WATER – helps it work & avoid impaction
- Onset = 2-3 days for MAX effect (like Osmotics)
- Fybogel Dose = 1 sachet BD – AVOID taking BEFORE BED (worsen bloating)
- Age = 6+ (although these are NOT in NICE guidance for <18s)
OSMOTIC LAXATIVES – Macrogol (PEG), Lactulose
MOA: Draws water into GIT from GI-epithelium softened, lubricated stools
INDICATIONS:
- 1st Line in Children
- 1st Line in Faecal Impaction (Macrogol - Adults & Kids)
- 1st Line in OIC (w/ Stimulants)
- 2nd Line in Adults & Pregnancy
- Hepatic Encephalopathy (Lactulose)
SIDE EFFECTS:
- Flatulence
- Dehydration (Take w/ LOTS of WATER)
- HYPOkalaemia (Xanthines, Digoxin, Insulin, β-agonists, Loops & Thiazides)
IMPORTANT POINTS:
- Onset = 2-3 days for MAX EFFECT (like BFAs)
- Macrogol OTC Age = 12+ (paediatric forms = POMs)
- Lactulose OTC Age = Birth
- Do NOT give Lactulose in IBS – worsens BLOATING
