Symptoms in the Pharmacy :Gastrointestinal Tract Problems(13)

Constipation in practice

Case 1
Mr Johnson is a middle-aged man who occasionally visits your pharmacy.
Today he complains of constipation, which he has had for
several weeks. He has been having a bowel movement every few
days; normally they are every day or every other day.

His motions
are hard and painful to pass. He has not tried any medicines as
he thought the problem would go of its own accord. He has never
had problems with constipation in the past. He has been taking
atenolol tablets 50 mg once a day, for over 1 year. He does not have
any other symptoms, except a slight feeling of abdominal discomfort.
You ask him about his diet; he tells you that since he was made
redundant from his job at a local factory 3 months ago, he has tended
to eat less than usual; his dietary intake sounds as if it is low in fibre.
He tells you that he has been applying for jobs, with no success so far.
He says he feels really down and is starting to think that he may never
get another job.

The pharmacist’s view

Mr Johnson’s symptoms are almost certainly due to the change in his
lifestyle and eating pattern. Now that he is not working he is likely to
be less physically active and his eating pattern has probably changed.
From what he has said, it sounds as if he is becoming depressed
because of his lack of success in finding work. Constipation seems to
be associated with depression, separately from the constipating effect
of some antidepressant drugs.

It would be worth asking Mr Johnson if he is sleeping well (signs of
clinical depression include disturbed sleep; either difficulty in getting
to sleep or waking early and not being able to get back to sleep).
Weight can change either way in depression. Some patients eat for
comfort, while others find their appetite is reduced. Depending on his
response, you might consider whether referral to his doctor is needed.

To address the dietary problems, he could be advised to start the day
with a wholemeal cereal and to eat at least four slices of wholemeal
bread each day. Baked beans are a cheap, good source of fibre. Fresh
vegetables are also fibre-rich. It would be important to stress that fluid
intake should also be increased. A high-fibre diet means patients
should increase their fibre intake until they pass one large, soft stool
each day; the amount of fibre needed to produce this effect will vary
markedly between patients. The introduction of dietary fibre should
be gradual; too rapid an increase can cause griping and wind.

To provide relief from the discomfort, a suppository of glycerin or
bisacodyl could be recommended to produce a bowel evacuation
quickly; in the longer term, dietary changes provide the key. He should
see the doctor if the suppository does not produce an effect; if it works
but the dietary changes have not been effective after 2 weeks, he
should go to his doctor. Mr Johnson’s medication is unlikely to be
responsible for his constipation because, although beta-blockers can
sometimes cause constipation, he has been taking the drug for over
1 year with no previous problems.

The doctor’s view

The advice given by the pharmacist is sensible. It is likely that Mr
Johnson’s physical and mental health have been affected by the impact
of a significant change in his life. The loss of his job and the uncertainty
of future employment is a major and continuing source of stress.
The fact that the pharmacist has taken time to check out how he has
been affected will in itself be therapeutic. It also gives the pharmacist
the opportunity to refer to the doctor if necessary. Many people are
reluctant to take such problems to their doctor but a recommendation
from the pharmacist might make the process easier. Hopefully the
advice given for constipation will at least improve one aspect of his
life. If the constipation does not resolve within 2 weeks, Mr Johnson
should see his doctor.

Case 2

Your counter assistant asks if you will have a word with a young
woman who is in the shop. She was recognised by your assistant as a
regular purchaser of stimulant laxatives. You explain to the woman
that you will need to ask a few questions because regular use of
laxatives may mean an underlying problem, which is not improving.
In answer to your questions she tells you that she diets almost constantly
and always suffers from constipation. 

Her weight appears to be within the range for her height. You show her your 

pharmacy’s body mass index (BMI) chart and work out with her where she is on the
chart, which confirms your initial feeling. However, she is reluctant to
accept your advice, saying that she definitely needs to lose some more
weight. You ask about her diet and she tells you that she has tried all
sorts of approaches, most of which involve eating very little.

The pharmacist’s view

Unfortunately this sort of story is all too common in community
pharmacy, with many women who seek to achieve weight below
the recommended range. The pharmacist can explain that constipation
often occurs during dieting simply because insufficient bulk and
fibre is being eaten to allow the gut to work normally. 

Perhaps the pharmacist might suggest that she joins a local group, either Weight
Watchers or a self-help group (the local health promotion unit will
know what is available). Despite the pharmacist’s advice, many customers
will still wish to purchase laxatives and the pharmacist will
need to consider how to handle refusal of sales. Offering stimulant
laxatives for sale by self-selection can only exacerbate the problems
and make it more difficult to monitor sales and refuse them when
necessary.

The doctor’s view

This is obviously a difficult problem for the pharmacist. It is inappropriate
for the young woman to continue taking laxatives and she could
benefit from counselling. However, a challenge from the pharmacist
could result in her simply buying the laxatives elsewhere. If, as is
likely, she has an eating disorder, she may have very low self-esteem
and be denying her problem. Both these factors make it more difficult
for the pharmacist to intervene most effectively. 

If she is seen by the doctor, an empathic approach is necessary. The
most important thing is to give her full opportunity to say what
she thinks about the problem, how it makes her feel and how it affects
her life. Establishing a supportive relationship with resultant trust
between patient and doctor is the major aim of the initial consultation.
Once this has been achieved, further therapeutic opportunities can be
discussed and decided on together.

Case 3

A man comes into the pharmacy and asks for some good laxative
tablets. Further questioning by the pharmacist reveals that the medicine
is for his dad who is aged 72. He does not know many details
except that his dad has been complaining of increasing constipation
over the last 2–3 months and has tried senna tablets without any
benefit.

The pharmacist’s view

Third-party or proxy consultations are often challenging because the
person making the request may not have all of the relevant information.
However, in this case the decision is quite clear. The patient
needs to be referred to the doctor because of the long history of the
complaint and the unsuccessful use of a stimulant laxative.

The doctor’s view

Referral to the GP should be recommended in this situation. A glycerin
suppository is a safe treatment to use in the meantime. Clearly, more
information is needed to make an opinion and diagnosis. A prolonged
and progressive change in bowel habit is an indication for referral to
hospital for further investigations as the father could have a large
bowel cancer. The GP would need to gather more information about
his symptoms and would perform an examination that would include
abdominal palpation and a digital rectal examination. 

This latter examination could confirm the presence of a rectal tumour. It is likely
that an urgent referral would then be made for further investigations
as an outpatient. At hospital the investigations could include sigmoidoscopy
plus a barium enema X-ray and/or a colonoscopy. In colonoscopy
a flexible fibre-optic tube is passed through the anus and then
up and around the whole of the large bowel to the caecum.