Constipation 🚽
Clinical guide for managing constipation. Laxative reference table, treatment protocols, and bowel management strategies for hospital inpatients.
🧠 Definition
- Infrequent or difficult passage of stools, often with straining or hard stools.
- Can be acute (often due to immobility, meds, or dehydration) or chronic.
📞 What to Ask / Orders to Make
- When was the last bowel movement?
- Passing flatus? (suggests partial obstruction vs complete)
- Any nausea/vomiting? Abdominal pain or distension?
- Baseline bowel habits?
- Mobility status, fluid intake, oral intake?
- Medications: opioids, anticholinergics, iron, CCBs?
- Order PRN laxative if none charted.
📋 Common Causes
- Medications: opioids, anticholinergics, iron, calcium, diuretics
- Dehydration
- Immobility
- Neurological disease (stroke, Parkinson's, MS)
- Metabolic: hypercalcaemia, hypothyroidism
- Obstruction (consider if no flatus, vomiting, distension)
🧾 History
- Time since last bowel movement and whether passing flatus
- Baseline pattern (e.g. daily/alternate days)
- Associated symptoms: pain, vomiting, distension
- Recent changes in mobility, diet, medications
🩺 Examination
- Vitals (esp. fever or hypotension if concern for obstruction or sepsis)
- Inspect for distension, scars, hernias
- Auscultate bowel sounds
- Palpate for tenderness or palpable faeces
- Per rectal exam: check for stool, mass, blood
🔍 Investigations
- Bloods: U&Es, calcium, TFTs if persistent
- AXR if suspecting obstruction (look for dilated loops)
- CT abdo/pelvis if concerned re: obstruction or malignancy
💊 Initial Management
- Rule out obstruction before giving laxatives
- Ensure hydration and mobility
- Start with oral laxatives: lactulose, senna
- Add suppositories or enema if no result in 24h
- Consider PR manual evacuation if impacted
⚠️ Special Considerations
- Avoid lactulose in patients with confusion (risk of bloating/gas)
- Opioid-induced: consider regular stimulant laxatives ± naloxegol
- Neuro patients: may need regular scheduled enemas or suppositories
Common Laxatives
Reference table for laxative medications
| Drug | Route | Dose | Frequency | Notes |
|---|---|---|---|---|
| Lactulose | PO | 15–30 mL | bd | Osmotic; may cause bloating |
| Senna | PO | 7.5–15 mg | nocte | Stimulant; avoid in obstruction |
| Movicol (macrogol) | PO | 1–2 sachets | od–tds | Osmotic; mix with water |
| Bisacodyl | PR / PO | 10 mg (PR) | prn | Stimulant; quick effect |
| Fybogel (ispaghula husk) | PO | 1–2 sachets | od–bd | Bulk-forming; ensure adequate fluid intake |
| Glycerin suppository | PR | 1 suppository | prn | For softening hard stools |
| Phosphate enema | PR | 1 enema | prn | Avoid in renal impairment |
Lactulose
PODose:15–30 mL
Frequency:bd
Notes: Osmotic; may cause bloating
Senna
PODose:7.5–15 mg
Frequency:nocte
Notes: Stimulant; avoid in obstruction
Movicol (macrogol)
PODose:1–2 sachets
Frequency:od–tds
Notes: Osmotic; mix with water
Bisacodyl
PR / PODose:10 mg (PR)
Frequency:prn
Notes: Stimulant; quick effect
Fybogel (ispaghula husk)
PODose:1–2 sachets
Frequency:od–bd
Notes: Bulk-forming; ensure adequate fluid intake
Glycerin suppository
PRDose:1 suppository
Frequency:prn
Notes: For softening hard stools
Phosphate enema
PRDose:1 enema
Frequency:prn
Notes: Avoid in renal impairment