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Pay attention to the causes

Problems with bowel movements are not only stressful for those affected, but often also associated with shame. We refer to chronic constipation when patients have had a bowel movement less than every third day for three months, the stool is very hard, they need to sit on the toilet for a long time and press hard. After defecation, the feeling remains that the bowels have only been partially emptied.
Marta Campbell
14.06.2021  12:00 Uhr

Chronic constipation is often idiopathic, that is without any explicable cause. It can also be caused by some diseases or medications. The former includes Parkinson’s disease, as well as the condition shortly after a stroke. Diseases in the anal region such as fissures, haemorrhoids or anal stenosis can cause the patients to keep back their stool which will then harden. As a result, acute constipation develops.

It helps if PTA checks the medication schedule whenever constipation occurs in connection with newly prescribed medicines. Opioids are classic constipation-promoting drugs. Constipation is one of the most common side effects of opioids. Opioid-induced constipation occurs at the beginning of an opioid therapy and usually persists throughout the treatment period. Psychotropic drugs such as tricyclic antidepressants or neuroleptics are also known to affect the bowel activity. Anticholinergics or some antihypertensives can slow down bowel movements as well and cause problems with the stool.

Addressing the taboo topic

In the case of Parkinson’s disease patients, but also people taking opioids, those affected benefit if PTA proactively addresses the topics of bowel emptying and constipation and offers appropriate advice.

To find a suitable laxative, the individual needs of the patient must be taken into account. The aim is to ensure a reliable effect with a defined effectiveness as well as a physiological stool consistency; in addition, the remedy should be well tolerated and easy to dose.

According to the step-by-step plan concept of the S2k-guideline Chronic Constipation, therapy in the case of mild symptoms should be started with dietary fibres such as linseed or psyllium husks (e.g. Mucofalk®, Agiocur®, Linusit® Gold Linseed). They increase the stool volume and thus provide a stretching stimulus in the rectum. During the application, it is important to drink sufficiently. However, the effect often does not suffice for patients with a delayed intestinal passage. Dietary fibres can also trigger unpleasant side effects such as flatulence or abdominal cramps.

The remedy of choice for a long-term therapy are therefore osmotically active preparations. Macrogols (e.g. Movicol®, Dulcolax Balance®) bind fluid in the intestinal lumen via osmotic effects and reduce reabsorption. The stool volume increases and a defecation stimulus is triggered. The powders are to be dissolved in water and taken one to three times a day, independent of any meals. They are available unflavoured as well as in different flavours. The effect is felt after one to two days. Sugar alcohols such as lactulose (e.g. Bifiteral®) have a similar effect. However, since intestinal bacteria break down the sugar alcohols, their use is usually accompanied by disturbing gas formation, flatulence and meteorism.

Stimulating the bowels

An alternative to osmolaxants are the bowel-stimulating laxatives sodium picosulphate (e.g. Laxoberal®) and bisacodyl (e.g. Dulcolax®). In the case of bisacodyl, PTA should point out that a time interval of at least one hour should be observed before taking milk or antacids. Otherwise, the protective coating of the laxative could already decompose in the stomach and irritate the stomach lining. Bisacodyl takes effect about six to eight hours after ingestion, sodium picosulphate ten to twelve hours. To be able to go to the toilet in the morning, patients should therefore take the drugs in the evening. One advantage of sodium picosulphate: the active ingredient is also available in liquid form. The drops are particularly suitable for patients who have difficulty swallowing solid medicines or need a flexible dosage.

Saline laxatives such as Glauber’s salt (Na2SO4) or Epsom salt (MgSO4) should, in the case of chronic constipation, be used with caution. Although they are effective, they may cause long-term adverse effects such as an electrolyte imbalance. If patients want a rektal emptying aid, PTA can recommend bisacodyl suppositories (e.g. Dulcolax® suppositories), glycerol suppositories (Glycilax® suppositories) or CO2-releasing suppositories (Lecicarbon®). If a monotherapy does not give the patient sufficient relief, preparations with different modes of action can be combined, such as bisacodyl and macrogols.

Patients who have concerns about a long-term treatment can be reassured by PTA: When applied as directed, prolonged use of laxatives is not dangerous. There are neither habituation effects and dose increases, nor potassium losses or any other serious side effects. The remedies improve well-being and can, should the worst case occur, protect against serious complications such as intestinal obstruction. However, they should not be used daily or prophylactically, but only as needed.

Deutsch/German Englisch/English
Abführmittel laxative
Blähungenflatulence gas, Darm bowels, intestines
Dauergebrauch permanent use, constant use
Flohsamenschalen psyllium husks
Gewöhnung habituation
Idiopathisch idiopathic
Klistier enema
Laxans laxative
Leinsamen linseed
Magenschleimhaut stomach lining, gastric mucosa
Medikationsplan medication schedule, medication plan
Obstipation constipation
Pressen press
Stufenplan step-by-step plan
Stuhlgang bowel movement, stool
Tropfen drops
Verstopfung constipation
Zäpfchen suppositories

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