Constipation in adults
Constipation in adults can usually be managed in primary care.
Primary Care Management Prior to referral
o Step-wise treatment in primary care:
o Careful history taking including looking for possible iatrogenic causes, and for red flags.
o Examination including PR examination.
o Blood tests including FBC, U&E, LFT, ferritin, TFT, Bone, Coeliac screen.
o Adjust the dose of any constipating medications used for an underlying condition, if possible
o Explore lifestyle changes and non-pharmacological interventions, for example, regular toileting 30 minutes after breakfast (sit for up to 10 minutes) with feet supported on a footstool
o Prescribe laxatives and other medications appropriately to relieve symptoms if needed. Laxatives can be used in combination, and doses titrated- for guidance please refer to https://cks.nice.org.uk/constipation#!scenario
o Suppositories or enemas (in addition to laxatives) if difficulty emptying the rectum
o If symptoms refractory to standard laxatives, consider Linaclotide (before Prucalopride or Lubiprostone (see BNF))
For additional information, please see Clinical Knowledge Summary for constipation https://cks.nice.org.uk/constipation#!scenario
When to consider referral:
Referral to colorectal is indicated when:
· Cancer is suspected – as per the 2 week colorectal form.
· Pain and bleeding on defecation (such as from an anal fissure) is severe or does not respond to treatment for constipation
o Consider colorectal referral or 2 wk referral depending on the criteria.
· Anal stenosis
o If present and not previously investigated, refer to secondary care.
Referral to the nurse led “Bowel and Bladder Specialist Service” is indicated when:
· Faecal incontinence is present – despite consideration & management of possible impaction.
· Secondary constipation is suspected, where the underlying cause is not amenable to treatment in primary care.
· Treatment is unsuccessful
o Treatment failure may be early, when attempts at relieving faecal loading fail, or late, if there is difficulty maintaining remission.
Refer to dietician if more detailed support with diet is required.
Information required with all referrals
o History of symptoms, examination findings including PR.
o Blood test results and management tried to date.