Constipation 🚽

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🧠 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

Dose:15–30 mL

Frequency:bd

Notes: Osmotic; may cause bloating

Senna

Dose:7.5–15 mg

Frequency:nocte

Notes: Stimulant; avoid in obstruction

Movicol (macrogol)

Dose:1–2 sachets

Frequency:od–tds

Notes: Osmotic; mix with water

Bisacodyl

PR / PO

Dose:10 mg (PR)

Frequency:prn

Notes: Stimulant; quick effect

Fybogel (ispaghula husk)

Dose:1–2 sachets

Frequency:od–bd

Notes: Bulk-forming; ensure adequate fluid intake

Glycerin suppository

Dose:1 suppository

Frequency:prn

Notes: For softening hard stools

Phosphate enema

Dose:1 enema

Frequency:prn

Notes: Avoid in renal impairment

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