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.
- 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
- 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.
- 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
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.
- 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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