Australian Doctor 10th May issue 2024 | Page 33

HOW TO TREAT 33
ausdoc . com . au 10 MAY2024

HOW TO TREAT 33

is not currently PBS-listed . Prucalopride successfully increases the
significantly more efficacious than placebo for chronic constipation and
material in the rectum . A negative digital rectal examination does not rule
for distal impaction if hard stool can be palpated in the rectal area . 59
39 , 59 large volumes of fluids at a time . Address possible aetiologies fol-
frequency of spontaneous bowel
irritable bowel syndrome-constipa-
out a proximal impaction and thus , an
For proximal impaction , oral lav-
lowing treatment , and institute pre-
movements per week in all varia-
tion subtype . 58
abdominal X-ray is indicated . 47
age with polyethylene glycol solu-
ventive therapy to avoid recurrence . 59
ble doses from 1mg to 4mg . There are no significant adverse events recorded , even in older people , and the most common was headache . 57 Linaclotide has limited approval for import and supply in Australia ; however , it has been shown to be
Management of faecal impaction
Faecal impaction is suggested by a history
of constipation with overflow diarrhoea . 39 A digital rectal examination may find copious volumes of faecal
If the faecal impaction is distal , then the use of enemas and suppositories can be helpful . The enema is best delivered with a Foley catheter past the hardened stool , with ample water in conjunction with oral laxatives . 59 Manual disimpaction is also an option
tions containing electrolytes may be used . This technique is contraindicated in bowel obstruction . In older people , the volume of oral regimens is often reduced ( 0.2-1L ) compared with younger adults ( 1-2L ) as older people may not be able to tolerate
PROGNOSIS
CONSTIPATION significantly impacts quality of life . Studies involving older individuals have demonstrated that those with chronic constipation tend to have lower scores in various
Exclude surgical and structural causes ( eg , cancer )
Treat reversible causes ( dehydration , medications , electrolyte abnormalities , medical conditions )
Non-pharmacological measures
• Lifestyle and dietary modifications
• Bowel retraining
• Biofeedback
Laxatives
• Osmotic laxatives are first-line treatment ( polyethylene glycol is more effective than lactulose )
• Avoid bulk-forming laxatives in those at risk of dehydration , opioid-induced constipation and faecal impaction
• If stools are soft but difficult to pass , a stimulant laxative is recommended
Enema or suppository ( use with care )
Figure 7 . CT scan demonstrating sigmoid volvulus , a surgical emergency .
Laxative-refractory constipation
• Prucalopride or linaclotide ( further evidence required in older persons )
Figure 8 . Stepwise management of constipation in older people .
Opioid-induced constipation
• Use less constipating opioids
• Opioid rotation
• Peripherally acting μ-receptor opioid antagonists ( further evidence required in older persons )
Nephron / CC BY-SA 3.0 / bit . ly / 45nJrmU
Figure 9 . Encourage a high-fibre diet with plentiful fruit and vegetables .
Figure 10 . High magnification micrograph of melanosis coli in a colonic biopsy . HPS stain .