Question

Ms. RJ is a 70 year old woman who present for a follow-up. She complains of hard ,dry stools over the past weeks. She tried using fiber and increase her fluid intake with no positive results.

Past medical history: hypertension, chronic renal deficiency. Had a stroke one year ago with little or no residual

Medication used: Verapamil SR 240mg daily, lisinopril 10mg PO daily, Calcium carbonate1250mg P.O twice day, Aspirin325mg PO daily. She was diagnosed constipation

What laxative do you recommend for her? Explain your answer and what are the common side effect of it?

What would you suggest if your first recommend fails? Give second line and third line treatment. What is your advise toward her?

What lifestyle changes would you recommend MS.CJ should take ? What counselling would you give her? How would you assess the success of this action?

Answer 1

Constipation is a common G.I problem encountered by patients with CKD.The causes may be sedentary life style,reduced intake of fluid and fiber. Along with that co-morbidities also contribute to GI disturbances. Anti hypertensive drugs like calcium antagonists(Verapamil) calcium containing antacids(Calcium carbonate) can also precipitate constipation.

1.For constipation in CKD clients, initial management is with PEG 3350 without electrolytes (Polyethylene Glycol) . Or lactulose oral dose can also be recommended. Both these drugs acts as an osmotic laxative, these are not absorbed or varies the blood glucose level(if patient is diabetic too). It attracts the water content in the colon by the process of osmosis and softens the stool and treats constipation.Bloating,flatulence,diarrhea and dehydration are common side effects of Osmotic laxatives.

2. If the first line of management fails, measures like suppositories and if it doesn't work microlax enema can be given. Rule out fecal impaction and bowel obstruction too. If any comorbidities are causing bowel obstruction, that should be addressed immediately.

3.Patient can be advised to be physically active and perform mild exercises. A sedentary life style, immobility are also precipitating factors of constipation. Encourage fiber intake approximately 20-38gm/day, within the dietary restrictions . Advice to optimize fluid intake within prescribed diet restrictions. Patient can be counselled regarding the possible cause of constipation in her case and the possible solutions to manage it. The success rate of the plan can be assessed during the follow up. Following the counselling session,the patient can be allowed to verbalize her doubts and also about how far she understood regarding the treatment plan. This helps to identify the extent of patient's understanding. Patient may be instructed to report promptly if the proposed methods didn't work.