Management of Constipation
Constipation is the difficult passage of small hard stools. It has also been
defined as infrequent bowel actions or a feeling of unsatisfi ed emptying of
the bowel. However, the emphasis is on the consistency of the stool rather
than on the frequency of defecation.
Colorectal cancer must be ruled out in adults.
Alarm symptoms
• Recent constipation in > 40 years of age
• Rectal bleeding
• Family history of cancer
Idiopathic (functional) constipation
The commonest type is simple constipation, essentially related to a faulty
diet and bad habits. Avery-Jones, who defi ned the disorder, describes it as
being due to one or more of the following causes:
• faulty diet
• neglect of the call to stool
• unfavourable living and working conditions
• lack of exercise
• travel
Management in children Differentiate from encopresis. Rule out
Hirschsprung’s disorder and anal fi ssure in infants.
• Encourage relaxed child–parent interaction with toilet training
(e.g. ‘after breakfast habit’ training).
• Establish an empty bowel: remove any impacted faeces with
microenemas (e.g. Microlax).
• Advice for (parents of) children over 18 mths:
– drink ample non-milk fl uids each day (be cautious of cows’ milk)
– use prune juice (contains sorbitol)
– get regular exercise (e.g. walking, running, outside games
or sport)
– provide high-fi bre foods (e.g. high-fi bre cereals, wholegrain bread,
fresh fruit with skins left on where possible, dried fruits such as
sultanas, apricots or prunes, fresh vegetables)
• Use a pharmaceutical preparation as a last resort to achieve regularity:
fi rst line: osmotic laxative, e.g. lactulose: 1–5 yrs: 5 mL bd
6–12 yrs: 10 mL bd
> 12 yrs: 15 mL bd or
Macrogel 3350 with electrolytes (Movicol)
2–12 years: 1 sachet Movicol half daily
> 12 years: 1 sachet Movicol daily
Consider stool softeners: paraffi n oil, e.g. Parachoc; poloxamer drops
Management in adults
• Similar principles as above
• Patient education, inc. ‘good habit’
• Adequate exercise
• Plenty of fl uids (e.g. water, fruit juice)
• Avoid laxatives and codeine compounds
• Optimal bulk diet
• Foods with bulk-forming properties (least to most): potato, banana,
cauliflower, peas, cabbage, lettuce, apple, carrot, wheat fi bre, bran
• Fruits with natural laxatives include prunes, fi gs, rhubarb, apricots
(e.g. prune juice)
• Cereals with wheat fi bre and bran
If unsuccessful:
• Bulk-producing agent (e.g. ispaghula—Fybogel, Agiolax), adults:
1 sachet in water bd or
Macrogel 3350 with electrolytes (Movicol)
1–2 sachets dissolved in water once daily
or
lactulose syrup 15–30 mL (o) daily until response then 10–20 mL daily
Constipation is the difficult passage of small hard stools. It has also been
defined as infrequent bowel actions or a feeling of unsatisfi ed emptying of
the bowel. However, the emphasis is on the consistency of the stool rather
than on the frequency of defecation.
Colorectal cancer must be ruled out in adults.
Alarm symptoms
• Recent constipation in > 40 years of age
• Rectal bleeding
• Family history of cancer
Idiopathic (functional) constipation
The commonest type is simple constipation, essentially related to a faulty
diet and bad habits. Avery-Jones, who defi ned the disorder, describes it as
being due to one or more of the following causes:
• faulty diet
• neglect of the call to stool
• unfavourable living and working conditions
• lack of exercise
• travel
Management in children Differentiate from encopresis. Rule out
Hirschsprung’s disorder and anal fi ssure in infants.
• Encourage relaxed child–parent interaction with toilet training
(e.g. ‘after breakfast habit’ training).
• Establish an empty bowel: remove any impacted faeces with
microenemas (e.g. Microlax).
• Advice for (parents of) children over 18 mths:
– drink ample non-milk fl uids each day (be cautious of cows’ milk)
– use prune juice (contains sorbitol)
– get regular exercise (e.g. walking, running, outside games
or sport)
– provide high-fi bre foods (e.g. high-fi bre cereals, wholegrain bread,
fresh fruit with skins left on where possible, dried fruits such as
sultanas, apricots or prunes, fresh vegetables)
• Use a pharmaceutical preparation as a last resort to achieve regularity:
fi rst line: osmotic laxative, e.g. lactulose: 1–5 yrs: 5 mL bd
6–12 yrs: 10 mL bd
> 12 yrs: 15 mL bd or
Macrogel 3350 with electrolytes (Movicol)
2–12 years: 1 sachet Movicol half daily
> 12 years: 1 sachet Movicol daily
Consider stool softeners: paraffi n oil, e.g. Parachoc; poloxamer drops
Management in adults
• Similar principles as above
• Patient education, inc. ‘good habit’
• Adequate exercise
• Plenty of fl uids (e.g. water, fruit juice)
• Avoid laxatives and codeine compounds
• Optimal bulk diet
• Foods with bulk-forming properties (least to most): potato, banana,
cauliflower, peas, cabbage, lettuce, apple, carrot, wheat fi bre, bran
• Fruits with natural laxatives include prunes, fi gs, rhubarb, apricots
(e.g. prune juice)
• Cereals with wheat fi bre and bran
If unsuccessful:
• Bulk-producing agent (e.g. ispaghula—Fybogel, Agiolax), adults:
1 sachet in water bd or
Macrogel 3350 with electrolytes (Movicol)
1–2 sachets dissolved in water once daily
or
lactulose syrup 15–30 mL (o) daily until response then 10–20 mL daily