Constipation

| Practice points|

• Psyllium is a bulking agent commonly used to treat constipation and regulate stool consistency. Ensure it is taken with plenty of water• Senna may be effective for the short-term management of constipation• Probiotics may decrease transit time in constipated patients. Supplements are best taken with meals to enhance bacterial survival

| Description |

• Medically defi ned as <3 bowel movements per week1

• Symptoms involve stool inconsistency, feelings of incomplete emptying, straining, hard and lumpy stools and urge for defecation1

• Prevalence in the general adult population ranges from 2%–26.9%2

- More prevalent in females and the elderly2

• Aetiology may involve various overlapping factors including: - Extrinsic: low fi bre intake, inadequate hydration, reduced mobility, some medications3

- Intrinsic: pelvic fl oor dysfunction, slow colon transit time3

| Management principles |

• Consult a GP if onset is acute or recent, associated with rectal blood loss, melaena or mucus, weight loss, fever, rectal pain, anorexia, nausea, vomiting or a family history of infl ammatory bowel disease or colorectal cancer• If no clear underlying cause, recommend non- drug treatments such as increasing dietary fi bre. If not effective consider treatment with bulking laxatives then osmotic laxatives

| Primary recommendations |

PSYLLIUM HUSK (Plantago ovata)

Mechanism of action• Decreases intra-colonic pressure and accelerates transit time8

• Increases stool water content, stool weight and total output9Research• Randomised controlled trials demonstrate superior effi cacy of psyllium over placebo for relieving constipation and improving stool consistency3

• A systematic review reported moderate evidence to support psyllium in chronic constipation with improvements in colonic transit time and stool frequency relative to placebo10

Adverse effects• May initially cause mild fl atulence, bloating and abdominal discomfort which reduce with long-term use. Ensure adequate water intake as there have been rare cases of abdominal obstruction11

Interactions• Concomitant use with oral drugs may decrease their absorption12

• May have an additive effect with hypoglycaemic drugs12

Dosage• Typically found in powder or seed form• Dosage range: Blond psyllium seed: 12–40 g whole seeds in divided doses/d11

SENNA (Cassia senna)

Mechanism of action• Acts on the myenteric plexus of the colon to stimulate peristaltic contractions which decreases gut transit time3

• Decreases water and salt absorption from the colon3

Research• Taking senna orally may be effective for the short- term treatment of constipation, although the available clinical research is mixed. Some studies have shown that, compared to other methods (e.g. polyethylene glycol; PEG), senna may be more effective, with fewer side effects13

• There is some evidence that senna may be benefi cial as a laxative for patients on opioid analgesics14

• Combination psyllium and senna may be more

Complementary medicines

PSYLLIUM HUSK (Plantago ovata)

SENNA (Cassia senna)

DIGESTION

effective for relieving constipation when compared to other methods (PEG, lactulose), with few adverse effects10,14

Adverse effects• Generally well tolerated for short-term use (< 7–10 days) in constipation14

• May cause abdominal pain, cramping, fl atulence, nausea, bloating, diarrhoea, and vomiting14

• Use cautiously in patients who have had a GI obstruction or gallstones and in patients with haemorrhoids, stomach ulcers and infl ammatory bowel conditions14

• Avoid long-term use (>10 days). Chronic use may cause ‘lazy-bowel syndrome’14

• Insuffi cient evidence for use in pregnancy. Trials have

not found adverse effects when used in lactation14

Interactions• Use cautiously in patients taking digoxin, diuretics and other laxatives.14

Dosage• Typically found in tablet form or granules • Commonly standardised to contain sennosides A and B14

• Senna is included in a number of non-prescription laxatives (e.g. Senokot)14

• Dosage range should be individualised as there is variability in response• Adult dose equivalent to senna pods 500 mg–2 g/d, dried leaf 1.5–6 g/d15

| Secondary recommendations |

PROBIOTICS• Gut microbiota are signifi cantly different in healthy individuals than those with chronic constipation.16 Probiotics lower colon pH which may enhance peristalsis and decrease colonic transit time16

• 2 meta-analyses of randomised trials found supplementation decreased transit time in constipated adults with greatest improvements using Bifi dobacterium lactis (strains HN019 and DN-173) 17,18

• In individual RCTs, a number of strains have been found to improve constipation and stool quality including Lactobacillus casei strain Shirota19, B. lactis DN-1730101820 and a multi-

strain Lactobacillus and Bifi dobacterium combination VSL#321

Dosage information• Typically found in tablet/capsule or powder form• Strength of probiotic preparations is quantifi ed by number of colony forming units (CFUs)/g: therapeutic effects: between 109 (1 billion)–1011

(150 billion) CFUs/d11

FLAXSEED (Linum usitatissimum)Constipated mice treated with fl axseed meal demonstrated increased stool frequency and weight.22 A small study found fl axseed supplementation may be associated with increased faecal weight similar to that found with psyllium23

| Diet and lifestyle recommendations |

• Increased dietary fi bre is associated with an increased number of bowel movements5

• Consumption of prunes may improve stool frequency and consistency6

• There is a positive association between the amount of vigorous physical exercise and the number of bowel movements5

• Insuffi cient fl uid intake may be linked to constipation7

• Massage and acupuncture may help relieve constipation2

REFERENCES 1. Rome Foundation, “Guidelines—Rome III diagnostic criteria for functional gastrointestinal disorders,” J Gastrointest Liver Dis 2006;15(3):307-12 2. Wang X, Yin J. Complementary and alternative therapies for chronic constipation. Evid Based Complement Altern Med. 2015; 2015:396396. 3. Leung L, Riutta T, Kotecha J, et al. Chronic constipation: an evidence-based review. J Am Board Fam Med 2011; 24(4):436-51. 4. Selby W, Corte C. Managing Constipation in adults. Aust Prescriber 2010;33:116-9 5. Sanjoaquin MA, Appleby PN, Spencer EA, Key TJ. Nutrition and lifestyle in relation to bowel movement frequency: a cross-sectional study of 20 630 men and women in EPIC–Oxford. Pub health Nutr 2004;7(1):77-83 6. Attaluri A, Donahoe R, Valestin J, et al. Randomised clinical trial: dried plums (prunes) vs. psyllium for constipation. Aliment Pharmacol Ther 2011; 33(7):822-8. 7. Robson KM, Kiely DK, Lembo T. Development of constipation in nursing home residents. Dis ColonRectum 2000; 43(7):940-3. 8. Hammerle C, Surawicz C. Updates on treatment of irritable bowel syndrome. World J Gastroenterol 2008; 14(17):2639-49. 9. Paré P, Fedorak RN. Systematic review of stimulant and nonstimulant laxatives for the treatment of functional constipation. Can J Gastroenterol Hepatol 2014; 28(10): 549-57. 10.. Ramkumar D, Rao SS. Effi cacy and safety of traditional medical therapies for chronic constipation: systematic review. Am J Gastroenterol 2005; 100(4):936-71. 11. Braun L, Cohen M. Herbs & Natural Supplements. 3rd ed. Chatswood: Elsevier; 2010. 12. Blackmores Institute Complementary Medicines Interaction Guide; 2016. 13. Natural Medicines 2016. Senna professional monograph 14. Ulbricht C, Conquer J, Costa D, et al. An Evidence-based systematic review of senna (Cassia senna) by the Natural Standard Research Collaboration. J Diet Suppl. 2011; 8(2):189-238. 15. Mills S, Bone K. The Essential Guide to Herbal Safety. Elsevier 2005 16. Chmielewska A, Szajewska H. Systematic review of randomised controlled trials: probiotics for functional constipation. World J Gastroenterol 2010; 16(1): 69-75. 17. Miller LE, Ouwehand AC. Probiotic supplementation decreases intestinal transit time: meta-analysis of randomized controlled trials. World J Gastroenterol 2013; 19(29):4718-25. 18. Dimidi E, Christodoulides S, Fragkos KC, et al. The effect of probiotics on functional constipation in adults: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr. 2014; 100(4):1075-84. 19. Sakai T, Makino H, Ishikawa E, et al. Fermented milk containing Lactobacillus casei strain Shirota reduces incidence of hard or lumpy stools in healthy population. Int J Food Sci Nutr 2011; 62(4):423-30. 20. Yang YX, He M, Hu G, et al. Effect of a fermented milk containing Bifi dobacterium lactis DN-173010 on Chinese constipated women. World J Gastroenterol 2008; 14(40):6237-321. 21. Kim SE, Choi SC, Park KS, et al. Change of fecal fl ora and effectiveness of the short-term VSL#3 probiotic treatment in patients with functional constipation. J Neurogastroenterol Motil 2015; 21(1):111-20. 22. Xu J, Zhou X, Chen C, et al. Laxative effects of partially defatted fl axseed meal on normal and experimental constipated mice. BMC Complement Altern Med 2012; 12:14. 23. Dahl WJ, Lockert EA, Cammer AL, et al. Effects of fl ax fi ber on laxation and glycemic response in healthy volunteers. J Med Food 2005; 8(4):508-11.

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