Symptoms in the Pharmacy :Gastrointestinal Tract Problems(11)

Constipation

Constipation is a condition that is difficult to define and is often selfdiagnosed
by patients. Generally it is characterised by the passage of
hard, dry stools less frequently than the person’s normal pattern. It is
important for the pharmacist to find out what the patient means by
constipation, and to establish what (if any) change in bowel habit has
occurred and over what period of time.

What you need to know

• Details of bowel habit
• Frequency and nature of bowel actions now
• When was the last bowel movement?
• What is the usual bowel habit?
• When did the problem start?
• Is there a previous history?
• Associated symptoms
• Abdominal pain/discomfort/bloating/distension
• Nausea and vomiting
• Blood in the stool
• Diet
• Any recent change in diet?
• Is the usual diet rich in fibre?
• Medication
• Present medication
• Any recent change in medication
• Previous use of laxatives

Significance of questions and answers

Details of bowel habit

Many people believe that a daily bowel movement is necessary for
good health and laxatives are often taken and abused as a result. In
fact, the normal range may vary from three movements in 1 day to
three in 1 week. Therefore an important health education role for the
pharmacist is in reassuring patients that their frequency of bowel
movement is normal. Patients who are constipated will usually com-

plain of hard stools which are difficult to pass and less frequent than
usual.
The determination of any change in bowel habit is essential, particularly
any prolonged change. A sudden change, which has lasted for
2 weeks or longer, would be an indication for referral.

Associated symptoms

Constipation is often associated with abdominal discomfort, bloating
and nausea. In some cases constipation can be so severe as to obstruct
the bowel. This obstruction or blockage usually becomes evident by
causing colicky abdominal pain, abdominal distension and vomiting.
When symptoms suggestive of obstruction are present, urgent referral
is necessary as hospital admission is the usual course of action. Constipation
is only one of many possible causes of obstruction. Other
causes such as bowel tumours or twisted bowels (volvulus) require
urgent surgical intervention.

Blood in the stool

The presence of blood in the stool can be associated with constipation
and although alarming, is not necessarily serious. In such situations
blood may arise from piles (haemorrhoids) or a small crack in the skin
on the edge of the anus (anal fissure). Both these conditions are
thought to be caused by a diet low in fibre that tends to produce
constipation. The bleeding is characteristically noted on toilet paper
after defecation. The bright red blood may be present on the surface of
the motion (not mixed in with the stool) and splashed around the
toilet pan. If piles are present, there is often discomfort on defecation.
The piles may drop down (prolapse) and protrude through the anus.
A fissure tends to cause less bleeding but much more severe pain on
defecation. Medical referral is advisable as there are other more
serious causes of bloody stools, especially where the blood is mixed
in with the motion.

Bowel cancer

Large bowel cancer may also present with a persisting change in bowel
habit. This condition kills about 20 000 people each year in the UK.
Early diagnosis and intervention can dramatically improve the prognosis.
The incidence of large bowel cancer rises significantly with age.
It is uncommon among people under 50 years. It is more common
amongst those living in northern Europe and North America compared
with southern Europe and Asia. The average age at diagnosis is
60–65 years.

 

Diet

Insufficient dietary fibre is a common cause of constipation. An impression
of the fibre content of the diet can be gained by asking what
would normally be eaten during a day, looking particularly for the
presence of wholemeal cereals, bread, fresh fruit and vegetables.
Changes in diet and lifestyle, e.g. following a job change, loss of
work, retirement or travel, may result in constipation. An inadequate
intake of food and fluids, e.g. in someone who has been ill, may be
responsible.

Medication

One or more laxatives may have already been taken in an attempt to
treat the symptoms. Failure of such medication may indicate that
referral to the doctor is the best option. Previous history of the use
of laxatives is relevant. Continuous use, especially of stimulant laxatives,
can result in a vicious circle where the contents of the gut are
expelled, causing a subsequent cessation of bowel actions for 1 or 2
days. This then leads to the false conclusion that constipation has
recurred and more laxatives are taken, and so on.
Chronic overuse of stimulant laxatives can result in loss of muscular
activity in the bowel wall (an atonic colon) and thus further constipation.

When to refer

• Change in bowel habit of 2 weeks or longer
• Presence of abdominal pain, vomiting, bloating
• Blood in stools
• Prescribed medication suspected of causing symptoms
• Failure of OTC medication