Constipation

Constipation is one of the most common complaints in hospital, especially on the geriatric wards.
Failure to treat constipation can lead to longer hospital stays and increased morbidity.

What’s normal?

  • Anything from 3 times per day to 3 times per week is normal for adults.

What causes it?
Many things cause constipation, most commonly in hospital, it is due to:

  • Medication such as codeine
  • Lack of fibre in the diet
  • Dehydration
  • Lack of exercise
  • Embarrassment at using shared facilities/commodes/bedpans.
  • Pain on defaecation due to fissures or haemorrhoids (avoidance of passing stool)

What problems can it cause?

  • Abdominal pain
  • Confusion (part of the ‘PINCH ME’ causes of delirium)
  • Overflow diarrhoea (Always rule out constipation if a patient develops loose)
  • Nausea and loss of appetite 
  • Constipation can cause urinary retention and overflow incontinence – this is because the hard stool can pressure on your urethra. 

Diagnosis

  • Speak to the patient – most of the time they will tell you they feel constipated
  • Do a PR examination!! It’s not as bad as you think, and in the end the patient will be grateful. 
  • The importance of this is to assess faecal impaction, which guides which laxatives you use. It can also help differentiate from overflow diarrhoea (caused by constipation) or true diarrhoea
  • You can take an enema with you so that you can administer it at the same time if necessary

Treating it with lifestyle and diet

  • Increase the amount of oral fluids
  • Increase mobility as possible
  • Recommend high fibre diets (more fruit and veg, wholemeal bread)
  • Speak to the patient and nurses about what can be done to ease anxiety over toilet facilities

Drug treatment 
There is no evidence-based guidance on the preferred order of the types of laxative. It is helpful to ask/examine for whether the stool is hard – in this case, it might be better to soften the stool first.
Most hospitals will have their own guidelines on treating constipation and which drugs are used first-line- look yours up on the intranet or ask the nurses!

Types of laxative:

  • Bulk-forming eg Fybogel – Works in a similar way to fibre. Adds bulk to your stool and softens it encouraging movement. 
    • These don’t work very well if it is opioid-induced. 
    • Start with 1 sachet BD. May take a few days to work but are thought to be more “physiological” 
  • Stimulants eg Senna/Bisacodyl – Speed up bowel movements. These work very well if your first-line treatment hasn’t worked. 
    • Initial dose 7.5 – 15ml OD (Usually given at night). Can gradually increase to 30mg daily if needed
  • Osmotic eg Lactulose – Reduces the amount of water absorbed by intestines, so the stool is softer and larger. Can cause bloating however and is sometimes not tolerated
    • Initially 10-15ml BD
    • Often used post-operatively 
  • Iso-osmotic eg Movicol – Traps fluid in the bowel to soften stool and encourages the movement of the intestine muscles. These require increased fluid intake. 
    • Be cautious in patients where the excess salt load could be harmful such as heart failure
    • Initially 1 sachet BD. 

Faecal impaction:

  • Do a PR examination to determine whether there is faecal impaction (a large amount of hard stool in the rectum)
  • Laxido or Movicol – 8 sachets a day in divided doses first line
  • Senna or Bisacodyl if the stool is soft but difficult to pass
  • Glycerol suppositories 4g daily are used as second-line
  • Enemas are used if all else fails – Phosphate enemas stimulate movement but if the stool is very hard will just cause pain! Give something to soften first eg Arachis oil enema.

Written By Dr Isabelle Hurrell (FY2)

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