9. Treatment of Bowel Conditions

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	Following a balanced diet and taking regular exercise are important for everyone, but a recent review has shown that dietary factors should not be assumed to be the major cause of constipation. The ‘Myths & Misconceptions About Chronic Constipation’ was a significant review and one that has brought about change in the way pharmacists should advise customers on constipation. Stimulant Laxatives stimulate the muscles of the colon to support or restart its own natural movement. Studies show that those laxatives containing bisacodyl, which is activated by bacteria in the large intestine, promote intestinal function by stimulating the muscles of the colon, and also stimulate the rectal muscles which may help to restore the "call to stool". Make use of educational materials for customers on bowel conditions as some people may be too embarrassed to seek advice directly from the pharmacist and would prefer to find out more about a condition in the first instance.

Lifestyle measures

Bowel disorders can affect anyone at any time and for any reason. Some people are more prone to these problems than others. Diet and lifestyle alterations may help improve, or even avoid bowel conditions.

In any case, most customers could benefit from advice on lifestyle factors that may be worsening their condition. Tips on how to improve health and wellbeing as outlined in the pharmacy contract will not only benefit bowel symptoms, it will reduce other, more serious illnesses.

Lifestyle advice for customers:

Diet and lifestyle changes - is it enough?

In the case of constipation, diet and lifestyle alterations are often recommended as a first-line option before taking any medication. Following a balanced diet and taking regular exercise are important for everyone, but a recent review has shown that dietary factors should not be assumed to be the major cause of constipation.¹¹

The Myths & Misconceptions About Chronic Constipation was a significant review and one that has brought about change in the way pharmacists should advise customers on constipation. To summarise, the key findings concluded by the authors were:¹¹

Diet

Fiction: previously held belief(s)

A diet lacking in fibre intake, can cause constipation

Fact: conclusion(s) of paper

Fluid intake

Fiction: previously held belief(s)

Increasing fluid intake can alleviate constipation

Fact: conclusion(s) of paper

Physical activity

Fiction: previously held belief(s)

A sedentary lifestyle contributes to constipation

Constipation can be treated by:

Fact: conclusion(s) of paper

Colon damage

Fiction: previously held belief(s)

Laxatives cause damage to the colon

Fact: conclusion(s) of paper

Risk of colorectal cancer

Fiction: previously held belief(s)

Laxatives increase the risk of colorectal cancer

Fact: conclusion(s) of paper

Electrolyte disturbance & Abdominal complaints

Fiction: previously held belief(s)

Laxatives can cause electrolyte disturbances or abdominal complaints in the intestine

Fact: conclusion(s) of paper

Tolerance

Fiction: previously held belief(s)

Tolerance is a problem with laxative use

Fact: conclusion(s) of paper

Addiction

Fiction: previously held belief(s)

Patients could become addicted to laxatives

Fact: conclusion(s) of paper

Rebound constipation

Fiction: previously held belief(s)

Laxatives induce physical dependence and stopping contact laxative intake can cause ‘rebound constipation’

Fact: conclusion(s) of paper

OTC treatments for bowel conditions - quick reference guide

Constipation

Stimulant Laxatives stimulate the muscles of the colon to support or restart its own natural movement. Studies show that those laxatives containing bisacodyl, which is activated by bacteria in the large intestine, promote intestinal function by stimulating the muscles of the colon, and also stimulate the rectal muscles which may help to restore the “call to stool”. Sodium picosulfate has a similar effect.

Plant-derived laxatives such as sennosides are also activated by bacteria in the large intestine. It is believed that the resulting chemical products stimulate the muscles of the colon but not of the rectum.

Saline or osmotic laxatives such as lactulose or sorbitol, work by attracting water to the colon to soften and swell the stool. Osmotic agents, however, draw water not only from the colon itself, but also from surrounding tissue and blood vessels, so that locally a temporary water depletion can occur.

Bulk forming laxatives act by absorbing water and swelling up, which, in turn, softens the stool and stimulates the squeezing action of the colon. This type of laxative may take 24-36 hours to work. Bulking agents can be difficult to swallow and to work properly, must be drunk with plenty of liquid. That may be a concern for elderly patients with a reduced feeling of thirst or those with a restricted fluid intake.

Stool softeners such as docusate sodium, help to soften hard, dry stools making them easier to pass, by increasing their absorption of water and acting as a lubricant. Stool softeners can also help deal with the problems associated with hard, dry stools in haemorrhoids and anal fissures.

Lubricants grease the stool enabling it to move through the intestine more easily. Some of them are partly absorbed, e.g. paraffin, but nowadays this is rarely recommended due to safety reasons.

Macrogols (polyethylene glycols) are administered along with extra fluids, so they don’t need to draw more water into the bowel from the body. Macrogols may be of long-term benefit to patients with persistent constipation and faecal impaction.

Diarrhoea

Antidiarrhoeal agents such as loperamide may be used, except in cases where there is blood or pus in the motions or if the diarrhoea is accompanied by high fever. In cases of acute diarrhoea advise drinking more fluids (3-4 litres a day), preferably containing sugar and salts or ready-mixed rehydration sachets. Chronic diarrhoea should be referred to a GP and long-term antidiarrhoeal use on a low dosage may be advised under medical supervision.

Flatulence

Antifoaming agents such as simeticone may be taken orally. This agent will “merge” the smaller gas bubbles into larger bubbles, thereby easing the release of gas within the gastrointestinal tract through burping or flatulence.

Bloating

Motility restorers such as domperidone block dopamine receptors found in the upper end of the digestive system. This results in tightening of the muscles at the entry to the stomach, relaxation of the muscles at the exit of the stomach and increased contraction of the muscles in the stomach itself. These actions speed the passage of food through the stomach into the intestine.

Abdominal pain and cramps (associated with IBS)

Antispasmodics such as hyoscine butylbromide, alverine citrate and mebeverine act locally in the gut to interrupt the signal from the brain that tells the muscles to cramp. The muscles then relax, the pain fades and the digestive process is returned to normal. Peppermint oil also has antispasmodic properties and directly relaxes gastrointestinal smooth muscle.

Haemorrhoids and anal fissure

Proprietary ointments and/or suppositories combining an anti-inflammatory steroid (such as hydrocortisone) together with various soothing emollients and astringents (such as zinc oxide, bismuth oxide, Balsam of Peru and others) are usually effective in relieving the symptoms of uncomplicated haemorrhoids. They are not recommended for use under the age of 18.

Medication with a stool softener such as docusate sodium, may be useful in the treatment of haemorrhoids and anal fissure by softening hard stools. Short-term use of a local anaesthetic may also be helpful in treating anal fissure and painful haemorrhoids.