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Constipation Care Pathway Overview

Constipation is a common clinical problem which drives many referrals which could be avoided, thereby reducing delays for patients and reducing the burden on secondary care.

This pathway has been written in collaboration with the Gastroenterology team at Gloucestershire Hospitals NHS Foundation Trust and lays down standard accepted care for patients presenting with constipation, including the use of newer medications and their place in its management.  It has been created to help GPs reach a diagnosis in acute and chronic constipation, to guide management within primary care and to define which patients require investigation and referral.

To enable GPs to prescribe in line with the recommendations made within this pathway, please note that the traffic light status for Naloxegol and Prucalopride have now been updated to ‘Green’ drugs on the Joint Formulary.

Constipation Overview: 

Constipation is defecation that is unsatisfactory due to infrequent stools, difficult stool passage, or seemingly incomplete defecation. It is common at all ages and is especially common in women, during pregnancy and in the elderly. Stools are often dry and hard, and may be abnormally large or abnormally small. 

  • Faecal impaction is retention of faeces to the extent that spontaneous evacuation is unlikely.  This can present with diarrhoea as a symptom of overflow. 
  • Secondary constipation is caused by a drug or medical condition (such as endocrine and metabolic diseases, myopathic and neurological conditions, and certain bowel conditions). 
  • Functional constipation is chronic constipation without a pathological cause such as constipation predominant IBS.  These patients often intolerant of high fibre diets due to the effects of bloating and discomfort.  Laxatives +/- linaclotide are useful treatments.  The low FODMAP diet may help relieve bloating and pain but will not treat constipation – please see the IBS pathway for further information.
  • Abdominal pain can be a presenting symptom of constipation as can diarrhoea, when overflow becomes troublesome.
  • High fibre diets can be poorly tolerated, particularly in patients with constipation predominant IBS and functional constipation– active management of constipation with osmotic laxatives to first speed transit should be considered for two-four weeks before introduction of a higher fibre diet to prevent exacerbation of bloating and abdominal discomfort. Over the counter laxatives should be encouraged if the constipation is not long term to align with GCCG implementation of NHSE guidance.
  • Obstructive defaecation syndrome should be considered as a cause for constipation.  Think of this if patients describe symptoms of an inability to initiate rectal emptying, a sensation of incomplete evacuation, a need to use pelvic pressure or rectal/vaginal digitation to aid evacuation, or excessive straining at stool.
  • Use the Bristol Stool Scale in clinic to help quickly and clearly identify patients with constipated stool and help patients recognise constipation.

Key Point

Colonoscopy is not a recommended investigation for patients with constipation as it is a poor predictor of serious pathology such as colorectal cancer (in the absence of obstructive symptoms) and it is more likely to result in a difficult or incomplete test. NICE ‘Do Not Do Recommendations’ state – “Do not use gastrointestinal endoscopy to investigate idiopathic constipation”.

No investigations are routinely required in an adult with constipation unless a secondary cause is suspected.  When appropriate, blood tests for TTG (coeliac disease), TSH, renal function and serum calcium should be considered.

Practice Point

Do not overlook potential ovarian cancer: - Appendix 4

Ovarian cancer can mimic constipation because it may cause abdominal bloating and a change in bowel habit.

The NICE Suspected Cancer recognition and Referral Guidance 2015 and locally agreed 2WW referral criteria recommend that:

  1. Ovarian cancer should be suspected and referred using the 2 week wait pathway when:
  • Physical examination identifies ascites and/or a pelvic or abdominal mass (which is obviously not uterine fibroids)
  • Ultrasound suggests ovarian cancer
  1. Serum CA125 should be checked if the woman has symptoms of:
  • Loss of appetite, early satiety (feeling full) or persistent abdominal distension
  • A change in bowel habit, unexplained weight loss or pelvic or abdominal pain
  • Increasing urinary urgency or frequency
  • Unexplained fatigue
  • New onset symptoms suggestive of IBS if aged over aged 50

If CA125 < 35 IU/ml: reassure but review if symptoms become more frequent or persistent.

If CA125 >= 35 IU/ml: arrange for a screening abdominal and pelvic USS.

If the USS suggests ovarian cancer, refer urgently under the 2 week wait rule. If it is negative, reassure the patient but review her if her symptoms become more frequent or persistent.

Summary of Investigation and Management of Adults with Constipation

Existing medication:

  • Avoid or adjust constipating medication where possible e.g. opiates.  Be aware that some medications that cannot easily be stopped such as anti-epileptics, antidepressant/antianxiety medication, hormone treatments can contribute to a change in colonic transit.

Lifestyle advice:

  • Fluids: ensure adequate fluid intake – see Patient and Carer Information section for Drinks Tracker
  • Fibre: increase dietary fibre intake may help some patients – often use of an osmotic laxative for two to four weeks before gentle introduction of a high fibre diet will help limit side effects of bloating/discomfort. Over the counter laxatives should be encouraged if the constipation is not long term to align with GCCG implementation of NHSE guidance.
  • Exercise: if practical, aim for 20 minutes of continuous moderate exercise 4 times per week (e.g. fast walking) to further stimulate peristalsis.

Blood tests: FBC for anaemia/iron deficiency, exclude endocrine disorders associated with thyroid, parathyroid disease and diabetes.  Check calcium level.  CA125 should be considered.  Baseline blood tests for change in bowel habit including TTG may prove useful.

Laxatives:

Consider trialling dietary advice first - if dietary measures prove to be ineffective or poorly tolerated, oral laxatives should be offered as follows:

  • Initially use a bulk-forming laxative.
  • If stools remain hard add in or switch to an osmotic laxative – these should be considered a first line laxative in patients with functional constipation as bulk forming laxatives (such as Fybogel) will exacerbate bloating and pain.
  • If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying add in a stimulant laxative.
  • Over the counter laxatives should be encouraged if the constipation is not long term to align with GCCG implementation of NHSE guidance.

Additional management of chronic constipation includes:

  • Initially relieving faecal loading/impaction, if present (strategies include use of oral laxatives, plus suppositories or enemas if the response to oral laxatives is insufficient or not fast enough).
  • Advising the person that it can take several months to be successfully weaned off all laxatives.
  • Titrating the dose of laxative gradually upwards (or downwards) to produce one or two soft, formed stools per day.
  • Continuing laxatives long term for those with secondary causes.
  • Consider trialling deprescribing where appropriate to avoid inappropriate long-term laxative use.

Obstructive defaecation:  include pelvic floor dyssynergy, rectocele, rectal intussusception, enterocele, pelvic organ prolapse, and overt rectal prolapse

Functional- in this situation the pelvic floor fails to relax or even tightens when a patient tries to open their bowel.  This can be further exacerbated by lifestyle stresses – it is important to recognise that patients may delay going to the toilet because they are too busy/no toilets where they work/fear or embarrassment of defaecating in public toilets and this prolongs transit.  This can be a problem for either stool type 1, 5-7.

Physical causes- these are caused by weakness in the pelvic floor rectoceles, enteroceles and internal prolapse (intussusception). These cause either a physical blockage to evacuation, or result in a pocket forming which traps some bowel content meaning evacuation is incomplete.

Management: Biofeedback training for constipation resulting from pelvic dyssynergy attempts to coordinate pelvic floor muscle relaxation with a downward intra-abdominal propulsive force.

Anxiety and psychological distress are associated with pelvic floor dyssynergy

Referral to the anorectal physiology department for biofeedback can help relieve symptoms in up to two thirds of patients.  Referral for surgical repair may also be indicated.

Biofeedback +/- trans-anal irrigation can be very useful at controlling symptoms.

When to Refer

Constipation in adults can usually be managed in primary care. However, surgical or gastroenterology referral is indicated as follows:

  • If cancer is suspected or red flags are present
  • If treatment escalation is unsuccessful
  • If there is faecal incontinence
  • As a single symptom, constipation is NOT an indicator for colonoscopy.  If other red flag symptoms are present urgent referral for colonoscopy is required.
  • If an underlying cause is suspected:  consider having the results from blood tests for inflammatory markers, hypothyroidism, hypercalcaemia, and coeliac disease available before the person attends their appointment.
  • Pain and bleeding on defecation (such as from an anal fissure) is severe or does not respond to treatment for constipation.
  • Management may require further tests (such as radiological imaging for bowel studies, or consideration of rectal biopsy, or transit studies).

Referral to the GI Physiology Service via bowel clinic/colorectal surgical teams may be appropriate for advice, investigation, biofeedback and monitoring.

Direct referral to the Physiotherapy and Continence Nurse Specialist Bowel clinic is recommended to help alleviate symptoms of incomplete evacuation or incontinence.  Trans-anal irrigation is also available as part of this service.

Consider referral to Dietetics if more detailed support with diet is required and the patient has not been helped by the advice in this pathway.

Please click the relevant flowchart box to be taken directly to textual information.

                                                  

Red Flags
Adults with the following symptoms MUST be referred using the suspected lower GI cancer pathway (for an appointment within 2 weeks) – Please use the 2ww Lower GI Referral Form:
  • Aged 40 and over with unexplained weight loss and abdominal pain
  • Aged 50 and over with unexplained altered blood or unsure of type
  • Aged 50 and over with unexplained (i.e.: not responding to local treatment after 6 weeks) isolated ano-rectal (bright red) bleeding and abnormal flexible sigmoidoscopy
  • Aged 60 and over with either of:
    • iron-deficiency anaemia or
    • changes in their bowel habit persistent for ≥ 6 weeks
    • tests show occult blood in their faeces (tests not currently available via the NHS in Gloucestershire)
  • Unexplained anal mass or ulceration
  • Any rectal mass
Adults with the following symptoms should be CONSIDERED for referral using the suspected lower GI cancer pathway (for an appointment within 2 weeks):
  • Aged under 50 with rectal bleeding (not responding to local treatment within 6 weeks ) and any of the following unexplained symptoms or findings:
    • abdominal pain
    • change in bowel habit persistent for ≥ 6 weeks
    • weight loss
    • iron-deficiency anaemia
  • Abdominal mass on CT abdomen pelvis
Most people have their constipation successfully managed in primary care without investigations.
Where optimal treatment fails, specialist referral and investigations can help determine which physiological subtype of constipation a person has, particularly if high cost long term medications are being considered.
In the event of non-response to treatment and lifestyle changes, a referral to secondary care may become necessary.  In cases where there is thought to be a defaecatory disorder such as incomplete evacuation, digitation to initiate passage of stool, prolapse, incontinence or faecal leakage, a referral to the bowel clinic  may be made.
Presentation

Constipation is a common problem at all ages.  Reported prevalence rates vary widely, at least partly because criteria for diagnosis vary.  A systematic review found the prevalence of constipation worldwide to range from 0.7% to 79% (median 16%).  Constipation is twice as common in women as in men and is more common in the elderly.  It is particularly common during pregnancy (about 40% of women complain of constipation during pregnancy).

  • Bloating
  • Abdominal pain
  • Rectal pain
  • Fissure / haemorrhoids
  • Prolapse
  • Impaction
  • Recurrent urinary tract infection (UTI)

  • Confusion
  • Overflow diarrhoea
  • Abdominal pain
  • Urinary retention
  • Nausea and loss of appetite
Pathophysiology

Several physiologic subtypes of chronic constipation have been described, including:

  • Colonic inertia, when movement of bowel contents through the colon is slowed.
  • Outlet delay constipation (or obstructed defecation) which can be caused by pelvic floor dyssynergia (the pelvic floor muscles contract or fail to relax during attempted defecation), and by anismus (the external anal sphincter contracts instead of relaxing during attempted defecation).
  • Constipation without delays in colonic transit or outlet delay — this is the least clearly defined, and most common, subgroup 
Differential Diagnosis

A wide variety of factors can lead to constipation. Many of these are rare and do not need to be excluded unless there is reasonable suspicion that they may be present. The list below is not exclusive:

  • Small bowel:
  • Large bowel
    • Abdominal Hernias
    • Appendicitis
    • Colon Cancer
    • Colonic Obstruction
    • Diverticulitis
    • Toxic Megacolon
    • Ogilvie Syndrome (intestinal pseudo-obstruction) - characterised by a clinical picture suggestive of mechanical obstruction in the absence of any demonstrable obstruction in the intestine
    • Peritonitis and Abdominal Sepsis

  • Anxiety Disorders
  • Depression
  • Dementia

  • Chagas Disease (American Trypanosomiasis)

  • Hypopituitarism
  • Hypothyroidism
  • Hyperparathyroidism
  • Type 2 Multiple Endocrine Neoplasia
  • Diabetes mellitus
  • Uraemia
  • Lead poisoning

  • Neuropathy
  • Parkinson’s disease
  • Multiple sclerosis
  • Spinal cord injuries

  • Scleroderma
  • Lupus
  • Amyloidosis
Practice Point

Do not overlook potential ovarian cancer: - Appendix 4

Ovarian cancer can mimic constipation because it may cause abdominal bloating and a change in bowel habit.

The NICE Suspected Cancer recognition and Referral Guidance 2015 and locally agreed 2WW referral criteria recommend that:

  1. Ovarian cancer should be suspected and referred using the 2 week wait pathway when:
  • Physical examination identifies ascites and/or a pelvic or abdominal mass (which is obviously not uterine fibroids)
  • Ultrasound suggests ovarian cancer
  1. Serum CA125 should be checked if the woman has symptoms of:
  • Loss of appetite, early satiety (feeling full) or persistent abdominal distension
  • A change in bowel habit, unexplained weight loss or pelvic or abdominal pain
  • Increasing urinary urgency or frequency
  • Unexplained fatigue
  • New onset symptoms suggestive of IBS if aged over aged 50

If CA125 < 35 IU/ml: reassure but review if symptoms become more frequent or persistent.

If CA125 >= 35 IU/ml: arrange for a screening abdominal and pelvic USS.

If the USS suggests ovarian cancer, refer urgently under the 2 week wait rule. If it is negative, reassure the patient but review her if her symptoms become more frequent or persistent.

Initial Primary Care Assessment

  • What is the person’s understanding about constipation?
  • Is an organic cause likely?
  • Are there any ‘red flags' that might indicate a serious underlying condition and require referral?
  • Is there a degree of faecal impaction?
  • Is there any faecal incontinence?
  • How severe is the condition and what impact is it having on the person?
  • Are there any predisposing factors?
  • How effective has management been to date?

History:

Diagnose constipation in adults when defecation is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defecation.

If a person continues to complain about constipation after a discussion of what is normal and what is abnormal (especially with respect to frequency), they are asking for help in managing their problem, and should be regarded as having (symptoms of) constipation.

  • Confirm meaning of constipation with patient
  • DH
  • Laxative History
  • Exclude Red flags and obstructive symptoms
  • ODS questionnaire (see below) - click here for printable version.
    • Score >8 Refer to bowel clinic

For each question please tick the box that best describes you

How often do you experience the following symptoms?

 

0
Never

1
Rarely

2
Monthly

3
Weekly

4
Daily

Straining to try and open your bowels
(e.g. needing to make a forceful or prolonged effort)

 

 

 

 

 

Feeling of having not fully emptied your rectum (back passage)

 

 

 

 

 

Needing to use an enema or laxative to try and help open your bowels

 

 

 

 

 

Using your finger in your vagina or rectum (or applying external pressure) to try and help open your bowels

 

 

 

 

 

Suffering abdominal discomfort or pain

 

 

 

 

 

Total Score                /20

  • Faecal masses are palpable abdominally, peri-anally, or on internal rectal examination.
  • Facecal impaction
  • Abdominal mass
  • PR mass
Initial Primary Care Management

    

How should I manage short duration constipation in adults?

  • Adjust any constipating medication, if possible.
  • Advise the person about increasing dietary fibre including use of flax seeds, drinking an adequate fluid intake (see Drinks Tracker), and exercise. Aim for 20 minutes continuous moderate exercise (e.g. fast walking) 4 times per week.
  • Advise use of over the counter (OTC) oral laxatives if dietary measures are ineffective, or while waiting for them to take effect:
    • Start treatment with a bulk-forming laxative (adequate fluid intake is important).
    • If stools remain hard, add or switch to an osmotic laxative.
    • If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, add a stimulant laxative.
  • If the person has opioid-induced constipation:
    • Avoid bulk-forming laxatives.
    • Advise use of over the counter (OTC) osmotic laxative (or Docusate which also softens stools) and a stimulant laxative.
    • Naloxegol 25mg PO od is licenced for opiate induced constipation where first line laxative treatment has failed.
  • Advise the person that laxatives can be stopped once the stools become soft and easily passed again.

Dehydration, reduced levels of physical activity, and low levels of dietary fibre are associated with constipation. However, the clinical impression is that increasing fluids above an adequate daily intake, increasing exercise, and advice to increase dietary fibre does not always relieve constipation.

For all laxatives, trial evidence on efficacy and safety is limited. This is mainly because these agents have been in use for a long time, clinical trials were far less robust at the time they were originally licensed, and few new clinical trials have been done.

Experts are in agreement on the general approach to treating constipation - clear faecal loading/impaction before starting to treat chronic constipation; use a stepped approach to treatment and adjust the dose, frequency, and combination of laxatives according to individual preference and response to treatment.

Advise the person that laxatives can be stopped once the stools become soft and easily passed again. Avoid bulk-forming laxatives. Use an osmotic laxative (or Docusate which also softens stools) and a stimulant laxative. Naloxegol 25mg PO od is licenced for opiate induced constipation where first line laxative treatment has failed.

 

  • AVOID bulk-forming laxatives.
  • These are not recommended in opioid-induced constipation because they distend the colon and stimulate peristalsis, which is blocked by opioids. This may result in painful colic and even obstruction.

  • USE osmotic laxatives in combination with stimulant laxatives and adjust their doses to optimise the response:
    • Osmotic laxatives retain water in the stool which makes bowel evacuation easier. Docusate also has a direct action to soften the stool.
    • Stimulant laxatives help overcome the reduced peristalsis caused by opioids.
  • INCREASE fluids, fruit and fibre intake in the patient’s diet (see dietary advice sheet).
  • ADD Naloxegol where other laxatives have failed to give a sustained response and opioids cannot be avoided. 25mg orally once daily is the licenced product as per NICE guidelines.

Initial management:

  • Begin by relieving faecal loading/impaction, if present.
  • Set realistic expectations for the results of treatment of chronic constipation.
  • Advise people about lifestyle measures — increasing dietary fibre (including the importance of regular meals), drinking an adequate fluid intake, and exercise. Aim for 20 minutes of continuous moderate exercise (e.g. fast walking) 4 times per week.
  • Adjust any constipating medication, if possible.

Laxatives are recommended:

  • If lifestyle measures are insufficient, or whilst waiting for them to take effect.
  • For people taking a constipating drug that cannot be stopped.
  • For people with other secondary causes of constipation.
  • As 'rescue' medicines for episodes of faecal loading.

If laxative treatment is indicated:

  • Start treatment with a bulk-forming laxative.
  • It is important to maintain good hydration when taking bulk-forming laxatives. This may be difficult for some people (for example the frail or elderly).
  • If stools remain hard, add or switch to an osmotic laxative.
  • Use macrogols as first choice of an osmotic laxative.
  • Use lactulose if macrogols are not effective, or not tolerated.
  • If stools are soft but the person still finds them difficult to pass or complains of inadequate emptying, add a stimulant laxative.
  • Adjust the dose, choice, and combination of laxative according to symptoms, speed with which relief is required, response to treatment, and individual preference.
  • Consider trialling deprescribing where appropriate to avoid inappropriate long-term laxative use.

Escalation of treatment with high cost medications:

  1. Chronic idiopathic constipation

High cost medication is recommended by NICE as an option for chronic constipation if:

  • The prescribing clinician has experience of treating chronic constipation and has carefully reviewed the patient’s previous laxative treatments.
  • Treatment with at least two laxatives from different classes, at the highest tolerated doses for at least 6 months has failed to provide adequate relief.
  • Invasive treatment for constipation is being considered.

The following medication is licensed:

  • Prucalopride NICE recommendations
    • Only in women at a dose of 1-2mg PO od.
    • If treatment is not effective after 4 weeks, the patient should be re-examined and the benefit of continuing treatment reconsidered.
  1. Constipation predominant IBS

Linaclotide (290mcg PO od) recommended by NICE in combination with laxative when laxative treatment has failed after 6 weeks of treatment.

A key part of the treatment of constipation is a diet which is balanced, ensures an adequate fluid intake and is high in fibre and (for patients without IBS) sorbitol. This is achieved by consuming foods which include a mixture of whole grains, fruits, and vegetables. This also fits in with the generally healthy 'five-a-day' policy on fruit and vegetable consumption.

Practice points

  1. Fluid intake is very important when eating a higher fibre diet or taking fibre supplements, although an adequate intake can be difficult for some people (for example, the frail or elderly).
  2. Fibre can cause bloating and flatulence if introduced too quickly.
    • Fibre intake should be increased gradually and then maintained for life.
    • Adults should aim to consume 30g fibre per day.
    • The effects of a high fibre diet may take as long as 4 weeks to take effect.
  3. Sorbitol is an osmotic laxative obtained from certain fruit and fruit juices.
    • It can be associated with increased bloating and wind production and so may not be suitable for all patients
    • It should be avoided in patients with a history of IBS.

See the Patient and Carer Information and Leaflets section for the Local Dietary advice for constipation sheet

When to Refer

Constipation in adults can usually be managed in primary care. However, referral is indicated as follows:

  • If cancer is suspected.
  • As a single symptom, constipation is NOT an indicator for colonoscopy.  If other red flag symptoms are present urgent referral for colonoscopy is required.
  • If an underlying cause is suspected:
    • consider having the results from blood tests for inflammatory markers, hypothyroidism, hypercalcaemia, and coeliac disease available before the person attends their appointment.
  • Pain and bleeding on defecation (such as from an anal fissure) is severe or does not respond to treatment for constipation.
  • If red flags are present, treatment is unsuccessful, or if there is faecal incontinence.

Consider surgical or gastroenterology referral if:

  • Treatment escalation is unsuccessful.
  • Management may require further tests (such as radiological imaging for bowel studies, or consideration of rectal biopsy, or transit studies).
  • Assessment is required prior to referral for other interventions (such as psychology, psychiatry).
  • Faecal incontinence is present.
  • Referral to the Anorectal Physiology Service may be appropriate for advice, investigation, biofeedback and monitoring.

Consider referral to dietetics if more detailed support with diet is required and the patient has not been helped by the advice in this pathway.

Joint Led Physio / Nurse Bowel Clinic - GHNHSFT

                       

Ongoing Primary Care Management

When and how to stop treatment

Consider trialling deprescribing where appropriate to avoid inappropriate long-term laxative use.

Safe to long term if not a stimulant, if patient wishes to stop wean over months as may relapse.

Laxatives can be slowly withdrawn when regular bowel movements occur without difficulty (for example, 2–4 weeks after defecation has become comfortable and a regular bowel pattern with soft, formed stools has been established).

The rate at which doses are reduced should be guided by the frequency and consistency of the stools. Weaning should be gradual in order to minimise the risk of requiring 'rescue therapy' for recurrent faecal loading. Laxative medication should not be suddenly stopped.

If a combination of laxatives has been used, reduce and stop one laxative at a time. Begin by reducing stimulant laxatives first, if possible. However, it may be necessary to also adjust the dose of the osmotic laxative to compensate.

Advise the person that it can take several months to be successfully weaned off all laxatives.

Relapses are common and should be treated early with increased doses of laxatives.

Laxatives need to be continued long term for:

  • People taking a constipating drug that cannot be stopped, such as an opioid.
  • People with a medical cause of constipation.
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