Makindo Medical Notes

💡 Constipation is common, usually benign, but always rule out bowel obstruction first 🚨 (look for distension, vomiting, absent bowel sounds, hernial orifices, AXR findings). ⚠️ Avoid stimulant laxatives until obstruction excluded.

🌿 Introduction

• Rome IV criteria exist for an academic diagnosis [Rome IV link], but most clinical practice is pragmatic.
• Diet: encourage hydration 🥛, mobility 🚶, and fibre (aim 30 g/day). Fruits high in sorbitol (apples, pears, plums, grapes, raspberries, prunes) are particularly helpful.
• Normal variation: some people pass stool twice daily, others twice weekly.

🧠 Anatomy & Physiology of Defaecation

• Colon: Absorbs water, compacts stool.
• Rectum: Storage; stretch receptors trigger defaecation reflex.
• Anus:
  • Internal sphincter = involuntary (smooth muscle).
  • External sphincter = voluntary (skeletal muscle).
• Puborectalis muscle: Maintains anorectal angle for continence; relaxes during defaecation to straighten the canal 💩.

🧾 Common Associations

• Childhood: Hirschsprung’s, cystic fibrosis
• Endocrine/metabolic: hypothyroid, diabetes, hypercalcaemia, pregnancy
• Neurological: Parkinson’s, MS, spinal cord disease
• Structural: colon cancer, diverticulitis, haemorrhoids
• Medications 💊: opiates, antidepressants, diuretics, CCBs, iron, anticholinergics, NSAIDs, aluminium antacids
• Acute illness: immobility, dehydration

🚩 Red Flags (Investigate)

• PR bleeding, weight loss, family history of colorectal cancer
• Tenesmus, anorexia, night sweats, fever, ↑ inflammatory markers
• Abdominal mass, distension, or pain on PR exam

💊 Laxative Classes

🏥 In-Hospital Constipation Pearls

• Common triggers: immobility, dehydration, opiates/codeine.
• Always examine the rectum (is there hard stool in the rectum?).
• Stop causative drugs if possible.
• Escalation for disimpaction: Microlax → Phosphate → Arachis oil → Manual removal.

💡 Toileting & Lifestyle Advice

• Encourage unhurried, regular routine ⏰.
• Respond promptly to urge to defecate.
• Support mobility and privacy.
• Ensure supported seating for frail patients.

⚠️ Cautions with Laxatives

• Avoid in suspected obstruction, perforation, paralytic ileus, toxic megacolon, Crohn’s/UC flare.
• Specific cautions:
  • Lactulose in galactosaemia
  • Bisacodyl in severe dehydration
  • Arachis oil enemas in peanut allergy
• Prolonged overuse → electrolyte imbalance (esp. hypokalaemia).